Approved: June 25, 2008
Revised: June, 2014
A boundary violation occurs when a physician disregards the professional limits that exist as a part of their relationship with patients and/or other members of the healthcare team. These boundary violations may include (but are not limited to) disregarding physical, sexual, emotional, social, spiritual, cultural and financial limits that exist between physicians and the above groups.
Breaches of the physician/patient boundaries occur on a continuum: from sharing personal information with a patient to becoming intimately involved with a patient. Minor breaches may not always be inappropriate but physicians need to be aware that lack of attention to the role of the physician and the power differential that exists can lead to further boundary slippage, the so called slippery slope. Education aimed at preventing violations and encouraging physicians to be aware of the risks is encouraged for all physicians.
The College has a clear standard of practice which prohibits any sexual involvement with patients. Breaches of this standard are taken very seriously.
The College maintains full discretion over what it considers a boundary violation and what the appropriate penalty will be in each case. When inappropriate boundary violations occur, the physician involved should be held accountable and measures taken to prevent recurrence. Once becoming aware of a boundary violation the College must then decide what information needs to be gathered, what assurances are needed to determine fitness to practice, and the monitoring required. With respect to sexual boundary violations, the College deems these interactions to always be unacceptable, regardless of consent. All sexual boundary violations, regardless of how they come to the attention of the College, will be investigated.
- Identification of physicians demonstrating a boundary violation:
- self report
- report by a colleague
- report by a treating healthcare professional
- identification through a complaint process
- Information gathering in situations of an alleged boundary violation. Regardless of the way in which a physician is identified, the process to determine their fitness to practice will be similar and include the following:
- Reports of individuals affected by the boundary violation.
- Reports from colleagues of work performance.
- Report from health authorities involved in the situation and past physician performance evaluations.
- Additional investigations or requirements.
If there is a serious concern about a physician’s fitness to practice, they can be asked to voluntarily withdraw from practice until all information is gathered or they could be suspended until fitness to practice was determined. This is a serious matter but patient safety must come first and the College will need to ensure that there is not a risk to patients. Physicians undergoing an investigation for a boundary violation may have conditions or restrictions placed on their practice to ensure patient safety while undergoing investigation. These can include the requirement for a chaperone to attend while seeing patients, restrictions in the type of patients seen, or the type of care provided. In both cases, the physician will be reminded to seek legal advice to ensure a fair process.
- Additional information may include the following:
- Cognitive assessment and neuropsychological testing to determine ability to practice.
- Physical assessment tailored to the specific problem: i.e.: orthopedic surgeon, neurologist, sleep disorder specialist, internists.
- Psychiatric assessment.
- Multidisciplinary assessment for complex cases or when there is a direct patient concern involved.
- Potential outcomes:
- Unfit to practice with no chance of recovery.
- Unfit to practice at the time of assessment but improvements likely.
- Fit to practice with practice limitations or restrictions.
- Fit to practice with no restrictions
- Monitoring: Boundary violations can impair the ability to practice, but in many cases physicians can be rehabilitated. Ongoing monitoring is required to ensure compliance to recommendations of treating experts, to reassess for fitness to practice and to ensure compliance with any practice restrictions or limitations. This can include the following:
- Reports from treating physicians.
- Reports from colleagues or designated practice monitor.
- Reassessment by a third party.
- Practice visits or audits to review their practice.
- Competency assessment.
- Monitoring of billing or medical records to determine compliance to practice restrictions.
- Evidence that chaperone requirements are adhered to.
- Continuing Care Contracts: These contracts are entered into to ensure compliance to the requirements as a condition of continued practice as outlined as a result of resolution of a disciplinary matter or as agreed to by the physician.
Appropriate boundaries in pediatrician-family patient relationship. Committee on Bioethics. August 1999. Pediatrics 104(2):334-336.
Gabbard G. Patient-therapist boundary issues. Psychiatric Times. October 2005. Vol XXII(12). Website: www.psychiatrictimes.com
Microys G, Prather V, Jones B, Robertson R. Physicians and family support program perspectives: boundaries: invisible but critical and worth thinking about. Website: www.albertadoctors.org
Roback H, Strassberg D, Iannelli R, Finlayson AJ R, Blanco M, Neufeld R. Canadian Journal of Psychiatry. May 2007. 52(5):315-322.
Sexual misconduct statement and policy. Policy statement of Tennessee State Board of Medical Examiners. Sept 1993.
Texas Medical Association, Boundary violations. Website: www.texmed.org