Boundary Violation

by Mark Hughes, MD, MA

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    00:00 Alright, so boundary violations are what we're trying to avoid.

    00:07 It's not only harmful to the patient, it's harmful to the relationship.

    00:11 And the concern would be that it's exploitive of the patient.

    00:16 So, again, if the patient is vulnerable as a result of their illness, a boundary violation is going to take advantage of that vulnerability and put them in worse off shape.

    00:29 Some examples for this might happen.

    00:31 So, as I said, generally we're focused more on the patient than them sharing information about themselves in their life and not so much about ourselves.

    00:40 So excessive self-disclosure about you, the clinician, should be avoided.

    00:45 So, it might be fine to say who your favorite, you know, sports team is or you know that you got a pet or you know some general things that are, you know, relatively neutral but excessive self-disclosure, talking about relationship difficulties that you're having or other things becomes more focused on you rather than the patient.

    01:11 And again, worrying about things like counter transference.

    01:16 When it comes to gift giving, you know things that are excessive.

    01:20 So, you don't want to have things that become a boundary violation.

    01:25 It might be fine to accept, you know, flowers or a box of candy from a patient as an expression of gratitude, but getting buck seats to a football game maybe excessive and change the dynamics of the relationship.

    01:41 So you have to pay attention to when you think it's inappropriate and then actually decline.

    01:47 Say "I thank you very much to nice gesture but I can't accept the gift." So, when we're doing a history, we obviously are trying to learn things about the patient to help in making a diagnosis or figure out, you know, treatment options but probing for inappropriate or irrelevant personal information about the patient if it's really not, you know, the intent towards therapy of the patient, that can be a boundary violation.

    02:17 Failing to respect the patient's privacy.

    02:19 So we do learn private information about the patient.

    02:23 We are going to have a separate lecture on that in this series, but the idea that you might, you know, disregard the need to protect that privacy is a boundary violation.

    02:34 So you learn this private information, you have to keep it secret and just within the relationship.

    02:44 And failing to obtain consent for intimate examination.

    02:46 So, there are, you know, checking a pulse is one thing, doing a gynecologic exam on a patient is another.

    02:54 So, there might be a need for having chaperones for the more intimate parts of the examination and really making sure you're checking in with the patient that they're going to be okay with that.

    03:06 So here are some strategies to avoid boundary violations.

    03:10 So, as I've said, you know avoid disclosing unnecessary personal information about yourself or sharing intimate details about your personal life.

    03:20 Give clear timely explanations of the reasons for your taking a history and doing examination.

    03:25 So it's not, you know, this inappropriate probing of the patient in their life but there's a reason that you are gathering information in the history taking or the reasons for you doing particular part of the exam.

    03:40 If you are getting a sexual history, make sure it's relevant to the clinical situation and performed in a sensitive manner.

    03:49 If there is going to be touching as, you know, with the therapeutic touch or during a physical examination, make sure that it's not misinterpreted by the patient.

    03:58 So, as I mentioned, use of chaperones is one way to avoid that to point out to the patient that you're not doing anything inappropriate.

    04:08 And, you know, respect the patient's right to privacy.

    04:11 So if it is going to be requiring a physical examination, make sure that there is appropriate draping so you're attentive as you're doing the exam that either using a sheet or a gown to appropriately drape the patient.

    04:25 And if the patient is having to change into, you know, a hospital gown that you step out of the room to allow them to change so they again don't feel any kind of violation of their personal space.

    About the Lecture

    The lecture Boundary Violation by Mark Hughes, MD, MA is from the course Communication with Patients and within the Health Care Team.

    Included Quiz Questions

    1. It harms the patient and the clinician-patient relationship.
    2. It does not harm the clinician.
    3. It irrevocably damages the patient-family relationship.
    4. It has no effect on the office staff.
    5. Boundary violations are often positive.
    1. Failing to respect a patient's privacy
    2. Accepting any gift from a patient
    3. Any self-disclosure
    4. Obtaining consent from a patient for an intimate examination
    5. Being late to an appointment

    Author of lecture Boundary Violation

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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