1. Maintaining Proper Boundaries Rheumatology Grand Rounds May 20, 2010 William H. Swiggart, MS, LPC/MHSP Co-Director, The Center for Professional Health

2. Maintaining Proper Boundaries The role of the Center for Professional Health The role of the Center for Professional Health Take a screening test Take a screening test Discuss the current rules and consequences associated with boundaries in medicine, DVD Discuss the current rules and consequences associated with boundaries in medicine, DVD Review the characteristics of physicians referred to the CME course on boundaries Review the characteristics of physicians referred to the CME course on boundaries Complete a brief evaluation Complete a brief evaluation

3. Programs Maintaining Proper Boundaries CME Course Prescribing Controlled Drugs CME Course Disruptive/Distressed Physician CME Course VUMC Faculty & Physician Wellness Committee Charlene Dewey M.D.,M.ed., Co-Director The Center for Professional Health

4. Boundary Violation Index 25 Questions 25 Questions N-never N-never R-rarely R-rarely S-sometimes S-sometimes O-often O-often

5. Boundary Violation Index Scoring Scoring N-never (0) N-never (0) R-rarely (1) R-rarely (1) S-sometimes (2) S-sometimes (2) O-often (3) O-often (3)

6. Boundary Violation Index Scoring Scoring Cut off =6

7. Hazardous Affairs DVD DVD prevention prevention Education Education

8. Prevalence of sexual boundary violations 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: 139-148.

9. Physician Demographics Total Participants – 571 Total Participants – 571 Age Range - 31 to 80 (Average - 49) Age Range - 31 to 80 (Average - 49) Sex - Male 95%, Female 5% Sex - Male 95%, Female 5% States – 45 and Canada States – 45 and Canada

10. Specialty Family / Internal Medicine – 40% Family / Internal Medicine – 40% Psychiatry – 10% Psychiatry – 10% Surgery – 12% Surgery – 12% OB / GYN – 7% OB / GYN – 7% Anesthesiology – 3% Anesthesiology – 3% Others – 28% Others – 28% N = 571 Feb. 2000 – May 2010

11. REASONS FOR REFERRAL Complaints from patients, family members, nurses Complaints from patients, family members, nurses Affair with patient, office nurse/staff Affair with patient, office nurse/staff

12. Lessons Learned Top 11 ways to get into Trouble

13. Step 1 Date someone you supervise such as office staff, i.e., nurse, secretary, a resident or intern Date someone you supervise such as office staff, i.e., nurse, secretary, a resident or intern

14. Step 2 If someone objects to your sexual jokes or flirting assume it is their problem. You can say anything you want to. If someone objects to your sexual jokes or flirting assume it is their problem. You can say anything you want to.

15. Step 3 Prescribe scheduled drugs or operate on someone with whom you are sexually involved. Prescribe scheduled drugs or operate on someone with whom you are sexually involved.

16. Step 4 Use the hospital or office computer to view or download pornography. Use the hospital or office computer to view or download pornography.

17. Step 5 Avoid even the appearance of professional boundaries in regards to dress, language and behavior in the office. Avoid even the appearance of professional boundaries in regards to dress, language and behavior in the office.

18. Step 6 Make comments about your patients underclothing, e.g. how pretty or where did you buy that? Make comments about your patients underclothing, e.g. how pretty or where did you buy that?

19. Step 7 Tell stories about your own sexual life. This will certainly impress your patients and make them feel more at ease during the breast exam. Tell stories about your own sexual life. This will certainly impress your patients and make them feel more at ease during the breast exam.

20. Step 8 Be present when your patient is disrobing and offer to help with those hard to reach items. Don’t use a chaperone in your office. They only make the patient uncomfortable. Be present when your patient is disrobing and offer to help with those hard to reach items. Don’t use a chaperone in your office. They only make the patient uncomfortable.

21. Step 9 Accept offers to meet after-hours from your patients even if it is just for coffee or a meal. Accept offers to meet after-hours from your patients even if it is just for coffee or a meal.

22. Step 10 Flood your life with work, long hours, and ignore your personal needs. A lack of balance between professional and personal life are set-ups for problems. Flood your life with work, long hours, and ignore your personal needs. A lack of balance between professional and personal life are set-ups for problems.

23. Step 11 Ignore state, federal and professional guidelines regarding sexual harassment, sexual impropriety and sexual violation. Ignore state, federal and professional guidelines regarding sexual harassment, sexual impropriety and sexual violation.

24. Slippery Slope Late appointments with no chaperone Business transactions/dual relationships Excessive physician self-disclosure Some forms of language use Personal gifts Personal gifts Special favors Special favors Flirting, jokes etc. Flirting, jokes etc. Grooming behavior Grooming behavior Casual workplace Casual workplace

25. Boundaries Differ in Different Specialties Psychiatry once a patient always a patient Psychiatry once a patient always a patient Primary Care Primary Care Surgeon Surgeon Pediatrician patient surrogate Pediatrician patient surrogate Anesthesiology Anesthesiology Rheumatology ???? Rheumatology ????

26. Key Concepts The physician holds the balance of power over patients, staff and students. The physician holds the balance of power over patients, staff and students. Mutual consent is not recognized as a defense for the physician. Mutual consent is not recognized as a defense for the physician. Patient and physician emotional vulnerabilities are at the core of boundary violations. Patient and physician emotional vulnerabilities are at the core of boundary violations. Self care by the physician is critical to prevent hazardous romantic relationships. Self care by the physician is critical to prevent hazardous romantic relationships.

27. Web Resources http://www.mc.vanderbilt.edu/cph http://www.fsmb.org/grpol_policydocs.html#2006