Canadian Medical Association Journal 1996; 154: 1021-1025
Part 1 of this article appeared in the Mar. 1, 1996, issue.
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
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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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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).
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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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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