Boundary violations in patient care: need for evolving professional practice standards and training

The article by Kurpad, Machado and Galgali (1) focuses on an issue which has probably not been discussed in Indian academic medical journals earlier. Nonsexual and sexual boundary violations (NSBV and SBV) certainly occur frequently in doctor-patient relations and this is confirmed by data from the article. The authors have omitted non-consensual acts, such as molestation and rape by doctors, from the purview of their article. The media has reported on patients’ complaints of such non-consensual acts (2, 3, 4).

However, consent can be a problematic concept in doctor-patient interactions in certain circumstances. An example is the case of patients with psychiatric conditions. If the psychiatrist is the person evaluating the patient’s ability to consent and is also a participant in unprofessional conduct, such as sexual contact with the patient, then there is clear conflict of interest for the psychiatrist. The psychiatrist might deem the patient as having been capable of consent, though in reality the patient might not have had this capacity, given his/her psychiatric condition. In this case, there might be a thin line between SBV and molestation/rape, and it would be difficult to interpret what happened.

A doctor-patient relationship has a power differential, with the patient often in awe of the doctor’s authority and control over the course of the treatment. In such circumstances, the validity of the consent by a patient to any sort of SBV would be questionable. SBV is also probably more common in certain medical specialties which involve frequent invasive procedures such as vaginal and rectal examination (such as surgery or obstetrics and gynaecology) and/or where patients are required to undress for examination (such as dermatology), as compared to other specialties such as ophthalmology or otolaryngology.

Defining what is acceptable behaviour and appropriate physical contact in a particular situation and cultural milieu is part of the process of evolving professional standards of conduct with patients in a specialty. Organisations such as the Associations of Surgeons of India and the Federation of Obstetric and Gynaecological Societies of India should take a lead in this regard. There should also be safe, confidential and reliable mechanisms available at the level of hospitals for patients to report boundary violations, and for follow-up by trained and credible individuals (1). These mechanisms need to be communicated through patient charters and public notices at hospitals.

I also concur with Kurpad and colleagues that orientation and mentorship towards professional conduct in a healthcare setting, and understanding of the need for maintaining boundaries in doctor-patient interactions needs to be included in the curricula for training at all levels of medical education.