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personality disordered doctors), this group is very unlikely to re-offend with appropriate treatment.
Therefore, unmet emotional needs of the doctor, overidentification with the patient and particularly intimate areas of medicine associated with long-term professional relationships with patients can all potentially enhance the strength of the transference–counter-transference relationship between doctor and patient.
However, the crossing of boundaries does not necessarily mean that an unethical act occurred: after all, the crossing or erosion of boundaries is a normal part of the evolution of intimate relationships between human beings. Clues as to what these other factors should be can be gleaned from examining the profiles of offending doctors.
Nor do all boundary transgressions between doctor and patient ultimately lead to sexual misconduct. A key factor in the identification of doctors at risk of violating boundaries is the enhanced vulnerability of a doctor to the transference–counter-transference dyad which occurs in varying degrees in every doctor–patient relationship.
It is important in the doctor–patient relationship that a ‘neutral, safe space' is established which allows a therapeutic alliance to grow. Three salient features describe the circumstances in which this type of relationship occurs: there is an expectation of trustworthiness, an unequal power relationship exists and the interaction occurs under conditions of privacy. Although it does not involve the sexualization of the doctor–patient relationship, it clearly illustrates the importance of recognizing all four types of power, and, in particular, the prominence of Hierarchical power: A consultant specialist was admitted to hospital with a severe multi-system disease causing severe renal impairment.First, the concepts of boundaries and transference are discussed and a profile of the medical practitioner at risk of offending is drawn.Secondly, three aspects of the doctor–patient relationship are explored: the general characteristics which promote health care; the importance of trust and the fiduciary relationship; and the role of power and authority in the relationship.In turn, to build such a relationship, the unequal power distribution between doctor and patient has to be acknowledged and contained in an ethically correct manner. As attempts were made to rapidly infuse intravenous fluids and rescue his remaining renal function, the specialist cried ‘I realized that they were the wrong pills but !The onus of responsibility for this last task falls on the person who has the most power in the relationship which, as I will argue, is always the doctor. the power that a physician possesses by virtue of her training in the discipline and the art or craft of medicine”. ' Despite having the Aesculapian power of a doctor, and the Social power of a hospital specialist, in addition to considerable Charismatic power (he was a well-liked and respected colleague), none of these were sufficient to counteract his lack of Hierarchical power by being a patient.
This does not mean that no such type of relationship may exist, but it has not been researched.