In the high-stress, life-or-death environment of the medical profession, Cupid's love arrow can strike about as quickly as an infection.

But before letting the heart do the rounds, it's imperative to consider the legal prescription for (or better yet, avoiding) sexual relationships in the medical workplace.

While not every forbidden love story begins like a RomCom and ends like a nightmarish documentary of a love affair gone wrong, in the medical profession, workplace romance can have serious and long-term side effects. What may seem like innocent flirtation or mutual admiration quickly and unexpectedly can spiral into a legal migraine for all involved.

Let's take a look at some of the consequences of misinterpreting the romantic pulse of the heart.

Mitigating Risks of Unlawful Harassment

During the recent "#MeToo" era, society at large became more aware of the inherent power dynamic that exists between executive-level employees and non-supervisory employees. This dynamic presents itself in the medical profession, where there is a hierarchy built around the initials following your name or how much additional training you may have in your area of expertise. 

Regardless, the medical profession is fraught with a perceived or actual imbalance of authority between medical providers, such as the relationship dynamic between attending physicians and residents or physicians and nurses. 

Sprinkle in the stressful, up-and-down situations these medical providers face each day, and you quickly can appreciate how these working relationships or even friendships can bud into something that one party thinks resembles a consensual romantic connection. This is not the medicine the doctor ordered and is contraindicated for maintaining a work environment free of unlawful harassment. 

Title VII of the Civil Rights Act prohibits sexual and other unlawful harassment in the workplace. According to the Equal Employment Opportunity Commission ("EEOC"),

Harassment is unwelcome conduct that is based on race, color, religion, sex (including sexual orientation, gender identity, or pregnancy), national origin, older age (beginning at age 40), disability, or genetic information (including family medical history). Harassment becomes unlawful where 1) enduring the offensive conduct becomes a condition of continued employment, or 2) the conduct is severe or pervasive enough to create a work environment that a reasonable person would consider intimidating, hostile, or abusive. . . .

. . . To be unlawful, the conduct must create a work environment that would be intimidating, hostile, or offensive to reasonable people.

Keep in mind that the intentions behind the alleged harasser are not necessarily important. Rather, the question centers on whether the conduct (e.g., a comment or physical action) was unwelcome (i.e., not desired) and objectively, and subjectively to the alleged victim, offensive. 

Additionally, conduct that once was welcome (e.g., mutual admiration or flirtation) may become unwelcome, especially if the alleged victim has indicated that the conduct is no longer welcome. 

For example, if an Attending physician and an Intern began a romantic relationship, but the Intern decided to break it off a few months later, the Attending physician's continued pursuit of the Intern could constitute harassment. 

The perception of unlawful harassment can create a myriad of legal headaches and liability exposure for the medical practice, but it also distracts from the purpose of the medical practice: ensuring patient care. 

Respecting Doctor-Patient Boundaries

Physicians and other medical professionals should be very cautious about maintaining professional boundaries with their patients. It is not only harmful to patients who may be in a vulnerable position, but it also can often be career crippling for the professional. The medical professional who finds themselves subject to a complaint of this nature may face potential discipline on their license from their licensing board. It is an issue the North Carolina Medical Board ("Board") takes seriously.

In examining why the physician should care about this, it's illuminating to understand how both the American Medical Association and the Board (as is representative of all state licensing boards) view the issue.

The American Medical Association ("AMA") has a comprehensive Code of Medical Ethics that covers a wide range of topics, including the ethical guidelines for maintaining professional boundaries with patients. Regarding professional and sexual boundaries, the AMA Code of Medical Ethics emphasizes the importance of maintaining clear and appropriate boundaries to ensure patient trust, safety, and the integrity of the patient-physician relationship.

The AMA's Code of Medical Ethics addresses this issue very clearly in Opinion 9.1.1. The opinion reads:

Romantic or Sexual Relationships with Patients

Romantic or sexual interactions between physicians and patients that occur concurrently with the patient physician relationship are unethical. Such interactions detract from the goals of the patient-physician relations and may exploit the vulnerability of the patient, compromise the physician's ability to make objective judgments about the patient's healthcare, and ultimately be detrimental to the patient's well-being. 

-Romantic or Sexual Relationships with Patients | AMA-Code (ama-assn.org)

The AMA, which is the professional advocacy association of physicians, warns even against physician and former patient sexual or romantic relationships due to the potential that the patient may be unduly influenced by the previous physician- patient relationship. 

The Board, which regulates the practice of medicine in North Carolina and licenses both physicians and physician assistants, as well as jointly regulates the practice of nurse practitioners with the North Carolina Board of Nursing, follows the position of the AMA. The Board has authority to discipline practitioners when they commit unprofessional conduct, and they routinely investigate those who find themselves the subject of a complaint regarding professional and sexual boundaries. 

The Board identifies this behavior as unprofessional and provides guidance regarding the professional and sexual boundaries between medical providers and patients. Specifically, their position on this matter is outlined in their position statements, Sexual Misconduct Involving Patients and Guidelines for Avoiding Misunderstandings During Patient Encounters and Physical Examinations.

Here are some key points from the Board's Position Statements:

Sexual Misconduct:

1. Definition of Licensee Sexual Misconduct: Licensee sexual misconduct is defined as behavior that exploits the licensee-patient relationship in a sexual manner. This includes verbal or physical actions, whether in person or virtually, that express thoughts or feelings of a sexual nature or could reasonably be interpreted as such by the patient.
2. Grooming Behaviors: Sexual misconduct can occur along a continuum of escalating severity. This continuum may begin with "grooming" behaviors that, while not overtly sexual, are meant to build trust and acquiescence. These behaviors could include gift-giving, special treatment, sharing personal information, or other actions to gain the patient's trust.
3. Physical Contact: Sexual misconduct is physical contact between a licensee and patient that is explicitly sexual and can be initiated by the patient. Examples include sexual intercourse, kissing in a romantic or sexual manner, and touching of genitals or breasts for a purpose other than appropriate examination.
4. Termination of licensee-patient relationship: Sexual misconduct can still occur if the relationship is terminated solely for the purpose of continuing a sexual relationship.

Guidelines to Avoid Misunderstanding:

1. Professional Demeanor: Licensees should maintain a professional demeanor at all times, particularly during disclosure of private information or physical examination, to avoid misunderstandings that could lead to boundary violations or sexual misconduct charges.
2. Patient Modesty and Privacy: Sensitivity to patient modesty and dignity must be maintained. Patients should be assured of privacy and should never be asked to disrobe in the presence of the licensee. Examining rooms should be well-maintained and equipped gowns, sheets and other appropriate with appropriate supplies.
3. Use of Chaperones: A third-party chaperone should be available during physical examinations, especially when examining breasts, genitalia, or rectum. If no chaperone is available, the patient should provide verbal informed consent for an unchaperoned examination.
4. Individualized Approach: Licensees should individualize the approach to physical examinations to minimize patient apprehension. An explanation of the necessity of the examination, the components, and the purpose of disrobing may be necessary.
5. Alertness to Patient Behavior: Licensees should be alert for suggestive or flirtatious behavior from patients and should prevent compromising situations from developing.

In summary, the AMA's Code of Medical Ethics and the Board's Position Statements are clear in their stance on maintaining professional boundaries and avoiding sexual or romantic interactions with patients. These guidelines are essential to preserving the trust, safety, and integrity of the patient-physician relationship. The wise medical provider will heed these guidelines and preserve both patient care and their ability to provide that care during their career.

Treatment Plan

In keeping with our medicine focus, the old adage, "an ounce of prevention is worth a pound of cure," is precisely the medicine these Juris Doctors ordered. Avoiding love affairs (or even the appearance of them) in the workplace and medical profession will prevent the messy legal battles that otherwise will result. The risks of a costly lawsuit, tarnishing your reputation, and jeopardizing your license, career, and patient care are not worth it.

If all else fails, remember: we enjoy the drama associated with a scandalous love affair on television, but it is unlikely to be as entertaining if you are the subject of the made-for-television movie. Maintain professional boundaries with patients and co-workers, ensure that you are creating an environment that fosters mutual respect, and avoid even the appearance of an improper relationship – your career depends on it.