Patients, Friends,and Relationship Boundaries
JAMES T.B. ROURKE, MD, MCLSC(FM) LINDSAY F.P. SMITH, MB, CHB, MRCGP
JUXDITH BELLE BROWNN, PHD
Can Fam Physician 1993;39:2557-2565
When patient and physician are close friends, both professional and personal relationships can suffer. Jointly exploring and setting explicit boundaries can help avoid conflict and maintain these valuable relationships.
This is particularly important when the physician practises in a small community where such concurrent relationships are unavoidable.
Does being friends with a patient”obscure judgment, and produce timidity and irresolution” in the physician’s practice?
When a patient is also a physician’s personal friend, the physician has obligations within both of these relationships．The obligations that we have to our friends are at two levels’
1) personal social obligations：We should respect the autonomy of others, not harm them, and be just in our dealings with them.
2) we have additional obligations to our personal friends: to do them good, to trust them, and to be loyal to them.
A)the patient-physician professional relationship： To them we should offer medical beneficence; and for them we should acquire and use expertise appropriately , maintain the standards of the profession and practise accordingly, practise for their benefit (fiduciary relationship), be compassionate, and also, perhaps, be just in distributing health care.
B)Patient’s obligations have social obligations and those of friendship as do physicians.
＜Introduction of cases＞
1)The patient kept overstepping the boundaries that the physician tried unilaterally to establish between their professional and personal relationships.
2) This case shows how a patient can set boundaries to a physician’s obligations, presumably to preserve their friendship and their professional (but now limited) relationship.
3) Physicians in particular need to be aware of possible transference and countertransference issues activated by life cycle changes.
4) They have developed and continue a mutually satisfactory business relationship and an enjoyable personal friendship centred on their recreational activities.
＜Practical implications for physicians＞
1)”Am I too close to probe my friend’s intimate history and physical being and to cope with bearing bad news if need be?” (eg, take a psychiatric history, perform vaginal or rectal examinations,care for a terminal illness).
2) “Can I be objective enough to not give too much, too little, or inappropriate care?” (eg, overinvestigate due to inappropriate anxiety).
3) “Will my friend comply with my medical care as well as he or she would with the care of a physician who was not a friend?” (eg, familiarity might lead to noncompliance).
One of the easiest and most appropriate boundaries to set is that of dealing with patient problems only within the appropriate setting, ie, only at the office or hospital.