■ Professionalism and ethics:
Integrating professional duties, societal expectations and personal wellbeing
Boundary crossings in patient care
Type of activity: Text case
This text case describes a situation in which progressive boundary crossings led to boundary violations. The facilitation questions and suggestions to faculty encourage discussion of appropriate and inappropriate boundaries in clinical practice, potential consequences of boundary crossings, and how boundary violations may be prevented.
A 39-year-old woman develops anxiety and depression. Her family physician refers her to a psychiatrist.
After several months of treatment, including prescription medication and psychotherapy, the patient is improving. The psychiatrist finds himself looking forward to their next appointments; he is gratified to see her improving under his care.
They begin to refer to each other using first names. During one session, after discussing the patient’s challenges in her marriage, the psychiatrist shares his feelings around his own difficult relationship with his spouse. He seeks the patient’s professional advice as an architect about his home renovation. He offers her a ride home after her consultation one day when her transportation arrangements fall through.
- What defines the difference between a boundary crossing and a boundary violation?
- Explain how boundary crossings can escalate. What situations can make physicians more vulnerable to boundary crossings?
- Why do boundary crossings affect the care a physician provides to their patient?
Suggestions to faculty
Consider continuing the discussion around boundaries by delving more deeply.
- How can physicians develop trust while maintaining healthy boundaries with their patients?
- How can self-disclosure by the physician to the patient harm a therapeutic relationship? Can it ever help a therapeutic relationship? When does self-disclosure become a boundary crossing?
- What additional challenges may present themselves to physicians working in small communities?