Watch Out for the Amorous Patient Physicians are sometimes portrayed as sexual predators of patients. That issue is in the public eye right now, after the Atlanta Journal-Constitutionrelease in July of its study uncovering thousands of cases of physician sexual abuse of patients.[1] There's also a flip side to this issue: There are many cases in which the tables are turned, and patients try to seduce physicians. Doctors have to be vigilant about amorous patients, according to experts who treat doctors for sexual offenses. Patients' advances can often be quite intense. In some cases, they may willfully entrap doctors or even level false accusations against them. State medical boards view these cases very seriously, and any hint at complicity can ruin a doctor's career. "Patients may try to initiate a physical relationship with the doctor, on the basis of unrealistic fantasies they might have about him or her," says to Michael C. Heitt, PsyD, a clinical psychologist in Pikesville, Maryland, who treats many doctors referred by the Maryland Board of Physicians. Dr Heitt says patients' expectations may be amped up by TV hospital shows, in which sex with doctors appears to be rampant. And there's a whole genre of romance novels about female patients falling for male doctors,[2] whereas just Googling "doctor-patient porn" opens a plethora of sites. The vast majority of doctors never respond to patients' come-ons, but almost every physician has been exposed to this, says Stephen J. Schenthal, MD, CEO and founder of Jacksonville, Florida-based Professional Boundaries Inc. (PBI), which offers classes to doctors referred by medical boards for sexual liaisons with patients and other "boundary" issues. At physician conferences, when Dr Schenthal asks a roomful of doctors whether they have ever encountered a seductive or flirtatious patient, "everybody raises their hand," he says. How often do these attempted seductions get to be a real problem? No one in the United States seems to know, but in Great Britain, the Medical Defence Union (MDU), representing physicians in malpractice actions, has issued a count for its own physicians. In 2012, the MDU said physicians' reports of being pursued by "a lovestruck patient" rose from 73 in 2002-2006 to 100 in 2007-2011, according to a report[3] in the Guardian. "Members report being bombarded with messages to their mobiles or email, and Twitter or Facebook accounts," an MDU official told the newspaper. There Are Blatant Seductions Seductive patients can be very overt about their intentions. In response to a Medscape article on physician/patient romance,[4] one dermatologist recalled the time that a patient had left her red panties in the examination room. Another physician said he was being "hit on like Normandy beach. Experts say that very blatant come-ons rarely tempt doctors. Indeed, Dr Kevin Pezzi, MD, a former emergency physician who says he has been hit on by female patients, says he never succumbed to any of these advances. In many cases, "I knew I was dealing with someone bereft of intelligence or common sense, or burdened by mental illness affecting judgment," he adds. What also bothered him was that "none of them knew me," he says. "They saw 'a doctor' and projected their beliefs about what doctors and their lifestyles are like onto me." Dr Pezzi recalls another doctor's experiences with a persistent patient. The patient asked the doctor for a date, and when he declined, she sent him notes and baked cookies. Later, he chanced upon her and her child in the local Walmart. She asked him for a date one more time, but the doctor said he would be moving soon. "That's OK," she replied, "we'll move with you." Some Doctors Are Intrigued by Patients' Advances The ban against doctors dating their own patients has existed for 25 centuries. The Hippocratic Oath,[5] written in the fifth century BC, states that a physician pledges to keep himself from "all seduction, and especially from the pleasures of love with women or with men." However, a growing number of physicians are interested in dating patients, provided they have cut the doctor/patient relationship off and have waited for a certain period. In a 2014 Medscape survey,[6] 22% said doctors should be able to date a patient after a 6-month waiting period. That number was up from just 12% in a 2010 Medscape survey. "Doctors sometimes wonder whether it is permissible to date patients expressing an interest," Dr Pezzi says. "That depends on the patient; the nature and duration of the professional relationship; and the state or country, with different ones imposing different restrictions." Dating ex-patients after a waiting period is recognized under law in many states, and it has been reaffirmed in the newly updated code of ethics[7] of the American Medical Association (AMA). However, the AMA code stipulates that such dating would be unethical if "the physician uses or exploits the trust, knowledge, emotions, or influence" that he or she had in the therapeutic relationship. In 2013, British doctors were allowed for the first time to date former patients. This became possible under new guidelines[8] issued by the General Medical Council, which licenses all British doctors. But the guidelines warn that such relationships may still be inappropriate, depending on the length of time since the therapeutic relationship was ended and the nature of that relationship. Meanwhile, the Medscape survey shows that more than two thirds of physicians oppose dating previous patients. Opponents say it that creates a moral gray zone that invites physicians to keep open the possibility of dating a patient if they simply wait a while. "My recommendation is to never date former patients," Dr Schenthal says. Why Some Patients Want to Seduce Their Doctors Why would patients want to seduce their doctors? The late psychiatrist Ethel Spector Person, MD, postulated that the patient might be trying to compensate for the physician's control in the therapeutic relationship. "Love acts as an attempt to exert control over the situation," she wrote[9] in 2003. "It is an example of power-seeking, if you will." Dr Heitt says that a doctor may inadvertently kindle a patient's feelings. "A doctor will often sit and listen to patients, and even touch them on the shoulder in a comforting way," he says. Some patients may misinterpret this as a more personal gesture than it is meant to be, he explains. The feelings that patients have for their doctors can be quite intense. And, as in a an interaction between any two people, signals are sometimes misinterpreted. A patient might believe that a physician is returning his or her feelings, but that could be wishful thinking; or a physician might decline the offer in order to protect himself or herself. But in some cases, patients may be so intent on pursuing doctors that they won't take no for an answer and may even make up stories about seduction if they don't cooperate. In Great Britain, a 50-year-old patient said she became "infatuated" with her gynecologist after he allegedly gave her great pleasure in 2006 during a medical examination, even though a nurse chaperone stood just a few feet away, according to a report[10] in the Daily Mail. She persisted with her claim for 3 years and even took it to trial. But when another doctor agreed to testify that she had pressed him for sex too, she withdrew the case and admitted she made up the incident. The accused gynecologist said he had been put through "a horrible ordeal," and the trial in particular had been "unspeakably stressful especially for my wife, our families and for me." Predatory patients are rare but can be very frightening, Dr Heitt says. Dr Schenthal says they may try to entice the doctor through favors. This might involve offering free tickets to a concert by a favorite of the doctor's, in hopes of creating a special relationship. In these cases, the patient doesn't accompany the doctor, but afterward she might call up to ask how it went. Is It the Patient's Fault? He doesn't like using the term "seductive patient" because it implies that the patient is responsible. "Physicians are 100% responsible for maintaining boundaries in a physician/patient relationship," he says. Dr Schenthal prefers the term "enticing patient." Patients who entice physicians, he says, are not necessarily seductive. In many cases, they may simply be looking for a close relationship with the doctor, or they are just naturally flirtatious and are not looking for sex, he says. He also objects to using the term "affair" to describe a doctor/patient romance, because it implies a mutual decision. Dr Schenthal says the relationship could never be truly mutual because physicians have such great power over the patient. Indeed, this view is very widely held throughout the physician-treatment community. When doctors come to PBI classes on boundaries, Dr Schenthal says, they begin to recognize that as much as the patient may have tried to seduce them, "the doctor seduced himself." He says this self-seduction involved doctors convincing themselves that the long-standing taboo against having sex with your patients, which goes back to Hippocrates, was somehow not applicable in their situation. Stephen M. Boreman is a San Francisco attorney who spent a decade representing the Medical Board of California in disciplinary cases against physicians, and he now does work for PBI. He says many patient/doctor sex cases that come before the board are "more or less mutual," and do not appear to be initiated by the patient, although he adds that it's not always clear who the initiator was. Boreman doesn't see much romance in these patient/doctor liaisons. "They're not falling in love," he says. "They just wanted to have sex." When the relationship ends, physicians can't expect much loyalty from their former partners, says Kenneth W. Goodman, PhD, director of the Institute for Bioethics and Health Policy at the University of Miami Miller School of Medicine. Former patients or their spouses might file a complaint with the medical board. "You have to be leery about what could happen if this thing goes south," he says. How a Seduction Unfolds Doctors who respond to patients' advances are "wounded healers" overwhelmed by personal problems, and their judgment is affected, Dr Schenthal says. "When you are in a period of imbalance, you can be vulnerable, and you may lower your guard," he says. These doctors are no longer engaging in moral reasoning. "Doctors are usually very rational beings, but when your emotions are in play, when you get aroused, you enter a 'hot state,' and you process a moral dilemma very differently than you usually would," he says. He says he has seen some very distinguished doctors—renowned researchers, deans of medical schools—ignore their better judgment and engage in illicit sex. For the sexual relationship to happen, the doctor and patient have to break through multiple boundaries that kept the relationship exclusively therapeutic, Dr Heitt says. They might start by talking more and more about their personal lives in the office visit. The patient might then be scheduled for the end of the day, so that they could talk longer. Then they may agree to meet at a coffee shop or restaurant. "Outside of the office, you no longer have the role of the doctor," Dr Heitt says. "You're not wearing your lab coat and tie." The doctor may not have done anything sexual, but "now there's a huge potential for that." As an example of what can happen when you accept a patient's invitation, Boreman points to the disciplinary case[11] of a California ob/gyn. A young patient of his said she wanted to interview him at a restaurant about his experiences as a doctor. After they ate dinner together, he walked her to her car. A handshake turned into an embrace and she groped him. He told her he couldn't have sex with her because she was his patient, but he got into her car and they fondled each other for some time. The woman stopped being his patient, and after several months, he contacted her and they dated. After they broke up, she filed a complaint against him with the medical board about the encounter. The doctor argued that it was brief and unintended, and it did not involve more than touching. An administrative law judge recommended that the charge be dropped, but the medical board imposed a public letter of reprimand. The doctor appealed the action, noting that the patient had seduced him. The court rejected his appeal, stating, "The idea that a physician could, with legal impunity, receive sexual favors from a patient as long as he does not return them would, in our view, create a loophole in the statute that the Legislature could neither have imagined nor intended." What Kind of Doctor Gets Seduced? Wanting to help people can make you susceptible to seduction, Dr Schenthal says, adding that this is a common trait of the profession. "Physicians are very good rescuers," he says. "They want to help patients in need." Rather than go for a particularly beautiful patient, they might prefer a needy person who wants to be rescued, he says. "The patient is going through a divorce, and you are, too," he says. "You try to help them, and that makes you feel appreciated and worthy as a physician." Doctors who want to be liked can also get into trouble. When a patient signals interest, "they don't like having to say no," Dr Schenthal says. Physicians who don't notice flirtatious patients can also get into trouble. Because such patients are everywhere, a physician who denies their existence is in many cases simply not paying attention, Dr Schenthal says. When you're unaware, "you're unable to recognize the situation and deal with it," he says. Burnt-out doctors are particularly at risk. "They feel unappreciated, dissatisfied with the profession," Dr Schenthal says. In addition, they might be going through a divorce, a death in the family, or another personal crisis. "A lonely physician meets a lonely patient, and they start breaking down boundaries," he says. Which Physicians Are at Risk? The risk of being seduced also varies according to gender, specialty, and age of the physician. The more frequent situation is a female patient pursuing a male doctor. Dr Schenthal says that female physicians may be less likely to get sexually involved with patients, but he adds that some women physicians are very susceptible to needy patients. About one fifth of PBI classes have a female professional in them, he reports. A diabetes nurse described her seduction by a male patient in a 2015 article[12] on the PCI website. She said the patient, 20 years older than her, invited her to friend him on Facebook, and then they began emailing each other. One day the patient changed his appointment to the end of the day, and they walked out of the office together. He invited her to join him at Starbucks, and they began meeting there on a regular basis. Next, she wrote, he told her that his wife was out of town and invited her over for dinner. This "led to a night of intimacy—the first of many," she said. Eventually his wife confronted him about all the emails on his cell phone, and they broke off the liaison. The husband and wife filed a lawsuit against the nurse, as well as complaints with the hospital and the state nursing board. Physicians in certain specialties are more at risk. Because forming sexual ties with patients takes time, Dr Schenthal says it usually involves those who have in longer-term relationships with patients, such as primary care doctors or psychiatrists. In contrast, doctors who have fleeting relationships with patients, such as emergency physicians, are under less risk. Younger physicians may be less at risk, because they tend to be under close supervision and often work in groups, making it hard to respond to patients' advances, Dr Schenthal says. But physicians in their 40s could potentially face more risk, because they may be encountering a midlife crisis, such as children going away to college, the death of a parent, or burnout, he says. Physicians in their 60s could be particularly at risk, Dr Schenthal says. If they haven't had to deal with any disciplinary actions, they may let their guard down. "They have a false sense of security that it will never happen to them," he says. They often tell Dr Schenthal, "I never thought it could happen to me." What You Need to Do to Protect Yourself When a patient tries to seduce you, be direct, Dr Heitt says. Such behavior as leaving panties in the exam room "should cause concern," he says. "If it occurs more than once, it most probably should be addressed with the patient in a direct way that is also tactful and gentle." Your response has to be unequivocal, Dr Schenthal adds. To let the patient down easy, he says that doctors often make ambiguous statements, such as, "Well, I'd like to go to dinner with you, but I can't because I'm your doctor." This may unintentionally encourage the patient to try again, he says. Being polite is key, Boreman says. "If you act outraged, the patient might get angry and decide to report a fictitious sexual harassment case with the board, which you would then have to answer," he says. "You don't want the hassle of a complaint." If a patient displays inappropriate behavior, such as slapping you on the rear, "it is important to take immediate action," Dr Schenthal says. He advises excusing yourself from the room and returning with a chaperone. "Document the event and the actions you took to remain professional in the medical record, in case this is brought in front of the regulatory board," he says. Dr Schenthal suggests recording the incident in the patient's medical record. The MDU in Great Britain advises[13] doctors to keep a log of all calls and contacts by the patient, and to retain the originals of all letters and gifts, for use as evidence. Conclusion "Physicians have to realize they are in a fishbowl," Boreman says. "They should avoid any situations where a potential misperception might tarnish their career." Source
