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In a patient doctor relationship, one of the realities is that our roles limit us from personal relationships. Do things get personal? I suppose inevitably as long as we are both human they will. But we do our best to stay professional and use the standard of practice and the guidelines presented by our profession’s specialty board to help counsel us. Because of years of increasing litigant awareness on both sides, patient and physician, this has culturally become important.
Each physician must decide what defines their ethical boundaries in their practice of care. Each patient at some point must understand that there is a difference between what they are receiving and what they are giving in this relationship. The patient doctor relationship is different from a friendship in part because there is an unequal level of power between them that opens up a huge index of interpretations on motives, intentions and fair play. It also robs the patient of receiving what is considered a more objective level of treatment. When things are personal, it’s more difficult to be objective. It’s more difficult to do our job.
When I was in medical school, the psychologist I saw became intensely special to me. She was the one who saw my vulnerabilities in every color. Even though I cried regularly, brought her gifts that, thank God she accepted, and felt affection toward her, she somehow reciprocated without making me think I’d ever hear about her personal life, see her cry, receive gifts from her nor affection beyond what was appropriate for our professional exchange. I learned so much from her but wish I could learn more.
Physicians do different things to help themselves learn and practice professionally. It isn’t easy. After all, we have feelings. Some of us have temperaments that are naturally what culture would consider professional; temperaments that predispose for cognitive processing, naturally not personalizing what isn’t about us and have needs outside of interpersonal relationships. Other physicians are designed to bring people into our inner space, and when that is not considered ethical, have an ongoing degree of struggle to maintain distance. It is an important skill for anyone who plans on practicing outside of prison to learn quickly.
In psychiatry, historically when we used to do more psychoanalysis, it was accepted practice to collect all fees at the beginning of the session. The patient placed the money on the table where it stayed throughout the hour as a reminder that this is a professional relationship. I have chosen to maintain a variation of that practice where I try to collect the fees in cash from patients rather than my staff. Sometimes when I’m behind or such I’m not able to but I try. My hope is that Freud got something right and that the patients, at some level, register that I am hired for a medical service which is perhaps more than friendship. You can imagine how this is less obvious to some seeing their psychiatrist rather than their podiatrist.
I have other support to help also, such as through my malpractice insurance, CAP-MPT. They are wonderful. They are available any time for a phone or email consultation on any question I have. (I believe they know my name by now.) They also send out regular newsletters on related topics to their clients which I read seriously and try to implement.
Before writing FriendtoYourself.com, I was much more guarded. I never treated friends or family and felt isolated from my community which I thought I was doing to maintain patient confidentiality issues. I’m so glad that has eased up a bit inside of me. I’m a better physician because of it. I will continue to learn about this dynamic balance in patient doctor relationships from my patients and from experience and welcome the growth.
Self-Care Tip – Give yourself the benefit of keeping a professional in your life who knows their role.
Question: What is your opinion about the patient doctor relationship? Do you ever struggle with boundaries? How do you see those boundaries as being in your favor of getting better medical care? Please tell us your story.
Related articles
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- The Price of Precaution and the Ethics of Risk (bioethicsdiscussion.blogspot.com)
- Reworking Choices With Your Physician as Part of Your Team (friendtoyourself.com)
- APA Guidelines for Practitioners (protectivemothersalliance.wordpress.com)
- Should a doctor block his/her patients on Google+ or Twitter? (casesblog.blogspot.com)
Thanks Doc, it’s a subject I have often wondered about. Must be very tough on you.
you’re welcome cindy and thanks for your thoughtfulness. what were your wandering wonderings about this in the past? i would luv to hear them.
A major problem for me – that has become better over the years – was that, as my dad was a doctor and I was surrounded by a lot of the ‘medical culture’ through my life, when he died I didn’t just lose a father, I also had to learn how to care for my own health, because the two were so intertwined. I also had to learn that health professionals and I are not on the same social level when I am the patient and they are my health provider. I still have difficulties with that. Like, when I visit my doctor, I find myself asking about his practice and how it’s going, not really thinking that it’s none of my business!
Your blog is a bit of a challenge for me, Sana. I never quite know if you’re writing as a personal blogger, blogging about her working life, or if you’re writing as a professional blogger with a bit of your personal life thrown in! I find it a bit confusing sometimes as I can’t quite see clear boundaries here.
i hear u on this val. family of physicians is another rich topic. your insight on your own dynamic relationship w/i that is rich.
yes, i’ve never been a great template for what the masses do. it’s uncomfortable at times indeed. personal disclosure is only ok, as far as i’m concerned, from the perspective of a physician if that physician is ok w it disclosed professionally as well. that’s been what i rudder with so far and am just doing my best. what do you think? let me know.
I think that a patient doctor relationship is so important. When I was in counseling, I knew that my psychologist was my doctor. I knew that she would not come over to my house or associate with me outside of the office. I think that (especially in the emotional sense) it is important for both the doctor and the patient to have boundaries. It helps us to talk things out better, and to face the past knowing that we won’t have to see the doctor anywhere else. It can be so hard. I have cried when I reached the point where I did not need to go to counseling anymore. I have felt like I lost a very good friend. But I also know that is what gave me the courage to talk about the past, and the things that I struggled with. I could not have brought myself to talk about them if I had to worry about someone else knowing and hating me for it. I am a people pleaser by nature. That makes it very hard for me to make the choices to get better. It makes it very hard for me to put myself first. The doctor patient relationship is one thing that makes healing possible for me.
this is a beautiful paragraph on pt-dr relationships for you and i think many of us can garner from it. thank u for your story on this. i luv how u described so well that maintaining your pt-dr rln is part of being your own friend. awesome.
I haven’t got to start any “relationship” yet. Although I am looking forward to starting with my first appointment on the 20th. So, I don’t have a story to tell yet.
Right now I am sitting with my father who may or may not be dying. He is very confused and hallucinates from time to time. Last night he said there were snakes on the ceiling and we need to get up and move. (he’s been a quad on a vent for 17 years)
This is all making me very emotional at a time when I need to be the strongest person around. I need help. My mother is starting to display early signs of dementia. She’s ben the primary caregiver all these years, and I’ve assured her that if/when she can no longer do this, I will be there. I’m very irritated with my only sibling, a brother 3 years older. While I’m spending my only time off caring for my parents, him and his wife are running around the midwest on their motorcycle. They used the parents house as a stop-over (free motel). They managed to stop and see dad for 20 minutes, but then the other motive was exposed, they needed money from Mom. Sheesh.
I am nervous about seeing this new Doctor, and choose to see someone in a town nearby. Everybody knows everyone in my small town and I want more privacy than that.
I suppose when I see the new Doc, I just tell my story and describe symptoms????
On a brighter note, I get an interview at my full time job for a position as a supervisor. More pay, better hours. Wish me luck, usually somebody’s friend already has the job and I’ve become one of the usual “also-interviewed”.
Enough for now. Gotta go set up the interview time.
congrats on the supervisor interview. that in itself is an honor. way to go. please let us know.
seeing a new doc is nerve racking. your family narrative sounds rough and i’m sorry to hear about your folks. u taking care of u is courageous. keep on.
Talk about style.Whenever I go see Dr. Jacobseon(my PCP for 30 years) he starts by “Keerist. You’re still alive?” Then he says”What’s wrong and make it quick, I’ve got sick people in the waiting and money to make.” Then I say “You better keep me alive or there will be less money for you to make.”
laughing loudly. u bring out the best in him i see.
It was a loss to move from friend to patient. That is just how it has to go in the self care process. Then there is the anxiety of the Dr. discovering who you really are and perhaps being disappointed.
M, these r such beautiful intuitive insights into yourself. thank u so much for sharing what many of us feel and may not have put a finger on yet.
I really related to this post. We have the same fine line in the teaching profession. Always a tough call, and ultimately so subjective…
nice connect. hadn’t thought of that but i see it now. hugs
I have never had a friend as my doctor or had a doctor become a friend. I only see my doctor once or twice a year so friendship has not developed and that’s ok.
I did see a psychologist for a while and under different circumstances I think she would have been someone I would have liked to explore friendship with. But I figured if friends could help me I wouldn’t need to see a professional…
patricia, this is articulate and resonates w me. thanks.
My pastoral counselor was, I was guessing, about my age. As we worked together, I began realizing that we both loved art and art history, musicals, The Kennedy Center activities, nature and Biblical studies. I knew I was too sick to be friends right then but I was certainly looking forward to being well because I was sure we would be fast friends then. I even mentioned it – a lot! – and she always responded politely that it would be fun. She never said it would be impossible and inappropriate so, of course, I continued to believe that it would happen one day. I’d never seen a counselor or a psychologist or psychiatrist before. I didn’t know the rules. We were friends with our kids’ pediatrician but had been before we had kids so there had never been a problem there, but, then again, he was treating our kids’ medical problems and not my emotional problems.
So, having wished for this great friendship with my pastoral counselor and having gotten no signs that it wouldn’t or couldn’t happen, when I suddenly understood that I had also “transferred” (?) to her and told her so (because my psychologist said I could trust the counselor with that information) and she (I have no doubt now) didn’t know how to handle transferrence and (I also have no doubt now) had her own problems that made her unable to handle mine, it absolutely destroyed me when she told me she would no longer work with me and would never, ever see me again under any circumstances. Among other things, one of my main issues were abandonment issues. It, therefore, took a full four years more of therapy for me to get over the hurt that this woman caused me, and, although I’ve been fine for almost eleven years since that painful time, thinking about it even now causes an ache that I have to talk myself through.
Physicians are so right to make it a practice not to be friends with their patients – professionals in the field of psychiaty, especially, because we, their patients, are so emotionally fragile. However, having experienced the pain that I did, I would hope that those professionals would be much more upfront with their patients – and MUCH more honest than my pastoral counselor. It would hardly seem necessary to mention being more sensitive, too, but, in her case (at least with me), her lack of sensitivity was one the the major issues.
Good post, Sana. Thank you. I am convinced that there are many people out there who don’t understand this issue. At least I would hope that i’m not the only one who has ever been clueless. And, as Patricia said, we do get in situations where it would be nice to explore a friendship with someone with whom we share so much – but, then again, if our exisitng friends couldn’t help to begin with…….
thanks nance. good point on the upfront bs. MD’s need to own that for sure.
Doc, I loved this: distance has bothered me in the past but it is such a strength. Thanks.
thank u kate. u nailed it in one sentence. that point about distance offering strength was amazing.
I have a couple thoughts from the “patient” side. (I’ve never been a psychiatrist.)
First, it occurs to me that most of my relationships have some sort of power imbalance, only without the ethical guidelines of a formalized doctor/patient relationship. I think there’s a potential for danger there.
Secondly, it is hard, at least from the patient side, not to feel genuine affection over time. After all, this is practically the one area of my life where someone actually listens and is interested in me. In today’s “me-oriented” world that is a pretty big deal.
I find the fee thing interesting. I just started with a psychoanalyst two weeks ago and she said nothing about it, so I wrote a check at the end of the session. (Next time I’ll have it prepared in advance now that I know how she likes the check filled out.)
Fun money factoid: I can pay an M.D. $100 for three harried minutes of time or $50 to my psychoanalyst for 50 minutes of time. No matter how you slice it – that is a much better deal! 🙂
intuitive point about all relationships having power imbalance. there’s a flux in power back and forth in all of them. it’s a problem if they don’t pulse. in doctor-pt combos it is imbalanced but it doesn’t pulse when healthy – counterintuitive. thanks for helping elucidate that.
re: money factoid – i’ll let u work that out 🙂
Great post Sana! Coming from a therapist’s perspective, I am a believer that boundaries need to be maintained in this type of relationship. The therapist is there to be objective, not be there as a friend. After all, money is involved. However, this does not mean that you are not friendly and enjoy the client as it is (one sided).
I have had some clients who have tried to cross boundaries or be my friend outside of therapy and i had to firmly explain that even though I like them, I am cannot have a friendship because it goes against the ethical guidelines that i follow for my profession. Also, if they ever want to come back to therapy, it could become an issue or become messy.
Sana, I really like that idea of paying up front before the session starts- you make great points with this methodology!
As with family and friends, they are always going to ask you for help…in this case, I usually preface things like “I’m not your therapist but”…If it is something that is more serious, I will help them find a therapist.
Personally, I didn’t want to be friends with my therapist…she was providing me with something far more greater than what a friend could provide and if I knew the intimate details of her life, that would have changed the way i viewed her as a person.
sharon dear, thank u so much for your insightful comments.
“something far more greater than what a friend could provide and if I knew the intimate details of her life, that would have changed” – awesome
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Great article. When I tried to help my parents with their medical issues, I have either been the hero or the dog. So I’ve decided not to talk about their medical issues anymore. They are elderly, I am a geriatric NP but I got them a geriatrician in their town now so I can remove myself.
I always have struggled with giving up too much of myself as a practitioner to my patients. It is a constant balance. I guess that is where compassion fatigue sets in.
I have found that I have had a better professional relationships with my therapist than my doctor. This could be because of my PTSD. I tend to read the doctors if they seem nice and want to heAR my problems then I open up more. I do like it when they show concern and want to help. Most of the doctors I have seen are like a fast food drive through. I have a problem. They give me advice or medication and boom they are gone after 5-10 min. Recently, I found a great practice od doctors. Most of them care, while I feel some do not. I am just another number. Thank you to the doctors that do care enough to get to know there patients by asking questions. It all stayed professional.
Hi Sheila! Thank you for putting this out there. I too don’t like to go to clinicians who “drive through”! 🙂 Clinicians are in a tough place right now in practice but I’m not saying that’s why some of us do this nor justifies it. I remember in a previous post we struggled with what I think plays into this – “you both, patient and psychiatrist, have to come to terms with each others’ agendas.” It is great news that you have found clinicians who are in flow with your needs. This is wonderful. Keep on!