Case study: conduct

Boundary Violations – overstepping the mark

Complaint received about a 52-year-old male chiropractor*.

The complainant, a female aged 25, attended the chiropractor for the first time for treatment for lower back pain and alleged that, during the treatment, the chiropractor touched her buttocks without consent. She also expressed concerns that, while lying on her back, he moved her legs in a way that exposed her underwear underneath her skirt. The complainant further alleged that the chiropractor did not call her by her name but referred to her as 'love'. He also offered her a discounted rate for the next three appointments to treat her back pain.

The complainant became concerned about the lack of explanation about the proposed treatment, the overfamiliar language, and what she considered may have been inappropriate touching. She felt wary of the motive behind the offered discounted treatment. The complainant  was uncertain if the chiropractor was treating her appropriately, and, although he had provided some relief for her back pain, she was sufficiently uncomfortable with the clinical encounter that she did not return for future treatments. She wanted to register a complaint in case this might indicate a concerning pattern of behaviour.

The HCCC made an initial assessment of the matter and the assessment officer provided the complaint to the practitioner and requested a response to the complaint. (A)

The practitioner provided details of the treatment and responded by commenting that he was shocked at receiving the complaint, as he had been working for nearly 30 years and had never had a complaint made against him previously. He commented that the treatment of this patient did not differ from his usual treatment of female patients and he did not consider that he had touched the complainant inappropriately. Also, he considered that he had followed his usual method of gaining consent as the complainant had signed an initial consent to treatment form. Additionally, he believed he had obtained verbal consent to touch her buttocks during the consultation. The chiropractor agreed that he had not provided draping as the complainant was wearing a longer skirt and considered the complainant was adequately covered with her clothing. He also agreed that he often used very familiar terms with patients such as 'love' and 'pet' in an attempt to make them comfortable and commented that no one had complained before.

The HCCC and the Council agreed that the complaint indicated a Boundary Violation complaint at the lower end of the spectrum, but the practices of the chiropractor were not in line with current best practice and the matter was referred to the Council for management. (B)

The Council considered the matter further and referred the practitioner to attend Counselling with two members of the Council. (C)

The practitioner attended the session by video conference. The Council members discussed the issues raised in the complaint:

Consent - Documentation of consent is vital – if it is not written down, it is considered to have not happened. Remember to obtain consent every time you are to touch a patient – male or female – whenever your hands will be in proximity to the patient’s genitals. Just because the patient has given their consent the first time, it does not mean that they have consented to be touched in the future. You are strongly encouraged to seek verbal consent at every treatment interaction. There are many reasons why it is appropriate or necessary to access the patient’s skin such as for soft tissue work and taping. However, if it is not necessary to remove clothing either partially or fully, don’t do it. If you need to remove clothing, ask for consent first.

As a part of your explanation of the treatment to the patient, you should explain where and how the patient will be touched, and, if the patient’s clothing is to be partially removed, ask the patient for their consent and appropriately record the consent in your notes.

You might think you have explained the treatment and process but ensure that the patient understands sufficiently to enable consent to be obtained. (Code of conduct - 3.5 & 3.3)

Patient privacy – If in doubt, drape. It is better to be very conservative when considering if it is necessary, and it is essential to protect the modesty of patients. The exposure that the chiropractor considers normal may be confronting to a patient, particularly young female patients, but all patients should be considered. We need to be mindful that a patient may expect to maintain higher levels of modesty that the practitioner is accustomed to and this is a part of our obligation to culturally safe and sensitive practice. (Code of conduct - 3.8)

Familiarity – For all patients, even those who you have been treating for many years, you should be mindful that some patients are uncomfortable with over-familiar or diminutive names. Generally, patients will not tell you that they are uncomfortable with this. You should always use your patient's preferred name. (Code of conduct 3.3) Over-familiar conduct is an example of not maintaining appropriate professional boundaries. (Code of conduct 9.2)

Patient perceptions – Chiropractors are trained at university to be aware of the perceptions of their patients. In the 'me too' climate, some experienced chiropractors of long-standing have demonstrated that they are not aware that practices around consent and privacy, have evolved. Care needs to be taken to ensure that patients, both women and men are comfortable with the treatment being proposed.

For experienced chiropractors, it is vital to consider how public perception has changed since you commenced practice and consider updating your practice to reflect modern values to protect both your patients and you.

Often a practitioner who has received a complaint comments that they consider the concerns of the complainant to be trivial, but it is important to remember the concern is very real to the patient. It can lead to long-term damage to the patient, the relationship with the patient and may result in reputational damage to the health professional or the profession as a whole.

Outcome – The Council did not consider that the treatment was incorrect or that the behaviour of the chiropractor was sexualised. The Council was concerned that the relaxed attitude of this experienced chiropractor toward this young patient had caused the misunderstanding.

The Council members discussed these issues and the chiropractor appeared to leave with a better understanding of the perspective of the patient. The Council was confident that the chiropractor understood what was expected and it was unlikely that this would happen again in the future.

A few things to add

Professional boundaries - Chiropractors should recognise that maintaining professional boundaries is vital for the practitioner and patient to engage safely in a therapeutic relationship (Code of conduct 9.2).

Personal relationships - Chiropractors must recognise the potential conflicts, risks, and complexities of providing care to those with whom they have a close relationship such as their family members, close friends, or work colleagues. The Code of conduct gives guidance on how to manage providing care to such people (Code of conduct 3.15).

Public Expectations - Public expectations have changed over time. It is best practice to not joke with patients even when trying to put them at ease. Practitioners are strongly encouraged not to make non-clinical comments about a patient’s appearance (Code of conduct 3.2).

(A) If a complaint is received about your conduct and that complaint has sufficient detail to raise concern, you will be provided with a copy of the complaint and invited to respond. The complainant may request to remain anonymous.

(B) More serious matters will stay with the HCCC who may order a further investigation or possible referral to the Police if the matter reveals criminal behaviour such as sexual assault. Matters that are more related to the expected standards of practicing chiropractors will be referred to the Council. Except in matters relating to advertising which will be referred to Ahpra.

(C) One of the options available to the Council is to refer the practitioner to counselling. Counselling is a process designed to assist the chiropractor to appreciate what is expected of them as a registered health practitioner.

Chiropractic Board of Australia - Code of conduct

*This case study is entirely fictional and bears no relationship to any practitioner.