A curriculum on physician-patient sexual misconduct and teacher-learner mistreatment Part 2: Teaching method

Gail Erlick Robinson, MD, FRCPC; Donna E. Stewart, MD, FRCPC

Canadian Medical Association Journal 1996; 154: 1021-1025


Dr. Robinson is professor of psychiatry and of obstetrics and gynecology and codirector of the Program in Women's Mental Health, Department of Psychiatry, University of Toronto, and director of the Program in Women's Mental Health, Toronto Hospital, Toronto, Ont. Dr. Stewart is professor of psychiatry, obstetrics and gynecology, anesthesia and surgery, and codirector of the Program in Women's Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ont. She also holds the Lillian Love Chair of Women's Health, Toronto Hospital, Toronto, Ont.

Part 1 of this article appeared in the Mar. 1, 1996, issue.


Copies of slides and handouts for this curriculum may be obtained by contacting Ms. Pam Hawes, Faculty of Medicine, University of Toronto, 802-620 University Ave., Toronto ON M5G 2C1; fax 416 978-7144

Paper reprints of the full text may be obtained from: Dr. Gail Erlick Robinson, Department of Psychiatry, Toronto Hospital, 8EN-231, 200 Elizabeth St., Toronto ON M5G 2C4; fax 416 340-4198


Contents


Abstract

Medical educators have become increasingly aware of the need for health care professionals to receive more training about the causes and consequences of physician-patient sexual misconduct and teacher-learner mistreatment and harassment. A curriculum in use at the University of Toronto includes a didactic component, consisting of lectures, and an experiential component, consisting of a workshop. This article concerns how, by discussing case vignettes designed to illustrate salient points, the participants have an opportunity to consider their responses in actual clinical and teaching situations. Evaluation of the course by 373 participants shows that the curriculum is considered acceptable and is likely to be of benefit. Of the course participants, 54% (15/28) of those attending the course for faculty and 39% (133/345) of those at subsequent courses stated that they would change their clinical and teaching practices in positive ways as a result of attending. A further 38% (130/345) stated that they already practised in a manner congruent with the model discussed.

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Introduction

Educators have recently become aware of the need to include in their programs teaching about sexual misconduct by physicians, and mistreatment and harassment of learners (students, residents, interns and other trainess) by teachers. However, few teaching models are available. We are aware of only two curricula, neither of which has been published in a professional journal. A 2-hour experiential Workshop on Boundaries in Professional Relationships, developed by Milgrom,[1] is directed mainly at employees of social agencies. A course for psychotherapists developed by Steres[2] consists of three 2-hour sessions over a 3-week period that combine didactic and experiential components. The American Psychiatric Association[3] and Steres[2] have developed training videotapes on sexual misconduct. However, these videotapes are solely concerned with psychotherapeutic relationships rather than with general physician-patient relationships.

The Faculty of Medicine of the University of Toronto has developed a curriculum on physician-patient sexual misconduct and teacher-learner mistreatment and harassment. The goal of the course is to ensure that all students and educators in the Faculty of Medicine can demonstrate knowledge of the ethical issues related to physician-patient sexual misconduct and teacher-learner mistreatment and harassment, skill in interacting with patients or learners, sensitivity to the effect of their language and behaviour, and awareness of the power relationship between physicians and their patients or medical educators and their students. The format of the course is the following. Two weeks before the course, a package of reprints and handouts on physician-patient sexual misconduct and teacher-learner mistreatment are distributed to participants. The half-day course includes a didactic portion, involving approximately 1 hour of lectures, followed by a 2-hour experiential workshop in which vignettes are used to illustrate the salient points.

The topics covered in the didactic portion of the program are described in the Mar. 1, 1996, issue of CMAJ (pages 643 to 649)[full text / résumé]. This article describes the workshop component and the evaluation of the program by participants.

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Workshop component

Educational objectives

As a result of this course, participants should be able to demonstrate skill in interacting with patients and learners by conveying sensitivity, warmth and concern through their verbal and nonverbal behaviour and demeanour without sexualizing the relationship. They should also be able to recognize warning signs of potential boundary violations.

Participants

The course has been taught to medical students, residents, fellows, faculty and physicians in practice. It has also been adapted for use in teaching students and members of allied health care professions.

Teaching methods

Vignettes

Simple vignettes about situations involving patients or learners are presented to emphasize particular dilemmas. The vignettes may be very general or tailored to fit the clinical experience of the particular specialty group being trained. The vignettes address touching, appropriate meeting places, use of language, personal disclosure, whether a patient or learner can consent to sexual contact with a physician or educator, post-termination relationships, uncomfortable atmospheres for students and staff, dating of trainees, and sex-role socialization and power differentials. The participant is asked to categorize a particular behaviour as "never okay," "always okay" or "sometimes okay."[1] If the behaviour is deemed "sometimes okay," the participant is asked to consider under which circumstances the behaviour would be acceptable. This use of clinical vignettes allows participants to discuss the issue and their practices and to exchange opinions. In our experience, a group of 12 to 15 participants allows maximum participation.

To discuss touching, for example, the participant is told: "You have just told your 25-year-old patient some bad news. When she bursts into tears, you move to her side and put your arm around her." Discussion of this scenario would raise issues such as the following. Is touching ever appropriate? Are certain types of touches (e.g., a pat on the hand or shoulder) more appropriate than others? Why would a physician put his arm around a patient? Are different types of touches suitable for different patients or situations? How may the patient feel or react to this touch? How would you know whether the patient was uncomfortable (i.e., could you count on her telling you)? What other methods can be used to comfort and show concern? What if the patient asks for a hug or kiss? What if the patient attempts to hug or kiss you without asking permission? The participant has an opportunity to think about his or her own motivation and the effect on the patient as well as to rehearse different ways of handling emotional situations with patients.

Another vignette concerns dating a student. "One of your students is very bright, attractive and witty. You ask the student out to a movie." Discussion of this scenario would likely raise the following issues. Is it permissible to date a student you are teaching and evaluating? Would a student truly feel free to refuse such a request? How could dating a student affect the teaching atmosphere for the student in question and for other students? How could it affect patient care? How would either participant feel if he or she wishes to terminate the relationship? What influence or perceived influence could this relationship have on grades, letters of reference or future training? Can sexual involvement between a teacher and a student be truly consensual? How could attraction between a teacher and a student be managed to create a positive learning environment? The participant is offered an opportunity to think about and discuss his or her motivation and behaviour and its potential positive or negative effect on the educational environment. Lively discussions about sexual tensions in teaching, supervision and evaluation often ensue.

The facilitator encourages thoughtful discussion rather than passing judgement. On the basis of his or her personal experience, the facilitator can guide the participants toward more sensitive and careful ways of dealing with patients and learners. Input from other group members helps participants to become aware of any inaccurate assumptions they may be making. The facilitator can promote discussion about whether a physician's behaviour would change depending on the sex of the physician and of the patient. This may include discussion of homosexual fantasies or fears, and of physicians' and patients' different cultural beliefs and expectations. Many participants spontaneously offer their personal experiences and dilemmas with patients or learners for discussion.

Warning signs

Physicians are taught to watch for thinking or behaviour that may indicate that they are moving toward violations of boundaries with patients (Table 1).[4] Many of these indicators may also be warning signs of potential violations of teacher-learner boundaries. Participants are also given guidelines to help them consider any behaviour toward patients or learners that could lead to problems (Table 2).

Educational strategies

The participant is asked to think about what behaviour is appropriate to his or her specialty, individual patients or learners and specific situations. However, in the case of direct sexual contact or dating of patients, the participant is told that this behaviour is never appropriate. The physician must appreciate that, even when he or she does something with good intentions, it may be misinterpreted by the patient or learner. Participants are helped to understand that they may not have enough awareness of the patient's or learner's thinking, culture and experience to assess whether he or she will see a touch as reassuring or threatening. Participants are advised to avoid risky behaviour when it may be impossible to determine its specific effect. It is also emphasized that the patient or learner may not feel comfortable in saying No to the physician at the time; as a result, he or she may endure upsetting behaviour without feeling able to protest.

Evaluation

There are two types of evaluation involved in a course such as this one. First, the individual participants' achievements of the course objectives are evaluated. Second, the course is evaluated by the students to determine its usefulness and its success in conveying the material. Participants can be evaluated on the basis of their participation in the discussion and their demonstrated attitudes, demeanour and skill in interacting with patients and learners in an ethical, sensitive and caring manner in response to the vignettes.

Participants at the first trial of the course, which was given to medical faculty at the University of Toronto, were asked to fill out a one-page evaluation. They were asked their age group (younger than 35 years of age or 35 and older), sex, whether they taught medical students or residents and whether they were in clinical practice. With the use of a 5-point scale ranging from poor (1) to excellent (5), they were asked to rate the course content, the reprints and handouts, the presentations, the case vignettes and discussion, whether the course would help participants in their teaching of medical students and residents and the applicability of the material to their clinical practice. Participants were asked whether they felt ready, partly ready or not ready to teach medical students and residents about these issues. They were also asked: Will you change anything in your practice or teaching as a result of this workshop and, if so, what will you change?

Of the 32 faculty members who participated, 28 (88%) completed the evaluation. Of these, 18 (64%) were 35 years of age or older, 16 (57%) were male, 26 (93%) taught medical students, 22 (79%) taught residents and 20 (71%) were in clinical practice. The mean rating of each of the aspects of the course was 4.2 for the course content, 3.9 for the reprints and handouts, 4.3 for the case vignettes and discussions, 4.3 for the course's helping participants teach their medical students and residents and 4.6 for its applicability to clinical practice. Nearly all of the faculty attendees who evaluated the workshop (96%) felt that they were partly (57%) or completely (39%) ready to teach medical students and residents about these issues. More than half (54%) felt that they were likely to change their clinical or teaching practices as a result of the course (Table 3). There were no significant differences of opinion on any of these topics on the basis of the age or sex of the attendees. However, those who rated the course highly (4 or 5), were much more likely (p < 0.01) to state that they intended to change their clinical or teaching practices as a result of taking the course.

After the course was presented to faculty members, several of the attendees became trainers in this area. These attendees, as well as the original trainers in the course for the faculty members, subsequently conducted similar courses for teachers, residents and medical students in all specialty departments. Of the 392 people who attended these courses, 345 (88%) completed an evaluation. Of those who completed an evaluation, 199 (58%) were men and 188 (54%) were under 35 years of age. The mean rating for each aspect of the course was 4.7 for the content, 4.7 for the case vignettes and discussions, 4.4 for the handouts and audiovisual aids and 4.5 for the course's applicability to clinical practice. Of participants who completed evaluations, 133 (39%) said that they were likely to change their clinical or teaching practices after attending the course, and a further 130 (38%) stated that they already practised in a manner congruent with the model discussed. As well, 142 participants wrote in comments about the course or how they would change their clinical practice or teaching as a result of it. Almost all of the comments were thoughtful and constructive and evinced knowledge and sensitivity; however, a few comments caused concern (Table 3).

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Discussion

Although there has been much publicity during the last few years about physician-patient sexual misconduct and, more recently, teacher-student mistreatment, medical-school curricula on these topics are only beginning to be developed. Physicians in the community and in small cities and towns may have no access to comprehensive courses on these ethical issues. The curriculum described in this article and in part 1 has several strengths. It provides an overview of relevant information, and it includes case vignettes that can be tailored to the particular specialty and level of training. The format is flexible, allowing modification of the content, length and process to accommodate the participants' experiences and comments. It also provides an opportunity for group discussion of issues and role playing. It can be used by teaching centres or by physicians in the community. It encourages physicians to think about their behaviour and its effect on patients and learners rather than setting out rigid rules of behaviour. The goal is to help physicians and learners develop a caring, professional relationship with patients, rather than adopting a cold, detached, defensive stance, in which the physician just avoids conducting certain examinations instead of learning how to do them properly. The program benefited from the enthusiastic support of the dean of medicine and the director of postgraduate training, who understood the importance of these issues for staff and learners and were willing to make these topics a mandatory part of all teaching programs.

There are some possible limitations of this course. We are concerned that this curriculum may serve as learners' only discussion about boundary issues during their training, whereas it should be the starting point for their awareness and discussion of these problems. All physicians would benefit from continued and regular discussion of these issues as well as from modelling of appropriate behaviour by senior physicians. Physicians who offer psychotherapy require continuing work in this area, in the form of attendance at seminars and of regular supervision. An additional difficulty is that the curriculum also requires facilitators who are knowledgeable and not judgemental, who understand participants' concerns and who are experienced in dealing with patients. We are also concerned that the faculty and students or trainees most in need of these sessions may not attend. Although the evaluation we have described here suggests that participants found the curriculum helpful and effective in encouraging them to change their clinical and teaching practices in positive ways, follow-up is required to ascertain whether attendees' behaviour actually changes. At present, this course appears to be a useful first step in thoughtful discussion of physician-patient sexual misconduct and teacher-learner mistreatment and harassment.

The development of this course was supported in part by the Ontario Ministry of Health's Wife Assault and Sexual Assault Grants Program for the Education of Health Professionals.

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References

  1. Milgrom JH: Boundaries in Professional Relationships: a Training Manual, Walk-In Counselling Center, Minneapolis, 1992
  2. Steres LM: Therapist/Patient Sexual Abuse and Sexual Attraction in Psychotherapy: a Professional Training Intervention [manual and videotape], La Jolla, Calif, 1991
  3. Ethical Concerns About Sexual Involvement Between Psychiatrists and Patients [videotape], American Psychiatric Association, Washington, 1986
  4. Epstein RS, Simon RI: The exploitation index: an early warning indication of boundary violations in psychotherapy. Bull Menninger Clin 1990; 54: 450-465

| CMAJ April 1, 1996 (vol 154, no 7) |