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Setting Boundaries:A Little Distance Can be Healthy
Jennifer Potter, M.D.Michael Kahn, M.D.
Beth Israel Deaconess Medical CenterHarvard Medical School
Miser et al, Fam Med, 1996
Let’s Begin with a Brief SurveyCompare Your Answers…
• Question (survey responses, interns, 1996)
• Is it acceptable to date or have sex with a current patient? (90%: unacceptable)
• Is it acceptable to date or have sex with a former patient (> 40%: acceptable)
Miser et al, 1996
Would You Know What to Do If…
• A patient asked you for a date? (60%)
• A patient had an erection during the exam? (47%)
• If a patient of the opposite sex made sexual advances toward you? (54%)
• If a patient of the same sex made sexual advances toward you? (33%)
• If you were sexually aroused by a patient? (69%)
Miser et al, 1996
Have You Ever Experienced…
• A patient making a non-verbal advance? (40%)
• A patient making a verbal advance? (47%)
• A patient making a physical advance? (10%)
Miser et al, 1996
Do You Know…
• Of any health professions student, resident, or attending clinician who has had a sexual relationship with a patient? (33%)
What Does All This Tell Us?
• Clinician-patient contact outside professional lines occurs commonly
• Many of us lack experience/confidence dealing with boundary issues
Farber et al, Arch Int Med, 1997
Professional Boundaries:A Definition
Mutually understood, unspoken, physical and emotional limits of the relationship between a trusting patient and a caring clinician
Farber et al, Arch Int Med, 1997
Boundary Parameters
• Contact time between the 2 individuals
• Amount of information shared by each party
• Degree of shared decision making
• Shared physical and emotional space
Breaches by Patients
• Wanting more time than the clinician has to give
• Being overly friendly or curious about the clinician’s personal life
• Being overtly seductive or attempting to initiate a sexual relationship
• Various forms of gift-giving
Breaches by Clinicians
• Unusual time, duration, location of appts.
• Unusual access/availability
• Mishandling of fees
• Some forms of language use
• Misuses of the physical examination
• Overtly seductive behavior/propositions
Boundary Breaches Are…
• Inevitable:– Intimate discussion topics
– Close physical proximity
– ‘Sexualization’ of caring
• Sometimes inadvertent:– Broad spectrum of behavioral norms
– Variables: age, sex, ethnicity, culture, past experiences
• Important to attend to in order to ‘do no harm’
Mild: Boundary Crossings
Moderate: Boundary Transgressions
Severe: Boundary Violations
Boundaries: An Ideal View
• Not too diffuse
• Not too inflexible
Clinician-Patient Relationships:A Delicate Balance
• Bonding Objectivity
• Intimacy Power
• Dependency Autonomy
• Disclosure Privacy
• And many more….
Clinician-Patient Sex:At One End of the Spectrum
• AMA Code of Ethics: ‘Sexual contact that occurs concurrent with the patient-physician relationship constitutes sexual misconduct’
• Mutual consent highly questionable:– Transference
– Power imbalance
• Personal involvement interferes with clinician capacity for objective professional judgment
Gabbard & Nadelson, JAMA, 1995
Sexual Misconduct:How Common Is It?
• True prevalence unknown:– Survey studies, low return rates– Reported by 3 - 12% of male physician respondents
– Reported by 0.3 - 4% of female physician respondents
• Male physician/female patient most common dyad– 20% of cases involve same-sex dyads
– 20% of the physician perpetrators are female
What About the Gray Areas?
Useful Clinical Approach
• Make a hypothesis:– What’s really going on?
• Put yourself in the patient’s shoes:– What does the patient want / need?
• Consider your own motivations:– What do I want / need?
Case: A Non-Verbal Boundary Breach“He Looked at My Breasts”
After examining a woman with a facial rash, an intern (female) asked her supervising resident (male) to take a look. As he was visually inspecting the rash, the patient suddenly accused him of looking at her breasts in a way that made her feel uncomfortable.
Case: A Non-Verbal Boundary Breach“He Looked at My Breasts”
Taken aback, he angrily addressed the intern: “Just treat her for contact dermatitis,” and stomped out the door. The intern was left not knowing what to say, either to the patient, in order to salvage the visit, or to the resident, who never mentioned a word about the incident during their subsequent work together.
Case: A Verbal Boundary Breach“You Have a Beautiful Body”
A patient described her first pelvic exam as “a terrible experience.” She came to the appointment feeling anxious and worried about the procedure. During the breast exam, the gynecologist made a disturbing remark: “You have a beautiful body.” She now believes he made this comment in a attempt to put her at ease; however, at the time it made her feel panicky, and she couldn’t wait to get out of the room.
Case: A Physical Boundary Breach“He Rubbed His Genitals Against Me”
A physician was charged with sexual misconduct by a patient who claimed that “he rubbed his genitals against me.” He adamantly denied the accusation. On further discussion with the patient, it became clear that during a hug she had experienced the pressure of the physician’s genitals on her pelvis as genital contact. This had reawakened old trauma.
Common Themes
• Perception is colored by prior experience
• Clinicians need to be mindful of their own urges and hidden meanings
• Burden is on the clinician to manage the encounter appropriately
Avoid Making Boundary Breaches
• Be aware of your feelings
• You don’t need to act on them!
• If you’re considering action…trust your gut:
– If it doesn’t feel OK, it probably isn’t
What if It’s Too Late?
• Be honest with yourself
• Chart a new course with the patient
• Don’t sweep it under the rug
– Talk it over with a colleague
What’s the Difference BetweenGoing the Extra Mile, and…
Crossing the Line?
It’s Often a Fine Line
Beware of the Slippery Slope
Be Mindful of Common Pitfalls
• Excessive self disclosure
• Dual relationships
• Physical contact
• Inappropriate gift giving
Self-Disclosure
Personal Information:To Share or Not to Share?
• The positive:– Chatting about mutual interests builds rapport
• The negative (if excessive role reversal): – Misuse of patient’s time, money
– Misuse of patient to satisfy clinician’s needs
– Perception of clinician as needy/vulnerable patient discomfort expressing their own concerns
• Trust your gut and know your patient
• If it doesn’t feel ‘right’, it probably isn’t
What if the Patient Asks?
• “Are you married?”
• “What does your husband do?”
• “Do you go to church?”
• “What did Santa bring your kids at Xmas?”
• Sometimes innocuous; can be a quagmire
• How do we handle assumptions? What if the clinician is gay? An atheist? Jewish?
Handling Intrusive Questions
• What is the meaning for the patient?
• Respond with the meaning in mind:– “I go to synagogue, and faith is very
important to me.”
• OK to deflect questions gracefully:– “I prefer not to answer questions about
myself– we have so little time and so much to discuss– let’s keep the focus on you.”
What About Off-Color Remarks?
• “Thank God I finally have a non-Jewish doctor.”
• “I can’t believe what this world is coming to…those blacks…”
• Silence implies collusion
• “We have different thoughts and feelings about this topic…let’s get back to you…”
Dual Relationships
• A ‘dual relationship’ exists when another type of relationship coexists simultaneously with the clinician-patient relationship
• Examples include: financial or business relationships, collegial relationships, family relationships, and personal friendships
• Especially common in rural settings
Challenges in Dual Relationships
• Boundaries are less clear
• Patient may…– Discuss medical problems in inappropriate settings
– Withhold information perceived as embarrassing, burdensome, etc.
– Be less likely to adhere to Rx recommendations
• Clinician may…– Feel uncomfortable probing social issues
– Avoid performing intimate parts of the physical exam
– Under-investigate (poor objectivity) or over-investigate (inappropriate anxiety)
3 Useful Questions to Ask When Considering a Dual Relationship
• Am I too close to probe this person’s intimate history, perform intimate exams, or cope with bearing bad news?
• Can I be objective enough to not give too much, too little, or inappropriate care?
• Will this person follow my recommendations as well as he / she would under the care of a clinician who he / she did not know personally?
Negotiate Boundaries Jointly
• Discuss explicitly
• Deal with patient problems only within the appropriate setting (not at a party or in the grocery store), except in emergencies
• Consider excluding ‘sensitive’ parts of the history and physical exam and having these dealt with by another doctor
• Revisit the topic periodically: agree in advance that if either party begins to feel uncomfortable, an alternative solution needs to be found
Physical Contact: What’s OK?
A Handshake?
A Comforting Gesture?
A Hug?
Useful Rule of Thumb…
If it doesn’t feel OK to do it in public (for example, in the waiting room), then it’s not OK to do it in private.
What if you are Ambushed?
Consider the ‘Freebie’
Push the ‘Pause Button’
• “Let me just pause you right there…”
• “I’m a bigger fan of handshakes than hugs…would that be OK?”
What About Gifts?
Patients Give Us Many Gifts…
• Non-tangible: respect, gratitude, flattery
• Tangible items: an enormous range
– Homemade items
– $$$$ (small and large amounts)
– Bottle of booze, box of chocolates
– Rent-free use of a vacation home
– Barter: services for services
– Donation for research
– Naming the clinician in a will
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We Like Receiving Gifts…
“What’s the catch?”
But, Gift-Giving is Complex:Multiple Meanings
• To express gratitude
• A quid pro quo:– For special attention
– For better treatment
– For tolerating the patient
– To be remembered
• To equalize the relationship
• To personalize the relationship
Compliments Are Enticing…
But, Beware of Flattery
Case (Part 1): “You’re the Best!”
A 35-year-old woman presented requesting ‘another opinion.’ She brought an annotated list of her symptoms, internet printouts about diseases she thought she might have, and copies of numerous prior evaluations. After a history and pertinent exam were completed, the patient exclaimed : “You’re the best! I’ve seen 5 doctors this year. None of them ever listened to me, gave me such a thorough exam, or managed to figure out what’s wrong. I know you will.”
(Part 2): “Why Won’t You Help Me?”
The clinician felt sympathetic, intrigued, and flattered. She reviewed the records, patiently answered numerous questions, and ran overtime. Labs were ordered and a f/u appointment made in one week. The patient called later the same day, requesting results. The receptionist told her they were not yet available. On arrival at work the next day, the MD was greeted by 3 phone messages: 1 from the patient (“Why won’t you help me?”), 1 from her husband (“We’re still waiting to hear from you”), and 1 from Patient Relations (“Patient complaining that her phone calls are not being returned”). She felt baffled, betrayed, and angry.
What Happened?
• The MD was seduced:– She ate up the idea of being ‘the best’
– She wanted to be ‘the one’ to crack the case
• The patient was starving (a bottomless pit):– She had unrealistic expectations
– No amount of attention could fill her
– She handled disappointment poorly
What Might Have Helped?Appreciate Our Own Hunger
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Appreciate Concept of Transference
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Can’t Let Ourselves Be Eaten Alive
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Set Limits & Expectations
• “I can see that you have 25 things to discuss and I’m aware that we have 15 minutes. Which 3 things do you think are most important to get to today?”
• “I’d like you to bring these records to your next appointment. We can review them together then.”
• “I’m glad you feel good about this appointment. But I’m sure the time will come when I disappoint you, just like the other providers you’ve worked with. If we’re going to be successful working together, that’s something we will have to work out.”
• “Here’s how the practice works…”
Tangible Gifts:Similarly Complicated
Consider the ‘Simple’ Gift
• A grateful patient expresses thanks by baking you an apple pie
• Is it okay to accept the apple pie?
Not As Simple as Apple Pie
• She brings more treats to subsequent visits
• You notice she never arrives empty-handed
• What is the meaning of her gifts?
• Does she expect anything in return?
• Do you feel obligated to her in any way?
• How will you feel when she arrives empty-handed?
Possible MeaningsPossible Responses
• Her behavior could be cultural
• She may feel un-deserving of care
• She may expect special treatment in return
• Ask about cultural norms
• Inform her she does not need to bring gifts in order to receive appropriate care
As It Turned Out…Definitely More Than Mom & Apple Pie
Now What?
• After a while, she begins to ask for favors: appointments during non-clinical time, phone vs. letter notification of results, etc.
• Clear limits need to be set with her
• It is never too late to try to get ‘back on track’
Expensive Gifts:Does Value Matter?
A middle-aged woman presented her internist with a gold and ruby ring made in her family’s jewelry business. She explained that she and her daughters wanted her to have it as a thank you for the special attention she had given them and their husband / father during the months surrounding his death.
When is a gift “to much?”
Do institutional guidelines help us?
How can gifts be declined gracefully?
When is a Gift Inappropriate?
• In the era of compliance…many institutional guidelines
• Some prohibit all gifts, others monetary gifts or gifts over a certain value
• Gifts are inappropriate when they impact the clinician-patient relationship negatively
• Clearly inappropriate: gifts that are too personal or intimate (eg. underwear), too extravagant (raising possibility of an ulterior motive or hypomanic behavior), or more than the patient can afford
Should I Accept a Gift?Useful Questions to Ask Oneself
• What are the apparent motives?
• Is there a context for the timing?
• Is the giving tied to relationship dynamics?
• Will the gift change how I feel about the pt?
• Will the gift have an impact on treatment?
• Is the gift ‘too much’?
Try the ‘NY Times headline test’…
Doctor Accepts Potato Knish
Doctor Takes $30K Tip From Patient
Gracefully Declining…
• Danger: rejecting a gift = rejecting the giver
• Express thanks; appreciate thoughtfulness
• Contextualize and de-personalize the refusal
• Suggest donating the gift to a practice fund, etc., so all can benefit
Let’s Turn Now to Sexual Issues
How Should We Handle It When…
• A patient is aroused during an exam?
• We feel aroused during an encounter?
• A patient makes a verbal proposition?
• A patient displays subtly inappropriate behavior?
• A patient acts in a grossly inappropriate manner?
When the Patient is Aroused
• Example: patient develops an erection
• Should we:
– Ignore it and continue the exam?
– Acknowledge that it is happening in some way?
• Little in the literature to guide us
Clinician Survey
• E-surveys sent to 80 PCPs– 21 responded (26% response rate); 13 female, 8 male
• Common event; especially when the patient is young and the clinician is female
• Makes both patients and clinicians uncomfortable• Thoughts about the meaning:
– Normal physiological response– Response to prolonged exam– Disinhibition (psychiatric or medical cause)– Sexual attraction or arousal
Survey, (cont.)
• Ignore and finish exam as quickly as possible– It’s a bodily event like a burp or passage of gas
• Acknowledge in a matter of fact way and continue– Explain that it’s normal, there’s nothing you can do to control it, and
that you are not embarrassed by it
• Ask if it’s too uncomfortable to continue the exam • Offer to examine with a chaperone present• Offer follow up for genital exam with a male clinician• Offer to leave the room until it resolves• Stop the exam and refer patient to urology• Discuss boundary issues if any hint of inappropriate behavior
When We Are Aroused
• Example: feel attracted to a patient
• Remember…– Feelings are normal
– It’s not OK to act on them
– Be cautious about non-verbal/verbal messages (example: “get a rise out of”)
Watch Your Language…
“Disrobe, and we’ll check my reflexes… I mean, your reflexes”
Invitations & Propositions:How Should We Respond?
Case: An Invitation
A resident on GI rotation was asked to preop an anxious, 35-year-old man presenting for colonoscopy (because of a FH hereditary polyposis). After introducing herself, and before even beginning the history-taking process, the patient chuckled and said: “What are you doing tonight? Do you want to go out for a drink?”
What’s Really Going On?What Does He Really Need?
• His comment could be an attempt to diffuse his anxiety about the procedure, change the power dynamics, establish gender role
• He needs reassurance, education, explanation
• Possible response: “It helps to think about being anywhere else but here, doesn’t it!?” Followed by: “I’m here to help you through this procedure today. Let’s talk about what we’re going to be doing…”
Addressing Inappropriate Sexual Behavior That is Subtle
Case: “I Feel a Lump in My Scrotum”
A 57-year-old man presented repeatedly for testicular examinations, stating: “I feel a lump in my scrotum.” Initial and follow-up exams were negative, as was an ultrasound. He initially refused to see a urologist (all male MDs) because of a h/o sexual abuse (male perpetrator). Eventually he agreed, and the urologist concurred that the exam was normal. Despite this reassurance, the patient returned again, this time asking to be examined after masturbating: “You’ll be able to feel the lump if you check me when I’m erect.”
What’s Really Going On?What Does He Really Need?
• At first, the patient was given the benefit of the doubt: perhaps a mass was present that was difficult to appreciate.
• As the story played out, it was clear that his behavior was manipulative, and that he needed clear limits.
• Possible response: “That’s not appropriate. From now on, when you need a genital exam, I’m going to refer you to the urologist.”
Addressing Inappropriate Sexual Behavior that is Blatant
Case: No Panties
An attractive young woman presents for her first office visit. She is wearing a mini-skirt and a low-cut top with no bra. Significant cleavage and erect nipples are showing. As you usher her into your office, she bats her eyes and is overtly flirtatious. You decide to ignore this at first, but during the interview quickly become aware that she is sitting in such a way that you have a bird’s eye view of her perineum. She is not wearing panties.
What’s Really Going On?What Does She Really Need?
• Is this warped attention-seeking behavior? Or is it a manifestation of an underlying psychiatric or medical disorder?
• Duty to rule out and treat illness
• Must also protect ourselves
• Set limits and obtain a chaperone
• Call for backup if necessary
Case: “You’ve Got Nice Knockers”
After a complicated surgery, a 45 year-old man with bipolar illness required frequent dressing changes. A nurse manager was called in after only 24 hours because the ward staff were disgusted by his behavior and reluctant to enter his room. On inquiry, she learned that the patient leered at the nurses, made obscene remarks, and on one occasion had actually reached out and squeezed a nurse’s breast, saying: “You’ve got nice knockers.”
What’s Really Going On?What Does He Really Need?
• Similar to the last case: most likely disinhibited
• Needs a workup and limits, limits, limits
• Safety first:– Take physical action: step away/push his hand aside
– Leave the room and obtain assistance, if need be
• If you do not feel threatened it can be effective to ‘name it and stop it’:– “Stop. It’s not OK to touch me. I don’t like it and nobody else
here likes that kind of behavior. If you want us to take care of you, you need to keep your hands to yourself.”
The Behavior is the ProblemNot the Patient
Boundaries are Healthy
Ask: “How Do I Feel”?Trust Your Gut
trustyourself.more than youyou knowthink you do
Ask: “What’s Going On”?Make a Hypothesis
Ask: “What is Needed”?For Me? For the Patient?
Take Assertive Action Steps
Don’t Go It Alone
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