Case Scenario

A 44-year-old woman who was new to my clinic presented for a routine annual checkup with breast and pelvic examinations. As usual, I performed the examination with my female medical assistant present. The patient requested a prescription for an oral contraceptive and was offered testing, including blood work and mammography.

One month later the patient returned and stated, “I just had to see you again.” During the office visit, she made little eye contact with me. She alluded to a difficult marriage and imminent divorce, and said that she was “looking for someone else” to provide for her and her 7-year-old son. She pointed to my wedding ring and said that she had not noticed it before. She then asked me if I was interested in having a relationship with her. I told her that I had no interest in her or in any of my patients outside of the professional doctor-patient relationship. I then told her that I was uncomfortable with her personal interest in me and that I thought it would be best if she saw one of my female partners in the future.

The following day, the patient sent a bouquet of flowers and a card to me at my office. I discussed the situation with the organization's risk manager and documented it. In addition, I noted the events in my dictation of the office visit of the previous day. I then sent the patient a letter formalizing the transfer of her care to one of my female partners.

The following week I received dried flowers, a package of homemade cookies and a card. The card contained poems about love and romance. The patient asked if a referral to my partner meant that we could interact socially. “I could easily fall in love with you,” she wrote, and even asked, “will you go to bed with me.” She suggested that my wife was blocking our “relationship” and alluded to the need to remove this barrier. The card also contained professional-grade photographs of her and her son.

I did not respond to her gifts and cards. I placed a note in the clinic computer that the patient was not to have an appointment scheduled with me or any other male physician. I also asked to be notified when she was in the clinic. The patient made no further attempts to contact me. Four months later she returned to the clinic with a sore throat and was seen by one of my partners.

Commentary

It is likely that all physicians, regardless of training, would recognize that this case scenario deals with a seductive patient. The physician's response was appropriate in that he immediately rejected the patient's proposal in a clear and unequivocal manner. He documented that interchange in the medical record, discussed the problem with a colleague and formally terminated his professional relationship with the patient in writing. He did not respond to the patient's subsequent cards and gifts.

Practice challenges rarely present in the clear and blatant manner described in this case scenario. In fact, most physicians-in-training are unable to identify seductive behavior in their patients. Furthermore, many physicians recall little specific training about the appropriate boundaries to maintain with patients. In Maryland, all new physician licensees attend an orientation session that focuses on boundary issues. The attendees usually have questions about what the licensing boards “allow” vis-à-vis dating patients and treating friends and family members. It seems apparent that many of these new doctors feel that they have not previously been provided with information on how to successfully navigate these uncharted waters. The preclusion against becoming socially intimate with patients stems from two basic assumptions. The first is that the physician holds the greater power in the doctor-patient relationship by virtue of his or her training and position. Because of this disparity, patients might be exploited by their physicians. The onus, therefore, remains with the physician to act always in the patient's best interest. The second assumption is that when a dual relationship exists with a patient (such as being both physician and lover), objectivity is lost. As a result, subsequent treatment may be compromised. In addition, a large body of literature suggests that when physicians become intimate with their patients, the patients often suffer significant and lasting emotional harm.

The code of ethics of the American Psychiatric Association instructs psychiatrists that the doctor-patient relationship is an enduring one, which precludes them from pursuing a personal, social or sexual relationship even if the patient is no longer under their care. Because patients may need to return for further therapy, personal involvement remains inadvisable.

The codes of the American Medical Association and the American Osteopathic Association warn physicians of their duty to act in their patients' best interests and not to exploit the doctor-patient relationship. The preclusion against pursuing a social or sexual relationship with patients was recently expanded to include “key third parties.” The latter refers to the people who often accompany patients to the office, such as the parent of a minor child or the caregiver of an adult patient. Beginning a personal relationship with a key third party might jeopardize the care of the patient.

When instructing new licensees in the orientation sessions, I encourage them to terminate their doctor-patient relationship before pursuing a social relationship with a patient. I also warn them that if their doctor-patient relationship included counseling or intimate examination of the patient, or if it was a long-term association, the risk remains that a subsequent personal relationship may be considered patient exploitation. Physicians often do not realize the enduring nature of the doctor-patient relationship and do not appreciate that the transference phenomenon is not limited to psychiatric care. Even a brief association with the physician can significantly affect the patient.

In these orientation sessions, someone always asks about the rural physician who has everyone in town for a patient. In nine years serving on the Maryland Board of Physician Quality Assurance, that scenario never presented to me. The typical physician who is disciplined for having sex with patients is married and has been involved with multiple patients. The patient most often makes complaints about physical impropriety after the sexual relationship has ended or when a subsequent treating therapist supports the patient in making a complaint. Often, the complaints come from the patient's spouse or even the physician's spouse. Licensing boards look at every complaint regarding physician impropriety and adjudicate it on the individual merits of the case.

The physician in this case scenario acted swiftly and appropriately to avoid becoming entangled in an inappropriate relationship. However, physicians must realize that, especially when they are personally stressed, they are vulnerable to becoming involved with their patients. Many physicians who are disciplined for unprofessional conduct with patients become involved when they are in the midst of a divorce, are stressed by overwork, have a family member who is ill or have recently suffered a significant loss. During such times, a compassionate patient may end up hearing a lot about a doctor's troubles rather than having his or her own health needs addressed. Physicians should realize that they can and should seek support and help from their colleagues when their personal troubles, rather than the patient's problems, become the focus of an office visit. Other warning signs indicating that the doctor-patient relationship may be becoming too intimate include scheduling favorite patients for the end of the day, offering free care, exchanging gifts and making arrangements to see the patient outside the office.

Finally, let's talk a bit about the seductive patient described in this case scenario. After one visit, she targeted the physician to be her next husband and supporter, and father to her child. Although the physician acted appropriately in terminating his contact with her, the patient was demonstrating enormous vulnerability and neediness. If at all possible, she should have been encouraged to see an appropriate counselor, with a suggestion that a divorce is always difficult and that having someone to work with during this stressful time would benefit her and her son. It is likely that this patient has serious underlying pathology. Seductive patients often have been victims of abuse, including incest, rape and physical abuse. They may have a history of emotional problems, including depression and suicide attempts, somatization disorders and medication dependence. A patient's behavior, as in this case, may be a loud cry for help. The physician needs to sever contact, but at the same time help to make sure that cry gets heard. For more information, consult the resources at the end of this article.