In September 2013, Gordon Schiff, MD, shared “a piece of his mind” on the patient-physician relationship in the Journal of the American Medical Association (JAMA). His article, “Crossing Boundaries—Violation or Obligation?” detailed the challenges he had faced in navigating the patient-physician relationship. Actions that he felt were extensions of his services and obligations to provide care for the patient—the whole patient—were met with either full support or complete opposition, and even deemed unprofessional, by colleagues and supervisors. These actions included helping a patient find a job, providing transportation money for a patient in need, and assisting a patient with paying for a prescription when insurance posed a hurdle.
Dr. Schiff’s piece struck a nerve with me. My reaction to his piece may have been heightened by my personal and global-health experiences in my home country of Malawi and several other limited-resource settings. While some actions I heard about were clearly violations (e.g., sexual relationships with patients), other interactions seemed less clear. Was helping a patient overcome systemic barriers to health by satisfying basic needs for food, clothing, shelter, and employment truly unprofessional? Was forging a personable and caring relationship not fundamental to medicine? Weren’t some of these actions a part of meaningful care?
As I thought more about these questions, I could see how providing extraordinary care could have unintended consequences. As much as we may not want to admit it, there are power dynamics at play in the patient-physician relationship. These dynamics can convert a seemingly innocent and caring act into one that exacerbates the vulnerabilities of physicians and patients alike. I then began to wonder how it would be possible to safeguard the patient-physician relationship without hampering meaningful, personable care. I was certain that I could not be the only one looking for guidance on this matter.
Accordingly, this issue of the AMA Journal of Ethics seeks to provide perspectives and guidance on navigating the patient-physician relationship and observing professional boundaries. The issue draws from multiple perspectives and uses a multidisciplinary approach. Each contribution is intended not to be prescriptive but, rather, to provide ethical considerations, strategies for critical thinking, and recommendations that can be applied in routine clinical care.
The three ethics cases in the issue were designed to mirror real-life scenarios: deciding whether to assist a patient with a job search, reconciling a practice policy prohibiting home visits with a patient’s need, and fielding a friend’s request for care. John Mazzullo, MD, a family medicine physician, draws from his decades of clinical and teaching experience to advise readers who may be able to help patients find jobs. From his contribution, we learn that empathy, respecting the patient’s privacy, not taking advantage of the patient, and offering a “helping hand” rather than setting up a system of dependency are key considerations. In their commentary, medical student Brian Kroener and Eric Goepfert, MD, grapple with the conflict that arises when the policies at a physician’s place of work are not aligned with his or her ethical standards. They examine both the actions an individual physician can take under these circumstances and whether the practice’s policy is wise. Lastly, Horacio Hojman, MD, addresses the situation in which a physician is approached by his best friend for care. Dr. Hojman highlights best practices, with reference to professional association guidelines.
Two pieces discuss the difficult role of professional self-regulation when it comes to observing boundaries. Building upon his experience equipping medical students with tools to help identify and report on ethical breaches (and issues of conduct) among peers, Leonard L. Glass, MD, discusses the challenges of acknowledging and reporting boundary violations by one’s colleagues. Joseph C. d’Oronzio, PhD, a bioethicist and founding director of the Professional Problem-Based Ethics (ProBE) Program, explains the actions taken by state medical licensing boards in response to boundary violations, including mandating rehabilitative educational programs like ProBE. He shares a wealth of information on disciplined physicians and provides a typical example of cases referred to the program and what it seeks to accomplish: to help physicians cultivate their judgment about appropriate boundaries rather than merely promoting obedience.
Four other contributions take up the idea of meaningful relationships with patients. Monica Bharel, MD, medical student Emily Thompson, Shira Heisler, MD, and Gordon D. Schiff, MD, all draw from personal experience to explore relationships with patients that are and should be closer than what we think of as typical when we are treating vulnerable patients. Dr. Bharel, chief medical officer of the Boston Health Care for the Homeless Program (BHCHP), emphasizes the importance of building trust with homeless patients, sometimes before any medical concerns can be addressed. Emily Thompson recounts observing the close bond between pediatricians and their hospitalized patients, arguing that professional boundaries need not be uniform across all specialties and that, in pediatrics, more frequent boundary crossings are beneficial to establish a social as well as a therapeutic relationship with patients. Dr. Heisler describes how Dr. Schiff has served as a “virtual mentor,” encouraging her to really see, respect, and partner with patients to combat the systemic forces that can affect their health and well-being. They outline ten useful long-term strategies for helping physicians maintain positive relationships with patients. Dr. Schiff complements this piece with an audio interview that covers reactions to and reflections on his JAMA article and his recommendations to students. We encourage you to listen to the podcast for his thoughts on how students, and even experienced physicians, can work their way through the gray areas of the patient-physician relationship while still providing exceptional care and maintaining meaningful relationships with patients.
At a broader, societal level, Roy Ahn, ScD, Kristina Tester, Zaid Altawil, MD, and Thomas F. Burke, MD, take up the topic of responsible activism. In their piece, they argue the need for more widespread professional standards of conduct for global health organizations.
Technology is changing medicine, and, with it, the patient-physician relationship. What was accepted conduct fewer than 50 years ago (e.g., house calls, close-knit physicians and patients) may be almost nonexistent today. James M. Thompson, MD, examines changes in the patient-physician relationship using his own professional career as an example. There are also new ways of communicating: physicians and patients are readily accessing health information through phones and computers, and social media is becoming ubiquitous, readily used by young and old alike. How should physicians use social media appropriately? Terry Kind, MD, MPH, reviews guidelines for physician conduct on social media, focusing on the formal recommendations of the American College of Physicians and the Association of Federation of State Medical Boards. Dr. Kind highlights social media’s potential to extend physician reach and promote healthy behaviors, but also notes that social media should be used thoughtfully and responsibly.
Navigating the physician-patient relationship can be challenging, especially early in our careers. We hope that readers will find this issue of the AMA Journal of Ethics practical and that the guiding questions, frameworks, and considerations will serve as useful references.