1. PHYSICIAN – PATIENT BOUNDARIES Ade Magallanes R-1 Behavioral Medicine April 2016

2. How do we characterize the physician – patient relationship? Role Theory Patient centered

3. Role Theory Each physician or patient acquires a specific set of rights and obligations that delineate what a person in that role can expect from others Specific as to what behaviors are required of him or her

4. Patient Centered Primary goal is the care of the patient; needs of physician are secondary Patient entrusts his/her well being to physician Patient is more vulnerable and exposed Physician has responsibility to act in patient’s best interest

5. What are physician – patient boundaries? Ideal ethical, physical and emotional constraints that delineate the limits of any relationship and provide safety when inequality exists between two individuals. Patients entrusting their health and well-being during vulnerable times leading to power differential

6. Why do boundaries exist? Set limits of behavior to protect more susceptible and or vulnerable patient from mistreatment from physician

7. Boundary crossing? Boundary violation? What is the difference?

8. Boundary crossing Departures from usual professional practice that are not exploitative and can actually assist in a patient’s management Can anyone give an example?

9. Boundary Violation Transgressions which harm the patient in some way. Unethical and unprofessional because they exploit the physician – patient relationship Undermine trust Can cause psychological harm Can compromise ongoing medical care

10. Boundary Conundrums Technology (focus on text/cell phone) Dual relationships Time and duration of appointments

11. Technology Anyone have a case or experience with this? Do you give your cell phone or pager # out to patients? What about if they ask you for it? Are you a bad doctor if you don’t give it out? Are you a better and more caring doctor if you do? Any instances where you believe this is appropriate? Why?

12. What are the ethical issues? How are duties and responsibilities of MDs affected by using text/cell phone? What kind of limits should MDs place on their availability if they chose to give their # out? What duties do MDs have regarding requests that are perceived as urgent by patient?

13. Dual Relationships Occur when a secondary relationship arises simultaneously within the primary one. What are the consequences? Are there benefits?

14. Time and duration of appointments Why are you giving this patient more time? Are any of your own needs as a physician being gratified by extending this appointment? What are the consequences of favoring some patients over others? What about your patients that are waiting? How do they perceive this?

15. Physician Risk Factors MDs that are under stress with insufficient emotional support Inexperienced physicians – naïve to complex and problematic effects of boundary crossings Physicians suffering from mental illness, e.g. mania which results in disinhibited behavior

16. Toolkit Steps/Questions to ask for preventing and managing boundary crossings 1. Recognize risk factors that may lead to boundary crossings 2. Examine the presence of behaviors or emotions that indicate a boundary has been crossed 3. Consider how boundary crossings affect patient care

17. Recognize factors that may lead to boundary crossings: ID with patient or family by physician Unresolved grief/loss on part of physician Professional sense of failing the patient Complex dysfunctional patient – family dynamics

18. Examine the presence of behaviors or emotions that indicate a boundary has been crossed. Avoidance Increased contact when medically unnecessary Feeling of personal responsibility to save patient Feeling that no other provider can care for patient in same way

19. Consider how boundary crossing may affect patient care Is what I am doing an accepted part of medical practice? Is what I am doing solely in the interest of the patient? Is it self- serving?

20. Discuss the situation with colleagues, interdisciplinary team or supervisor Find support