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Flirting with Malpractice
By Jean McAulay

Protect yourself and your practice from unwanted sexual advances.

It was not hard for Dr. Gregg Lodes to notice the patient’s outfits were getting skimpier with each visit, but when his patient showed up in a braless halter top and tiny shorts slit up the sides, alarm bells sounded in his head. “I said to myself, ‘You better make sure you do everything exactly as you have in every other visit,’” explains Philadelphia area chiropractor Gregg Lodes, M.S., D.C. “It was like she was fishing and wondered if I would nibble.”

Lodes was on target to be wary and exercise additional caution. He paid no attention to the patient’s advances and projected a professonal attitude. Fortunately, his patient got the message and showed up appropriately dressed for her next appointment.

Although not something chiropractors talk about often publicly, the intimacy of the doctor-patient relationship is ripe with potential pitfalls for misunderstanding, blurring of professional and personal boundaries and, at times, even abuse of power. Even when all interactions are conducted on the up-and-up, an accusation of sexual misconduct is often sufficient to ruin a chiropractor’s reputation and practice.

“What I find when I talk with doctors in the field is they think they know it all,” says Michael J. Stahl, D.C., co-author of “Ethical Perspectives: Sexual Boundary Issues and the Chiropractic Paradigm.” “They just don’t appreciate that the standards for what’s acceptable behavior are getting more stringent.”

Stahl credits famous cases such as those involving President Clinton and Monica Lewinsky, Justice Clarence Thomas and Anita Hill, and Catholic priests and underage parishioners with heightening public awareness of sexual misconduct and elevating expectations regarding the behavior of those in positions of authority and power. “People in fiduciary roles are being held to a higher standard and there is a culture of zero tolerance. I don’t think most doctors take it seriously enough,” Stahl says.

The numbers may convince them. In a September 2004 article in the Journal of Manipulative and Physiological Therapeutics Stahl and co-author Stephen Forman, D.C., reported the incidence rate of disciplinary actions against chiropractors for sexual misconduct was 339 percent higher than for medical doctors. A practicing chiropractor himself, Stahl urges his colleagues to protect themselves from false accusations—as well as temptation—and to protect the reputation of the profession. His message isn’t always positively received.

“When we wrote the book, some chiropractors accused us of lying and others said we were out to get the profession and were giving detractors ammunition,” Stahl says. “I can’t change the results. These numbers aren’t based on my opinions. They’re fully adjudicated cases. The academic side of the profession has been more receptive and has wanted to know why the differences exist.”

Chiropractic college programs hit the topic of professional integrity, including sexual misconduct, in greater depth than in the past. Several concepts may help explain the higher incidence of disciplinary actions against chiropractors. Medical practices are often populated with numerous physicians and staff, creating less privacy, treatment is often conducted using equipment or devices rather than skin-to-skin contact, and MDs typically don’t see patients as frequently, resulting in a less personal relationship.

Stahl thinks some of the traits that make chiropractors such sought after health care providers—being caring, spending more time with patients and listening—can create greater opportunities for problems. “In an effort to be caring, considerate and empathetic, I think we sometimes let professional boundary lines blur,” Stahl says.

One of the reasons romantic relationships between doctors and patients are taboo is the inequality of power in the relationship. The doctor is often viewed in an almost parental light and may be idealized as the patient’s ultimate caretaker. Some argue this imbalance is permanent and thus conclude it is never acceptable for a doctor and former patient to form a romantic bond. Doctors could also be called upon in the future to offer testimony regarding the patient; a personal relationship would hamper impartiality.

Lisa Brown, D.C., is careful to maintain professional boundaries with patients in her Tampa, Fla., practice, Lifeline Chiropractic. She makes sure there’s a third person in the office, dresses professionally and encourages patients to talk about their spouses as she stresses that her practice is family oriented. “I usually refer to the practice as ‘we’ or ‘we’re’ so patients feel my comments represent the whole office and not just me personally.”

She’s also learned during more than 14 years of practice that it’s best to address any awkward situations that do arise head-on. “If my hand slips during an adjustment, I immediately say ‘Excuse me,’ and that makes it less weird and less of an event. If there are off-color jokes or overtones, I let the patient know it’s not appropriate and I ask them not to bring it up again. It’s awkward sometimes and it takes guts to do it because I don’t want to tick them off, but it’s my livelihood and my reputation at stake.”

Even if the tone is not sexual, and Brown feels the conversation is crossing into highly personal territory, she’ll refer patients to a counselor. “I’ll thank the person for trusting me enough to share their thoughts with me. Then I’ll reiterate our goals and objectives for their care and that my focus is on their spine and their family’s chiropractic health. Then I recommend someone for them to talk to,” Brown says.

“I feel part of the reason I’ve been blessed in practice is that I do develop caring relationships with my patients, but it is a bit of a dichotomy. I may call to check on a patient who is going through a very difficult time personally, but most of the time the focus of our relationship is chiropractic.”

The steps Brown and Lodes follow in the daily operation of their practices will serve them well not only in avoiding issues of misconduct or misunderstanding with patients, but also in protecting them should they ever be falsely accused. Being able to point to consistent, appropriate procedures that are used with every patient (and can be corroborated by other patients and staff members) can provide a significant defense if a patient raises false accusations or even misinterprets something said or done in the office.

“Tolerating off-color jokes or offensive material suggests a culture in which sexual misconduct might be tolerated and will give more weight to charges brought against you,” Stahl says. “All staff members need to follow the same office procedures as well, including no off-color comments, use of appropriate gowning procedures and treating patients in a professional manner.”

There are myriad shades of gray in personal interaction so health professionals have to be extremely careful to ensure their behavior is not open to interpretation. One area that requires particular caution is called the transition zone—the area between the chiropractic table and the exit. Sometimes doctors who behave professionally and appropriately during examination and treatment loosen up considerably once the patient leaves the table. Patients also may feel freer in what they say and do once the clinical portion of the visit is concluded. Professionalism is the order of the day no matter how long the patient chats at the front desk.

Behavior expectations rise even further when caring for a minor. Stahl says a parent must be in the adjusting and exam rooms with anyone under 18 years of age. Lodes’ warning signals go way up when the patient is a provocatively dressed teenager. “Teenage girls will come into the office wearing low riding sweat pants and cropped tops that leave a lot of skin exposed, as well as thongs above the rise of the pants. It’s an uncomfortable situation and there has to be a parent in the room,” he says.

Short of keeping your patients at arms length or only adjusting in a crowded room, there are plenty of steps to take to protect yourself from unwelcome advances from patients, false accusations or, let’s be honest, temptation.

n Have a third person in the office when seeing patients and only see patients during regular business hours. Never care for a minor without parental supervision and consider a same-sex chaperone in the room if a patient’s behavior or mental state arouse concern. n Use the “talking exam” that includes explaining beforehand what you will be doing and what parts of the body you will be touching, getting the patient’s consent every step of the way. Be especially careful if you are using a technique not used previously with the patient or one that involves touching personal areas.

- Be consistent in your instructions to patients for adjustment procedures, gowning etc., so if something is misinterpreted by one patient, you can provide 30 others who received the same instructions without confusion.

- Trust your gut. If your radar goes off, you’re probably reading signals that say the patient is there for something other than chiropractic care.

- Be mindful of your own intentions. Patients will pick up on your subtle behavior if you show interest in a more intimate relationship. As tempting as the situation may be, stop and consider the significant risks to your practice and livelihood. If you think the attraction is mutual, at the very least release the patient from your practice immediately and consult your state law regarding how much time must pass from the release from care until a dating relationship could be pursued. State laws vary significantly on this issue but every state forbids sexual relationships with current patients. Document the termination of the professional relationship with a lawyer.

- Know the specifics of your state’s laws regarding relationships with patients. Also familiarize yourself with the FCLB’s Code of Ethics for regulatory board members, which provides some helpful guidelines that can be applied to private practice in any state.

- Never turn to patients for emotional support or favors, and don’t provide special favors to patients, including waiving fees.

Chiropractors tend to be caring people who enter practice to help others. Although that genuine warmth appeals to patients and creates a natural instinct to reach out, maintaining professional boundaries best serves doctors and patients with a comfortable, predictable and non-threatening environment for healing.