Professional Conduct
| Author | Hy Bloom |
| Pages | 1271-1331 |
CHAPTER 59
Professional Conduct
Hy Bloom
Primum non nocere — First, do no harm.
I. INTRODUCTION
e designation “professional” has historically conjured a strong positive image of a respected service
provider who, through specic and intensive education (along with training and experience), brings
special knowledge and skill to issues that signicantly aect people’s lives. Physicians have always occu-
pied a high position in the hierarchy of respected professionals, although two or three decades ago their
position was higher. Competence, integrity, and propriety of physician behaviour have come under scru-
tiny of medical regulatory bodies, the courts, the public, and the media. As a result of increasing media
attention to all facets of physician behaviour, the public has come to see the previously revered physician
as no less vulnerable to behavioural foibles and dyscontrol as anyone else. Today, physicians and other
health care providers who act inappropriately in the professional sphere (and to some extent, in the pri-
vate sphere) risk severe consequences that include permanent loss of their ability to practice their chosen
profession. At no time in the history of modern medicine have physicians been so accountable for their
behaviour and competence to such diverse constituencies (Kirk & Blank, 2005). e increased scrutiny,
higher expectations, and anxiety about potential loss of professional status have made the practice of
medicine more professionally challenging and personally taxing.
On the positive side, however, increased accountability promotes higher standards, serves the pub-
lic’s interests better, and, according to Kirk and Blank (2005), stimulates collective empowerment of
physicians by compelling leadership in the profession.
is chapter will review the basic professional framework within which physicians are required to act,
as well as describe the various problematic physician behaviours and their consequences. ere are in-
numerable ways in which physicians can get into diculties with their regulatory bodies, the provincial
and territorial colleges of physicians and surgeons, as well as with medical associations. Any behavioural-
regulatory or quasi-penal scheme will treat transg ressions at the benign end of the behavioural spectrum
optimistically, through reprimand and remediation. Transgressions at the malignant end of the spec-
trum, however, involving risk of harm to the public, the prevention of which is one of the raison d’êtres
of professional regulatory bodies, are frequently met with a harsh public-protection oriented approach
that can, and oen does, involve suspension or revocation of licensure.
Expectations about the nature of the doctor-patient relationship are core to the discussion, as are
the tenets of proper professional behaviour. ese will be reviewed, as wi ll the spectrum of problematic
behaviours: from boundary violations and disruptive physician behaviour (DPB) to sexual improprieties
that generally result in a nding of professional misconduct.
Hy Bloom
Medical and psychiatric ethics are areas that have received a great deal of attention over the last
number of years. e circumscribed discussion of ethics that follows in this chapter is focused on ethics
withi n forensic psychiatry.
Finally, the chapter will deal with the clinician’s role in assessing wayward physicians (and other
professionals), and in discovering the causes of the problem behaviour. It sets out the steps necessary to
remediate problem behaviour and to manage risk. Assessing peers and other professionals has become
yet another forensic task.
II. THE DOCTOR-PATIENT RELATIONSHIP
A. Meeting the Patient’s Expectations
Any discussion of situations in which physicians might get into trouble for acts of commission or omis-
sion begins with a review of the doctor-patient relationship and the pitfalls that could give rise to profes-
sional discipline proceedings, a civil action, or both.
e word “patient” conjures the image of a person who, because of his concern about his physical
and emotional well-being, is already vulnerable and is more so if he is aicted with a condition that
requires medical attention. When vulnerable, people want “skilled and knowledgeable pract itioners
available to cure disease, alleviate symptoms, restore function, and ease suering” (Rhodes et al., 2004).
To achieve these ends, physicians are granted considerable responsibility and power to aect the lives of
patients. Dereliction or abuse of the power, through acts of commission or omission, can result in sig-
nicant negative consequences. Medicine must consequently be trustworthy. Rhodes et al. (2004) assert
the proposition that physicians and medical institutions must “seek trust and make themselves deserving
of that trust” (emphasis in original) as a foundational principle of medical ethics.
e commitment physicians make to act in the interest of their patients and society is, according to
Rhodes et al. (2004), another key foundational principle. In this regard, a physician’s duciary respon-
sibility serves as a compass to help guide the clinician away from an ethical misdirection, and settles any
ambiguity or potential conict in meeting a patient’s needs. A duciary relationship is created when a
patient places her trust and condence in the physician, who, due to superior knowledge, training, and
position, comes to manage one or more of her needs. e duciary relationship usually connotes a power
imbalance and concomitant moral, personal, and professional responsibility to the patient.
Rhodes et al. (2004) note several corollary premises stemming from the above foundational principles:
• Professional competency: Only those with knowledge and skills are worthy of trust.
• Caring: Physicians full their professional obligations even in the face of conicting interests. Pa-
tients are more likely to trust physicians who genuinely care about their interests.
• Condentiality: If patients are going to disclose personal information crucial to ensuring their well-
being, condentiality is essential.
• Non-judgmental regard: Patients do not want to be judged as a pre-condition of receiving help.
• Non-sexual regard: Patients must be satised that disclosure of sexual information and touching of
their sexual organs are for their medical benet alone, and not intended to gratify the physician’s
prurient or other needs.
• Respect: e patient’s values and beliefs concerning must be regarded and the physician’s va lues and
beliefs not imposed.
is o-repeated quotation by pediatrician Sir James Spence captures the essence of the duciary rela-
tionship:
Professional Conduct
e essential unit of medical pract ice is the occasion when, in the intimacy of the consulting room, or sick
room, a person who is ill, or believes himself to be il l, seeks the advice of a doctor whom he trusts. is is
the consultation and all else in t he practice of medicine derives from it. (Henry, 1965)
e doctor-patient relationship is both contractual and duciary in natu re. In the former context, the
patient’s request for services constitutes an oer, and the commencement of care constitutes the phys-
ician’s acceptance.
Except in an emergency, the physician has a right to refuse to accept a patient, but once the relation-
ship comes into existence, services must be provided until they are no longer required, or until alternate
arrangements have been made. Physicians must provide adequate notice of a plan to terminate services
(see the Canadian Medical Association’s Code of Ethics).
As patients have become more enlightened medical consumers, they have become increasingly adver-
sarial. A good relationship between a doctor and patient can and does reduce the risk of litigation. Some
basics for ensuring a good doctor-patient relationship are touched on in Table 59.1 below.
Table . Checklist for Ensuring a Good Doctor-Patient Relationship
• Review the scope of the relationship and its limitations
• Clarify treatment goals and limitations
• Treat the patient as collaborator, and emphasize that role
• Keep the patient (and family, where applicable) informed, especially about risk
• Listen to the patient
• Don’t talk down to the patient
• Treat the whole patient, not just the disorder
B. Physician Self-Awareness
According to Haerty (2006), personal reection is “a core element of virtually all denitions of profes-
sionalism.” Considering the unique role physicians occupy — privy to highly condential information, to
dicult personal, and at times, painfu l, feelings, and in a position to provide (or fai l to provide) potentially
life-altering interventions — some measure of introspection or self-knowledge and awareness should be
expected of them. e saying, “know thyself,” comes to mind. is injunction emphasizes the import-
ance of the physician gaining self-knowledge and self-awareness before she inltrates the physical and
psychological domains of the patient. Rhodes et al. (2004) argue that a physician ought to know both
what motivate d her to pursue a career in medicine, and what continues to motivate everyday professional
decision making.
Dedication is yet another pillar of medical practice: dedication to the values, the moral platform, and
the work of medicine. Work–life balance is an admirable goal for physicians, as it is for any professional,
but physicians hold more than a job. eirs is a professional and social identity replete with obligations
and expectations that include dedication to patient care as well as to the scientic and social ideals of
medical practice. A physician can’t punch out at the end of her shi, thereby relieving herself of the
burden and responsibility of her professional role until the next workday.
C. Motivation for Becoming a Physician
e motivation for becoming a physician is intriguing in its own right, and knowing th is motivation can,
in some instances, facilitate understanding and treatin) the psychological determinants of many kinds
of improper professional conduct. It is, unfortunately, a discussion that is well beyond the scope of this
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