I am glad the College is taking a strong position of no tolerance of sexual abuse by physicians. I am concerned about the line:
the Discipline Committee has explicit authority to require that mandatory revocation take effect immediately upon a finding of sexual abuse rather than waiting for a penalty hearing;
A scenario has occurred at my hospital more than a year ago whereby a patient accused a [physician] of [sexual abuse]. [Note: specific details about the scenario have been removed to protect the identities of the parties involved. The main concern raised in the scenario was: if there is no due process of investigation by the college/hospital/authorities, any accusations of sexual abuse may result in physicians being unfairly suspended from performing clinical duties].
Further clarification regarding the discipline committee definition of “finding of sexual abuse rather than waiting for a penalty hearing” would be appreciated.
This is true. there must be some reasonable grounds of allegation to remove some ones license. There are so many people who do false allegations. for example if they don’t get what they want from their MD etc.
As a CPSO member, I just want to remind College that importance of protecting doctors is no less that protecting patients. While fully supporting the College’s stance in protecting the public, I have the feeling that CPSO goes liberally after every doctor with whatever complaints they receive and there is nothing in place to protect physicians’ psychological health when unsubstantiated allegations are made against them. There should be systems and protocols in place to involve and penalize the physician after their misconduct is PROVEN.
There needs to be a recognition that having a third party, especially of the opposite sex to the patient, may be tortuous for the patient in some circumstances. For example, if the patient has a history of sexual abuse/assault, forcing him/her to undergo an intimate examination while a third party is watching can trigger PTSD reactions in that patient. This is obviously harmful, of varying degrees, to patients. Knowing that it is generally accepted that anywhere from one quarter to one third of women in Canada will experience some form of sexual assault in her lifetime, it ought to be understood that doctors should actively try to minimize patient discomfort during intimate examinations, and be able to document steps taken toward that end. The College ought to provide doctors with guidelines for doing this. There needs to be clear language that protects patients from doctors who refuse, under any circumstances, to ask the third party to leave the room, even when if becomes clear that it is causing the patient much distress and he/she asks repeatedly for the third party to leave the room. Forcing a patient to endure this is an abuse of power, and should be clearly spelled out as a form of emotional sexual abuse. Clear language would protect both patient and doctor, as it would leave no uncertainty in the minds of both as to what proper conduct is. If a doctor wishes to have a third party in the room for his/her own protection, patient input as to who the third party is should be respected whenever possible. If the doctor and patient cannot agree on the third party, the doctor should refrain from conducting an intimate examination of the patient; the patient should be clearly told the rationale for this, and this should be well documented in the consultation notes. The patient should be offered a referral to another doctor – it may simply be a case of gender that triggers a patient, and no fault of the doctor.
It is interesting to note that Policy Statements 246 and 266 of The Society of Obstetricians and Gynecologists of Canada (SOGC) do spell out that patient participation in “any” education of students should be voluntary, and that if a woman does not wish a third party to be present, her wishes should be respected. However, there doesn’t seem to be clear language regarding this for doctors in general. If SOGC recognizes a need to address it, the College ought to as well.
I appreciate the opportunity to add my opinion to this. I am a patient.
Occasionally a patient may be very needy and hunger for a brief friendship hug or a brief pat on the shoulder. To deny this kind of affirmation is a blow to the physician-patient relationship. A helpful guide is: don’t do anything you would not do to a father, mother, brother or sister in a healthy family. This allows for some cultural differences. How ever, if unsure, it is better to err on the side of being cautious.
With existing rules , there is sill some room for discretion when revocation of license is considered. In the new rules,covering more categories of abuse, there doesn’t seem to be. This seems to exclude all grey areas or extenuating circumstances. If so, I believe such absolutism is unjust.
Can the CPSO give more guidance on the minimum requirements when for examining breasts or genital areas?
Is it obligatory to ask if the patient wants a third party be present or only have one if the patient request one? In a busy hospital practice where nursing staff move between physicians, it may not always be convenient and time efficient to have a nurse present for every breast examination.
Is it obligatory to explain to a patient with breast cancer why a breast examination is being performed? And in how much detail?
In answer to your last two questions, I say, yes, you do. Not just because it is policy, but because it is the respectful thing to do. As a former cancer patient, I can tell you that the patient you describe is probably scared, and she regularly sees a parade of doctors/residents/students who all want to examine her breast, some clumsily and painfully and not very respectfully. You can set yourself apart from them by setting aside pragmatism for a minute, and looking at this patient as a human being who wants to be included in her health care decisions. That starts with asking permission to examine, and explanations for doing so. Here is how I would like it done: after history taking/discussion, you say, “Mrs Smith, I’d like to take a look at your breast now. An examination will help me to understand ______________. I need to understand that
because ____________. Is that OK? Do you have any questions for me before I begin? Do you want a nurse or your husband to be in the room while I examine your breast? I know it might be tender, so I will be as
gentle as I can be. You can help by letting me know what areas are painful when I touch you.” Let the patient know that you respect her enough to ask her permission – never say “I’m going to do a breast exam now” – that leaves her out of the process. Including her in the process means you see her as a partner in her health care. She will be much more likely to comply if she feels included. She will also see you as a breath of fresh air from the doctors (and I’m sorry, but there are many) who just see her as a medical puzzle to be solved, rather than as a human being who has feelings, and badly wants to be involved in her healthcare.
Please let me know if this is painful
Other health care professional (including retired)
Response to (3.b) I agree that the “subjective mindset of the patient” should be central to the analysis in order to determine whether a physician – patient relationship exists. It is refreshing to see the word empower used as it is rarely used in this context. I take issue however with the accepted belief that the patient – doctor relationship is inherently a power relationship with the doctor having the power and the patient being vulnerable. If that is the case then that sets up another kind of abuse. Needing to seek help with a problem does not indicate vulnerability. A person who uses his power over another person is also vulnerable. A healthy interactive relationship is what is needed. The professional has general knowledge that the patient does not necessarily have but the patient has inner knowledge that is needed for the professional to be effective. The concept of the “vulnerable patient” is disempowering the patient.
If you are a male physician with only one female secretary she can chaperone an intimate exam by using a headset phone in the exam room.
I am glad the College is taking a strong position of no tolerance of sexual abuse by physicians. I am concerned about the line:
the Discipline Committee has explicit authority to require that mandatory revocation take effect immediately upon a finding of sexual abuse rather than waiting for a penalty hearing;
A scenario has occurred at my hospital more than a year ago whereby a patient accused a [physician] of [sexual abuse]. [Note: specific details about the scenario have been removed to protect the identities of the parties involved. The main concern raised in the scenario was: if there is no due process of investigation by the college/hospital/authorities, any accusations of sexual abuse may result in physicians being unfairly suspended from performing clinical duties].
Further clarification regarding the discipline committee definition of “finding of sexual abuse rather than waiting for a penalty hearing” would be appreciated.
This is true. there must be some reasonable grounds of allegation to remove some ones license. There are so many people who do false allegations. for example if they don’t get what they want from their MD etc.
Agree with this comment
As a CPSO member, I just want to remind College that importance of protecting doctors is no less that protecting patients. While fully supporting the College’s stance in protecting the public, I have the feeling that CPSO goes liberally after every doctor with whatever complaints they receive and there is nothing in place to protect physicians’ psychological health when unsubstantiated allegations are made against them. There should be systems and protocols in place to involve and penalize the physician after their misconduct is PROVEN.
Very valid point
There needs to be a recognition that having a third party, especially of the opposite sex to the patient, may be tortuous for the patient in some circumstances. For example, if the patient has a history of sexual abuse/assault, forcing him/her to undergo an intimate examination while a third party is watching can trigger PTSD reactions in that patient. This is obviously harmful, of varying degrees, to patients. Knowing that it is generally accepted that anywhere from one quarter to one third of women in Canada will experience some form of sexual assault in her lifetime, it ought to be understood that doctors should actively try to minimize patient discomfort during intimate examinations, and be able to document steps taken toward that end. The College ought to provide doctors with guidelines for doing this. There needs to be clear language that protects patients from doctors who refuse, under any circumstances, to ask the third party to leave the room, even when if becomes clear that it is causing the patient much distress and he/she asks repeatedly for the third party to leave the room. Forcing a patient to endure this is an abuse of power, and should be clearly spelled out as a form of emotional sexual abuse. Clear language would protect both patient and doctor, as it would leave no uncertainty in the minds of both as to what proper conduct is. If a doctor wishes to have a third party in the room for his/her own protection, patient input as to who the third party is should be respected whenever possible. If the doctor and patient cannot agree on the third party, the doctor should refrain from conducting an intimate examination of the patient; the patient should be clearly told the rationale for this, and this should be well documented in the consultation notes. The patient should be offered a referral to another doctor – it may simply be a case of gender that triggers a patient, and no fault of the doctor.
It is interesting to note that Policy Statements 246 and 266 of The Society of Obstetricians and Gynecologists of Canada (SOGC) do spell out that patient participation in “any” education of students should be voluntary, and that if a woman does not wish a third party to be present, her wishes should be respected. However, there doesn’t seem to be clear language regarding this for doctors in general. If SOGC recognizes a need to address it, the College ought to as well.
I appreciate the opportunity to add my opinion to this. I am a patient.
PARO
Response in PDF format.
OMA
Response in PDF format.
Occasionally a patient may be very needy and hunger for a brief friendship hug or a brief pat on the shoulder. To deny this kind of affirmation is a blow to the physician-patient relationship. A helpful guide is: don’t do anything you would not do to a father, mother, brother or sister in a healthy family. This allows for some cultural differences. How ever, if unsure, it is better to err on the side of being cautious.
With existing rules , there is sill some room for discretion when revocation of license is considered. In the new rules,covering more categories of abuse, there doesn’t seem to be. This seems to exclude all grey areas or extenuating circumstances. If so, I believe such absolutism is unjust.
Can the CPSO give more guidance on the minimum requirements when for examining breasts or genital areas?
Is it obligatory to ask if the patient wants a third party be present or only have one if the patient request one? In a busy hospital practice where nursing staff move between physicians, it may not always be convenient and time efficient to have a nurse present for every breast examination.
Is it obligatory to explain to a patient with breast cancer why a breast examination is being performed? And in how much detail?
In answer to your last two questions, I say, yes, you do. Not just because it is policy, but because it is the respectful thing to do. As a former cancer patient, I can tell you that the patient you describe is probably scared, and she regularly sees a parade of doctors/residents/students who all want to examine her breast, some clumsily and painfully and not very respectfully. You can set yourself apart from them by setting aside pragmatism for a minute, and looking at this patient as a human being who wants to be included in her health care decisions. That starts with asking permission to examine, and explanations for doing so. Here is how I would like it done: after history taking/discussion, you say, “Mrs Smith, I’d like to take a look at your breast now. An examination will help me to understand ______________. I need to understand that
because ____________. Is that OK? Do you have any questions for me before I begin? Do you want a nurse or your husband to be in the room while I examine your breast? I know it might be tender, so I will be as
gentle as I can be. You can help by letting me know what areas are painful when I touch you.” Let the patient know that you respect her enough to ask her permission – never say “I’m going to do a breast exam now” – that leaves her out of the process. Including her in the process means you see her as a partner in her health care. She will be much more likely to comply if she feels included. She will also see you as a breath of fresh air from the doctors (and I’m sorry, but there are many) who just see her as a medical puzzle to be solved, rather than as a human being who has feelings, and badly wants to be involved in her healthcare.
Please let me know if this is painful
Response in PDF format.
OTLA
Response in PDF format.
Response to (3.b) I agree that the “subjective mindset of the patient” should be central to the analysis in order to determine whether a physician – patient relationship exists. It is refreshing to see the word empower used as it is rarely used in this context. I take issue however with the accepted belief that the patient – doctor relationship is inherently a power relationship with the doctor having the power and the patient being vulnerable. If that is the case then that sets up another kind of abuse. Needing to seek help with a problem does not indicate vulnerability. A person who uses his power over another person is also vulnerable. A healthy interactive relationship is what is needed. The professional has general knowledge that the patient does not necessarily have but the patient has inner knowledge that is needed for the professional to be effective. The concept of the “vulnerable patient” is disempowering the patient.
OMA-Section on General and Family Practice
Response in PDF format.