CME
*-e e e
.CC
SUMMARY
Family physicians have
privileged access to the
intimate lives of their
patients. Such access is
essential for good
patient-physician
relationships. However,
int(mate access renders
patients vulnerable to harm
and places a tremendous
burden of trust upon
physidans. Physicians earn
this trust by exercising care
in drawing and preserving the
boundary between
appropriate and inappropriate
intimacy.
RESUME
Les mededns de famille ont un
acces privilegie a la vie intime
de leurs patients. Un tel acces
est essentiel pour la qualite
de la relation patient-medecin.
Cet acces a l'intimite rend
toutefois les patients
vulnerables a certains torts
et place une lourde
responsabilite de confiance sur
les medecins qui gagnent cette
confiance en prenant soin de
determiner et de preserver la
fronti6re entre l'intimite
appropriee et non appropriee.
Con Fam Physicion 1996;42:1505-1508.
--*- FOR PRESCRIBING INFORMATION SEE PAGE 1600
Intimacy in the
patient-physician
relationship
MICHAEL YEO, PHD
MARK LONGHURST, MD
COMMITTEE ON ETHICS OF THE COLLEGE
OF FAMILY PHYSICIANS OF CANADA
- @ @ @ @ @ @ @ @ ***-
ECENT REPORTS OF ABUSE IN
Da physician-patient relation-
ships have chronicled inci-
dents of misconduct in
sordid detail."2 With good reason,
these reports have alarmed both the
public and physicians. In the after-
math, many physicians are uncertain
about the implications of measures to
prevent and correct inappropriate
physician behaviour.3
The College of Family Physicians
of Canada's Committee on Ethics is
concerned that family physicians will
become overly cautious and distance
themselves from their patients to pro-
tect against possible recriminations.
This would not be good medicine.
Although some intimacies with
patients are reprehensible, intimacy is
not always so. Indeed, appropriate
intimacy is essential to good physician-
patient relationships. The Committee
on Ethics want to help physicians dis-
tinguish between appropriate and
inappropriate intimacy in situations
Dr Yeo is an Ethicist at the Canadian Medical we expose our intimate selves to oth-
Association in Ottawa, Ont. Dr Longhurst
is an Associate Professor ofFamily Medicine
in the Department ofFamily Practice
at the Universi_y ofBritish Columbia.
VOL 42: AUGUST . AQOT 1996 * Canadian Family Physician Le Midecin defamille canadien 1505
*****@ - @ @ @ @ *- @ @ @ *******
where the boundaries are unclear. We
will not discuss acts, such as sexual
overtures toward patients, which are
inappropriate under any circum-
stances, and generally are known to be
so by those who transgress.
What is intimacy?
The word intimacy comes from two
roots, one meaning announcing or
disclosing, the other what is inner-
most. Literally defined, intimacy is the
disclosure of what is innermost. It
pertains to our core self, those aspects
of our being most closely linked to our
sense of identity. Our bodies, our
innermost thoughts and feelings, and
private information about ourselves
fall within the sphere of intimacy.
Intimacy is immensely important
in our lives. We need to communicate
and share what is closest to us with
certain others. We need others to
know, recognize, and accept us so that
we can forge deep bonds: to love and
be loved, to care for and be cared for.
But intimacy is a fragile good. When
ers, we become vulnerable. With good
reason, therefore, we choose carefully
what we disclose to others and to
whom we disclose ourselves.
 CME
*n i p - a t
Intimacy patient-physician relationship
in the
Professional intimacy
Professional intimacy pertains to physicians'
proper manner when intervening in patients'
lives. Intimacy in the physician-patient relation-
ship is of two main kinds.
First is the intimacy of physical disclosure and
contact. Patients permit their physicians to touch
their bodies in ways that would be inappropriate
for others, and to see them naked, blemished, and
in unflattering positions.
Second is the intimacy of personal and emo-
tional disclosure, including communications
about the body and about life situations and life
stories. These intimacies are necessary for physi-
cians to help their patients. Indeed, the very act
of opening oneself to a physician can be thera-
peutic. However, these intimacies render patients
vulnerable to harm.
Intimacy, vulnerability, and trust
Intimacy and vulnerability are asymmetrical in
the physician-patient relationship. Ordinarily, the
physician is in a position of superior knowledge
and power. Patients usually do not know their
physicians intimately. Patients are vulnerable, and
often are made more so by illness. Because physi-
cians are less vulnerable and have greater power,
their responsibility and burden of trust is greater.
Patients need to trust their physicians; physicians
do not need to trust their patients. To betray the
trust of a vulnerable person who has come under
one's care in a professional relationship is a
greater wrong than to betray the trust of someone
with whom one is on more even footing.
Two main kinds of trust can be distinguished
in the physician-patient relationship. One is role
trust. This is bestowed simply because one is a
physician and enjoys the confidence of the
authorities that regulate the profession. Second is
earned trust. This trust is vested in a physician
based on performance and behaviour. The physi-
cian builds this trust over time. As trust develops,
patients become increasingly willing to open
themselves.
Both kinds of trust are based on the expecta-
tion that physicians act primarily for the good of
their patients. Intimacy is appropriate when it
1506 Canadian Famiy Physician * Le Medecin defamille canadien * VOL 42: AUGUST *AOUT 1996
serves this good. When physicians relate intimate-
ly with patients for their own ends, intimacy
becomes betrayal of trust.
Family physicians' special situation
Family physicians and their patients are in an
especially sensitive situation in the dynamic of
intimacy, vulnerability, and trust. Family medicine
promotes long-term, caring relationships between
physicians and their patients. Family physicians
are in a position to learn a great deal about their
patients' most intimate physical, psychological,
and social situations, and this exposure renders
patients especially vulnerable. The vulnerability
might be increased by the disarming trust a
patient invests in a particular physician.
Opportunities for inappropriate behaviour, or
even for mistaken perceptions of inappropriate
behaviour, are greater than with most other spe-
cialties, as are the risks for both patients and
physicians.4
Family medicine sees patients as complete peo-
ple in the context of their ongoing life stories. All
facets of life - physical, sexual, emotional, psycho-
logical - influence the problems patients bring to
their family physicians. Physicians and patients
sometimes have difficulty moving back and forth
among these intimate facets and the intimacy of
the patient's physical body. In some cases it is dif-
ficult to distinguish between strictly health needs
and personal needs that extend beyond what a
physician should appropriately provide.
Boundaries become blurred; signals easily
become crossed.
Some measure of empathy is also an ingredient
of good family practice. Good "scientific" man-
agement of patients' problems is not enough. To
be effective, family physicians have to become
involved in patients' experience of illness and
enter the drama of the physician-patient relation-
ship. At times it is even appropriate for family
physicians to open themselves to patients to facili-
tate healing. However, the greater the involve-
ment, the greater the risk of inappropriate
intimacy or the perception of it.
While long-term relationships allow physicians
to learn more about their patients, they also

enable patients to learn more about their physi-
cians. Although the balance of power in the rela-
tionship is on the side of the physician, physicians
too have vulnerabilities, which some patients try
to exploit. It is especially important for family
physicians to be aware of their personal weak-
nesses and alert to signs that a relationship is
becoming, or mistakenly perceived as becoming,
something more than professional caring. The
most effective way to prevent overstepping the
bounds of professional intimacy is to have a clear
understanding of where the boundaries are and a
strong sense of self-awareness.
Intimacy and boundaries
At the extremes, the distinction between appropri-
ate and inappropriate intimacy is clear. Touching
a patient to satisfy one's own sexual needs is clear-
ly inappropriate. Touching a patient to assist diag-
nosis is clearly appropriate, provided the patient
has explicitly or implicitly consented to the touch.
Guidance is needed for the situations that lie
between extremes. No formula can substitute for
physician judgment in these matters, but certain
criteria can and should guide judgment.
Patient's best interests. The physician-patient
relationship is therapeutic. When moving in a
patient's sphere of intimacy, anything a physician
does that is not for a patient's benefit is morally
suspect and reprehensible if the physician's rather
than the patient's needs are being met.
Patient's wishes and consent. Although ref-
erence to a patient's best interests is crucial for
distinguishing appropriate and inappropriate inti-
macy, it is not sufficient. It is also important that
physicians act in accordance with patients' wishes
and as authorized by patients' consent. This
means that in gray areas a physician cannot uni-
laterally draw the line between appropriate and
inappropriate intimacy. What a physician believes
to be appropriate might not be so in a patient's
eyes, and what is appropriate for one patient
might not be for another. As a rule, if a patient
believes a physician is doing something inappro-
priate, it is so, however well-intentioned.
VOL 42: AUGUST . A0OT 1996 * Canadian Family Physician * Le Midecin defamille canadien 1507
CME
Intimacy in the patient-physidian relationship
Cultural norms. Norms concerning intimacy
and the private matters upon which it encroaches
vary from one culture to another. Patients with
certain cultural backgrounds and assumptions
might interpret a physician's speech and actions
otherwise than intended. For example, direct and
persisting eye contact can be interpreted as very
invasive behaviour. Physicians must be attentive
and sensitive to cultural factors bearing on how
their behaviour is interpreted.
Context. Behaviour appropriate in one situation
might be inappropriate in another. Putting an
arm around a patient as a gesture of consolation
and empathy might be appropriate, depending
on the patient, the rapport that exists in the rela-
tionship, and other factors. In other circum-
stances, such touching would be clearly
inappropriate or at least misunderstood. Good
communication is essential. Physicians can pre-
vent misunderstanding by explaining in advance
the reasons for particular interventions and by
ensuring that patients authorize them either
implicitly or explicitly.
Touching illustrates the boundary problem
Touching is the intimate behaviour most charged
with meaning, most open to misinterpretation,
and most likely to lead to transgressions. The
main reason for touching is to gain information
about a patient's physical condition and to plan
treatment or preventive strategies. Physicians
must ensure that patients understand the touch as
related to the diagnostic or therapeutic process.
It is especially important to ensure proper pro-
tocol and composure during a physical examina-
tion. Good physicians maintain a proper
professional demeanour and proceed with as
much sensitivity to and respect for patients' feel-
ings as possible. They explain why and how the
examination will be done and ensure that patients
understand and consent, especially before exam-
ining the breasts or sexual organs. They watch for
signs of apprehension, and adapt the examination
for patients' comfort.
Good physicians do not normally conduct
social conversation during examinations. Positive

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1508 Canadian Family Physician . Le Medecin defamille canadien * VOL 42: AUGUST
CME
000* 0000 0**
or negative remarks about a patient's appearance are
inappropriate unless therapeutically relevant. Direct or
indirect jokes about patients or their physical condition
are almost always inappropriate.
Physical examinations can be especially charged
with meaning when patients are also receiving psy-
chotherapy from the physician. Physical contact in such
cases (even a procedure as routine as a pelvic examina-
tion) is very risky. Good physicians are extremely reluc-
tant to act in both of these capacities to a patient.
Conclusion
Intimacy is integral to the physician-patient rela-
tionship in family medicine. This poses risks, both
for patients and physicians. In seeking to minimize
risks, good physicians are careful to preserve and
cultivate only intimacy appropriate for good family
practice.
Effective clinicians worthy of the trust vested in
them develop and exercise good judgment about the
boundary between appropriate and inappropriate inti-
macy. Those involved in education at all levels need to
review and perhaps strengthen programs for both
trainees and practising physicians to help them culti-
vate their judgment in these matters and to ensure that
they give good quality care appropriately in a patient-
friendly environment. 0
Correspondence to: Dr M.E Longhurst, Chilliwack General
Hospital, 45600 Menholm Rd, Chilliwack, BC V2P1P7
References
1. Task Force on Sexual Abuse of Patients, College of Physicians
and Surgeons of Ontario. Final report of the Task Force on Sexual Abuse
ofPatients. Toronto, Ont: College of Physicians and Surgeons of
Ontario, 1991.
2. British Columbia College of Physicians. Crossing the boundaries. The
Report ofthe Committee on Physician Sexual Misconduct. Vancouver, BC:
British Columbia College of Physicians, 1992.
3. Cohen M, Woodward CA, Ferrier B, Williams P Sanctions
against sexual abuse of patients by doctors: sex differences in atti-
tudes among young family physicians. Can Med Assoc]
1995; 153(2): 169-76.
4. Kardener S, Fuller M, Mensch I. A survey of physicians' attitudes
and practices regarding erotic and nonerotic contact with patients.
AmJPsychiatry 1973;130:1077.
* *.
AOAOOTFOR
1996 PRESCRIBING INFORMATION SEE PAGE 1503 *