“First, Do No Harm” Part III: Prevent Abuse
This 3-part series that began in May 2023 has focused on what healthcare systems need to consider related to the sexual abuse of patients in the care of physicians and other healthcare providers. The second blog focused on how offenders operate and how to manage access needed to offend.
This final installment focuses on leveraging policies and education to mitigate the other components an offender needs: privacy and control.
According to the American Medical Association (AMA) Code of Medical Ethics, “a physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights; a physician shall uphold the standards of professionalism…; a physician shall respect the rights of patient, colleagues, and other health professional…” These principles were adopted in 1957 and continue to be the essentials of “honorable behavior for the physician.”1
Patient Safety Policies and Procedures to Protect Both Patient and Provider
Policies for patient-provider interactions are not new in healthcare; however, not all policies are without challenges. For example, one of the oldest and most debated policies for preventing abuse is minimizing privacy – the requirement of a medical chaperone when conducting certain types of examinations.
References to medical chaperones began in the literature in the 1970s and 1980s with varying role descriptions and understandings of the concept. Currently, the AMA urges physicians to have medical chaperones available for patients as part of their Code of Medical Ethics under the patient-physician relationship to “protect the interests of both patients and physicians.” 2 In a study by DuBois, et al focusing on sexual violations in medicine, the author reported an alarming 19% of sodomy cases occurred with a chaperone, parent, nurse or other individual in the room with the patient-victim and physician-offender.3 Some studies suggest that medical chaperones may be an illusion of safety, further allowing harmful behaviors to go unnoticed.4
Many healthcare systems, especially those with a publicized sexual misconduct litigation, would agree that having a well-written policy on designated medical chaperones that includes obligatory training, requirements for all intimate examinations, and mandated documentation in the medical record sets safety standards for provider-patient interactions.
Ultimately, the policy and procedure in and of itself is not a singular solution. Still, the layers of policy implementation, training, and communication that acknowledge the power imbalance that exists during a sensitive exam can open a dialogue regarding unnecessary privacy as well as defusing it. Many healthcare organizations have entire websites dedicated to this patient safety feature and other vital components such as staff training, patient education, and reporting tools. It also highlights expectations of professional behavior and commitment to patient advocacy. These are critical components for policies to be effective in organizations as complex as hospitals and other healthcare settings.5
Policies such as requiring medical chaperones are not meant to replace healthcare privacy standards or circumvent the patient-provider relationship. Rather, they are intended to eliminate unnecessary privacy and protect both patient and provider when engaged in sensitive examinations or procedures. Part of the role of a chaperone is to acknowledge that there is a power differential between provider and patient during a sensitive exam and to ensure that this “power” does not become a controlling or manipulating force in the relationship.
Training To Level Set the Patient-Provider Relationship
The ideal patient-provider relationship will always include mutual respect and a sense of partnership. However, the traditional relationship between patient and provider has been viewed as paternalistic, creating an inherent power imbalance that many feel exists due to the knowledge and ability a healthcare provider acquires to treat patients. Society has typically provided physicians with no other profession’s powers, including permission to open the human body, prescribe potentially lethal substances, and remove and/or replace organs or other body parts.6 Thus, to question this power means to risk not being treated for disease, cared for when in pain, or cured of a ravaging illness. Here lies the crux of the power imbalance and the ability to manipulate or control the relationship.
Mandatory training, continued education, and other forms of ongoing learning are critical for healthcare providers. However, few systems ensure the rigor of training on their own policies and procedures, including how to report concerns of inappropriate behavior, policy violations, or boundary-crossing behaviors. Similarly, although most state licensing boards will require a course in professional boundaries, this is not an annual requirement. Most currently available courses do not address how to build healthy relationships with peers and patients, how to recognize power imbalances and strategies to overcome them, how sexual misconduct drifts into medical practice, how boundary crossings occur, or the slippery slope of inappropriate behaviors that can lead to sexual assault. Similarly, though the AMA Code of Medical Ethics and most state medical boards are clear about the responsibility of physicians to report peers if they suspect or observe inappropriate behaviors, few share details on how to respond or why reporting is paramount for them as professionals, as well as for their organization, and the patient.7
The issues aren’t merely a lack of relevant education. “Training can address and fix one problem, and that is lack of skills and knowledge… If the performance issue isn’t caused by a lack of skill, then more training isn’t the answer.” 8. The best training may not be directly focused on sexual abuse in the healthcare arena, but may be more related to solutions that solve for better response and reporting, such as lack of communication, respect of peers and patients, or a system that holds people accountable for their actions.8 In a recent JAMA editorial, Dr. Pamela Miller discussed research examining sexual harassment, disruptive behavior, and abuse in the medical community and concluded that the problem was the community itself – providers unable to treat each other appropriately.9
While these types of training topics must be explored, consideration of the role of all key stakeholders remains paramount. For example, supervisors must be trained to monitor interactions and spot boundary crossings. Similarly, hospital administrators must understand the time-sensitive nature of responding to reports of these behaviors as well as immediate steps to mitigate the risks associated with such behaviors for their patients, staff, and organizational reputation. Lastly, patients must not only know their rights but also their role and responsibility to report.
Although some would argue that patients are educated every time they meet with a physician, these concepts only began receiving genuine attention by healthcare systems around the topic of informed consent in the AHA’s A Patient’s Bill of Rights, published in 1972.10 However; the focus has always been for the patient to consent to the care offered. It is about telling, not teaching, and obtaining consent, not empowering patients to lead with their own knowledge and understanding to create a healthy patient-provider relationship. To remove opportunities for control and abuse and dismantle power hierarchies, all key stakeholders must know and understand their roles and responsibilities as a part of the care team. Through this approach, patients, providers, and healthcare systems can create a true culture of safety.
Final Thought: We Can and Must Prevent Harm – A Call to Action
Healthcare is grounded and founded on the Hippocratic Oath ideals of “do no harm.” Yet, it is plagued by provider misconduct, loss of trust from patients, and system failures to protect those in its care. All three bear the burden of vulnerability to incidents of sexual harassment and abuse that come from power imbalances and hierarchies. The resulting trauma and catastrophic consequences are not only for patients but also for providers and healthcare systems. However, abuse can be prevented. It’s time for healthcare entities to create a culture of safety that includes a zero-tolerance stance on provider disruptive behavior and sexual misconduct. By leveraging best practices to manage access, mitigate unnecessary privacy, and defuse power imbalances from becoming issues of control, healthcare providers and systems can achieve their pledge to “do no harm.”
1American Medical Association (AMA) Code of Medical Ethics https://code-medical-ethics.ama-assn.org/
2AMA Code of Medical Ethics Opinions (ama-assn.org)2.4 Use of Chaperones
3DuBois JM, Walsh HA, Chibnall JT, et al. Sexual violation of patients by physicians: A mixed-methods, exploratory analysis of 101 cases. Sex Abuse2019;31:503-523.
4Ron Paterson; Physicians, Patients, Sex and Chaperones: Rethinking Medical Regulation. Journal of Medical Regulation1 July 2021; 107 (2): 17–24. doi: https://doi.org/10.30770/2572-1852-107.2.17
6KoeckC. Imbalance of power between patients and doctors BMJ 2014; 349 :g7485 doi:10.1136/bmj.g7485
7AMA Code of Medical Ethics Reporting Incompetent or Unethical Behaviors by Colleagues | AMA-Code (ama-assn.org) 4.2 Opinion
8Leonard, B. (2015) The Keys to Improving the Effectiveness of Training. SHRM website https://www.shrm.org/ResourcesAndTools/hr-topics/organizational-and-employee-development/Pages/effective-training-techniques.aspx
9Editorial June 6, 2023 Disrespectful Conduct in the Medical Profession. We Have Met the Enemy and They Are Us Pamela S. Douglas, MD1,2 Author Affiliations Article Information JAMA. 2023;329(21):1829-1831. doi:10.1001/jama.2023.3694
10American Hospital Association https://www.aha.org/other-resources/patient-care-partnership