Boundary Crossings and Violations in Special Situations

by Mark Hughes, MD, MA

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    00:00 Let's talk about 3 kinds of situations where it's important for the clinician to be mindful of boundary crossings.

    00:07 The first would be romantic and sexual relationships.

    00:10 The second would be instances where friends are also patients.

    00:15 And the third is when friends and family are not our patients, but they might come to us seeking advice or actual treatment.

    00:24 The first scenario is romantic and sexual relationships with patients.

    00:28 So the first and most important thing to say is sexual contact with the patient is always a boundary violation.

    00:35 So a romantic or sexual relationship of any type between a clinician and a patient would be considered inappropriate and therefore forbidden.

    00:44 Even if the patient consents to it, that is not a defense to an allegation of sexual abuse.

    00:51 Because the patient is vulnerable and in a vulnerable situation, the clinician cannot take advantage of that relationship then to make it progress to either a romantic or sexual relationship.

    01:04 And the more vulnerable the patient, the greater the power imbalance is between the patient and the clinician.

    01:10 So, if patients are suffering from emotional or emotional illness or have chronic disease, the heightened vulnerability means it's even more important to observe the boundaries with these patients and avoid it progressing to any kind of romantic or sexual relationship.

    01:28 The second scenario is when we have patients who are also friends or maybe we have friends who become our patients.

    01:38 Here, there's a dual relationship with this person.

    01:42 We both have a friendly relationship with them, but now we're also in a therapeutic relationship with them as their clinician trying to take care of their healthcare needs.

    01:53 So, we might be able to socialize with them.

    01:56 This, you know, commonly happen in small communities where there may be limited access to physicians or other clinicians.

    02:04 So, you know, the people that you're going to be friends with in the community may very well be your patients.

    02:12 In these cases, it's still important for the clinician to be conscious of the potential for boundary crossings and as much as possible to separate their personal and their professional obligations.

    02:23 So even upfront in establishing a patient relationship with your friend, it's being clear about what those boundaries are and that they understand it and both of you will respect that.

    02:36 The closer the relationship is between the clinician and the patient, there is going to be the greater the risk of a perceived boundary violation.

    02:44 So, you might deviate from what you think is your professional obligation in terms of managing their disease process because they're a friend.

    02:55 You might learn very sensitive information as a result of the clinical encounter, but that has bearings on your friendship or, you know, perhaps your mutual friends or if they're married, you know, you learn things about your friend who is the patient and that has impacts on their spouse who is also a friend of yours.

    03:15 So, it can get very tricky so you really have to be very clear and cognizant of boundary violations and at all times you're really trying to maintain that objectivity.

    03:26 So, when we're friends, we're much more subjective, we're much more feeling towards, you know, wanting to be there for our friend and support them but the dynamic of a therapeutic relationship is a little different and has to maintain that objectivity to know how to best treat the patient.

    03:45 Now, you may have encountered already in your training or as you progress you're going to have times when family or friends just come to you and seek your advice.

    03:55 So they're not your patients, they're not in a therapeutic relationship with you, but nonetheless they know that you've got some clinical expertise and they're coming to you either, you know, to get a treatment or prescribe a medication or maybe it's, you know, they've got these symptoms, what do you think they mean.

    04:13 Generally, the policies that are established would say that physician should not treat or prescribe for family members.

    04:23 There may be minor conditions that they could treat, there could be emergency situations where they might do that, but generally it should be avoided because, again, you're not having that objectivity towards the family member.

    04:37 You may, you know, if you start doing this you may find that you're not actually asking personal questions about the patient because you don't want to, you know, interrupt the family dynamics or you may not perform a complete physical examination.

    04:52 You may not actually document the encounter.

    04:54 And we're going to have another lecture about the importance of documentation.

    04:57 So when you're just doing this, you know, as a courtesy to a family member, all of these things mean that you're not actually being objective in managing what you would normally do as the clinician.

    05:14 And it might be on, you know, the side of your family member or friends that they are reluctant to share the sensitive information.

    05:20 Or, you know, in order to just avoid any kind of sensitive topic, they would just give you false information which also is not going to be ultimately beneficial for them in terms of taking care of whatever their condition is.

    05:39 I mentioned this before, but it maybe that, you know, protecting confidential information could be even more in jeopardy.

    05:47 So, your friend who is not, you know, your patient but is sharing things that they've had an affair and now they have a sexually transmitted disease.

    06:00 What are you going to do with that confidential information if you know that it has bearing on, you know, their spouse who is also your friend? Are you going to break confidentiality? Becomes very awkward in those circumstances.

    06:12 So, best to avoid, you know, getting into these treatment dilemmas.

    06:19 And it may be times when, you know, the family member actually experiences serious complications.

    06:24 So, there've been some, you know, historic examples of, you know, physicians performing surgery on their own loved ones.

    06:32 But what if there were complications from that? What it might have a devastating effect on the physician that they cause this complication but didn't intend it, but it happened and now their family member wears off.

    06:45 And also for the family member who's, you know, agreed to this, what's the relationship dynamic going to be now with this clinician who has been a family member? So I think the end message for all of these would be when it's not a therapeutic relationship, you should generally try to avoid treatment or advice.

    07:10 So it's important when it's outside this therapeutic relationship to first of all be cognizant of the boundary crossing, know when it might lead to a violation, always maintain your objectivity, obviously show concern for your loved one.

    07:24 You know, your family member, your friend, you're concerned about them, you want to be supportive but figure out other ways that you might assist them.

    07:31 So it might be reasonable to offer knowledgeable advice without crossing line into actually giving them a diagnosis or providing treatment to them.

    07:40 It may mean that you assist them in finding a qualified physician.

    07:44 So, they describe their symptoms, what they're worried about.

    07:48 You can, you know, help guide them to the right position to take care of that condition.

    07:54 There also are going to be challenges in navigating the healthcare system and so your knowledge as the clinician about how the system works might facilitate them getting through the system and getting to the appropriate care they need.

    08:07 And also, it may be reasonable to accompany them to any of their medical appointments if that's possible.

    08:13 You can be another set of listening ears that, you know, hear the information from the physician or other clinician.

    08:20 It's also a means of you being able to ask questions on behalf of your family member or friend.

    About the Lecture

    The lecture Boundary Crossings and Violations in Special Situations by Mark Hughes, MD, MA is from the course Communication with Patients and within the Health Care Team.

    Included Quiz Questions

    1. Having a romantic relationship with a patient
    2. Caring for a colleague as a patient
    3. Having a platonic relationship with a patient
    4. Giving friends medical advice
    5. Caring for a family member as a patient in an emergency
    1. By maintaining objectivity
    2. By combining personal and professional lives
    3. By never discussing work with family
    4. By never discussing family at work
    5. By never discussing work or family
    1. Avoid treating family members except for minor conditions or emergencies.
    2. Avoid treating family members except for major surgeries.
    3. Treat first-degree family members outside of a therapeutic relationship.
    4. Treat friends outside of a therapeutic relationship.
    5. Treat second-degree family members outside of a therapeutic relationship.
    1. Recommending a specific doctor
    2. Sending a prescription
    3. Prescribing a narcotic
    4. Offering psychotherapy
    5. Writing a doctor's note

    Author of lecture Boundary Crossings and Violations in Special Situations

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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