Explaining the ethical line between patient and physician

       DEAR DR. ROACH: Recently, a physician in my area lost his license for having an intimate relationship with several of his patients. I’m just curious why this is considered so unethical if both parties are adults who are sound of mind. Are physicians not allowed to have relationships with patients outside of their practice? If I want to see my physician for personal reasons and not medical ones, should I find a different provider first? — N.E.
       ANSWER: The reason it is unethical for physicians to have intimate relationships with their own patients is that they are in a position of trust and responsibility, so any sexual relationship with a patient is misconduct. For former patients, the ethical boundary is blurred; it depends on the type of relationship that the physician had. If you saw someone in the emergency room who ordered an ankle X-ray, that’s a very different situation from one in which there was an ongoing therapeutic relationship. In the first case, a relationship may not be inappropriate, but in the second one, I feel a relationship is never appropriate: There is too much potential for the physician to exploit the trust that derives from the patient-physician relationship. A smaller but significant consideration is that physicians who treat people they are emotionally close to have difficulty being objective as physicians.
       Experienced therapists recognize the issue of transference: a patient (or client) develops romantic feelings for the therapist, whose professional role is to be a careful and attentive listener as well as try to use his or her expertise to help the patient. It is not uncommon, and is part of the goal of some types of psychotherapy. However, the patient is not seeing the therapist as a person, but as an ideal. Thus, development of strong positive feelings is understandable.
       Countertransference, when the therapist develops strong feelings for the patient, may be useful to a therapist for understanding his or her patient. I suspect the physician who lost his license had difficulty understanding countertransference. The American Psychiatric Association’s ethical guidelines prohibit sexual relationships with current or former patients due to the inherent inequality in the relationship and patients’ vulnerability to their therapists.
       DEAR DR. ROACH: I’m an 80-year-old man in good health. Ten years ago, I was diagnosed with prostate cancer (a fast-growing kind) with a PSA level of 4.5. Thirty days after surgery, it was down to 0.25. After 10 years, it is now 10.5. I have had three MRIs, three bone scans, three chest X-rays: all negative. My doctor talks of hormone therapy.
       Does a PSA test diagnose only prostate cancer, or does it find others, such as colon, throat or skin cancer? Is a PSA of 10.5 too high? When do I need hormone therapy? I have no symptoms. — A.B.
       ANSWER: The PSA test is quite, but not perfectly, specific for prostate (both normal and cancer), as its name states; “PSA” stands for “prostate specific antigen.” Only prostate cells make it in large quantities, normally.
       In men with a history of prostate cancer who have had surgery, high levels of PSA almost always mean a recurrence of the cancer, whether locally (near the surgical site) or distally (such as in a bone). That’s why your doctor has ordered so many tests to find out where the cancer might be. However, given no obvious source of cancer and no symptoms, I would not be in a rush to treat you with hormonal therapy. The goal would be symptom management, if any develop.
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       Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, FL 32803. Health newsletters may be ordered from www.rbmamall.com.
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