Maintaining Professional Boundaries in Chiropractic Care
Laura M. Cascella, MA, CPHRM
Maintaining professional boundaries is essential in healthcare. When boundaries are crossed —or the patient perceives they are crossed — the provider–patient relationship can quickly deteriorate. As a result, the provider may face allegations of misconduct and/or malpractice.
Sexual misconduct is a growing concern in various healthcare settings, and chiropractic care is no exception. In fact, chiropractors should have heightened vigilance due to the nature of the care and treatment they provide, which often involves a very hands-on approach. Additionally, chiropractors often see patients with a degree of frequency that lends itself to more personal and familiar relationships, which can blur the lines of professionalism.
Unfortunately, no universal rules or standards exist when it comes to maintaining professional boundaries. Obvious strategies include not engaging in romantic or personal relationships with patients, not touching patients in ways that are not clinically necessary, not photographing patients without their permission, not making innuendoes or sexual jokes, and so on.
Yet, malpractice claims indicate that issues related to sexual misconduct often arise from less conspicuous circumstances. Actions or behaviors that might seem innocuous could potentially feel like a violation to a patient based on their background, perspective, culture, or other factors. Sometimes these situations may occur due to a simple lack of understanding about treatment, inadequate communication, cultural differences, or environmental factors.
Thus, careful attention to verbal and nonverbal indicators (e.g., body language), as well as sensitivity to patient’s privacy, dignity, and modesty are imperative. The following strategies can help chiropractors address shifting boundaries and maintain professional and ethical relationships with patients:
- Adhere to professional standards and guidance regarding the provision of care and doctor–patient relationships (e.g., the American Chiropractic Association’s Code of Ethics and the International Chiropractors Association’s Code of Professional Ethics).
- Devise and follow clear policies related to electronic communication, such as email, texting, and social media. These policies should address behaviors that might violate professional boundaries (e.g., sending patients requests to connect, accepting requests from patients to connect, and using the internet to find personal details about patients).
- Develop a clinical chaperone policy for your practice that specifies the availability and use of chaperones for examinations and treatments. Chaperones can give patients a sense of security and verify that the provider’s behavior was appropriate. Make sure chaperones are trained healthcare professionals.
- Notify patients of their right to request a chaperone. Specify in your new patient welcome brochure or information packet that chaperones are always available upon request. Display signage that offers the option of a clinical chaperone for any patient requesting one.
- Have parents or guardians remain in the room during examination and treatment of minor patients. (Note: Parents or guardians should not serve as chaperones, and involving a chaperone is still a prudent approach.)
- Conduct thorough informed consent discussions with patients prior to initiating treatments or procedures. In addition to explaining benefits, risks, and alternatives, also explain the purpose of the proposed treatment or procedure and how it is performed.
- Ask for patients’ consent before physically touching them. Explain what you’re doing as you’re doing it, and encourage them to speak up if they are uncomfortable. Doing so can help alleviate feelings of vulnerability.
- When performing physical examinations, use only the necessary amount of physical contact to obtain information for diagnosis and provide treatment, and always wear gloves when performing sensitive examinations or treatments.
- Avoid comments about patients’ bodies that are not clinically relevant to their care. Even comments intended as compliments might make patients uncomfortable.
- Be mindful of varying degrees of patient modesty and respond appropriately to each patient’s needs and expectations. Consider the cultural implications of privacy and modesty when interacting with diverse patient populations.
- Engage in respectful behaviors that honor patient’s confidentiality and privacy. For example:
- Ensure that privacy is maintained during patient encounters in the office. Conduct discussions that involve personal or sensitive information in private areas and lower your voice to avoid inadvertent disclosure.
- If patient care occurs in a private exam room, knock on the door and ask permission before entering.
- If patients need to fully or partially remove any clothing for examination or treatment, specifically tell them which items to remove and which items they can still wear. Properly drape patients to minimize exposure but allow adequate access to the treatment area.
- Include questions about respectful, professional care in patient satisfaction surveys. Review feedback to determine strategies for further improving the patient experience.
- Make sure a mechanism is in place for patients to report concerns and complaints about any interactions that occur in the practice, and develop a protocol to consistently investigate these reports.
- Be aware that patients might initiate boundary violations, either intentionally or unintentionally. Develop protocols for responding to inappropriate behavior, including redirecting the patient (e.g., “we need to keep this professional”) or naming the behavior and giving specific directions (e.g., “what you’re doing is harassment; you need to stop”). Make sure all staff members feel empowered to raise concerns about patients and report inappropriate patient interactions.
- Participate in and provide training to staff members on professionalism, ethics, professional boundaries, sexual misconduct, and sexual harassment. Make sure training covers a range of scenarios, including both clear-cut and gray areas of misconduct.
Professional and ethical behavior is vital to establishing trust, building rapport, and creating safe patient encounters. When boundaries are crossed, even inadvertently, significant fallout can occur. The patient might experience physical and emotional harm, and the provider might face reputational damage, liability exposure, and financial implications. Developing policies and approaches that support ethical behavior and reinforce respectful patient encounters can help chiropractors avoid potential misconduct pitfalls and ensure patients receive high-quality and sensitive care.
To learn more, take MedPro’s on-demand continuing education programs titled Sexual Misconduct: Crossing Professional Boundaries and Sexual Misconduct: Risk Strategies and Insights.
