AMA Journal of Ethics^®

Case

Mr. Berkley is a physical therapist on a home-based primary care (HBPC) team. The HBPC team is multidisciplinary, with independent practitioners who visit patients in their homes. The team meets weekly, and is composed of physicians, nurse practitioners, physician assistants, physical therapists, respiratory therapists, social workers, dieticians, and nondenominational members of the clergy. The team’s leader, Dr. Miller, is a specialist in geriatric medicine.

When the team learned that one of their patients, Mr. Noland, was not adhering to his prescribed regimen of antipsychotic medication, the team members worked diligently with him, explaining the medication’s importance and encouraging him to take it, but his adherence remained spotty.

At a recent team meeting, Mr. Berkley, a physical therapist, cheerfully reported that Mr. Noland had become much more consistent with taking his antipsychotic medication. However, other team members did not seem pleased by this news. A few of them had seen Mr. Berkley taking small gifts, meals, and groceries to Mr. Noland’s house. They believed this violated professional boundaries. Other team members noted that Mr. Berkley and Mr. Noland shared the same religion and surmised this might be motivating Mr. Berkley to give special attention to Mr. Noland. The team members discussed their concerns, with most concluding that Mr. Berkley’s conduct was inappropriate and set the wrong example for patient care. They recommended that Mr. Berkley be removed from Mr. Noland’s case. Mr. Berkley responded that his care had led to Mr. Noland’s improved adherence to his medication regimen.

After the meeting, Dr. Miller decided to investigate by making a visit to Mr. Noland’s house. Dr. Miller confirmed the allegations discussed at the team meeting. She mentioned to Mr. Noland that Mr. Berkley might be assigned to another client. Mr. Noland was upset by this and threatened to stop taking his medication if Mr. Berkley stopped visiting.

Commentary

This case involves serious conflict within an interdisciplinary team. The conflict centers on the behavior of the physical therapist, Mr. Berkley, who has achieved an important team goal, that of getting the patient, Mr. Noland, to take his antipsychotic medication consistently. However, Mr. Berkley appears to have done this at the expense of the team, which has become troubled to the point of recommending that he be removed from Mr. Noland’s case. This conflict raises several questions. Is this a conflict over Mr. Berkley’s practice style or is it an actual breach professional boundaries? How might Mr. Berkley’s actions have changed Mr. Noland’s expectations for other members of the team? Is it appropriate for team members to make this judgment, or should it instead come from the team leader? How should we characterize Mr. Berkley’s potential conflict of interest? And finally, how should these issues be resolved?

Practice Style versus Violation of Professional Boundaries

Is Mr. Berkley’s behavior a matter of practice style or does it violate professional boundaries? The team alleges that Mr. Berkley’s “conduct was inappropriate” and that it “set the wrong example for patient care.” Mr. Berkley, on the other hand, insists that he has provided “care that led to Mr. Noland’s improved adherence to his medication regimen.” Which is it? First, it appears that Mr. Berkley’s practice style is highly personable. This is clearly an asset that has enabled him to forge a relationship, which has been instrumental in getting Mr. Noland to take his medicine consistently. However, what troubles the team is not Mr. Berkley’s personable style; it is the extra attention he bestows upon Mr. Noland in the form of gifts, meals, and groceries.

Gift giving of any sort lies within the personal domain, outside the professional boundaries of even the most personable clinician. Our obligations as professionals require us to stay in the professional role as much as possible. To do this, a professional needs to limit his or her activities to things that pertain to direct clinical care. Exceptions may occur when personal and professional relationships inescapably blur, such as in rural communities, but that is not the case here [1].

Meals and groceries can also be categorized as gifts, but providing them may instead represent an attempt to meet a legitimate need. If Mr. Noland lacks sufficient food, Mr. Berkley should have enlisted the expertise of the team social worker so that resources could be identified and accessed as needed. Instead Mr. Berkley chose to provide meals and groceries, bypassing his colleague, team protocols and conventional professional boundaries.

Changing Expectations for Care and Team Dynamics

How might Mr. Berkley’s actions change Mr. Noland’s expectations for care from other members of the team? Since Mr. Noland receives special attention and gifts from Mr. Berkley, he might expect other team members to treat him the same way and view them in a less favorable light if they didn’t. This raises the question of whether the other team members will receive less favorable patient satisfaction surveys from Mr. Noland for staying within professional boundaries, which may, in turn, negatively impact their careers. Team members may resent Mr. Berkley for putting them in this position, which could have been avoided had he stayed within professional boundaries. In short, situations like this can sour intrateam relationships, which will negatively affect team function. Therefore, it is imperative that the situation be resolved in favor of restoring the team’s functional balance.

The Ethics of Interdisciplinary Teams’ Decision-Making Procedures

Is it appropriate for team members to make a judgment that Mr. Berkley violated professional boundaries, or should such a determination come from the team leader? To answer this, we need to look briefly at the ethics of interdisciplinary teams. The core virtue of the team is mutual trust [2]. The team has to be able to trust that each member knows, values, and respects each discipline’s role and functions. When trust is broken either through professional boundary violations or by bypassing a team member, the team becomes compromised.

In HBPC and other interdisciplinary team practices, the individual professional is replaced by the team [3]. The result is a team-patient relationship, not merely a group of individual professional-patient relationships. For the team to be most effective, and therefore benefit the patient most, it must function as an interdisciplinary unit. When individual members disrupt team unity, the team’s effectiveness becomes compromised. In Mr. Berkley’s case, he has cultivated a special relationship with Mr. Noland, which, though helpful in achieving the team’s goal of medication adherence, has critically disrupted the team, making it less effective. It seems he has allowed his professional-patient and personal relationships to eclipse the team-patient relationship.

So is it appropriate for team members to make the judgment that Mr. Berkley has violated professional boundaries? Yes. Each member of the team has an equal stake in the effectiveness of the team as a whole, so it is appropriate to handle such matters democratically. If a team member’s behavior causes conflict within the team, the team has a responsibility to self-monitor and correct any perceived imbalance. If the team is not able to correct the situation collaboratively, the team leader, Dr. Miller, must intervene.

Exploring Conflicts of Interest

Apart from generating conflict within the interdisciplinary team, Mr. Berkley may also have a conflict of interest. As a physical therapist, his primary fiduciary interest is to provide good physical therapy for Mr. Noland. As an interdisciplinary team member, he has an interest in the quality of care provided by the team as a unit. However, he also appears to have a third unidentified personal interest that has led to gift giving and resulted in intrateam conflict.

In exploring this personal conflict of interest, some consideration should be given to possible motivations for Mr. Berkley’s behavior. First, is this how he treats all of his patients? Or is there something special about Mr. Noland? It has been noted by many of the team members that Mr. Berkley and Mr. Noland share the same religion. Is Mr. Berkley showing faith-based favoritism, or is he simply being generous? Is his faith interest conflicting with and compromising his interest in good team care and commitment to professional boundaries?

Second, is Mr. Berkley gloating with his cheerful announcement that Mr. Noland had become much more consistent with taking his medication? Is Mr. Berkley exhibiting passive-aggressive behavior toward his own team members by working outside of team and professional boundaries? Is he hoping to ensure that Mr. Noland gives him patient satisfaction ratings that exceed those given to the other members of the team? If so, he may be letting his own self-interest, or more properly, self-aggrandizement, take center stage. There is much that needs to be explored here. The team leader, Dr. Miller, needs to gain insight from other team members about these matters, as well as from Mr. Noland.

Working toward a Resolution

The first step toward resolution of intrateam conflict should take place within the team, as it has here. Team members communicated their concerns directly to Mr. Berkley and invited him to respond. If the conflict cannot be resolved at the team level, Dr. Miller would need to take further steps. She will need to meet privately with Mr. Berkley. She will also need to meet with the other team members, either separately or as a group. She may also need to take the step of meeting directly with the patient, as she does here by visiting Mr. Noland.

Once the allegations regarding Mr. Berkley’s actions are confirmed, Dr. Miller could choose to remove Mr. Berkley from the case. However, if Dr. Miller determines that Mr. Berkley’s behavior is a one-time exception to an otherwise consistent record of professionalism—especially if Mr. Berkley explains that he was trying anything and everything to get Mr. Noland to take his medications—she might also decide to allow him to continue to care for Mr. Noland with the proviso that no further gifts or food be given. If Dr. Miller determines that Mr. Berkley is showing faith-based favoritism toward Mr. Noland, or is engaging in self-aggrandizing behavior, or both, she should counsel Mr. Berkley to stop the behavior immediately. She should explain why the behavior violates professional norms and boundaries and highlight the disruptive effect it has on the team. In the event that Dr. Miller concludes that Mr. Berkley’s actions are part of a larger pattern of behavior that has caused intrateam conflict in other cases, she should strongly consider removing Mr. Berkley from the team altogether.

Though Mr. Noland threatened to stop his medication if Dr. Miller removes Mr. Berkley from his care, this should not affect Dr. Miller’s decision. Dr. Miller has an ethical responsibility to restore balance and effectiveness to the team. If she decides to remove Mr. Berkley from Mr. Noland’s case or from the team, she should explain to Mr. Noland that the team is there for his benefit, that optimizing his health includes adhering to the medication regimen, and that stopping his medication would only hurt himself. For Dr. Miller to capitulate to Mr. Noland’s threat and keep Mr. Berkley involved with no behavior change would not only be to let Mr. Noland manipulate her but would constitute a failure as significant as any exhibited by Mr. Berkley. It would allow a compromised team to continue to give compromised care.