Good Fences: Understanding and Addressing Boundary Crossings and Violations in Rural Practice

2. A Note to Facilitators • Dear Facilitator, • Thank you for using Rural PREP’s materials to create an active learning experience for your site. • Use this slide deck, along with the online Facilitator Lesson Plan, to facilitate the Grand Rounds event at your site. Many of the slides contain additional information in the presenter notes area, so be sure to review the presentation and the notes prior to your Grand Rounds event.

3. Session Overview • 10 minutes: Go over and discuss pre-assignment answers with the full group • 20 minutes: Watch a recording of Randy Longenecker’s Presentation • 20 minutes: Facilitate the Team Activity • 5 minutes: General Discussion and Social Charge • 5 minutes: Evaluation of the Learning Materials as a group (5 minutes)

4. Good Fences Rural PREP Grand Rounds Presenter: Randy Longenecker, MD Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio This presentation was originally recorded on August 23rd, 2018, in front of several live, online sites connecting from different places across the country.

5. Objectives • After this presentation, participants will be able to: • Articulate the difference between boundary crossings and boundary violations • Describe and recognize a dual relationship • Develop a personal and professional plan for negotiating dual relationships in rural practice

6. Team Readiness Quiz • Which of the following are boundary crossings and which are boundary violations? Why and how might it be different in rural practice?

7. Team Readiness Quiz • A family physician calls in a script for his son’s acne medication

8. Team Readiness Quiz • A family physician calls in a script for his son’s acne medication • Boundary crossing; becomes a violation in a number of ways, e.g. if it is not documented in the son’s medical record; if it were deemed by the son’s primary physician or consulting dermatologist to be inappropriate medical care, or it undermines the son’s relationship with his physician (PC or consultant) • These can be mitigated by at least a documented approval from another physician. A rural physician should always have someone who is a physician for family member, even if it is a remote physician consultant.

9. Team Readiness Quiz • A female physician has a consensual sexual affair with one of her male patients

10. Team Readiness Quiz • A female physician has a consensual sexual affair with one of her male patients • This is always a boundary violation, prohibited by medical boards and considered unethical by all major professional associations

11. Team Readiness Quiz • A hospital-employed physician accepts a quilt from an Amish family in payment for services rendered

12. Team Readiness Quiz • A hospital-employed physician accepts a quilt from an Amish family in payment for services rendered • This is neither a crossing or violation, as long as the physician’s employer is aware and approves. It could be a violation of policy or contract as a hospital employee.

13. Team Readiness Quiz • A family physician offers their employees free well-adult exams, including a complete physical

14. Team Readiness Quiz • A family physician offers their employees free well-adult exams, including a complete physical • Clearly a boundary crossing; very easily becomes a boundary violation because of perverse financial incentives and multiple potential conflicts of interest around the employer-employee relationship and the intimacy of the doctor-patient relationship, history taking of intimate life details, and of course any intimate exams. This could potentially be insurance fraud if the employee or physician submits the service for insurance reimbursement in part or in whole. This is not a good idea and rarely, even in rural practice, are there no other alternatives. If a physician does care for employees, the relationship must be professional, including appropriate documentation and billing. Doing something for free increases the power differential between doctor and patient and increases the chances of inappropriate care and abuse of the either relationship.

15. Good Fences Rural PREP Grand Rounds Presenter: Randy Longenecker, MD Assistant Dean Rural and Underserved Programs Ohio University Heritage College of Osteopathic Medicine Athens, Ohio August 23, 2018 Launch the Presentation Now

16. Team Activity

17. Team Activity Choose a case, from among the cases of boundary violations that you have observed yourselves and have in mind, and outline for your practice setting how such a violation might be addressed, including any of the following: Office policy Reporting mechanism Preventive program Case remedy, including reparations

18. Discussion

19. Social Charge • What are you personally going to do with this information?

20. Evaluation • Please evaluate these learning materials as a group: • https://goo.gl/forms/uGj2hfNzSmzre2mY2