Physician-Patient Boundaries: Professionalism Training Using Video Vignettes
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One patient-family described gratitude for their church community who brought meals to their home in a period when one parent was at work and the other was at the hospital with a sick child, leaving no one to cook for the other siblings. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance. One patient, self-described as a "non-church-goer," described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen.
Some find it helpful to have a clear approach or structure in mind when opening a discussion on spirituality with a patient or taking a spiritual history.
A group at Brown University School of Medicine has developed a teaching tool to help begin the process of incorporating a spiritual assessment into the patient interview which they call the HOPE questions: Sources of hope, meaning, comfort, strength, peace, love and connection.
Personal spirituality and practices E: When things are tough, what keeps you going?
Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation
P Are there spiritual practices or beliefs that are important to you personally? E Are there ways that your personal beliefs affect your health care choices or might provide guidance as we discuss decisions about your care near the end of your life? How can respect for persons involve a spiritual perspective? The principle of respect for persons undergirds our duties as health care professionals to treat all persons fairly, to safeguard the autonomy of patients, and to limit the risks of harm by calculating the burdens and benefits of the care plan.
Likewise, it is reinforced in religious hospitals whose mission is to care for persons as "children of God," regardless of socio-economic standing. Such caring implies care for the whole person, physically, emotionally, socially and spiritually. How should I work with hospital chaplains? It is heartening to know that the physician is not alone in relating to the spiritual needs of the patient, but can enjoy the team work of well trained hospital chaplains who are prepared to help when the spiritual needs of the patient are outside the competence of the physician.
Board Certification Objective Requirements: Stephen King, personal communication, Need date Chaplains play an important role in a team approach to caring for patients. The onset of serious illness or accident often induces spiritual reflection as patients wonder, "what is the meaning of my life now?
Practical questions concerning the permissibility of procedures such as an autopsy, in vitro fertilization, pregnancy termination, blood transfusion, organ donation, the removal of life supports such as ventilators, dialysis, or artificially administered nutrition and hydration, or employment of the Death with Dignity Act, arise regularly for persons of faith.
In many cases, the chaplain will have specialized knowledge of how medical procedures are viewed by various religious bodies. In each case, the chaplain will first attempt to elicit the patient's current understanding or belief about the permissibility of the procedure in question. The chaplain is also prepared to respond to patients experiencing religious struggle through expert listening and communication skills. The chaplain is a helpful resource in providing or arranging for rituals that are important to patients under particular circumstances.
Some patients may wish to hear the assurances of Scripture, others may want the chaplain to lead them in prayer, and still others may wish for the sacraments of communion, baptism, anointing, formerly, the last ritesdepending upon their faith system. The chaplain may provide these direct services for the patient, or may act as liaison with the patient's clergy person.
In one case, a surgeon called for the chaplain to consult with a patient who was inexplicably refusing a life-saving surgical procedure. The chaplain gently probed the patient's story in an empathic manner, leading the patient to "confess" to a belief that her current illness was God's punishment for a previous sin. The ensuing discussion revolved around notions of God's forgiveness and the patient's request for prayer.
In this case, the chaplain became the "embodiment" of God's forgiveness as he heard the patient's confession, provided reassurance of God's forgiving nature, and offered a prayer acknowledging her penitence and desire for forgiveness and healing. The conference with the chaplain opened the door for this patient to accept the care plan that she had refused earlier.
In another case, a neonatologist summoned the chaplain to the NICU when it became apparent that a newly born premature infant was not going to live and the parents were distraught at the notion that their baby would die without the sacrament of baptism.
Sometimes, in the fast moving delivery of health care, the chaplain, by his or her job description, is the only one on the team with sufficient time to follow up on these important patient needs and concerns. What role should my personal beliefs play in the physician-patient relationship? Whether you are religious, or nonreligious, your beliefs may affect the physician-patient relationship.
Care must be taken that the nonreligious physician does not underestimate the importance of the patient's belief system. Care must be taken that the religious physician who believes differently than the patient, does not impose his or her beliefs onto the patient at this vulnerable time. In both cases, the principle of respect for the patient should transcend the ideology of the physician. Our first concern is to listen to the patient. Physicians are autonomous agents who are free to hold their own beliefs and to follow their consciences.
They may be atheists, agnostics, or believers. It is clear that religious beliefs are important to the lives of many physicians. Medicine is a secular vocation for some, while some physicians attest to a sense of being "called" by God to the profession of medicine. For example, the opening line from the Oath of Maimonides, a scholar of Torah and a physician incorporates this concept: In a much earlier time in the history of the world, the priest and the medicine man were one and the same in most cultures, until the development of scientific medicine led to a division between the professions.
After Descartes and the French Revolution it was said that the body belongs to the physician and the soul to the priest. In our current culture of medicine, some physicians wonder whether, when and how to express themselves to patients regarding their own faith. The general consensus is that physicians should take their cues from the patient, with care not to impose their own beliefs.
In one study reported in the Southern Medical Journal inphysicians from a variety of religious backgrounds reported they would be comfortable discussing their beliefs if asked about them by patients Olive, The study shows that physicians with spiritual beliefs that are important to them integrate their beliefs into their interactions with patients in a variety of ways.
These interactions were more likely in the face of a serious or life-threatening illness and religious discussions did not take place with the majority of their patients ibid.
Obstacles to discussing Spirituality with Patients Some physicians find a number of reasons to avoid discussions revolving around the spiritual beliefs, needs and interests of their patients. Reasons for not opening this subject include the scarcity of time in office visits, lack of familiarity with the subject matter of spirituality, or the lack of knowledge and experience with the varieties of religious expressions in our pluralistic culture.
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Many admit to having had no training in managing such discussions. Others are wary of violating ethical and professional boundaries by appearing to impose their views on patients. Nonreligious physicians have expressed anxiety that a religious patient may ask them to pray.
In such instances, one could invite the patient to speak the prayer while the physician joins in reverent silence. On the other hand, some physicians regularly incorporate spiritual history taking into the bio-psycho-social-spiritual interview, and others find opportunities where sharing their own beliefs or praying with a particular patient in special circumstances has a unique value to that patient.
These and a myriad of other questions have religious and spiritual significance for a wide spectrum of our society and deserve a sensitive dialogue with physicians who attend to patients facing these troubling issues. Often, such questions are initiated in doctor-patient discussions and may trigger a referral to the chaplain. How can we approach spirituality in medicine with physicians-in-training? The UW School of Medicine was an early leader among medical schools in addressing the topic of patient-spirituality.
In an elective course, originating in Spring,"Spirituality in Health Care," the range of topics goes beyond simply teaching spiritual history taking.
Students are encouraged to practice self-care in order to remain healthy as providers for others, and to give intentional consideration to their deep values and their own spirituality as components of their spiritual well-being. The purpose of this interdisciplinary course is to provide an opportunity for interactive learning about relationships between spirituality, ethics and health care.
Some of the goals of the class are as follows: To heighten student awareness of ways in which their own faith system provides resources for encounters with illness, suffering and death.
To foster student understanding, respect and appreciation for the individuality and diversity of patients' beliefs, values, spirituality and culture regarding illness, its meaning, cause, treatment, and outcome. To strengthen students in their commitment to relationship-centered medicine that emphasizes care of the suffering person rather than attention simply to the pathophysiology of disease, and recognizes the physician as a dynamic component of that relationship.
To facilitate students in recognizing the role of the hospital chaplain and the patient's clergy as partners in the health care team in providing care for the patient. To encourage students in developing and maintaining a program of physical, emotional and spiritual self-care, which includes attention to the purpose and meaning of their lives and work. McCormick, Until recently, there were all too few medical schools that offered formal courses in spirituality in medicine for medical students and residents.
This situation is changing. InAAMC developed medical school objectives related to spirituality and cultural issues: Association of American Medical Colleges, Beyond the four years of medical school, residency programs, particularly those with a primary care focus and a palliative care focus, are incorporating education in spirituality training residents.
Christina Puchalski combined efforts as co-directors of this conference for several years. Patients facing serious illness, accident, or death often experience a crisis of meaning.
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Some patients are profoundly comforted by their spiritual beliefs. Others may encounter religious struggle or negative ways of coping with illness. Most offending physicians, however, realize that they have made poor choices and regret them.
Carr contrasts the characteristics of physicians who can achieve rehabilitation with those who cannot. Among the disease and physician characteristics that Carr considers to be indicators of a positive prognosis for physicians who have committed sexual boundary violations are: For most physicians, the ultimate goal of their treatment is rehabilitation and return to medical practice.
To achieve this, they must be able to sustain safe and healthy doctor-patient relationships. Based on our experiences working with impaired physicians, we agree with Carr that most physicians who have committed a sexual boundary violation can be rehabilitated so that they can return to practice. In some cases, career change may be necessary. For physicians in psychotherapy, treatment goals and strategies include an understanding of factors leading to doctor-patient boundary violations and rehearsing scenarios for alternative behaviors.
Nonetheless, the priority of the medical board is to protect the public from exploitative doctors. For that reason, the psychiatrist, counselor, or therapist working with a physician who has crossed boundaries should not offer guarantees of confidentiality if the problem behavior reoccurs. In this sense, the therapy model for treating these physicians is similar to that of military psychiatrists or occupational physicians who examine patients for work readiness and report to the employer if the subject is unfit for duty.
This obligation can pose a conflict for the psychiatrist or therapist unless the treating doctor and the patient are each committed to the primary goal of public protection. Summary Physicians who cross sexual boundaries with patients place themselves in great peril.
They risk tainting or destroying their professional reputations; damaging their health; and losing their jobs, contracts with payers, and hospital privileges.
They jeopardize their financial security, bring shame to and conflict within their families, and may lose their license to practice medicine. Public awareness about the problem of sexual boundary violations by professionals is growing, as is disdain for all persons in fiduciary roles who engage in sex with those for whom they are responsible and over which they have power, whether they be wards, patients, or parishioners. The clergy scandals in the Catholic church highlight this growing public intolerance.
However, some physicians who demonstrate remorse, undergo therapy, and are willing to work with the Board of Medical Practice to regain the public trust can reclaim their careers. Acknowledgement The authors wish to thank Christina Rich, J. Louis Park, president of the Minnesota Physician-Patient Alliance, and a clinical associate professor of psychiatry at the University of Minnesota.
West J Med ; From boundary violations to sexual misconduct. Psychiatr Clin North Am. Minnesota Board of Medical Practice. J Miss State Med Assoc. Minnesota Statutes, Chapter Obstacles to the dynamic understanding of therapist-patient sexual relations. Roberts K, Specker S. The health professional services program: