Recognizing boundary issues
Originally published September 2014
Patients depend on and trust their physicians. The relationship between the two is also characterized by an imbalance of power and a particular vulnerability on the part of the patient. As a result, physicians have a fiduciary duty to patients. They must act in good faith and with loyalty toward patients, never placing their own personal interests ahead of their patients. Practitioners' professional behaviour must be beyond reproach and appropriate boundaries must be maintained with patients.
A boundary in this context is an accepted social, physical, or psychological space between people. Boundaries create an appropriate therapeutic distance between physician and patient and clarify their respective roles and expectations.1
Boundary transgressions include a wide range of behaviours, from the more subtle to the obvious. Most medical regulatory authorities (Colleges) recognize two categories of transgression: crossings and violations.
Misunderstandings and carelessness can sometimes result in a boundary crossing. For example, accepting a small gift from patient might help strengthen the relationship, though such a gesture might be accompanied by inappropriate patient expectations related to the provision of future care. Similarly, the holding of the hand of a grieving patient may be appreciated, but some patients might not welcome physical contact so this could represent a boundary crossing.
Harmful and exploitative acts would be considered boundary violations. Examples of boundary violations include sexual contact, giving or accepting inappropriate or elaborate gifts, probing for private information that has no relevance to the clinical issue, acting in a dual capacity, excessive self-disclosure, entering into business relationships with patients, and failing to obtain adequate consent prior to intimate examinations. Professional consequences for boundary violations may include revocation of licence, public censure, and financial penalties.
Case example: Dual relationshipsA young family physician has a patient who he later befriends. They enjoy playing squash together. During a game the patient trips and strikes his head forcibly on the side wall of the court. He is able to finish the game but has some mild neck discomfort afterwards. The physician examines him briefly and feels that the injury is strictly soft tissue. The following morning the patient is awoken from sleep with severe neck pain, facial numbness, and intermittent vertigo. He is seen by his physician friend who examines him briefly and assures him that worsening neck pain is expected on the second day after a soft tissue injury. By the evening, the patient has developed severe vertigo, ataxia, and dysarthria. He is seen by another physician who refers him to a neurologist. The patient is diagnosed with spontaneous vertebral artery dissection and Wallenberg syndrome. His recovery is very limited.
- Maintaining objectivity is difficult when there is a dual relationship. In this instance, the physician assumed that worsening neck pain was secondary to the minor injury that he witnessed. A more careful history would have revealed the patient was awoken from sleep with the sudden onset of pain. Under scrutiny, it is unlikely that the physician's brief assessment would be seen as meeting the standard of care. Having an impartial colleague examine the patient may have led to an earlier diagnosis.
Case example: Intimate examinationsA male emergency physician evaluates a male patient with chronic abdominal pain and an extensive psychiatric history. As a routine part of the physical evaluation, the groins and genitalia are examined. No abnormalities are detected and the patient is discharged. Two days later the physician is notified by the patient advocate that the patient has complained, stating that the physician neither informed him nor sought his consent prior to the genital portion of the examination. The physician apologizes to the patient and subsequently revises his practice to include a consent discussion prior to performing intimate examinations with same-sex patients.
- An intimate examination of any patient requires both an explanation and express consent. It is prudent for doctors to have a chaperone present when performing intimate examinations of patients of the opposite sex. During an examination of same sex patients, doctors may also wish to have a chaperone.
- Patient complaints may provide an opportunity to change a traditional practice that is inconsistent with the current societal or professional norms.
- Patients should have privacy when undressing and re-dressing. A gown should be provided. Avoid adjusting or removing a patient's clothing without express consent.
Case example: Intimacy after the termination of the doctor-patient relationshipA newly qualified female family physician is working in a small community. At a dinner party she meets a recently divorced teacher whom she finds attractive and engaging. She accepts the teacher into her practice and provides routine care and extensive counselling during the ensuing two years. Neither party pursues a personal relationship during this time although they often see each other at social events. Consensually, they decide to pursue a relationship and the physician advises that she can no longer have him as a patient and terminates the professional relationship. The physician ends the intimate relationship after two years. Shortly thereafter she receives a College complaint alleging professional misconduct and sexual exploitation, citing the College's policy on boundaries and sexual abuse. The matter proceeds to discipline, where the physician's licence is temporarily suspended and she is required to attend a boundaries course. In the opinion of the College, the patient was vulnerable because he received psychotherapy from the physician.
- In instances where sexual contact occurs after the doctor-patient relationship has ended, the physician may still be found to have committed professional misconduct.
- In determining the propriety of a sexual relationship between a physician and a former patient, a number of factors will be considered: length and nature of the doctor-patient relationship, the extent to which the patient has confided personal and sensitive information, whether psychotherapy has been offered, and the vulnerability of the patient.
- A physician has an ethical obligation not to exploit the trust and dependence of both current and former patients.
- Advice may be necessary prior to making a decision to enter into a personal relationship with a former patient.
- An inherent power balance exists both during and after some doctor-patient professional relationships.
- College guidelines on terminating a doctor-patient relationship should be applied.
- Physicians should be familiar with College guidelines or policies on boundaries.
- All Colleges have "zero tolerance" with respect to sexual abuse.
Case example: Accepting gifts and favoursAn internist has a close personal relationship with a wealthy business owner with whom he frequently travels and attends exclusive fishing lodges, often at the businessman's expense. The internist also sees him regularly as a patient and provides care for a stable cardiac condition. During an office visit the patient asks to have a travel insurance form completed prior to an extended trip to the United States. He successfully encourages his physician friend to downplay his cardiac history. While away, the patient suffers a serious myocardial infarction requiring prolonged and expensive hospitalization. The insurer requests a copy of his medical record and denies the claim after becoming aware of his pre-existing cardiac condition. The insurer lodges a complaint with the internist's College alleging willful misrepresentation. The College issues a verbal caution to the internist and he is required to attend a course on boundaries.
- Dual relationships with patients result in conflict of interest, lessen clinical objectivity, and ultimately may impair clinical judgment.
- Accepting gifts or other financial benefits from patients may create an expectation that the patient will be afforded special status and that the favours will be reciprocated.
In situations where boundaries are unclear and subject to interpretation, members are encouraged to contact the CMPA.
- Paré, Michael. 2009. "Boundary issues." In CanMEDS physician health guide: A practical handbook for physician health and well-being, 2009, edited by D. Puddester, L. Flynn, J. Cohen, 76-77. Ottawa.