Monday, August 16, 2010

Doctor-Patient Sex and Quality of Care

The Providence (Rhode Island) Journal blog reported that Dr. Brian Kwetkowski, a family physician, relinquished his medical license after it was revealed that he had conducted a three-year affair with a patient. The affair started when the patient was 19.

I found the comments about the blog post fascinating. I've copied them here, with my own comments written in bold italics:
Ernie said: "Doctors have affairs with their patients all the time in soap operas. Dr. Kwetkowski should apply as a soap opera actor now that he's done this in real life." (I don't follow soap operas, but it would be interesting to know how these affairs are handled. Is the exam room presented as an acceptable boy meets girl/boy meets boy/girl meets girl venue? If so it would make for good soap drama but terrible public education about professional ethics.)

Providence said: "Why did the guy have to turn in his license? She was over 18 - old enough to consent to a relationship. Maybe that "relationships" law needs to be reconsidered. Doctors can fall in love with patients, can't they?" (Providence is right - Doctors can fall in love with their patients, with "can" meaning that (a) love feelings occur and (b) love feelings aren't morally reprehensible. The moral issue isn't what a physician feels, but what the physician does. I agree with Providence that a 19-year old is entitled to "consent" (or to "initiate"). But in my view, and the prevailing view of the medical profession and licensure boards, the physician is not allowed to be part of a sexual relationship with a patient.)


A Patient said: "my opinion to this is (and I have every right to it! - that the female patient is and was an adult when this started and this obviously was consensual. I hate the fact that I'm loosing the one doctor that really meant a great deal to me and my family all because of this. How many doctors or any other professionals out there has had an affair, big friggin'deal! It's their life and they shall do with it as they will, who are we to judge?? It is none of our business. That mother should just deal with the fact that her daughter did this as an adult and mommy should have dealt with the daughter. What skeletons are hiding in your closet? Shall someone probe into your life? Or is mommy just looking for a financial boost in her bank account?" (Dr. Kwetkowski's patient makes several important points here: (1) If we knew the facts we might conclude that the affair was indeed consensual. It would be condescending to assume that the affair must have been exploitative. (2) The patient sees no basis for the ethical perspective I argued for in a recent post - that sexual relationships with patients are wrong quite apart from whether the patient is harmed. The patient appears to be putting what I see as a professional relationship that entails distinctive obligations into the framework of market exchange between consenting adults, within which anything the two parties agree to is OK. (3) The patient invokes a teaching I agree with - "let he or she who is without sin cast the first stone." I do not conclude from the fact of the affair that Dr. Kwetkowski is an evil human being, but I do conclude that he violated his ethical responsibilities as a physician. (4) The patient reports having received excellent care from Dr. Kwetkowski. There's no reason to doubt this.)

Linda Tente said: "Dr. Briam Kwetowski is my phsician. He has been my doctor since 2001. He is the most efficient, knowledgeable, honest, trustworthy, caring humanitarian and family doctor anyone could know. I can't imagine having anyone else as my doctor. I don't know the circumstances that put him in this awkward position, but I do know the public does not have to be protected against him. My God he saves lives and families. He heals and protects his patients. Who of us has lived our lives without personal indiscretions? This does not impact his ability to uphold the Hippocratic oath. Dr K hold your head high. I am sure once all the details are disclosed you will be vindicated. Me and my family cannot wait for this to be cleared up and you return to your office. I am proud to know you and be your friend as well as one of your loyal patients. Stay well!" (This is a very important comment. It amplifies the previous patient's praise of Dr. Kwetkowski. There's no reason to doubt that a physician who, like Dr. Kwetkowski, violates the prohibition of sexual relationships with patients might provide superb care to his other patients. Apparently that was true for Dr. Kwetkowski.)
I don't know if Dr. Kwetkowski has lost his license on a permanent basis. If I had been on the Rhode Island Board of Licensure I would have wanted to know more about the history of his practice. Was this affair a solitary event, or did he have a pattern of sexual involvement with patients? If it was a pattern I would have favored permanent loss of licensure. If it was a single event, if his practice performance was otherwise commendable, and if other factors suggested that he was capable of upholding professional expectations in the future, I would have been open to a time-limited suspension of licensure, followed by a supervised return to practice.

19 comments:

Anonymous said...

Interesting article and life situation. The article does not mention the age of the physician or how long he had known the female patient before the relationship started. As we all know the reason for the "relationships between physician and patient" is looked down upon is because of the power imbalance which can adversely influence the "balance" in a relationship. This can and does create possible grounds for abuse.
The other point that I found clearly stated by the other women patients who were quoted is that they would be adversely affected if he permanently lost his license to practice. They "don't know where to get another physician". This is a very real concern and could bias their view of the "potential" wrongness of his actions.
Pamela RN (Canada)

Jim Sabin said...

Hi Pamela -

I'm sorry for the delay in responding. I was on vacation in Wyoming for 10 days and have been slow getting back to speed.

I agree that this is a very interesting situation. From my perspective, the question of the physician's age and how long he had known the patient is important for thinking about the psychology of the relationship, but not relevant for the overall ethical assessment of Dr. Kwetkowski's actions.

The grief and loss commented on by other of his patients dramatizes the fact that although Dr. Kwetkowski acted improperly by having a sexual relationship with his patient, he appears to have been an excellent caretaker for others, perhaps for the vast majority of his practice.

Best

Jim

Anonymous said...

At the time these articles were written, Dr. K. was 41. I know that from reading it in another article.

I'm not from RI, but lived there for a little more than a decade and Dr. K. was my doctor. Today I learned of his situation when tried to contact his office to request medical records be forwarded to me NY.

Physicians are obligated to abide by a code of ethics, I do understand that and agree that some sort of disciplinary action is justified. I don't however, believe that surrendering his license to practice medicine, permanently, is the appropriate measure of justice.

If you knew Dr. K., you would know that he is good man. I'm going to speculate for a moment (and anticipate some backlash for it) that as a non-native RI'er, who lived there for many years, and got to know the quirks of the resident culture, combined with the social demographics of the patient population of the geographic area in which Dr. K's practice was located--- the comments are not all that shocking. RI'ers fight change of any sort. Try asking a native for directions and they will give you directions by navigating you around landmarks that "used to be there." If you're not from there, you don't know that it used to be there!
But in my opinion, the most likely reason for the patients being so upset is that Dr. K. really was one of a kind. He never rushed you. He knew and remembered details about not just your health, but YOU, as a person.

I'll be the first one to admit that I am a terrible patient. Unless there is something seriously wrong with me, I see no reason to go to the doctor's office. I had always been that way. That is, until I met Dr. K. When I first met him, he was practicing with a large group in Pawtucket, RI, off of Blackstone Blvd. I wasn't fond of the practice but Dr. K. I liked. When he decided to step out and set up his own shop, I found him. Gradually, he did teach me the value of not being that person who waits until they are two steps away from death before dragging themselves to the doctor's office.

I hope his suspension is temporary. I also hope that his relationship with this woman turned out to be worth everything he has gone through and is going through. He took his medicine like a grown up and did not try to avoid punishment for violating the ethical code. To me, those are actions that tell speak just as loudly about the man's character as the actions he was judged for.

Jim Sabin said...

Dear Anonymous -

Thank you for your thoughtful comments. I was especially interested in your description of what Dr. Kwetkowski was like as a physician: "Dr. K. really was one of a kind. He never rushed you. He knew and remembered details about not just your health, but YOU, as a person."

This is exactly how we physicians should be with our patients, but all-to-often are not. It's easy to see how those characteristics could lead a patient to feel uniquely well understood and cared for, and to fall in love with him. And if Dr. Kwetkowski was at a vulnerable point in his life, that kind of idealization could lead to the kind of romantic/sexual involvement that occurred.

The important point that emerges from your comment and the comments published in the RI blog is that Dr. Kwetkowski was clearly a very talented caregiver. As I said in my original comment, if the affair with his patient was a single episode, and if Dr. Kwetkowski acknowledged his ethical violation and took steps to deal with whatever internal factors allowed it to happen, I would favor the possibility of a carefully supervised ultimate return to practice.

We human beings are complex creatures. Dr. Kwetkowski appears to have been capable of rendering superb care while, at the same time, commiting an egregious ethical violation. If it was indeed a single violation, not a pattern of exploitation, I hope he learns from his experience and finds ways of using his talents again.

Best

Jim

Anonymous said...

Dear Jim,

I read some really good comments on your blog. I have 1st hand facts regarding this case. This woman was 11 when she 1st starting seeing Dr. K she was a troubled foster child, who had just been placed in a prospective adoptive home. Dr. K cared for her all these years until Mom found out about the affair. The women told me that during an office visit Dr. K walked up to her and kissed her on the lips. She was stunned, he told her that he knew since the time she was 12 how beautiful she would be (the woman was now 18) They had sex in his office the same office where I took my children and sat on the same table they had sex on. This child/woman had many mental health issues. She had poor self esteem, among many other issues including losing both birth parents as a young child. Dr. K knew all of this. The women told me that after they had sex the first time Dr. K gave her money. It was not a small amount of money either. Although over time he continued to give her money whenever she wanted it. This is why she continued her relationship with him. Not to mention the fact that she was receiving free health care. This woman was also seriously addicted to heroin so she would do anything to get money. There is no way on this earth that he did not know she was a drug attic all the signs were there. Many people out there had some really nasty comments but I just bit my tongue and said if only they knew the truth. I feel as though Dr. K preyed on the young lady he definitely without a doubt knew how vulnerable she was. There was never a relationship of sorts it was just sex once in a while and money exchanged hands. The saddest part of this story is this young lady died last week from a drug overdose. It was people like Dr. K that helped make her feel more useless than she already did. It is time the record is set straight about this young lady. My whole family were patients of Dr. K's for a very long time we all looked up to him he was a very good doctor that was until we found out about the so called affair with this women. I know she looked up to him too. She was young, vulnerable and Dr. K definitely should have known better. Hopefully he will never do something like this with a patient again. RIP young lady.

Jim Sabin said...

Dear Anonymous -

Thank you for this very sad followup to the story about Dr. K and his patient. What a tragic life the young woman led.

I believe the word "victim" applies very strongly to the situation you describe. Dr. K had cared for this troubled child from age 11. A heroin addict who is receiving money for sex from an authority figure isn't a "consenting adult." An person with an addiction needs a competent, caring physician, not a sexual predator or a paying customer.

The behavior you describe is reprehensible - a violation of basic human ethics as well as professional ethics. But the important fact remains that Dr. K apparently took excellent care of many/most/almost all of his patients.

Without knowing the facts of the case I'd been uncertain as to what I would have recommended if I'd been on the medical board. The story you present would have led me to opt for permanent loss of license.

Let us hope that this troubled young person is indeed resting in peace!

Best

Jim

Anonymous said...

I question the credibility of the story that was recently presented here, just saying. What makes that information "first hand"???

Jim Sabin said...

Dear Anonymous -

Thank you for raising an important question.

I assume you're referring to the comment posted on November 26, 2011. If you're asking whether I have independent evidence that the comment is (a) true and (b) based on first hand information - I don't. It was written in a way that seemed trustworthy, but of course could have been false, or even maliciously intended.

Your question could be asked about many of the comments that have come in around the theme of doctor-patient sex. My policy has been (a) only post comments that seem plausible and (b) be careful to convey that my responses are to the comment and that I don't have independent information.

My aim is to respond to comments thoughtfully and respectfully, while not making accusations towards physicians the way a plaintiff's attorney would in the context of litigation.

Best

Jim

Anonymous said...

The story is credible because I am the dead women's mother. The mother who adopted this young lady and her brother. I took all 5 of my children to Dr K. He was a great doctor. I am still having a hard time finding a replacement. But that does not make what he did ok. Like I said in my story he met my daughter when she was 11 years old her mother had just been murdered. He know her life situation and the problems she had since that first visit I brought her to through her teen year she was a very troubled child. That is why it upset me so, because I too looked up to Dr. K and never would have expected that from him. Every person out there was so quick to judge me and my family saying we wanted money etc. Believe me I would never in my life do such a thing. Dr. K turned in his own license nobody told him to. He did he right thing. Rest in peace princess.

Jim Sabin said...

Dear "mother of the princess" -

Thank you for your comment. The story is progressively more painful as we hear more. This young woman lost her birth mother to murder, and later lost her trustworthy physician, who turned into an exploiter.

But as emerged so clearly from many of Dr. Kwetkowski's patients, he apparently was an excellent caretaker for most of his patients.

What a tragic situation!

Best

Jim

Anonymous said...

Here is the problem.. while yes, doctor/patient relations should be kept professional.. they were both consenting adults. The young woman may have needed help, however- in a court of law an addiction would not get her off the hook for murder- she would be tried as an adult, so why is everyone making it seem like she was a poor defenseless child. I know Dr. K as my doctor, but I also know people who know him out of practice. This is a caring and insanely smart man who has helped so many people, including myself. There are 3 sides to every story: His, hers and then the truth. While I offer my condolences for anyone's loss pertaining to the young woman- he was a better role model than the life she was living & financially helped her. You describe her as an addict, troubled, and only staying with him for his money. Is this how you want her to be portrayed? I think the comments have been very emotionally charged and the accusations are hard ones. I have learned a few things in life and my best friend was an addict for years before we had to thus end our friendship because she was robbing people blind.. Never trust an addict. If they are THAT addicted as it was made to look in these past comments- manipulation of those who surround them tend to be the major tool they use in getting their way. I do not think he should have turned in his license, but he did- because he is just that kind of person. This man worked hard for years and devoted his life to the medical field and from what it seems like, let his heart get in the way and helped out the wrong people. I hope he is practicing again and I would love to know where because I will finally have my family doctor back.

Jim Sabin said...

Dear Anonymous

Thank you for your comment. You add to the picture of Dr. Kwetkowski as a physician capable of providing superb care.

While I do not, of course, have any first hand knowledge of the situation, from what's been said in the comments I don't agree with your view of the patient as a "consenting adult." The picture that emerges from the comments is of a desperate person - immature, addicted, and in need of money. Those aren't the preconditions for true "informed consent."

But in terms of medical licensure, doctor-patient sexual involvement is seen as a betrayal of the medical role, even if the patient-partner is a mature adult who is fully capable of self-guidance.

I am sorry that you have lost a physician who you found so excellent and trustworthy!

Best

Jim

Anonymous said...

Dr. Kwetkowski is a great Dr and I was saddened when he had to close his practice. He did get his license back and working somewhere in Warwick, but there are stipulations. I would not be afraid to have him as my pcp if he was closer to where I live. Great doctor, great person. He just made a mistake, which makes him human.

Jim Sabin said...

Dear Anonymous -

Thank you for bringing me up to date on Dr. Kwetkowski's situation. I've now read the report of his reinstatement on the Rhode Island website. I'll probably write a post about the Medical Board's action. I would guess that the fact that so many of his former patients describe him as having provided excellent care, just as you do, contributed to the Board's decision.

Again, thank you for the follow up. I hope that Dr. Kwetkowski's return to practice continues to be successful, from the joint perspectives of clinical care and medical ethics.

Best

Jim

Anonymous said...

Dear anonymous November 26,2011 ~

Clearly you either do not know the true facts of this case or you are flat out lying. Or perhaps it is both. Regardless, I know him very well, and on a highly personal level. I agree he made a poor decision in ethical judgment as a physician, but the fact remains the same..he is a tremendous doctor and a wonderful, honorable man. This affair began when the young woman was 19, and that is 100 % the truth. The medical board requires lie detector testing. So, as I am quite sorry for the tragic loss of this young lady, I still feel compelled to make it very clear to all that Dr. Kwetkowski is by no means a threat to his patients nor a deviant who preys on troubled young women. I think if we compare the life histories, you said yourself she had a "severe heroin " addiction and a lifetime of psychological issues, it is clear that perhaps you might have been misinformed of the exact way the events carried out. Believe me, he was subjected to extreme scrutiny and questioning in which it is impossible to lie..and what you have typed above is simply not the truth!

Anonymous said...

And to the mother,
I'm sorry for your loss, truly I am. I'm sure many might think you were after money ...however, I wouldn't have dreamed of thinking of you. I do however, think your daughter is capable of it. Again, she was an adult and as adults we cannot use our past as an excuse for behaviour thats unacceptable. Although he clearly made an extremely poor decision, your daughter also played a role in this that isn't one of pure innocence. She was a consenting adult , and her past is no excuse to say otherwise. Had he been in any other profession, this would not be a big deal! You must know in your heart, that your daughter also made an error in judgement. For that, I judge her.

Jim Sabin said...

Dear Anonymous -

I assume both comments are from the same "Anonymous," so I'm making a single response.

Your comments read as if you (a) acknowledge that Dr. Kwetkowski was sexually involved with the young woman but (b) believe that he should not be seen as a "deviant" or chronic exploiter. Many of his patients wrote in the same vein - that he was an excellent physician to them. It's entirely possible that this was a single incident and that a crystal ball would have told us that it would never be repeated. Unfortunately, we don't have crystal balls to tell us about the future with unerring accuracy.

And, separately, even if a lie detector was used, the technology is not infallible. It's not "impossible to lie." But it's entirely possible that a human being can make a single major mistake that is (a) uncharacteristic and (b) never repeated.

Your second comment raises complex questions. With regard to responsibility, an addicted 19 year old, perhaps short of money, and in a child-like relationship to a physician who has cared for her since childhood, is not the same as a mature, non-addicted adult. From the facts that I'm aware of, launching a sexual relationship in that situation could be seen as having some of the characteristics of child abuse as well as some of the characteristics of a relationship between consenting adults.

But the theme that emerges again and again in the comments on this post and others on the same topic is that physicians can exhibit severe ethical lapses in one situation and conduct themselves very well in others.

Thank you for your comments!

Best

Jim

Anonymous said...

Regardless of what anyone says Dr. K did something wrong, he paid the price for that and my daughter is dead. I never said my daughter didn't lie, manipulate and steal among many many other things drug addicts do. She was far from perfect. But she was my daughter, a year has passed now since she died. Anonymous says I flat out lied about some of the statement I made. I didn't lie about anything my daughter told half truths so maybe some of those things were also half truths. but some things I did know first hand because I had a short conversation with Dr. K. If he took a lie detector test that's great. But like I said he did something wrong it was against the oath he took as a doctor. And people look up to their doctor, I know I do, I looked up to and trusted Dr. K for many years, myself, my husband and our 5 children. And I will probably never ever find another doctor as good and kind and caring as Dr. K was. It's been a year and I still haven't. Hopefully he learned his lesson and will never become involved with a patient again. anonymous

Jim Sabin said...

Dear anonymous -
I am sorry for the delay in posting your comment - somehow it didn't come to my attention until today,
As you say, people with addictions often show problematic behaviors - manipulation, lying, stealing and more. These behaviors can create confusion and uncertainty for physicians. But even if your daughter was "seductive" in a medical relationship, it is the responsibility of the physician not to follow the seductive invitation.
The fact that even after the events you describe you recognize and appreciate Dr. K's positive skills provides further testimony to the fact that a physician can perform very well in one sphere of activity and very poorly in another.
Thank you for your thoughtful comment!
Best
Jim