Physician-Patient Relationships: Obligations and Avoiding Sexual Misconduct Pitfalls

One of my former patients, M.M., whom I still interact with on social occasions, recently shared that he has a new friendship with a family physician, Y.Z., in his cycling club. They met 3 months ago and soon began to socialize outside of club activities. They are both in their 30s. Although M.M. stated that he wanted to take their friendship further, he has not encouraged Y.Z.

Two weeks ago, he mentioned to Y.Z. that he had pain in his left hip. She thought he might have greater trochanteric bursitis and offered to treat him with heated extracorporeal shock wave therapy. Because M.M. has a high copay for insurance, she offered to provide treatment at his home. He was initially hesitant, but she persisted. When they were alone in his apartment, she asked him to disrobe from the waist down so she could properly examine his hip and perform the treatment. She reassured him that, as a physician, she had seen it all before. He complied and received the treatment. M.M. now feels awkward around Y.Z. and is confused about the relationship after being exposed in front of her: Is she his doctor, his friend, or something more intimate? What should I advise him as his friend who is also a physician?

Physicians may encounter situations that challenge the boundaries between themselves and their patients. These challenges can lead to instances or allegations of patient exploitation that can result in serious legal and professional consequences for the physician.

Unintentionally Creating a Physician-Patient Relationship

A relevant challenge can be determining whether and when a physician-patient relationship is established. Existence of a physician-patient relationship imposes a fiduciary duty on the physician to focus exclusively on the patient's welfare, shunning all competing or selfish considerations.^1–3 The American Medical Association has published extensive guidance defining the ethical parameters of physicians' obligations toward the public, as supported by law, with specific attention to what patients can expect in the context of a physician-patient relationship.² These duties are legally binding and can be terminated only by mutual consent, the end of the need for further treatment, unilaterally by the patient, or unilaterally by the physician with proper notice and referral.^1,4,5 Simply referring the patient to another physician may not be sufficient to legally terminate a physician-patient relationship.^1,5

States differ in defining exactly what legally establishes a physician-patient relationship, and cases involving physician discipline, malpractice, and even criminal charges may hinge on these details.^1,6 A physician-patient relationship is usually, but not always, created by a conscious, mutually consensual agreement between the parties. Physician-patient relationships are typically generated by an office visit, writing a prescription, receiving payment for services, or written contract.^1,5,7

Nevertheless, legal experts and case law maintain that physicians can enter into a physician-patient relationship by examining (ie, by inspection or touch), diagnosing, or treating a person (even with over-the-counter remedies). Such actions initiate an implied—and legally binding—relationship between patient and physician, with its associated moral, ethical, legal, and fiduciary obligations.^1,2,4,5 A mnemonic to help remember these responsibilities is 4-3-2-1 CARE (Table 1).^{1–3,5,7–9}