William H. Swiggart, MS, Co-Director Vanderbilt Center for Professional Health Vanderbilt University School of Medicine

Goals Present data collected from physicians attending a professional development course on maintaining proper boundaries. Vanderbilt University School of Medicine

O BJECTIVES 1. At the end of this lecture participants will be able to: 2. Evaluate the results from several self- report instruments. 3. Describe one screening instrument for identifying at risk behavior. 4. Identify one prevention/educational tool addressing boundary issues in medicine. Vanderbilt University School of Medicine

AGENDA 1. A brief description of the programs presented by the Center for Professional Health at Vanderbilt school of medicine. 2. Review demographic, referral, and self- report data from over 500 physicians attending the maintaining proper boundaries course. 3. Describe one screening and one prevention tool. 4. Summary. Vanderbilt University School of Medicine

Vanderbilt Center for Professional Health Professional Development Courses Program for Distressed Physicians © Prescribing Controlled Drugs© Maintaining Proper Boundaries© Vanderbilt University School of Medicine

PHYSICIAN DEMOGRAPHICS  No: 870  Gender: Male - 94% Female - 6%  Age range: yrs  Mean age: 49 yrs  Ethnic Origin: 78% Caucasian; 5% African American, 9% Asian and 4% Hispanic Vanderbilt University School of Medicine Jan 2015

PHYSICIAN SPECIALITY  Family Practice/GP 30%  Internal Medicine 10%  Medical Specialty 7%  Surgery Specialty 8%  General Surgery 4%  OB/Gyn 8%  Psychiatry 9%  Other 24* * anesthesiology, neurology, emergency, dentist Vanderbilt University School of Medicine

SOURCE OF REFERRAL  Board of Medical Examiners  Physician Health Program  Treatment Center  Self Referral  Attorney Vanderbilt University School of Medicine

P REVALENCE OF S EXUAL B OUNDARY V IOLATIONS 3% 10% 954,224 physicians currently in practice Swiggart, W., K. Starr, et al. (2002). Sexual boundaries and physicians: overview and educational approach to the problem. Sexual Addiction & Compulsivity 9: Vanderbilt University School of Medicine

ASSESSMENTS  FACES II (Family Adaptability and Cohesion Scales)  KSCS (Kalichman Sexual Compulsivity Scale)  ACE (Adverse Childhood Experiences)  BVI (Boundary Violation Index, research)  RSQ (Relationship Style Questionnaire)

FACES II Vanderbilt University School of Medicine D.H. Olson, R. Bell, J. Portner. FACES II Life Innovations, 1992.

FACES II C ONTROL Vanderbilt University School of Medicine

REASONS FOR REFERRAL  Complaints from patients, family members, nurses  Affair with patient, office nurse/staff  Flirting  Cybersex Vanderbilt University School of Medicine

A DVERSE C HILDHOOD E XPERIENCES (ACE) Vanderbilt University School of Medicine Anda R., Felitti V. The Adverse Childhood Experiences Study. The Adverse Childhood Experiences Study, at

S LIPPERY S LOPE Late appointments with no chaperone Business transactions/dual relationships Excessive physician self-disclosure Some forms of language use Some forms of language use Personal gifts Personal gifts Special favors Special favors Flirting, jokes etc. Flirting, jokes etc. Grooming Grooming Casual workplace Casual workplace Vanderbilt University School of Medicine

B OUNDARY V IOLATION I NDEX (BVI) © A screening instrument designed to assess the attitudes, thoughts and behaviors of physicians at increased risk for sexual misconduct with patients and staff. Swiggart W, Feurer ID, Samenow C, Delmonico DL, Spickard WA. The Sexual Boundary Violation Index: A Validation Study. Sexual Addiction & Compulsivity; Vol 15. Number 2, 2008.

BOUNDARY VIOLATION INDEX (BVI) ©  Identify risk factors  Cut Off = 6 Vanderbilt University School of Medicine

B OUNDARY V IOLATION I NDEX © Last Updated Oct 2014 Vanderbilt University School of Medicine

B OUNDARY V IOLATION I NDEX © Please circle the response that best characterizes your behaviors. N = never (0)R = rarely (1)S = sometimes (2) often= (3) 1. I have told patients personal things about myself in order to impress them. 10. I have engaged in a personal relationship with a patient either while I was treating him/her, or after treatment was terminated. 13. I take great pride in the fact that such an attractive, wealthy, powerful, or important patient is seeking my help. 14. I have found myself talking about my personal life or problems with patients. 18. I have found myself trying to influence my patients to support causes, business deals, or positions in which I have personal interest. 23. I have made exceptions for patients, e.g., scheduling, benefits, and/or fees, because I found the patient attractive, appealing or impressive. 25. I have sought social contact with patients outside of scheduled clinic visits. Vanderbilt University School of Medicine

RSQ  Results from three courses Vanderbilt University School of Medicine Bartholomew & Horowitz, 1991; Griffin & Bartholomew, 1994

RSQ Vanderbilt University School of Medicine Relationship Styles: Maintaining Proper Boundaries

KSCS Vanderbilt University School of Medicine Kalichman Sexual Compulsivity Scale Kalichman, Johnson, Adair, Rompa, Multhauf & Kelly (1994). Originally created by Patrick Carnes in 1987 for clinical use in a 12-step program for individuals complaining of sexual control issues, issues managing sexual behavior, and/or thoughts and individuals who thought they had a sex addiction.

H AZARDOUS A FFAIRS L EARNING M ODULE G OALS 1 ) Instruct participants on the general definitions, rules and guidelines around professional conduct regarding professional boundaries and sexual misconduct in the medical profession; 2) make physicians aware of their own vulnerabilities; 3) help physicians understand how to prevent crossing sexual boundaries, and 4) stimulate reflection on current and future professional practice behaviors. Vanderbilt University School of Medicine

H AZARDOUS A FFAIRS L EARNING M ODULE  List the levels of sexual misconduct.  Define sexual harassment.  Compare and contrast the types of sexual misconduct as defined by the Federation of State Medical Boards (FSMB).  Identify three (3) main risk behaviors for sexual misconduct based on various issues like self- wellness, stress, social behaviors, and medical cultures.  Identify five (5) behaviors on the slippery slope. Vanderbilt University School of Medicine

K EY C ONCEPTS  The physician holds the balance of power over patients, staff and students.  Mutual consent is not recognized as a defense for the physician.  Patient and physician emotional vulnerabilities are at the core of boundary violations.  Self care by the physician is critical to prevent hazardous romantic relationships. Vanderbilt University School of Medicine

S UMMARY /R ECOMMENDATIONS  Physicians lack training in the complexity of sexual boundary misconduct.  An educational approach can resolve most of the problem.  A pre-emptive approach is better than a post-violation intervention.  The process is complaint generated. Vanderbilt University School of Medicine

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