The topic of abuse in the doctor-patient relationship has received increased attention for the past 2 decades. This book presents a comprehensive overview of the British experience and, I believe, will be an important addition to our literature on this topic. The book was written at the request of the Royal College of Psychiatrists and in response to a widely publicized and, ultimately, policy changing event in the United Kingdom, namely the Kerr/Haslam Inquiry. The scandal that triggered this Inquiry was brought about by the shocking discovery that two psychiatrists (Kerr and Haslam), who worked in the same hospital in the northern part of England, were able to engage in sexually inappropriate behaviors with a significant number of patients during a period spanning many years in the 1970s and 1980s. Complaints had apparently been received on both physicians over the years but had been either ignored or discarded on the grounds of “psychiatric illness.”
This book, edited by three seasoned academic physicians (two psychiatrists and one obstetrician/gynecologist), with contributions from a wide range of professionals, is well written, informative, and balanced. Following its thematic structure, it can roughly be divided into three sections.
The first section maps the territory of exploration and defines the problem of abuse. It contains chapters on ethical principles/considerations, definition of boundaries and boundary violations, history, and prevalence of the problem. I found the historical chapter in this section to be particularly interesting because it presents four well-documented cases of boundary violations by famous (or infamous) physicians in the 19th and 20th centuries in Europe (Ernest Jones, Freud’s biographer and protégé, is one of the examples). This chapter painfully demonstrates how, for centuries, the voices of the victims (often children, women, or the mentally ill) were ignored or quickly dismissed.
The middle section of the book contains chapters on abuse of the doctor-patient relationship that focus on several disciplines considered to be at “higher risk”: Psychiatrists, Obstetrician/Gynecologists, Primary Care Physicians, Nurses, Psychotherapists, and Sex Therapists. Each chapter describes inherent vulnerabilities specific to a particular discipline and provides ample background information, historical data, and pertinent clinical examples. Most chapters offer thoughtful recommendations meant to help minimize future risk of abuse, as well as balanced analyses of challenges that disciplines may be facing as they try to implement change. These chapters are mainly focused on the issue of sexual abuse, although other forms of abuse are presented and discussed, such as excessive or often unnecessary medical or surgical interventions, breach of privacy or confidentiality, financial profit, improper prescribing practices, reluctance to report a colleague, and finally, reluctance of the disciplines to police themselves.
This section also investigates, in a very thoughtful and impartial way, a number of underlying reasons for abuse—not to excuse but to understand and hopefully intervene and correct. Some of the reasons explored are professional stress, overwork, burnout, troubled personal lives, transference enactments, loneliness/social isolation, and impaired self-esteem, among others. I found the chapters in this section to be thought provoking, carefully reasoned, unbiased and nonargumentative—all in all, interesting and stimulating to read.
The final section deals with regulation, management, remediation, and prevention. A good chapter by Dr. Fiona Subotsky on medical management provides a useful outline of a systematic institutional model that could potentially offer a higher level of protection against patient/clinician boundary violations. This model would require professional organizations to create clear policies, clinical standards, and develop clear clinician hiring and training practices as well as ongoing clinical performance evaluations. It would also emphasize the critical need for patient education, support, complaint management, and resolution. This point (frequently discussed in the book) cannot be stressed enough: educating and empowering patients, thereby reducing the power imbalance in the doctor-patient relationship, will go a long way in our struggle to reduce boundary violations and abuse. This sets the stage for the rest of the chapters in this section that describe, in greater depth, the national regulatory system that provides professional oversight in the United Kingdom. These chapters also provide a concise historic panoramic view of the regulatory changes that have been implemented in the United Kingdom in the past 2 decades in response to patient complaints and public pressure.
In the book’s appendix, the reader will find a useful and interesting discussion of several clinical examples of doctor/patient boundary violations and how those cases were pursued and resolved. This final chapter successfully brings together many of the threads woven throughout this book.
In conclusion, I found this book to be well written, timely, comprehensive in scope, and of interest to anyone who wants to learn more about this sensitive and significant topic and how it is being currently addressed, especially in the United Kingdom. Given its multidisciplinary approach, this book can be useful not only to physicians but also to a wide audience of nurses, social workers, psychologists, other healthcare professionals, and the lay public.
Radu V. Saveanu, MD
Department of Psychiatry
and Behavioral Sciences
University of Miami
Miller School of Medicine
Dr Saveanu has indicated financial relationships with Novartis, Brain Resources, Inc.
The author declares no conflict of interest.