Negotiating the personal-professional boundary

 

During a recent discussion on the dynamics of doctor patient relationships, we were talking about professionalism and professional boundaries. When practicing medicine in underserved rural areas, professional boundaries are blurred. The other day, a patient with a chronic skin condition whom I was treating in my clinic, saw me in the bus on my way to the clinic. He lifted his t shirt then and there to show me his skin rash over the abdomen. That is one extreme of how loosely defined professional boundaries are. How does the doctor balance being connected with the patient, maintaining good rapport and relationships, being sensitive to the local culture, and at the same time maintaining professional boundaries? I can make sure that I don’t breach professional boundaries with my patients, but how do I handle it when patients liberally transgress the boundaries? 

 

Mr. M was a 65 year old man with cancer of the voice box. He was treated in a government regional cancer hospital and was in the end stage of his life. We were providing comfort care for him by providing pain relief and nutritional supplements. His daughter, a 24 year old woman, was his main care-giver. She was going through emotional burn out and caregiver fatigue. During one counseling session with her, I had shared my phone number as a gesture of support letting her know that she can call me in case she has any doubts or questions regarding her father’s care. Mr. M passed away peacefully in sleep within two months. His daughter kept texting me for a long time after that. Initially she used to send “good morning”, “good evening” messages. But over time she started asking me to call her and talk to her. She started texting me that she was feeling very lonely and sad and needed to spend some time with me. I called her back one day and told her clearly that while I empathize with her situation, she needs to find friends whom she can talk to. I told her I cannot be that friend for her. This happened almost 10 years ago, but I still vividly remember how hard that conversation was. When I discussed this episode with some colleagues, they told me that it was a bad idea to share my phone number. I have shared my phone number as a gesture of good faith with many patients, and I have never been disturbed unnecessarily by anyone. Even in this case, the woman perceived a warm friendship and support due to the shared experience of care-giving for her father. She told me herself that I would be the only person who would understand her pain as I was there with them during their final days of suffering. I was not comfortable to continue a personal relationship with her outside of the professional context and I found talking to her and breaking it off was the right thing to do. But it was a hard call because I kept questioning whether I am abandoning her. 

 

Over the past 3 months one Mrs. M, an elderly lady in her 80s visits me in the clinic. She is almost blind with cataract in both her eyes. She can barely hear and I must go very close to her ear and speak loudly to communicate with her. One time she developed severe gastritis and was unable to eat anything. I prescribed some antacids for her. But she did not bring money with her and so could not buy them. I paid her bill and bought her the antacids. She was so moved by that gesture that from the next visit, she started bringing me gifts like biscuit packets, bananas, small packets of groundnuts etc. I told her that she need not bring those for me. But she never stopped. For the past four weeks she has been coming every week demanding that I should come home with her and share a meal with her. I would tell her that I have a busy clinic with lot of people waiting to see me. But she would throw a tantrum like a child that I should immediately get up and walk with her to her home and share her lunch with her. I firmly and clearly told her that I cannot come with her in the middle of my workday. I found it very hard to see her sad face when I spoke to her sternly like that. In as much as I liked the attention and love that Mrs. M was showing me, I found it problematic to get into a personal relationship with her that would make me compromise my professional commitment in the clinic. When I discussed this with my colleagues, they suggested that I should just go and visit her home after the clinic one of the days even if I do not share a meal with her. Maybe I should do that, or maybe I should keep it strictly professional with Mrs. M. I sometimes wonder if I did something wrong by purchasing her antacids for her that day? Is it a practice I can sustain over the long run? For how many other patients can I buy medicines? At what point should I have drawn my professional boundary? By not buying the antacids, but just giving her a single dose and asking her to come back with money for the rest? By not accepting her small gifts, snacks and eatables? It was very hard to break it off with such a weak, vulnerable and elderly lady who had started getting emotionally dependent. 

 

The hardest breach of my personal space by a patient was the episode that happened with Mrs. A. She had hypertension and diabetes and came to me to get medicines. We had a warm doctor-patient relationship. One day during a routine clinical encounter Mrs. A asked me, “Doctor, tell me about your family. Wife? Children?” I told her that I am not married and do not have children. Mrs. A went quiet after that and did not say anything. The very next day she came to the clinic and asked to talk to me. I was seeing patients and asked her to wait. When there was a lean interval with no patients waiting, I called her over. As soon as she came in, she broke down and started crying. She was emotionally very much distraught and said, “I cannot digest the fact that you don’t have a family. How can you be like this? You are such a good person, why has God given you this fate?” and she was inconsolable. I was stunned and speechless. On one hand I was moved that she cared so much about me. On the other hand, I felt very awkward about how to handle this situation. I tried to calm her down by saying that it is a personal choice, I am not suffering because of it, I have a good social circle and many such things but to no avail. Hearing her loud cries, other staff from the clinic came and peeped into the consultation room to check on her. It was not only awkward, but embarrassing. I allowed her to fully vent out her emotions and then calmed her down and sent her away. It did not end there, the very next day, she walked into the clinic with a woman from her neighborhood and said, “This woman is a lawyer and is still unmarried. I will do what your parents failed to do for you. Marry this woman…” That reached the extent of my patience. I very firmly told Mrs. A that this is very inappropriate. I apologized to the woman for the embarrassment caused to her. And I told Mrs. A that I respect her, but she cannot come back to the clinic if she doesn’t stop doing things like this. Mrs. A was very upset and walked away. She stopped seeing me after that. I was deeply traumatized by this episode. I kept questioning myself if I had led on Mrs. A to believe that I am unhappy with my social status. Should I have cut off the invasion into my private space when she cried and expressed emotional distress over my marital status? By allowing her to enter my personal space, not only did I embarrass myself, but also led to unnecessary embarrassment to one other woman. Over and above all this, I also felt guilty for pushing Mrs. A away from our professional relationship. 

 

Mr. AS is a young man who came to me a few years ago with vague symptoms involving aches and pains over multiple parts of his body. On detailed evaluation, I understood that he was suffering from prolonged grief due to the loss of his grandmother. Mr. AS is from a dysfunctional family. His father is an alcoholic and used to abuse his mother at home. His mother left his father and started living with another man. He was stuck in a loveless home, and his grandmother was his only source of comfort. So, when she passed away Mr. AS was distraught and he struggled with prolonged grief. I referred him for psychiatric evaluation and treatment. The treatment started helping him and he used to come to our clinic regularly to talk to me and vent out his feelings. He would make all kinds of pretexts for the clinic visit, some pain here, some ache there. But it would be mainly to have a talk session. One time he expressed a very low mood and as a gesture of good faith, I shared my phone number. The act of sharing my phone number must have led him to believe that our relationship has moved to a different plane. He started calling me at odd hours and talking about things like small fights with his girlfriend, disagreements at his workplace, fights with his mother etc. I was getting very uncomfortable with his calls at odd times and one day things got extreme. I was in the middle of an important meeting and he called. I silenced the call, but he kept calling repeatedly. I was afraid it was an emergency and so got out of the meeting and attended the call. He said, “I called just like that because I was bored. How are you?” I got irritated and told him firmly that he must stop calling me like that. Then I called him back later that evening and told him clearly that I am not a “friend”. I am his doctor and he is free to call me only to talk about his health and illness. I am not his friend with whom he can talk all random things. It was a rude shock for him. I felt very bad for hurting him, but it had to be done. That day I wondered how psychologists and therapists handle this kind of a professional boundary laying. Despite being a doctor for 25+ years did I fail to establish clear boundaries with Mr. AS? It was a disturbing feeling. 

 

The issue of professional boundaries is an inherent clash between empathy, personal relationships with patients and the professionalism of medical practice. Many doctors came to the medical profession to connect with people and help them. This requires personal relationship with patients. But that puts the doctor in a position of vulnerability where the professional boundary can get breached. In each of the encounters I have described above, I have questioned myself if I have failed in maintaining my professionalism, or if I have failed to support my patient by being self-centered and abandoning them. I have also felt a deep sense of personal failure for not being able to proactively prevent such breaches of professionalism. I have asked myself, “Did I lead them on to enter my private space?” But now over the years I have understood that professional boundaries are not walls, but are doors. While a wall is rigid and excludes, a door makes the boundary flexible and allows to a limit and when it is time, shuts. I have understood that professional boundaries are constantly under negotiation. Empathy and connection with my patients demanded that I engage personally with Mr. M’s daughter, Mrs. M, Mrs. A and Mr. AS. But when the professional boundary was breached, I had to shut the door and let them gently but clearly out. I am continuously learning and evolving in the process of negotiating the personal-professional boundary.