Respecting boundaries

Staying on side

Maintaining appropriate boundaries

Fence in a fieldPatients depend on and trust their physicians. Consequently, physicians must ensure that they are professional at all times and maintain appropriate boundaries with patients.

What is a boundary?

A boundary 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. [REF]
Paré, Michael. "Boundary Issues," CanMEDS Physician Health Guide (2009).
.  In simplest terms, boundaries define limits of the therapeutic relationship.

There are two categories of boundary transgressions:

  • boundary crossings
  • boundary violations

Boundary crossings are usually benign, such as accepting baked goods from a patient to share with office staff. Sometimes boundaries are crossed deliberately, such as when a physician holds the hand of a patient who has reached out for support after receiving unpleasant news.

In other cases, boundaries are crossed due to carelessness, lack of attention, or simple misunderstandings. [REF]

Paré, Michael. "Boundary Issues," CanMEDS Physician Health Guide (2009).
For example, a patient may be offended at what you think is a harmless joke, or a more conservative patient who prefers to be addressed as "Mrs." may be insulted if addressed by her first name or "dear."

It is important to recognize that the lines between appropriate behaviour and boundary crossings are blurry.

When the boundaries of the therapeutic relationship are crossed, caregivers enter a "grey area" in which the consequences of their action on the patient's well-being may be positive (welcomed supportive touch), neutral (addressing the patient by first name according to his or her request), or negative (holding the patient's hand who is uncomfortable and thus increasing her anxiety).

At times it may be helpful to enter a grey area, but in doing so, there is also a greater risk of harm, exploitation, or other detrimental effects to the patient. [REF]
Paré, Michael. "Boundary Issues," CanMEDS Physician Health Guide (2009).

Boundary violations are harmful or exploitative to the patient. Sexual contact with a patient is always considered a boundary violation. Some other examples are:

  • excessive self-disclosure
  • giving or accepting inappropriate or elaborate gifts
  • probing for inappropriate or irrelevant personal information
  • failing to obtain consent for intimate examinations
  • failing to respect a patient's privacy

Although most boundary transgressions are thought of as intrusive behaviour, the opposite may also hold: the physician may be under-involved (e.g. formal, cold, distant, dismissive, not empathic). This can also result in harm and lead to complaints.