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Medical Boundaries: Which Are Necessary?

AsklepiosPrize

Did you hear the one about the doctor who went fishing with his patient?

Neither had I until a friend told us about a trip he’d taken with his doctor to go fly fishing.

I wondered if he always went fishing with his doctor and he said, “No, if I have to take off my pants we meet at his office.”

This set me to thinking, as usual. In my training as a social worker, boundaries were—if you can imagine this—simultaneously rigid and blurry. They were rigid when it came to three basic things:

  1. Whatever is done must be done for the benefit of the patient. Period.
  2. No sexual relations whatsoever—implied, verbal, or physical—with any patient even when that patient has been terminated from treatment.
  3. No manipulation of the patient for personal gain, e.g., getting particularly close so you can meet his Hollywood producer cousin.

After that, however, the rules are fuzzier. In social work, the office is not the only place treatment takes place—it happens in the home, on the street, in homeless shelters, domestic violence advocacy centers, in schools, and just about anywhere else people get hurt or feel unhappy or need help. It is one of the few schools of psychotherapy that accounts for the person in situ—that we are more than a conglomerate of neural impulses or internal motivations. We live, breath, and move in an environment. We are driven not only by our own minds but by the currents that surround us. Interventions, then, must not only take those forces/currents into account, but deal with them. Sometimes that means that we move the office outside into the patient’s life.

But what about being—rather, more specifically, would I become friends with a patient? Or, conversely, would you be friends with your doctor?

Personally, there’s something about the idea that makes me nostalgic. There was a time, not that long ago, that a doctor was not a deity surrounded by the impermeable membrane of incomprehensible technology. A doctor was just another member of the community. He raised children that went to school with our children. He went to religious services with (or near) us. He got sick, took walks, bought food, and went fishing just like everyone else. We knew his first name. He knew all of ours.

Healing was not some private province. It was part of the large, bumpy wheel of living and dying.

If I’ve told you all this story before, forgive me, but it’s one of my favorites. My father is a doctor. Retired for 15 or so years, he still goes to Grand Rounds at 91 years old to learn and talk shop. Besides my mother, his only true love was and still is medicine. After he served on an army hospital ship in the South Pacific, he opened a small office in the Bronx.

Most of his patients came and went like they do in most physicians’ offices. One couple was different.  Harry was a strapping Scots-Irish trucker who was as easy-going as a man could be and as hardy as an oak tree; his wife, Irene, was as delicate as a porcelain tea cup and a consummate worrier. They came in for physicals or those occasional minor complaints that fill a family practice, until one day he came down with a fever of unknown origin. (There were far more of those fevers then than there are now.)

They called my father’s answering service in the middle of the night. The phone rang in our home and my father ran out with his medicine bag (he still has it) at 1 or 2 in the morning. He stayed there with them, holding Irene’s hand and doing whatever doctors did for mysterious and dangerous fevers until it broke. It was hours and hours.

The point of the story is not just that Harry got well or that Irene was happy. They became friends. They stopped at my father’s office to say hello, to bring pastries, to help with odds and ends. They started coming to the house for birthday parties and holidays. We called them Uncle Harry and Aunt Irene. And they still went to my father for medical care until the day they moved into a retirement village hundreds of miles away. And even then, they did nothing without consulting my father first.

How would that fare today? I honestly don’t know how most medical doctors would handle it. I suspect that most would avoid it for a number of reasons, not the least of them being liability anxiety. In social work, it is a bit easier to go out on a limb for a patient, to step out of the office for a moment. I have done it more than once—gone to graduations of clients whose families were far away, attended baptisms, stood quietly at memorial services, and walked frightened patients into health care centers when they wouldn’t (or couldn’t) go alone. It sits well with me. And it seems to have been good for them, which is how I measure it. I mind the basics (those three rigid rules) scrupulously, but I leave liability to the side, where it belongs.

Maybe I shouldn’t be so carefree about it, but I believe that proper (meaning spiritual rather than romantic) love—more than technique—is the source of cure. Especially in my work. Maybe not so much in the emergency room…but even there I think a point could be made for it.

I occasionally meet with one M.D., who is also a classical homeopath,  to discuss cases. He has been a teacher and a friend over the last few years. I’ve watched him work and he seems to feel the same way about medical boundaries. I don’t think he walks his patients into advocacy centers, but I’ve seen him attend his patients in his home office with a compassion and warmth that is unique in the business today. He dresses casually. He listens. He offers water or tea. He makes himself available both in terms of time and emotion. I don’t think he frets too much about liability either.

I guess people just have to do what they are comfortable with. If they are afraid of being sued, then perhaps they should take the precautions they need to avoid it. I don’t know if that makes it better or worse. They say we draw in what we fear most. I do know one thing. Harry and Irene lived a long time and they loved my father till the day they died.

 

 

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