"Boundaries" between physician and patient
Why do we use the language of property rights to talk about relationships?
A few weeks ago, I facilitated a small group discussion with third-year medical students about boundaries.
It was an interesting discussion. The students, who had just finished up their first year of intensive clinical work, had lots of good cases to discuss. What constitutes an appropriate, professional relationship between doctor (or doctor-in-training) and patient? What happens if that relationship turns into something else: friendship, neighbors, Facebook friends?
The topic of the discussion was, officially, boundaries. For years now, I’ve noticed the term become ubiquitous in the public discourse. It’s everywhere in therapy-talk, in online self-help, and even, as we demonstrated a few weeks ago, in medical education.
What is it about this particular metaphor that captures our imagination, seems so useful in the way we conceive of ourselves in relation to others?
Writing in the magazine Parapraxis, the writer Lily Scherlis beautifully captures part of what has gotten under my skin about our pop-psych obsession with boundaries.
I am not anti-boundaries, but they are so rarely questioned—they have a seductive moral authority as the dominant metaphor for how human relationships should work. If you invoke this discourse of the sacred thresholds between people, you will be heard. But I doubt that there is a deeper plane of existence where boundaries live. There is no substratum beneath the appearances of things where lines between people are etched: boundaries are just a wildly influential story about how people work …
Boundaries do this by teaching us to relate to other people as if they are the one thing social systems are most determined to protect: property.
When we talk about boundaries in the physician-patient relationship, we talk about each of us as nation-states with borders that must remain strictly patrolled.
The term started showing up in the psychiatric literature in the 1990s. (Also here: Boundaries in the Physician-Patient Relationship.) It mostly referred to sexual relationships between psychiatrist and patient, which apparently needed clarifying as not a good thing to embark on.
Now, boundaries are everywhere in medicine. The term is omnipresent. Boundaries are needed to protect patients from the power imbalance between physician and patient; they’re needed to protect clinicians from burnout.
I don’t disagree that breaches of physician-patient boundaries can be harmful. In fact, I’d put myself on the more “boundaried” end of the spectrum when it comes to the way I relate to my patients.
But why is this the dominant metaphor? Why is it that boundaries will protect us, and from what?
Here are some of my “boundaries:” I don’t give out my cell phone number. I don’t check messages from my patients after-hours or on the weekends. I rarely take on friends or neighbors as patients. I admit I have prescribed medications for my son, in a pinch, but I usually like to keep my work relationships at work, and my personal relationships personal. My doctor friends praise me for it: “Mara, you have such good boundaries around work!”
I see these invisible fences as a way to protect other parts of my identity – parent, spouse, friend, daughter – from the capitalistic encroachment of work. Technology makes it easy: patients can send me a message at any hour, and if I so choose, I can respond. For me, these boundaries act as a defense against the ever-frenzied pace of corporate medicine, rather than a psychological choice of not letting my patients get too close. It’s about protecting the quantity of communication rather than the depth of communication.
But maybe my patients don’t see it that way. Maybe they think my boundaries are too fortified, and access to their physician is hidden behind 1-800 numbers and call centers and administrative staff who all provide layers of bureaucracy between us.
My boundaries protect me, the doctor, but they are also conceptualized as a way to protect our patients. If you go to a doctor who is also your neighbor, does it make it hard to talk about sex or drinking, if you know you’ll see the doc at the next neighborhood cookout? If you disagree with your doctor’s political views after seeing his Facebook posts, would it make you give up on an otherwise positive relationship?
Once, I gave a ride to a patient, in a perfect storm of circumstances. She was 97, and I knew she used a perpetually unreliable patient transportation service to come to see me. She was my last patient of the day, and as I left the office after seeing her, I found her and her daughter waiting for their ride in the parking lot in the pouring rain. It was an easy decision: they got in my car, and I dropped them off at their home about a mile away. Then I went home. It felt like the right thing to do.
But that story of “boundary-violation” is, for me, the exception, not the rule – it’s something I rarely do. Inherent in my decision to drive her home was luck – I happened to come upon her as I finished up for the day, I had no other patients to see – and also bias. I felt safe with her in my car because she was a 97-year old woman; perhaps I wouldn’t have done the same for a young man.
In our discussion the other week, my students brought up lots of interesting cases. What about paying for a patient’s Uber home? Or giving a patient a twenty dollar bill to pay for his medications? What about a patient who wants to follow us on social media? Or a patient who gives us a gift?
I laughed, recounting some of the gifts I’ve received (and accepted) from patients: a handle of Bailey’s Irish Cream. (I gave it to a nurse; not a fan.) A onesie for my son that said, “If you can read this, you’re standing too close. #MyMomIsADoctor.” A handmade, Taylor Swift-style beaded bracelet from a patient with dementia.
My students and I had a hearty discussion that touched on many ethical issues. But I felt like something was off. By using boundaries as the primary relational framework between physician and patient, are we missing out?
Boundaries are a Band-Aid in a bad world: if you can’t expect people to care for you and treat you well and protect you from violence or scarcity, you can at least protect yourself from their needs. They aren’t straightforwardly wrong to do this: negotiating other people’s needs, which are often unreasonable and unfulfillable and intolerable, is fraught, baffling, and overwhelming. It demands a good strong metaphor, and the image of boundaries is unusually tensile. But the term takes on its own momentum, overrunning intimacy with alienation. In its most extreme forms, boundary-speak makes it feel like some of us have given up on each other: the only effective social strategy left is to lock yourself in, fortify your defenses. If your emotional defense budget isn’t big enough to hold the line and you get trampled by other people’s greed, that’s on you.
I know an older doctor who thinks our obsession with boundaries is harming our field. He practiced medicine in a different time. He did house calls, and gave his personal phone number to every one of his patients. From all the stories he’s told me, he had meaningful relationships with his patients and looks back on a deeply fulfilling career in medicine. He felt like he did real good.
He also didn’t use an electronic medical record, where the number of messages patients send me continues to balloon. He had a stay-at-home spouse, who cooked his meals and picked up the kids from school. He controlled his own practice, didn’t have his schedule determined by the C-suite that tells me I always, always must make room for more patients. He didn’t find his expertise undermined by corporate medicine, like when a patient tells me, “Fine, I’ll just go to an online doctor” when I won’t prescribe them the antibiotics they don’t need but think that they do.
But I also think my colleague is on to something. Connection between doctors and patients can feel special, can feel like a unique and meaningful relationship.
It feels powerful when my patients ask me about my toddler son or my aging parents, although I’ve wondered at times if disclosing details about my family is a “boundary violation.”
And it also feels powerful when patients ask more of our relationship, too, treating me like a trusted advisor who knows them intimately, not a dial-a-doc who sends along those antibiotics without question. Their needs are not something to always shield myself from. That’s my job, after all — to help.
Spot on. I'm a therapist (training as an analyst), and I hate the word "boundaries". Every time I hear a 22-year-old repeatedly talk about "boundaries" and "toxic" people, I cringe internally and sometimes ask them to elaborate on what they mean. I find myself using the word more than I would like (as well as toxic), when I can't think of a substitute, but I usually use air quotes when I say it, or say something like "for lack of a better word". I see how it can be weaponized, as when a person accuses someone of violating their boundaries when the reverse actually seems to be true.
Boundaries, I think, should be flexible, and negotiable, and they vary so much depending on the nature of the relationship between the two people. Plus, they can change over time. Granted, they are crucial sometimes in cases where some form of abuse or emotional harm is occurring.
Thanks for sharing the link to the article in Parapraxis.
Yes, thanks for sharing this. I too find myself using the term more than I'd like! 😬