Sep 5

Sep 5 Bite-Size: Professional Boundaries — an Integral Part of Medicine.

Introduction

A new blog concept for my website. These blogs tend to be small and introduce a concept or talks about an experience I had. Bite-size blogs should be a little less than 2 minutes read and may be less than 600 words. Nothing too prominent with a relaxed feel to it and no insane reference list.

In this edition of Bite-Size, I wanted to talk about professional boundaries and its presence in medicine. It can be tricky to form a doctor-patient professional relationship and also making sure no boundaries are crossed, especially when medicine is becoming a lot less formal than it used to be. Why and how do boundaries get crossed? I thought this topic was interesting and very relevant in medicine.

Professional boundaries

Professional boundaries are integral to a good doctor-patient relationship. They promote good care for patients and protect both parties. Good medical practice involves (see Medical Board AHPRA):

Maintaining professional boundaries.
Never using your professional position to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This includes those close to the patient, such as their carer, guardian or spouse or the parent of a child patient. Specific guidelines on sexual boundaries have been developed by the Medical Board of Australia under the National Law.12
Avoiding expressing your personal beliefs to your patients in ways that exploit their vulnerability or that are likely to cause them distress.

Introduction

Professional boundary is a fascinating topic, especially when medicine has become a lot less formal from what it used to be. Doctors nowadays can have tattoos, piercings, dyed hair and so on (which makes them seem more human and approachable). The doctor-patient professional relationship is a crucial core for successful consultations, general care and the wellbeing for that patient. There is a lot of intimacy and power, which needs to be balanced, as doctors are present when patients are at the most stressful or worst time in their lives. The patient must feel comfortable, be able to discuss highly confidential sensitive issues with their doctors and create a lasting relationship that can go into generations. For example, my father, who is a general practitioner, has a strong relationship with a patient who was newly pregnant and told her that he saw her on the ultrasound machine when her mother was pregnant. He has a strong relationship with that family through generations with strict professional boundaries, and in the long run, there is an intimate trust that is beneficial for all.

Crossing professional boundaries can be done over a period of time and without realising that boundaries are being crossed. It is like a slippery slope. Acknowledging that they are predatory doctors who take advantage, normal doctors (who upholds the adequate standards in medicine) may not be fully aware when they cross boundaries or let boundaries being crossed from patients. It has been found that boundaries are more likely to be crossed when doctors are tired, stressed and lack emotional support. This particular situation may occur, especially when a professional relationship has to be established in medicine, as doctors can cross boundaries as they may feel heard by someone. Their world may feel lonely from speaking to so many people and yet having no one to listen about their problems and lives. Since medicine is becoming less formal, for example, encouraging the use of first names, crossing boundaries may increase. What is important is the distinction between boundary crossing and boundary violation. Gutheil and Gabbard mention that boundary crossing may sometimes be beneficial as long as it is safe and that there are no exploitations. In contrast, boundary violation causes harm to patients and should never occur. It is interesting to note that some patient may feel that consultations are casual and misinterpret the situation. Patients may feel hurt when a doctor guards himself/herself from a certain response or a certain vibe that they got from that particular patient.

A further exacerbation is that doctors hold power over patients, which includes a power of authority. For example, at a later and severe stage of psychological manipulation along with gaslighting enables the doctor not to prescribe medications to a specific patient unless that patient can do particular favours in return such as sexual relationships or abuse. Abusers can exploit that power of authority and are very good at it, especially on a younger patient who has been previously abused (which is undoubtedly helped from access to the previous history of that particular patient). This obviously speaks about predatory doctors. So why is this relevant? Severe exploitation has destructive effects on a patient and can be similar to a parent abusing a child. A distrust is established, and patients may never be able to recover where guilt, depression, PTSD, suicidal tendencies and increased in drug use have been noted. This example is extreme as a normal and upstanding doctor would never hold this destructive power over a patient. Still, the slippery slope of abusing of this power or boundary-crossing could occur without realising it.

Preventive strategies need to be in place so that doctors are more aware when they are crossing the line or how to respond when a patient is unintentionally or intentionally crossing barriers. These strategies are education about the matter of the subject, recognising pattern/situations, ethics, and support groups to manage emotional and psychological distress doctors may have. There is also a need in strategies for the survivors to pursue and file a complaint without feeling shame or the fear of not being believed, however, challenges such as finding proof often lack as consultations are private.

The doctor-patient professional relationship can be tricky, scary in its way and yet amazing if done right or have severe legal and ethical consequences if it is not done correctly. The statistics that demonstrate the number of doctors who had inappropriate relationships is worrying. Yet, I understand why it has increased. Medicine has become more informal and casual, which may entice patients to suggest inappropriate things (such as the RACGP house cleaning example). Doctors are becoming more hip and cool with tattoos, piercings, hair dyes and so on; hence, they are more approachable, more natural to talk to about sensitive issues and therefore gain trust more quickly. I can relate as I dress more casually (away from those white coats) and to some extent, a little different from the simple look of what doctors should look like. I wasn't aware that patients would become more comfortable, which increases the likelihood of boundary-crossing. I understand that there may be no support groups available for doctors or that there is a stigma in joining support groups or the lack of acknowledging that there is a problem and seek help. Failing to seek help could entice doctors to cross boundaries. However, my future job is to create meaningful relationships as I will be present in the patient's worst time of their lives, and I will have to learn and identify boundaries to keep absolute integrity and safety for the patient and myself.

I really enjoyed this topic and I hope you did too. Let me know some of your stories where patients or doctors crossed boundaries or some tips you may have in responding to a particular event.

Published 5th September 2020. Last reviewed 1st December 2021.

Reference

Galletly AC. Crossing professional boundaries in medicine: the slippery slope to patient sexual exploitation. Med J Aust. 2004;181(7):380-383. doi:10.5694/j.1326-5377.3004.tb06334.x

Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice; theoretical and risk management dimensions. Am J Psychiatry. 1993;150:188-196.

Medical Board AHPRA authors. Good medical practice: a code of conduct for doctors in Australia. Medical Board AHPRA website. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx. Reviewed July 20th, 2020. Accessed August 20th, 2020.

Sara Bird. Managing professional boundaries. Royal Australian College of General Practitioner website. https://www.racgp.org.au/afp/2013/september/managing-professional-boundaries/. Published September, 2013. Accessed August 20th, 2020.