Mutual trust, respect, and confidentiality are the cornerstones of any healthy doctor-patient therapeutic relationship. Due to the inherent power imbalance at play, seemingly innocent and caring acts may exacerbate the patient’s vulnerabilities and inadvertently become a boundary transgression. Learning how to protect the therapeutic relationship without hindering meaningful and personable care involves ongoing self-reflection and education.

See also: Case studies - Keeping Within Professional Boundaries

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Risk Factors

  • Being personally or professionally isolated. Being unwell or under stress increases the risk of lapses in judgements and further boundary violations, particularly when practitioners have inadequate emotional support or counselling available to them .
  • Having poor communications skills. Misunderstandings are more likely to occur when explanations are conveyed with ambiguity and without clear-cut emphasis on how and why a particular advice is given. 
  • Lacking clarity of professional limits. You may need to share information to build trust with patients and assist them in some of their most vulnerable, traumatic, and stressful moments. This can lead to interactions with them outside the clinic, hospital, or practice where boundary crossings may occur.
  • Lacking appropriate training and/or experience. Trusting young practitioners are more likely to be unaware of the intricated ties of professional boundaries and, thus, more likely to engage in boundary violations.
  • The changing nature and delivery of healthcare. Less formal approaches to healthcare delivery in favour of a more relaxed and collaborative one with patients make it difficult to maintain clear professional and personal boundaries. Being too cold or distant may not support effective communication either. Instead, the ideal approach is to strike the right balance without risking the patient's misinterpretation of a more casual style.  

Sexual behaviours that may constitute boundary violations

  • Sexualised behaviour, including words or actions that could reasonably be interpreted as being intended to arouse or gratify sexual desire
  • Sexual exploitation or abuse, including sexual harassment (unwelcome behaviour of a sexual nature including, but not limited to, gestures and expressions), or entering a consensual sexual relationship.
  • Sexual assault, from physical touching (or examination without consent) to rape,  is a criminal offence.

Impact of boundary transgressions

Claims, complaints, and investigations arising out of the violation of professional boundaries can have long-lasting, detrimental effects on practitioners and patients. According to Ahpra’s 2020/21 annual report, the regulator received 568 notifications about a possible failure to maintain appropriate professional boundaries . This was a significant 22.6% increase in notifications compared to the year prior. Of note, 53.2% of notifications involved medical practitioners.

Alarmingly, boundary notifications had a higher proportion of suspensions through immediate action (34.9%) compared to all notifications (27.9%). Of the immediate action taken, 52.2% was about medical practitioners. The serious nature of these breaches was reflected in the outcomes. Action from Ahpra was taken more often about boundary notifications compared to all notifications:

  • 10.3% resulted in a caution or reprimand (compared to 5.0% for all notifications)
  • 12.8% resulted in conditions being imposed on a practitioner’s registration (compared to 7.2% for all)
  • 5.0% resulted in a practitioner’s registration being surrendered, suspended, or cancelled (compared to 0.7% for all).

Key advice to minimise your risk

According to the Royal Australian College of General Practitioners’ (RAGCP) guide to managing professional boundaries, good medical practice:

“Relies on trust between doctors and patients and their families. It is important to be aware that it is always unethical and unprofessional for a doctor to breach this trust by entering into a sexual relationship with a patient, regardless of whether the patient has consented to the relationship”.

“It may also be unethical and unprofessional for a doctor to enter into a sexual relationship with a former patient, an existing patient’s carer or a close relative of an existing patient, if this breaches the trust the patient placed in the doctor”.

To uphold and maintain the trust that patients place in you, developing awareness and ongoing self-reflection are key. When in doubt about a potential boundary violation, ask yourself1 :

  • Is what I am doing part of accepted medical or dental practice?
  • Could this behaviour be interpreted as a high-risk action?
  • If I saw this behaviour or action in another practitioner, would it be reasonable for me to doubt his/her intentions? 
  • Are my actions directed solely towards the best interest of the patient?
  • Are my actions self-serving?
  • Is what I am doing secretive? Would I be happy to share it with my spouse, partner, colleagues, or employer?
  • Am I disclosing personal and sensitive information about myself or my family to my patients?
  • Do I feel worried or guilty about this behaviour?
  • Has someone made comments about my approach or recommended I stop? Have I seen similar behaviour reprimanded by the Medical/Dental Board, Ahpra or any of the Healthcare Complaint Commissions?
  • Do I tell patients personal aspects of myself to impress them?
  • Do I disclose personal and sensitive information about my patient’s life to third parties?  (Even when I think I am protecting their identity)?
  • Do I make seemingly harmless exceptions for patients that I attractive or physically appealing? (Eg special scheduling, reducing fees, extra healthcare services) 

Terminating the doctor-patient relationship

If there is a severe breakdown in trust and rapport that makes it impossible to continue providing care, you should consider terminating the therapeutic relationship. Where possible, this should be done in person. If you are concerned the patient will return and be rude or violent, you can further protect yourself by putting this in writing following your conversation. If the patient does not respond, you need to exhaust your follow up procedure. You have the legal and ethical obligation to ensure and facilitate the continuity of care as you transition the patient’s care. You must also comply with the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia  when ending a doctor-patient relationship.

MIPS resources

Webinars

MIPS panel: Common practice scenarios - what would you do?

Beyond Negligence

Online interactions - What should you do?

Articles

Facebook - Avoiding professional commentary

Maintaining Your Professional Profile

Major professional and personal risks for junior practitioners

Ahpra celebrates changes to the regulatory landscape of sexual boundaries notifications

This information is not intended to be legal advice and as such should not be relied on as a substitute. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Should you wish to obtain further information you can review our Member Handbook Combined PDS and FSG or contact MIPS on 1800 061 113. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Information is current as at the date published.

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