Scenario –
Personal Accountability
A patient who was
involved in a motor vehicle collision has been coming to see you over the past
month. Their symptoms included back pain, neck pain and left arm pain.
After two-three
treatments, you feel like you have built a good rapport with the patient. At
the end of a treatment, you call them “kiddo” and tap them on the nose before
leaving the room.
You are surprised to
hear from the College a week later informing you that the patient has submitted
a complaint against you for unprofessional conduct. The Complaints Director has
asked you to provide a response in writing.
In your letter of
response, you (a regulated member) state:
“… a clinical visit need not be a stale or socially vacant experience.
The optimal atmosphere is generally a balance of clinical professionalism
blended with a courteous and friendly tone. The gesture of an innocuous light
tap is not uncommonly used by individuals to denote the end of a session. This
might occur on the arm, shoulder, back or as in this instance, a light tap on
the forehead or nose. This was such an innocent gesture and was certainly not
intended to create discomfort. Likewise, the use of the term “kiddo” is a term
of endearment like “friend” or other similar reference. I would never expect a
patient to find objection to the use of such innocuous expressions that have
wide-spread use in a variety of circumstances. I’m sorry they perceived my
communication as inappropriate or unprofessional. I will exercise heightened
vigilance in monitoring my exchanges with all patients but particularly with
those who may be of a more sensitive disposition.”
The Conduct in Question
The conduct in
question will focus on the behaviours and decisions of the chiropractor before
and after the “nose tap” and “kiddo” comment. There are three primary issues in
this regulated member conduct: personal accountability, professional boundaries
and informed consent. Personal accountability has the most impact; without it,
the regulated member will struggle to maintain professional boundaries and
practice appropriate informed consent.
Personal Accountability
In their written
response, the regulated member adopts a victim mindset to avoid taking personal
accountability for their behaviour. The regulated member writes several
examples of why their behaviour is acceptable, completing dismissing the patient’s
concerns while stating the patient’s “sensitive disposition” is the issue.
A regulated member is
accountable for their actions and choices and must adhere to the Standards of
Practice, Code of Ethics and CCOA Directives.
Other Issues
In this scenario,
there are issues regarding professional boundaries and informed consent. However,
the focus of this scenario is personal accountability.
Advice to the Profession – Ethical Decision Making
Personal Accountability
Personal
accountability is an individual taking responsibility for the consequences of
their actions and choices. It is essential to a regulated member’s professional
conduct performance.
Stephen R. Covey in his
book ‘The 7 Habits of Highly Effective People’ describes responsibility
as follows:
“Look at the word
responsibility— “response-ability”—the ability to choose your response. Highly
proactive people recognize that responsibility. They do not blame
circumstances, conditions, or conditioning for their behaviour.”
Stephen R. Covey
further clarifies that when we make a mistake, the responsible way to address
this mistake is very simple:
“The proactive approach to a mistake
is to acknowledge it instantly, correct and learn from it.”
Personal Accountability Consideration
for Regulated Members of the CCOA
Personal
accountability requires contemplation and awareness of our actions and behaviours.
These are essential personal and professional skills that help us identify the
congruency of our actions to the outcomes and requirements that are established
in the Standards of Practice, Code of Ethics and CCOA Directives.
The CCOA does not
expect that regulated members are flawless or perfect in all aspects of their
professional conduct. The CCOA recognizes that regulated members may, occasionally,
or in isolation, make a poor decision or behave poorly. Occasional or isolated
errors are not the same as patterns of poor decisions or poor behaviour.
Personal Accountability and Trust
James Clear, in his book "Atomic
Habits," emphasizes the importance of accountability in building trust. He
states, "When we judge ourselves, we are more likely to follow through on
commitments because our brains are wired to avoid the pain of being
wrong." This means that when we hold ourselves accountable, we are more
likely to stick to our commitments, and as a result, build trust with others.
The combined effort of regulated members to
be personally accountable to the Standards
of Practice, Code of Ethics and CCOA Directives, establishes,
maintains and builds trust with patients,
government, stakeholders, other healthcare providers and our peers.
Professional Expectations and
Personal Accountability
There is an
expectation that regulated members must consistently consider the Standards of
Practice, Code of Ethics and CCOA Directives and self-evaluate themselves based
on these.
When an error is made,
the regulated member needs to personally acknowledge the mistake instantly,
correct the mistake and learn from it.
Part of owning our
mistakes means that we communicate with all individuals impacted by our
decision or behaviour and the resulting error. Disclosure should include what
we have learned and our action plan to avoid errors in the future.
The Standards of
Practice and Code of Ethics do contain some absolute reporting rules that a
regulated member must follow. At times, personal accountability will require
self-reporting or reporting of a colleague to the College.
Complaints and Personal
Accountability
When the College is
addressing poor behaviour and decisions, the focus is to investigate patterns
of actions. These patterns are identified with evidence gathered through
investigation and inspections. They may be summative or cumulative. A summative pattern occurs when the evidence identifies
multiple behaviours and judgements errors that culminated in an event. A
cumulative pattern occurs when there is a repetition of one or more behaviours
and judgements over time.
The chance of a
regulated member interacting with the Complaints Director under Part IV of the
Act increases when a regulated member is not consistent with their personal
accountability. The failure of the regulated member to self-reflect, identify
and address conduct when it was isolated or occasional, leads to the regulated
member normalizing poor decision making and behaviour. This leads to a progressive
departure from following the Standards of Practice, Code of Ethics and CCOA
Directives.
The Complaints process
may uncover unprofessional conduct when evidence demonstrates a lack of
personal accountability Part IV of the Health Professions Act is the
tool that the College uses to impose accountability for a regulated member’s
failure to be personally accountability.
When a regulated member’s fails to be
personally accountable, there are often enhanced accountability measures to
remediate behaviour associated with findings of unprofessional conduct,
including financial fines or other conditions. The primary outcomes the College
pursues are public protection and professional competence.
What Standards and Ethics apply to this scenario
In this scenario, there are multiple Standards
of Practice and Codes of Ethics that may apply. The CCOA Guidelines on
Professional Boundaries is also available to all regulated members to provide
guidance in managing the chiropractor-patient relationship.
CCOA Code of Ethics
2. Nonmaleficence (do no harm)
Chiropractic treatment, in all circumstances and situations, must be
expressly intended not to leave the patient in a worse state than if no
treatment had been performed.
Article A14: Doctor-patient Boundaries
Due to the inherent inequality of power in the doctor-patient
relationship, chiropractors must maintain the clear separation between
professional and inappropriate personal relationships.
Standards of Practice
6.1 Professional Boundaries with
Patients
Regulated members must always maintain
professional boundaries with patients.
Professional boundaries in patient care are physical and
emotional limits of the therapeutic relationship between the patient and the
regulated member. The regulated member’s responsibility is always to act in the
patient’s best interest and to manage the boundaries within the doctor-patient
relationship. Additionally, regulated members must recognize that each
patient’s boundaries will be unique to their own experiences, including their
culture, age, values or experiences of trauma.
Scenario Specific Advice
In this situation, the
regulated member could have demonstrated personal accountability with the
following response:
“Thank you for bringing this patient experience to my attention. I have
reflected on the situation raised in your letter. This situation is difficult
for me to consider and recognize that I have made errors in actions and
choices.
I tapped the patient on the nose while calling them “kiddo.”
At the time, it seemed so innocuous to me as I have practiced with a
preference of maintaining a casual and friendly tone.
I have considered the Standards of Practice, Code of Ethics, CCOA
Directives and Communications. My actions are out of touch with the current
expectations for the profession.
I am disappointed in my actions and recognize that they had, and may
still have, a negative impact on the patient.
I acknowledge that I need to take immediate action to adjust my personal
filters relative to the chiropractor-patient relationship. I will enhance my
knowledge and skills to align with the current expectations for
chiropractor-patient relationships. I think that expanding my knowledge and
skills will provide for better decisions and behaviour in my professional
relationships as I reset my filters.
If you have other recommendations on how I can improve, please let me
know."