William H. Swiggart, MS, Co-Director
Vanderbilt Center for Professional Health
Vanderbilt University School of Medicine
Goals
Present data collected from physicians
attending a professional development
course on maintaining proper
boundaries.
Vanderbilt University School of Medicine
OBJECTIVES
1.
2.
3.
4.
At the end of this lecture participants
will be able to:
Evaluate the results from several selfreport instruments.
Describe one screening instrument for
identifying at risk behavior.
Identify one prevention/educational tool
addressing boundary issues in
medicine.
Vanderbilt University School of Medicine
AGENDA
A brief description of the programs
presented by the Center for
Professional Health at Vanderbilt school
of medicine.
2. Review demographic, referral, and selfreport data from over 500 physicians
attending the maintaining proper
boundaries course.
3. Describe one screening and one
prevention tool.
4. Summary.
1.
Vanderbilt University School of Medicine
Vanderbilt
Center for Professional Health
Professional Development Courses
Program for Distressed Physicians©
Prescribing Controlled Drugs©
Maintaining Proper Boundaries©
Vanderbilt University School of Medicine
PHYSICIAN DEMOGRAPHICS





No: 870
Gender: Male - 94%
Female - 6%
Age range: 31-80 yrs
Mean age: 49 yrs
Ethnic Origin: 78% Caucasian; 5%
African American, 9% Asian and 4%
Hispanic
Jan 2015
Vanderbilt University School of Medicine
PHYSICIAN SPECIALITY








Family Practice/GP 30%
Internal Medicine 10%
Medical Specialty 7%
Surgery Specialty 8%
General Surgery 4%
OB/Gyn 8%
Psychiatry 9%
Other 24*
* anesthesiology, neurology, emergency, dentist
Vanderbilt University School of Medicine
SOURCE OF REFERRAL





Board of Medical Examiners
Physician Health Program
Treatment Center
Self Referral
Attorney
Vanderbilt University School of Medicine
PREVALENCE OF SEXUAL BOUNDARY
VIOLATIONS
3%
10%
954,224 physicians currently in
practice
Swiggart, W., K. Starr, et al. (2002). Sexual boundaries and physicians: overview
and educational approach to the problem. Sexual Addiction & Compulsivity 9: 139148.
Vanderbilt University School of Medicine
ASSESSMENTS

FACES II (Family Adaptability and
Cohesion Scales)
 KSCS (Kalichman Sexual Compulsivity
Scale)
 ACE (Adverse Childhood Experiences)
 BVI (Boundary Violation Index,
research)
 RSQ (Relationship Style Questionnaire)
FACES II
FACES II
Total N
877
%
Balanced:
N
Separated Structured
Separated Flexible
Connected Structured
Connected Flexible
276
31
54
26
70
126
Midrange:
N
Disengaged Structured
Disengaged Flexible
Separated Rigid
Separated Chaotic
Connected Rigid
Connected Chaotic
Enmeshed Structured
Enmeshed Flexible
273
31
Extreme:
Disengaged Rigid
Enmeshed Rigid
Enmeshed Chaotic
328
N
46
10
102
2
47
14
16
36
37
301
7
20
D.H. Olson, R. Bell, J. Portner. FACES II Life Innovations, 1992.
Vanderbilt University School of Medicine
FACES II CONTROL
FACES II
Total N
Balanced:
N
Separated Structured
Separated Flexible
Connected Structured
Connected Flexible
Midrange:
N
Disengaged Structured
Disengaged Flexible
Separated Rigid
Separated Chaotic
Connected Rigid
Connected Chaotic
Enmeshed Structured
Enmeshed Flexible
Extreme:
N
Disengaged Rigid
Enmeshed Rigid
Enmeshed Chaotic
177
88
12
7
21
48
59
3
2
13
0
9
8
0
24
30
19
0
11
%
50
33
17
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REASONS FOR REFERRAL

Complaints from patients, family
members, nurses
 Affair with patient, office nurse/staff
 Flirting
 Cybersex
Vanderbilt University School of Medicine
ADVERSE CHILDHOOD
EXPERIENCES (ACE)
Number of Adverse Childhood Experiences in CPH Courses
ACE Score
Total
N=17,337
www.cdc.gov
Total
N=264
MPB
Total
N=255
PCD
Total
N=78
DMD
Total
N=597
CPH
0
36%
33%
37%
41%
36%
1
26%
20%
27%
19%
23%
2
16%
15%
13%
14%
14%
3
10%
13%
7%
12%
10%
4 or >
13%
19%
16%
14%
17%
Anda R., Felitti V. The Adverse Childhood Experiences Study. The Adverse Childhood
Experiences Study, at http://www.acestudy.org
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SLIPPERY SLOPE
Late appointments with no chaperone
Business transactions/dual
relationships
Excessive physician self-disclosure
Some forms of language use
Personal gifts
Special favors
Flirting, jokes etc.
Grooming
Casual
workplace
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BOUNDARY VIOLATION INDEX
(BVI)©
A screening instrument designed to assess
the attitudes, thoughts and behaviors of
physicians
at increased risk for sexual misconduct with
patients and staff.
Swiggart W, Feurer ID, Samenow C, Delmonico DL, Spickard WA. The Sexual
Boundary Violation Index: A Validation Study. Sexual Addiction & Compulsivity;
Vol 15. Number 2, 2008.
Vanderbilt University School of Medicine
BOUNDARY VIOLATION INDEX
(BVI)©

Identify risk factors

Cut Off = 6
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BOUNDARY VIOLATION INDEX©
BVI
TOTAL
N
812
No. of > 6
597
Average Score
9.21
Cut Off = 6
Last Updated Oct 2014
Vanderbilt University School of Medicine
BOUNDARY VIOLATION INDEX©
Please circle the response that best characterizes your
behaviors.
N = never (0) R = rarely (1) S = sometimes (2) often= (3)
1. I have told patients personal things about myself in order to impress
them.
10. I have engaged in a personal relationship with a patient either
while I was treating him/her, or after treatment was terminated.
13. I take great pride in the fact that such an attractive, wealthy,
powerful, or important patient is seeking my help.
14. I have found myself talking about my personal life or problems with
patients.
18. I have found myself trying to influence my patients to support causes,
business deals, or positions in which I have personal interest.
23. I have made exceptions for patients, e.g., scheduling, benefits, and/or
fees, because I found the patient attractive, appealing or impressive.
25. I have sought social contact with patients outside of scheduled
clinic visits.
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RSQ

Results from three courses
PCD
Style
MPB
DMD
Total
N
158
%
N
79
%
N
21
%
258
A -SECURE
62
39
29
37
8
38
99
B-CAUTIOUS
46
29
30
38
4
19
80
C- SUPPORT SEEKING
9
6
5
6
2
10
16
D-SELF RELIANT
41
26
15
19
7
33
63
Bartholomew & Horowitz, 1991; Griffin & Bartholomew, 1994
Vanderbilt University School of Medicine
RSQ
Relationship Styles: Maintaining Proper Boundaries
Relationship Style
A-SECURE
B- CAUTIOUS C -SUPPORT SEEKING D-SELF RELIANT
Self Evaluation
29
37%
30 38%
5
6%
15
19%
Actual Test Resuts
20
25%
13 16%
6
8%
40
51%
Vanderbilt University School of Medicine
KSCS
Kalichman Sexual Compulsivity Scale
TOTAL
KSCS
Interpretation of Scores
N of Cases
438
No. of scores between 24-30:
9
No of scores >30:
30
Kalichman, Johnson, Adair, Rompa, Multhauf & Kelly (1994). Originally created by Patrick
Carnes in 1987 for clinical use in a 12-step program for individuals complaining of sexual
control issues, issues managing sexual behavior, and/or thoughts and individuals who thought
they had a sex addiction.
Vanderbilt University School of Medicine
HAZARDOUS AFFAIRS
LEARNING MODULE GOALS
1) Instruct participants on the general
definitions, rules and guidelines around
professional conduct regarding
professional boundaries and sexual
misconduct in the medical profession;
2) make physicians aware of their own
vulnerabilities;
3) help physicians understand how to
prevent crossing sexual boundaries, and
4) stimulate reflection on current and future
professional practice behaviors.
Vanderbilt University School of Medicine
HAZARDOUS AFFAIRS
LEARNING MODULE

List the levels of sexual misconduct.
 Define sexual harassment.
 Compare and contrast the types of sexual
misconduct as defined by the Federation of
State Medical Boards (FSMB).
 Identify three (3) main risk behaviors for sexual
misconduct based on various issues like selfwellness, stress, social behaviors, and medical
cultures.
 Identify five (5) behaviors on the slippery slope.
Vanderbilt University School of Medicine
KEY CONCEPTS

The physician holds the balance of power over
patients, staff and students.
 Mutual consent is not recognized as a defense
for the physician.
 Patient and physician emotional vulnerabilities
are at the core of boundary violations.
 Self care by the physician is critical to prevent
hazardous romantic relationships.
Vanderbilt University School of Medicine
SUMMARY/RECOMMENDATIONS

Physicians lack training in the complexity
of sexual boundary misconduct.
 An educational approach can resolve
most of the problem.
 A pre-emptive approach is better than a
post-violation intervention.
 The process is complaint generated.
Vanderbilt University School of Medicine
Vanderbilt Center for
Professional Health
1107 Oxford House
Nashville, TN 37232-4300
Phone: 615-936-0678
Email: cph@vanderbilt.edu
Website: www.mc.vanderbilt.edu/cph
Vanderbilt University School of Medicine