Doctors who cross the line

Neil Ravin

August 12, 1993|By Neil Ravin

''These people are the bottom of the barrel . . . no punishment is bad enough.''

-- Ann Landers NO, Ann Landers is not talking about carjackers who throw babies from windows. She is referring to doctors -- the ones who have sex with their patients.

The subject of sex with patients is not a hot topic in doctors' lounges around most towns. It excites non-doctors far more.

But examining the line drawn between doctors and patients in personal, emotional and sexual terms is illuminating.

The doctor is granted a special exception in our culture. No husband would be pleased to learn his wife had stripped naked before another man and had her private parts handled.

Unless, of course, that other man was her gynecologist.

My neighbors know I have examined the breasts of their spouses, yet they are happy about it.

This exception is granted on the condition that I look at these women ''clinically'' and never display any overt sexual behavior toward my patients.

That prohibition extends beyond the time and place of the examination. When I see the patient at the swimming pool I am expected to be as sexually uninterested as I was in the examining room.

All this is understandable and practical. I could not function as a physician, nor they as my patients, if it were any different. It is the tacit contract I have with the patient and her family.

In fact, this is a proscription that medicine takes very seriously.

Periodically, a journal arrives on my desk from the Maryland Board of Physician Quality Assurance, which lists disciplinary actions against physicians who have been judged to have strayed beyond acceptable medical practice.

It surprises me how few of these cases have anything to do with money, science or a physician neglecting patients in some egregious way.

Instead, the offenses for which they often lose their licenses involve sex. They involve longstanding relationships between a doctor and a woman who may have started as a patient and become a lover.

Writing in the journal of the Montgomery County Medical Society, Dr. Cheryl Winchell notes that, when it comes to doctors who cross that line with their patients, ''True love is not a defense.''

Winchell cites the case of a psychiatrist who married a patient only to find himself judged guilty of unethical and unprofessional conduct. He had had sex with his future wife while caring for her in a doctor-patient relationship and that is forbidden under all circumstances.

The AMA Council on Ethical and Judicial Affairs states the matter simply: ''Sexual contact or a romantic relationship with a patient concurrent with the physician-patient relationship is unethical.''

End of discussion. But . . .

When non-medical friends have had a second gin and tonic, they sometimes ask how I can do it.

''How can you look at this beautiful woman, naked before you, lying there on the examination table and not get turned on?''

After all, that's what Playboy and Penthouse are all about. The visual turn-on. Looking at naked women. But as skin-magazine editors well know, titillation doesn't just happen.

The women in their magazines lose sexual allure unless they are posed and put in the proper position and setting.

A woman in a bikini at a pool draws a few stares, but she would have a far different impact if she greeted you at your door with wineglass in hand.

Titillation is a function of denial. In our society, we are protected from exposure to nakedness. Once you are repeatedly exposed, it loses impact.

The fact is, as a doctor, you don't get turned on just because someone is naked. There is an old medical adage: 90 percent of sex occurs above the nose.

That is to say, despite all the emphasis on healthy sexual organs, adequate blood flow, appropriate hormone levels and intact neurological synapses, sex begins in the brain. One might add, in a brain prepared by culture.

A woman who is having her breast manipulated for the purpose of discovering a malignant tumor is not in the mood.

A physician who has seen breasts daily for years, who has seen breasts flayed open in the operating room and seen a rock-hard cancer in that tissue, is not turned on by his patient's breast.

The same is true for other body parts. As you go through medical school, you handle vaginas, cervixes, penises and breasts repeatedly. And you quickly realize it's not the anatomical entity that has to do with sex.

A breast on a cold metal slab in the lab has no appeal. It's the setting and the response.

And when you are looking at a breast and a possible cancer within, you are not having thoughts you'd hesitate to project on a video screen in front of the patient's spouse.

That, at least, is the prevailing truth. But there are always exceptions. There are people with psychopathologies among doctors, just as there are among priests, generals and congressmen.

The image of doctors as potential lovers is a staple of soap operas precisely because romance with patients is forbidden fruit. The doctor is not supposed to be interested. His mind is supposed to be on higher things.

We want our doctors to be aloof, heroic and beyond temptations of the flesh and yet we want them to be regular middle-class Joes who drive cars no fancier than ours and take modest vacations -- in Ocean City, not Antigua.

A recent poll found that the average citizen thinks doctors should make no more than $80,000 a year. In effect, that's trying to have it both ways.

Americans want doctors to be people of uncommon intellect, exceptional achievement and remarkable emotional detachment who are willing to work for ordinary pay in increasingly difficult circumstances.

Oh, well. They always told us during the long nights of internship that medicine wasn't supposed to be easy.

Neil Ravin is an endocrinologist in Chevy Chase.

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