Boundary Crossings A discussion David B Feller MD

Boundary Crossings: A discussion David B Feller, MD David M. Quillen, MD

Introduction What do WE mean by boundary crossing? n What do other people call boundary crossing? n Why do we feel that this is an important topic? n Discussion by examples n

Goal of Presentation Have an interactive dialog on a variety of boundary crossings n Talk to understanding n – Prevention failure – Management of stress Impact on Students and Residents n Impact on ourselves n

What is a boundary? n Dictionary – A line or a plane indicating a limit? n Physician <–> patient (In most cases would also include other types of care givers) – Physical and/or psychological structure that divide, separate, or define. ” n Dr. Howard Brook, University of Toronto

Boundaries - professional Professional Distance Maintained Physician From: Boundaries and Relationships, CL. Whitfield 1993. Patient

Boundaries – not professional Professional distance inappropriate Physician From: Boundaries and Relationships, CL. Whitfield 1993. Patient

Why is this important? n n Patients Physician We believe that discussing these difficult issues can prevent errors and reduce stress. Not simple – Too close is obviously a problem – Too distant is also a problem n The right distance is not fixed – Part of the problem

Who is responsible n Ethical – Physician n Legal – Physician n Professional – Physician n Doctor <–> Patient relationship – Both share responsibility

Cross vs. violate A “crossing” indicates some element of a problem n A “violation” indicates harm (to the patient) n n n Note: We recognize that patients have harmed physicians. An uncommon event and not the focus of today’s discussion. Note: There are physicians who are predators (sexual). As colleagues we need to recognize this and appropriately protect all patients.

Variability What is appropriate for one provider may not be for another n What is appropriate informality for FM may not be appropriate for therapists n Examples? n

Teaching Boundary Identification n For psychologists/psychiatrists – Formal instruction about identification and management – Career-long Balint groups to process and remind n For family physicians – Some instruction in most blatant examples of boundary violations (sexual, physical violence) in med school – Some outlet for evaluation in Balint groups in residency.

Why the difference? Time n Perception of reduced need n Perception that setting boundaries stifles the family physician-patient relationship making it too rigid, less dynamic and genuine n Difference in the type of care n

Physician vs. Therapist n Physician – – – Touch pt See pt undressed Provide directed advice – Home visits n Bedroom – Communicate with family n Therapist

Types of Boundary Crossing n n Professional Sexual – Pt -> Doc – Doc -> Pt n n n Social Racial Gender specific Financial Behavioral

Teach Residents and Students with Examples Professional n Financial n Social n Sexual/Affectionate n Inappropriate behavior n Teach that open discussion is a way to work towards management n

Help Learners be Sensitive to… Location. Be aware of boundary crossings in non-clinical settings. n All aren’t bad, and some might promote a better doctor/patient relationship. n Be constantly aware. n Talk to colleagues about it. n

Professional Boundaries n Large area that covers many issues – Inappropriate medical requests n Narcotics n Work excuses n Disability requests (parking permits) n Other medications

Softer Sexual/Affection Crossings Patient asking specifically for opposite (or same sex) provider not just for comfort’s sake, n Comments on dress/appearance n Hugs n “I love you” n

Sexual Crossings n Some are obvious, unavoidable crossings – Many if not most family docs have experienced unintentional male sexual arousal n Not just Female doc -> male pt – Some medical schools discuss this with students.

Sexual Crossings Some are obvious, clear violations, ie. intentional sexual arousal or advancement n Managing intentional vs. unintentional n – Sensitivity is important n May not be clear violations to our learners.

Story (Doc -> Pt) sexual n n n MSIII “A” is told to do a complete physical exam on patient “Y”, including genital exam “Y” is a 17 y. o. and to “A” very attractive “A” is so disturbed by the attraction, the decision is made and followed through to go into neonatology to avoid further such incidences

Story (Pt -> Doc) sexual n PGY-1 “B” is in clinic and has a patient for a routine physical exam. During the exam, patient “x” becomes sexually aroused – Unintentional vs. intentional

Story (Pt -> Doc) sexual PGY-2 “C” is in clinic an has a patient “Z” of the opposite gender with bipolar disorder. n “Z” is very sexually suggestive to the point of suggesting meeting later after clinic. n

Story (Pt -> Doc) professional Physician “D” has been in practice for a number of years and is in clinic. n A regular male patient “Y” in his 50’s request a prescription for Viagra n “Y” does not have ED n Inappropriate drug seeking is a professional boundary crossing n

Story (Pt -> Doc) professional Patient come to the clinic drunk n Patient demands inappropriate treatment or testing n Patient offers an inappropriate gift of thanks (monetary etc) n – Physician accepts

Story - professional Patient emails and calls the clinic 3 -4 times a week n Boundary crossing? n Solutions? n

Small town problems n n n In a small town physicians, patients and social circles cross. Lesson from last years presentation this had more of the audience participating that any other issue. Being stopped in the parking lot and various other places in the community, medication refills, requests for $$, etc. Patients who start out as friends Patients who become friends Neighbors with medical problems Problems of “Being a doctor” rather than having a job (historic attitude towards physicians? )

Social Boundaries - children n n 38 y. o. female patient presents with many complaints including long history of depression, recurrent miscarriage, and mastalgia. She is accompanied by her 13 y. o. son and 8 y. o. daughter. When it becomes clear that she will discuss personal details related to these complaints, you offer to have her children be watched in the waiting room, but she waves you off saying "Oh doctor, they know all of this. " When time for the exam, you again offer another room for the children, but again she defers saying "They know what I look like, " and suddenly takes off her top. You cover her with a gown and proceed. The other side: Parents that are unwilling to leave the room when appropriate (as felt by physician)

Self Disclosure by Physician – A resident comes to ask your advice. While on her gynecology rotation, she noticed that the attending level gynecologist she is training under often gives details of her own experience with her IUD when counseling patients, including the detail that her husband can’t feel it. She notices that some patients respond well while others clearly seem uncomfortable. She asks your thoughts on this practice. – When is self disclosure an effective tool and when is it inappropriate?

Making Special Arrangements – R. F. is a 60 y. o. CIO of your hospital an influential and well -known member of your community who establishes with you. You have a good first visit. 2 weeks later, her personal assistant calls to say that R. F. has sliced her finger open on a letter opener, so although you have a full schedule, you fit her in at lunchtime. A week later, she emails to ask if you could change her follow up visit to a Saturday due to her busy schedule, even though you don’t have weekend hours. Next she calls with a “sinus infection” and asks for “the only thing that ever works: Levaquin. ” She is so busy that you say yes to all of her requests. – Poor quality of medical care in some instances

Making Special Arrangements Does this flexibility of response make “the relationship real, dynamic, and genuine” n or are you taking pride in the fact that such and important person is seeking your help? n

Being Asked Personal Issues n Personal Questions? – Obvious ones n More subtle ones – – “How many kids do you have? ” – “Is your husband a doctor too? ” – “Are you a religious person, doc? ” – “Will you pray with me, doc? ”

Being Asked Personal Issues – D. B. is a 45 y. o. male who comes to establish. His wife is a nurse in your office. She says he hasn’t been to the doctor’s office in a long time and she is desperate that someone have screen him for hypertension and diabetes. – During the first few minutes he tells you “Doc, I’m a political junkie. Knowing a person’s political party is as important to me as knowing what they look like. Could you tell me your political party? ”

Giving Gifts to Patients – S. S. is a 24 y. o. exotic dancer, mother of 2 and 6 y. o. kids, who is your OB patient. She has been slow to warm up to you, but by the end off the pregnancy, she smiles often and seems comfortable around you. Labor is hard, but you help her deliver a healthy son. You have two sons. So at her pp visit, you present her with two bags of hand me down newborn boy clothes. – She accepts them, but obviously seems uncomfortable.

Getting Gifts from patients Examples? n What might be appropriate? n What might be inappropriate? n

Conclusions Consequences can be very serious n Significant stress n Open discussion a major part of the solution n Important for learners n Important for our profession n – Identify inappropriate physician behavior – Manage difficult patients

References and Resources n http: //www. stfm. org/fmhub/fm 2006/September/Francois 570. pdf – CME workshop in recognizing boundary limits during a medical visit. Goulet F, Jacques A, Gagnon R, Boulé R, Girard G, Frenette J. Fam Med. 2006 Sep; 38(8): 570 -6. n http: //www. mja. com. au/public/issues/181_07_041004/gal 10557_fm. html – Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Cherrie A Galletly. Med J Aust. 2004 Oct 4; 181(7): 380 -3