Crossing Boundaries—Violation or Obligation?

By Gordon D. Schiff, MD
JAMA, September 25, 2013

It is 5 pm on Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors. This allegation of an ethics violation was not only personally painful; it also raised important, controversial, and timely questions about appropriate professional roles.

Physicians must indeed respect certain boundaries. A growing literature and guidelines have admonished physicians and other health professionals to strictly respect boundaries to avoid improper expectations, dependency, legal liabilities, and confusion of personal and professional relationships. Most concerning were data documenting sexual relationships between physicians (often psychiatrists) and their patients.

However, some interpretations of these restrictions risk constructing a misguided model—one that discourages physicians from humanly caring for and about their patients. This new paradigm risks encouraging detached, arms-length, uncaring relationships. When do “boundaries” become barriers to meaningful caring relationships? And will such bounded thinking serve to rationalize abdication of our professional and personal responsibilities to humanely respond to patient suffering and underlying injustices?

While I had rarely paid for a patient’s medication as I did on that Friday afternoon, in this situation it seemed reasonable and appropriate. Various ethics and conflict of interest rules prohibiting physicians from having “financial relationships” with patients may be appropriate when it comes to physicians taking or soliciting money from patients. But what about the propriety of giving money to a needy patient in this particular situation? While other alternatives such as using a special fund might be preferable, when I found that no such fund existed at my hospital (and the drug insurance plan denied coverage due to a technical glitch in the patient’s enrollment), was it wrong to personally help a patient in such a moment of need?

Everything we do in medicine has risks. Whether prescribing a medication or performing surgery, we, in consultation with the patient and family, must weigh potential benefits and risks. When considering reaching out to help patients in need, possible adverse effects should be weighed against the benefits in that particular context and situation.

In weighing such risks, however, we need to be clear whose risks we are considering. Many of these risks are actually more risks to physicians, rather than to patients. Thus, those insisting on stricter boundaries need to rethink what they mean by “limits.” Who are those limits designed to protect? Are “limits” protecting the patient, or are they protecting us—protecting our time or even protecting our consciences, allowing us to avoid painful questions of inequality or taking needed moral action? While there is nothing inherently wrong with protecting caregivers against overwhelming time demands or burnout, let’s not pretend we are imposing limits for patients rather than our own best interests.

The American Medical Association’s Code of Medical Ethics states: “The practice of medicine … is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering. … The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest … and to advocate for their patients’ welfare.” The type of caring relationships embodied in this statement, and the kindness I believe most patients and physicians yearn for, has been pejoratively dubbed “nostalgic professionalism.” This outmoded model of professionalism, it is argued, needs to be replaced by a more dispassionate business-like model where limitations and boundaries are more circumscribed and it is clear that we are not our patients’ friends, neighbors, or personal advocates for issues beyond their medical problems. Short of avoiding caring for poor patients entirely or not being part of the community in which our patients live and work (both unfortunately not rare), personal engagement with patients as people, not just as “clients” or “consumers,” is inevitable, and even desirable. For many of us (particularly primary care physicians), more than any P4P (pay-for-performance) financial incentives, our most fulfilling rewards and professional satisfactions come from having meaningful relationships with our patients, as well as our ability to broadly ameliorate their problems and suffering. Of course we have to make daily compromises with reality, especially the realities of suffering and hardships poor and underserved patients face—problems we obviously can’t personally cure. Nonetheless, we should try within the limitations of our time, resources, and abilities to help where we can.

The real danger of personal engagement is not that we further complicate already complicated relationships with our patients by doing too much. Rather it is that of tokenism—of doing too little and feeling satisfied and excused from addressing the social and economic injustices that underlie poor patients’ suffering. It is here we have to be mindful of the fundamental distinction between charity and solidarity. Yes, we need to be charitable in every way possible, but we also need to stand alongside our patients in striving for a fairer, more caring world. If physicians want to stand aloof, addressing only the biomedical problems, ignoring and seemingly indifferent to the social circumstances of our patients, then patient/relation-centered medical homes are likely to feel more like gated communities than places where people live and work together. Fortunately, the two strands of genuine “caring DNA” are closely intertwined. Collective advocacy for societal change and personal advocacy and helping of individual patients cross-fertilize and nourish each other. Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.

For my home office that I use for my health reform advocacy work, I had put away all of my credentials and hung on the wall only one item: The Oath of Hippocrates. Regarding today’s message, one sentence stands out: “Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves.” Boundaries are as old as the profession.

But what has happened with boundaries now that we seem to have transitioned from the profession of medicine to the business of medicine? “Care providers” are to turn to the clinic directors or whatever entity is representing the business to learn about redefined boundaries that are best for… the business?

What about establishing boundaries between the healing arts professions and the financial accounting functions for health care that should be relegated to the virtual back office? How about allowing the health care professionals to revert to the traditional Hippocratic concepts of boundaries?

In fact, instead of limiting boundary considerations strictly to the one-on-one interaction between patients and professionals, shouldn’t we be exploring the boundaries that Gordon Schiff implies when he refers to “collective advocacy for societal change and personal advocacy and helping of individual patients”?

If we were to use that collective advocacy for societal change to establish a single payer system, we could break down barriers, allowing us to come closer to achieving optimal care for all patients. As Schiff says, “Minimizing barriers for professionals and patients working together for this shared agenda represents true patient-centered medical care.”

After reading Gordy Schiff’s commentary and seeing that his moral compass is set on the primacy of the patient, it should come as no surprise to readers that he has been very active in Physicians for a National Health Program, having served as its president. Thank goodness he understands as much as anyone where our professional boundaries should be. Sadly, the stewards of the new business world of medicine will never understand.