PDF download for The Psychiatrist-Woman Patient Relationship Arms, S.: The Immaculate Deception: A New Look at Women and Childbirth in. Secondly, three aspects of the doctor–patient relationship are explored: the . The large majority of cases of sexualization occur between female patients and. Doctors who enter into a personal relationship with a patient put nature of the doctor-patient relationship and the power imbalance in that relationship. . emergency department, treated a female patient for a fractured wrist.
Nor do all boundary transgressions between doctor and patient ultimately lead to sexual misconduct. Clues as to what these other factors should be can be gleaned from examining the profiles of offending doctors.
Profiles of doctors who violate boundaries A key factor in the identification of doctors at risk of violating boundaries is the enhanced vulnerability of a doctor to the transference—counter-transference dyad which occurs in varying degrees in every doctor—patient relationship.
Doctors can mistake the feelings of love that arise in a therapeutic relationship as being the same as love that arises elsewhere; it is not. Transferences per se, as with boundary crossings, also occur in normal love relationships, 12 and therefore are also a necessary but not sufficient condition for ethical unacceptability.
However, it is the existence and persistence of this type of transference, linked with the fiduciary relationship and unequal power structure, which makes most relationships with former patients ethically unacceptable see following sections. In turn, to build such a relationship, the unequal power distribution between doctor and patient has to be acknowledged and contained in an ethically correct manner.
The onus of responsibility for this last task falls on the person who has the most power in the relationship which, as I will argue, is always the doctor. To explain why this is always the case, even with former patients, it is useful to consider the sources of medical power in light of a framework suggested by family practitioner and ethicist, Howard Brody. In his book The Healer's Power, 20 Brody outlines three sources of medical power: Aesculapian, Charismatic and Social.
It has also been suggested that another source of power —Hierarchical power, the power inherent by one's position in a medical hierarchy e. Although it does not involve the sexualization of the doctor—patient relationship, it clearly illustrates the importance of recognizing all four types of power, and, in particular, the prominence of Hierarchical power: A consultant specialist was admitted to hospital with a severe multi-system disease causing severe renal impairment.
After 6 weeks in hospital, on the day of his planned discharge, he was accidentally given another patient's medication. Instead of receiving his azathioprine and corticosteroids, he was given a high dose of frusemide and captopril. Simply by the sheer nature of taking on the role of patient, regardless of any other type of power, there is always an unequal power differential between the doctor and patient.
This applies in both general practice and hospital-based medicine, although it may be accentuated by the latter's institutional culture. However, there is also the question of whether this type of power would be accentuated further in a fee-for-service situation, as exists in general practice in Australasia, as opposed to free public hospital treatment. This differential is exacerbated further by any imbalances arising from the other three sources of power.
Charismatic power may not always be less on the patient's side depending on the personalities of patient and doctor. Equally, Social power may vary in doctor— patient relationships depending on the social status of the individuals. This may also relate to the gender roles of the patient and doctor.
The large majority of cases of sexualization occur between female patients and male doctors. Therefore, the onus of responsibility for controlling the power imbalance in an ethically correct manner is always on the doctor. However, what is the relevance of this analysis to relationships with former, not current patients?
Several points can be made. Information gained in such a power imbalance can be artificially intimate—one does not normally begin to discuss details of sexual function within a few minutes of meeting a stranger, for example, but this frequently happens in general practice consultations. Secondly, given the strength of Hierarchical power in determining one's overall power in the doctor—patient relationship as illustrated by the case historyit is hard to see how a relationship of equals could develop from such unequal beginnings.
Autonomous choice and consent How should a claim be judged that a former patient gave his or her free consent before entering into the relationship? The validity of consent of a former patient, as opposed to a current one, is a little more debated, but evidence is against that being a former patient materially alters the situation.
Transferences can persist indefinitely and with it the perpetuation of the potential or real incompetence of the patient to recognize these feelings for their true nature and the same for doctors with respect to counter-transference: Zelas is a little less prohibitive. Meaningful consent to a sexualized relationship cannot be given in a situation of unequal power: Non-judgmental approach with an open mind: Data from relatives are important, but that should not prejudice one's mind.
Similarly, educational qualifications, social background, financial conditions should not come in the way of making a sound scientific evidence-based diagnosis and treatment plan. Depending on the therapist's approach, both methods can serve the purpose well.
A combination of both and judicious mix is the best approach. Good empathy and sincere effort to understand patient's feelings: This is the crux of the approach and can never be over-emphasised.
Involving relatives in an appropriate way: Relatives can offer valuable data and insights into the patient's condition while at times try to unduly influence therapy. It is necessary to ensure the first while being aware the second does not happen.
Especially in psychotherapy, and with all patients, there must be an assurance that their case histories will not be revealed without their consent. Discussion about various treatment modalities: This can be discussed with the patient in case the doctor feels that he has insight into his condition and can understand the same.
If that is not possible, the relatives must always be taken into confidence. To keep the humane factor in mind even while treating patients with limited capacity to assimilate what the psychiatrist is saying or doing. Models of approach We can discuss models of approach under the following heads: In case of treating psychotic patients very active and may be at times an assertive attitude is necessary.
Passive attitude from the doctor is seen in case where he feels nothing further can be done, or when he feels potential legal threats. Defensive approach is prevalent especially in psychiatry to ward off legal threats. At times, clients land up mainly for guidance on certain interpersonal or occupational matters, or seek cooperation to resolve interpersonal stresses, e. The therapist must decide where advice ends and therapy starts.
And where advice itself is therapy. The therapist may have to get involved in a mutual participatory model, wherein there is a lot of give and take of ideas and action plans. Clients, who prefer to take charge of their lives, but with specialised help, are especially suited for this model. The psychiatrist has more chances to develop social and physical intimacy with his patients. However, the guidelines maintain that this is unprofessional. In a case where you already have social intimacy with a patient, it is preferable to refer this patient to another psychiatrist.
Certain reportable conditions Patient expressing suicidal or homicidal intentions: Consents Informed consent is both an ethical and legal issue. It consists of the following components: The patient and relatives must be given reasonable information about the sickness and possible modes of treatment in the language they understand. Common side effects of any drugs need to be told. Consent for any procedure or treatment is necessary.
Either implied consent, oral consent or written consent, as the case may be. In case of procedures like electroconvulsive therapy in psychiatry, there is the need to have details in the language understood by the patient and his relatives.
This is the capacity to weigh, reason and make reasonable decisions based thereon.
If a patient is incompetent, appropriate health care proxy, e. For practical reasons, when a patient is not competent, relative's consent for the treatment should be considered sufficient.
However, when legal hassles are anticipated, e. Malpractice and liabilities Misdiagnosis: It is not expected that a psychiatrist should diagnose by the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases system. But he must use his average skills in coming to conclusions.
Doctor-Patient Relationship in Psychiatry
Legal issues arise when an organic condition in missed, and suicidal or homicidal risks are not properly evaluated. This includes under-treatment, over-treatment, wrong treatment, treatment without informed consent, involuntary treatment, side effects of treatment. When prolonged hospitalisation is necessary, the patient and relatives should be properly explained.
If necessary, a second opinion should be sought even in case of voluntary admissions. Definite guidelines exist in the case of involuntary admissions and must be followed.
Improper relationship with the patient. Sexual relationship with a patient, exploiting a patient, social and economic deals with patient are not acceptable.
As written earlier, even social intimacy with patient is not desirable. Any sexual or physical intimacy is considered malpractice. There remain certain grey areas: Who bears responsibilities for mistakes done by subordinates? What is a psychiatrist's legal standing in a joint consultation? Liability prevention Liability prevention consists of the following: Needless to say, the greater the competence, the lesser the need for liability prevention.