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.