The sexual abuse of patients by doctors is a devastating breach of power and trust – a monstrous violation of physicians' Hippocratic Oath to "first, do no harm."
Last month, the disgraced USA Gymnastics doctor Larry Nassar was sentenced to up to 175 years in prison after more than 150 sexual-assault victims came forward.
Closer to home, more than 60 women and men have alleged that a Halifax RCMP doctor sexually abused them, performing unneeded and spurious breast, vaginal and rectal exams over a period of 22 years.
Scan any of Canada's medical-college websites today and you'll find rotating lists of disciplinary cases involving doctors sexually abusing their patients. Some have their licences revoked for molesting victims during sensitive exams, others for engaging in relationships with those they've been tasked to treat – all serious transgressions of professional boundaries.
Long before the most recent horrifying cases emerged, serious efforts were under way to try to thwart predatory doctors in Canada. A 300-page Ontario task force report released in 2016 proposed a raft of recommendations to stem the sexual abuse of patients, including an independent protection agency to more vigorously deal with culpable doctors, as well as stiff fines for hospitals, universities and private clinics that fail to report such abuses.
Given how profoundly such crimes damage patients and erode the public's trust in medicine, some argue that such penalties are too little, too late. They'd like to see prevention that starts earlier.
"The majority of us as health-care providers wouldn't harm a patient. But there are some within our midst," said Dr. Sheila Macdonald, clinical manager of the Sexual Assault/Domestic Violence Care Centre at Women's College Hospital in Toronto.
"There's a desire to want to minimize and make it seem like a lesser issue than it is," Macdonald said. "This is why it's hard to get people to engage, despite the significant impact it has on patients."
The lens is now on the training grounds for Canada's next generation of doctors. Some are questioning whether medical schools are doing enough to address the harms of patient sexual abuse and how well they are equipping their students to report colleagues who would violate the fundamental oath of medicine. They argue that educators who view abusive doctors as outliers don't give this problem enough airtime in their classrooms. They're agitating for more of a focus on the patient, as well as stronger trauma-informed curriculums.
School officials, meanwhile, insist that professionalism is ingrained in the fibre of all learning throughout medical school.
"Is it taught? Absolutely. Is it modelled? Absolutely," said Dr. Geneviève Moineau, president and chief executive officer of the Association of Faculties of Medicine of Canada. The organization represents Canada's 17 faculties of medicine and guides them on a host of issues. "Faculties do whatever they can to ensure that they are protecting the public first," Moineau said.
Speaking with The Globe and Mail, deans and vice-deans at eight medical schools across Canada emphasized that students and residents are continually assessed not just on their knowledge and skills but on their professionalism. Doctor-patient boundaries are woven into every aspect of med school.
One of the first things undergraduates learn about is the stark power differential between patient and doctor.
"Patients come to you sharing things that are difficult to talk about. Then you have to examine them, so they're not wearing their usual clothes or they're unrobed. They're feeling vulnerable because of that. Physicians are in the position of power," said Dr. Gurdeep Parhar, executive associate dean of clinical partnerships and professionalism in the faculty of medicine at the University of British Columbia.
Parhar said students learn early on how to communicate with patients using proper terminology, how to drape (or cover) patients respectfully during examinations and how to obtain informed and continuous consent. Students role-play interviews and schools hire actors who play out more difficult scenarios in a safe test environment. In their later years, students learn about boundary violations in clinical practice. During sensitive examinations, students are always supervised.
Med-school ethics aim high, said Dr. Christie McClelland, a second-year psychiatry resident at Dalhousie University in Halifax. "Not assaulting patients is the absolute lowest bar for behaviour," McClelland said. "Our training through lectures, practical skills, role-playing, professionalism courses and observed clinical interactions with patients aims far above this most basic, presumed standard of conduct."
Preventing patient abuse is integrated "all the way through our training," said Kaylynn Purdy, who is vice-president of medical education for the Canadian Federation of Medical Students and a fourth-year student in the Northern Ontario School of Medicine at Lakehead University in Thunder Bay.
Still, Purdy said her class never reviewed any of the high-profile abuse cases in the news. That was left for students to discuss among themselves.
Macdonald said educators should be wary of skirting the issue and dismissing predators such as Nassar as one-offs: Their reach is wide and catastrophic. "They never victimize just one person," she said. "And we never know the true number because patients are too afraid to come forward and report."
In January, University of Ottawa clinic doctor Vincent Nadon was arrested and charged with sexual assault and voyeurism for allegedly filming a patient during a medical exam. Nadon has since been charged with sexually assaulting 10 other patients since 1995. And in Brampton, Ont., three female patients and a nurse accused physician Brian Thicke – father of the late actor Alan Thicke – of groping them over four decades.
Education can serve as a deterrent for would-be predators, Macdonald said, if instructors stress the mandatory reporting of colleagues who cross the line. "It sends a message to anyone who's thinking about perpetrating abuse: We're onto you."
Macdonald worked with Senator Marilou McPhedran on Ontario's 2016 task force report. McPhedran chaired two other independent inquiries into the issue in 1991 and 2001. She is urging educators to build more empathy in their young charges for patients who are sexually exploited by doctors.
"There is no accountability for the fact that the education does not teach medical students the true damage done by the crossing of these boundaries," McPhedran said.
She said the Ontario medical students she interviewed in 2000 and 2015 told her about an institutional attitude that occasionally portrays patients as the ones who cross the line and behave inappropriately – even as the onus is always on health-care providers to set the tone and demarcate professional boundaries.
"This is something I heard directly from male and female medical students," McPhedran said. "They told me that they learn in a fear-based environment: 'We are taught to be afraid of patients and what they could to our careers – to our lives.'" (Asked about this, Moineau said, "There's no focus on defensiveness in our curriculum that I'm aware of.")
Others see different institutional blind spots. Purdy says she would like more training devoted to good care for LGBTQ and Indigenous patients, communities that have suffered a long history of abuse and marginalization by health-care providers. "These patients may not be as revealing or forthcoming," Purdy said. "Being aware of why that is, plus ways to navigate that so that patients feel safer, is important."
She also expresses regret that her class didn't get more instruction on caring for sexual-assault victims. "I didn't really get a lot of training on how to do a pelvic examination on a woman who had been raped," Purdy said. "I don't really know how to approach that."
Experts say this is the next frontier at med school: being better doctors for vulnerable patients.
"Trauma-informed care curriculum continues to be lacking," said Dr. Jenna Webber, who pushed for this type of education during her time as national officer of reproductive and sexual health for the Canadian Federation of Medical Students in 2015 and 2016.
Webber, a physician resident at Queen's University in Kingston, says she wants better universal training for students so they can quickly recognize signs of trauma, make such patients feel safe rather than alienated and ensure that they have the best resources on hand.
Some recently developed training is promising. Alberta Health Services offers a voluntary educational program to help providers be more responsive with patients suffering from trauma. At the University of Western Ontario's Schulich School of Medicine & Dentistry, students are trained in recognizing sexual violence and helping those patients, said Dr. Jay Rosenfield, vice-dean, education. And at the University of Toronto, students examine the negative impacts of sexual abuse on patients, according to Dr. Patricia Houston, vice-dean of the school's MD Program.
More broadly, Ontario's six medical schools and the College of Physicians and Surgeons of Ontario launched an educational module on preventing the sexual abuse of patients in 2016. Referencing legislation and using case studies, the lessons examine power imbalances between doctors and those they treat, boundary violations in person and online, as well as providers' duty to report violations. Students can access the modules independently or faculty and College staff can use them in sessions on professionalism, said Kathryn Clarke, senior communications adviser for the College.
While professionalism training is crucial, some question whether it can foil predators who've managed to get into med school. Dalhousie's McClelland would like to see school authorities screen students more rigorously, identify unprofessional conduct faster and expel those who are exhibiting serious red flags.
"Teaching people right from wrong isn't the deficit in this cohort. Something so fundamental isn't learned in one's 20s or 30s," McClelland said. "Doctors in the media who have done this knew it was wrong and knew the damage it would cause. They did it anyway. Such an individual shouldn't be in medical school." (As McPhedran puts it, "Attitudes are a precursor to action.")
Moineau said students who commit minor infractions (the example she offered is a student not understanding personal space) are sent for "remediation." Where laws are broken, schools are to involve authorities. Although students are heavily monitored, Moineau admitted that manipulators can slip through. "It's impossible to actually detect those who may have a tendency to harm patients," Moineau said. "I wish we did. If we did, we would."
This is why, she said, more needs to be done to embolden bystanders. "In my perfect world, we would be in a health-care environment and in a learning environment where everyone felt safe to speak up," Moineau said. "Although we currently all have mechanisms in place for that to occur, we're not there yet."
Education on the prevention of patient abuse is evolving alongside a larger tectonic shift in health care – a move away from a paternalistic culture in which doctors are beyond reproach, toward more respectful, patient-centric medicine, the way it should have always been. "We must not revere doctors or anyone else to a level where we think they are above questioning," Dalhousie's McClelland said. "This is obviously still a challenge."
For his part, UBC's Parhar is heartened by what he's seeing in his students.
"Most of us aren't in the habit of reporting things," he said. "But we're all recognizing, especially with the #MeToo campaign, that by being silent we're complicit. And we can't be. This generation is a lot more comfortable speaking up than previous ones may have been."