Crossing Doctor-Patient Boundaries: A New Paradigm?
By John Graham
September 25th, 2013
In the September 25, 2013 issue of JAMA (2013:310(12): 1233-1234) there is an interesting article entitled, “Crossing Boundaries – Violation or Obligation?” by Gordon D. Schiff, M.D. Dr. Schiff’s article appears in the section A Piece of My Mind and raises an issue that deals with finding a healthy balance in the doctor-patient relationship.
Schiff’s article begins this way: “It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors. This allegation of an ethics violation was not only personally painful; it also raised important, controversial, and timely questions about appropriate professional roles.”
I think any physician would identify with Schiff’s lament. His article acknowledges that physicians must respect certain boundaries in patient relationships in order to avoid “improper expectations, dependency, legal liabilities, and confusion of personal and professional relationships.” But, what concerns him is what he says is a “new paradigm (that) risks encouraging detached, arms-length, uncaring relationships.” He asks, “When do ‘boundaries’ become barriers to meaningful caring relationships?” A great question and one that is worthy of the consideration of decision-makers and all involved in patient care.
Of course, the creation of boundaries is intended to protect the patient. For example, an act of kindness which the doctor described can cause a patient to feel he or she must respond reciprocally. Still, while weighing such risks, Schiff says, “we need to be clear whose risks we are considering. Many of these risks are actually more risks to physicians, rather than to patients. Thus, those insisting on stricter boundaries need to rethink what they mean by ‘limits.’ Who are those limits designed to protect?” He goes on to say, “Let’s not pretend we are imposing limits for patients rather than our own best interests.”
He quotes the AMA Code of Medical Ethics which states: “The practice of medicine . . . is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. . . The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self interest . . . and to advocate for their patients’ welfare.”
Schiff is concerned that this code of ethics is now considered to be an “outmoded model of professionalism” which reformers hope to replace with a “more dispassionate business-like model where limitations and boundaries are more circumscribed and it is clear that we are not our patients’ friends, neighbors, or personal advocates for issues beyond their medical problems.”
He says “the real danger of personal engagement is not that we further complicate already complicated relationships with our patients by doing to much. Rather, it is that of tokenism—of doing too little and feeling satisfied and excused from addressing the social and economic injustices that underlie poor patient’ suffering.” He goes on to say, “We also need to stand alongside our patients in striving for a fairer, more caring world. If physicians want to stand aloof, addressing only the biomedical problems, ignoring and seemingly indifferent to their social circumstances of our patients, then patient/relation-centered medical homes are likely to feel more like gated communities than places where people live and work together. . . Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.”
As a physician (plastic surgeon) and as a priest (Episcopal), I applaud everything Dr. Schiff has to say in his article and commend it to every healthcare professional. Perhaps the decision-makers in this matter should read Thomas Moore’s excellent book: Care of the Soul in Medicine (Hay publishing, 2010). It would be a good starting point for anyone who must make decisions that will affect the sanctity of our long-honored doctor-patient relationship.