Schwartz Rounds

Marlene Lockey, LCSWIn this column Marlene Lockey, L.C.S.W., senior social work counselor and coordinator of Schwartz Center Rounds at MD Anderson Cancer Center, describes a discussion around the difficult topic of setting boundaries in clinical care situations.

“The Issue of Professional Boundaries,” which includes accepting gifts from patients, treating family members who have medical problems, writing prescriptions for others who are not patients and responding to requests of a personal nature from patients may sometimes cause us to reflect upon and define the scope of our relationship with and obligations to patients and family members. In this discussion held several months ago and reported by a member of MD Anderson's social work staff, practitioners and others discuss the ethical, communication and professional dilemmas presented when boundary issues are encountered.

The University of Texas MD Anderson Cancer Center
Schwartz Rounds: March 26, 2009
Written by Marlene Lockey, L.C.S.W., co-facilitator

When Friends or Family Ask

If you work in the medical field long enough, friends, family members, colleagues or even the retail clerk are apt to ask you for medical advice, ask you to use your influence to impact their care or someone else's care or even to provide free medical care.The fact that medical professionals are seen as caring persons as well as their being accessible may make them easily approachable for personal requests or favors. At this Schwartz Rounds, two professionals related difficult experiences in which they had to set a "boundary" or limit regarding professional practice. Yet knowing one is making the right response doesn't do away with the discomfort inside that sometimes comes when you must say "no". Their examples prompted those attending to talk about their own experiences and discuss a range of emotional responses when boundaries are challenged in such interactions.

It was generally agreed the most difficult challenge to compassion and professional responsibility are requests from family and/or close friends. One physician related the experiences when a parent of a schoolmate of her child or even the school itself called to tell of someone with cancer and ask if she could help get an appointment for them. She stated that she felt somewhat like the "neighborhood GP" but it was actually satisfying for her to help with a referral or to expedite an appointment. But not all requests are so comfortable to deal with, such as requests outside the clinician's expertise or inquiries about how a patient under their care is doing medically.

These may come in the form of requests for prescriptions or a medical examination or a "curbside consult." When the friend or family member has limited income, perhaps no insurance, then it can be a battle with emotions to refuse to write a prescription or provide medical care. This may also fly in the face of both ethical and legal issues and blur the boundary of whether you are acting as a friend or have entered the role of provider. Family requests can be particularly vexing and invoke considerable guilt when a provider is reminded of times that the family has helped or when family does not have an understanding of professional boundaries or imply that you might be withholding negative information from them. Others unfamiliar with medical codes of ethics or legal issues may not understand our reluctance to cross professional boundaries.

Professionals from different disciplines related their interactions when they were challenged with setting a boundary. Other seasoned professionals representing different professions offered their experience for setting boundaries and dealing with the emotional conflicts that might arise. They suggested having a plan to handle requests that cross boundaries or risk patient confidentiality. 

For example: When asked how a friend/family member is doing, always acknowledge the concern: "You must be worried about Timmy's dad."

Provide reassurance: "We've assembled a good team to take care of him."

Shift the topic: "I hear that your own son hit a home run." 

If the inquirer does not pick up on the fact that you are declining the conversation and pursues questioning, be more direct and honest: "As part of Timmy's father's medical team, I can't reveal any information about his care." 

Redirect: "You might ask Timmy's mom about how he is doing."

Health care professionals frequently encounter issues related to professional boundaries. These include not only requests for medical care or confidential information but issues of receiving gifts, personal relationships with patients and families and even financial relationships. It was acknowledged that healthy interactions involving one's medical identity require respected boundaries in order to remain involved while staying grounded and committed to our professional ideals. With a plan for dealing with requests outside established professional relationships, compassion and care can be communicated comfortably through a response that also maintains professional responsibility. Outside interests, community activities and family are sources of renewal when dealing with the stress of boundary issues and talking to colleagues or obtaining an opinion from a medical ethicist about professional issues that come up which threaten boundaries can be helpful.

Additional Questions for Reflection

From where does our sense of boundaries with patients and family members emanate? Is this an ethical issue, related to professional code of conduct or legal obligations of practice?

What are the potential consequences of accepting favors or gifts from patients? What practice boundaries are being crossed?

Have there been times when you’ve questioned whether an interaction with a patient approached a boundary you were reluctant to cross?

What resources are available to you if you have a question about whether an interaction with a patient, family or staff member violates a boundary issue?

How can each of our institutions better educate practitioners and others about boundary issues?

Download: When Friends or Family Ask PDF Formatted File

References for Schwartz Center Rounds

Gabbard, G.O. and Nadelson, C.
"Professional Boundaries in the Physician-Patient Relationship"
JAMA. 273(18):1445-9, 1995 May 10.
  This article discusses the concept of professional boundaries as it derives from the basic principles and nature of the relationship with patients and families. It presents the different types of boundary violations (sexual, dual relationships, gifts and services, language, self-disclosure) and their prevention.

Rourke, J T. Smith, L F. Brown, J B.
"Patients, Friends and Relationship Boundaries"
Canadian Family Physician. 39:2557-64, 1993 Dec.
  This article uses clinical cases to illustrate the conflicts that may develop when physicians become "friends" with patients..

Lychholm, L.
"Should Physicians Accept Gifts from Patients"
JAMA. 280(22):1944-6, 1998 Dec 9.
  This article discusses gift giving and accepting between physicians and patients which is very important due to the frequency of this practice.