practice partner
also physician-friend, physician-employee, physicianpartner. “The patient can only be a patient,” he says.
What gets in the way of that clear equation? Part
of it is the physician’s naiveté, states Dr. Silcox, i.e.,
a failure to recognize that accepting gifts, becoming
friends or giving a patient a job immediately sets up
a dual relationship.
“So the patient thinks they’re special and are owed
special service or favors,” he says. “Anything that creates specialness with a patient is to be avoided.”
He suggests that physicians can get into trouble for
the same reason they got into the field – a desire to
help. “Physicians are vulnerable. They’re prone to do
everything that will be seen as kind and supportive to
patients.”
As Dr. Silcox says, it’s so much easier to say thanks
for a gift, or to hire a patient to do needed work, than
it is to think ahead to the possible complications.
Stepping Away from the Line
Degrees of dual relationships are sometimes impossible to avoid entirely. In smaller communities, for
instance, physicians might inevitably move in some
of the same social circles as their patients or encounter them in public places.
“So if you see each other at the grocery store, and
the patient says ‘I have an infection or pain, can you
look at it?’, you say they need to make an appointment where you’ll have your charts and files,” says
Dr. Silcox. “Maintain the separateness of the role.”
The Western course runs through scripts to help
physicians respond to situations where boundary
crossings and violations may arise. Course attendees
are instructed on how to preserve the physicianpatient relationship while withdrawing from the
non-clinical relationship.
For instance, if a patient proposes an investment
together, you can say “Sorry, but I’ve just confirmed
with the College that we can’t go into a business relationship because it’s contrary to the rules.”
That approach tends to work well, as it avoids outright rejection. Instead, it invokes an outside authority like the College. That takes matters out of the
physician’s hands, says Dr. Silcox.
Are there times when some physicians might
become more susceptible to boundary crossings
or violations? Certainly, physicians who get into
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Dialogue Issue 2, 2015
trouble might blame fatigue, work, or life stress. In
other circumstances, physicians may argue that it
was the patient who crossed the boundary, and they
were simply being polite. Regardless, it is the physician who is responsible for maintaining boundaries.
“Physicians have no excuses,” Dr. Silcox says.
That’s a heavy burden, but it reflects physicians’
fiduciary duty to always act in their patients’ best
interests. Physicians have an ethical obligation not
to exploit the trust, knowledge and dependence that
develops during the physician-patient relationship.
“We spend a lot of time in medical school on
competence and safety, and not nearly as much on
ethics,” Dr. Silcox says. “If you don’t have an ethical
framework, the competence and safety will suffer.
Excellence is an outcome; safe, ethical and competent
care is the underpinning.”
Is taking coffee from a patient really a big deal? On
the surface, no. Maybe it’s an innocent gesture, and
you were just going to get a cup anyway. But it could
symbolize something else, says Dr. Silcox – the idea
that you could gradually become beholden to the
patient, treat them differently, or think of your needs
first. This jeopardizes the physician’s duty to maintain
emotional and clinical objectivity and professional
judgment, which can adversely impact patient care.
Learn more
• or information on upcoming sessions for “UnF
derstanding Boundaries and Managing the Risks
Inherent in the Physician-Patient Relationship” at
Western, visit http://www.schulich.uwo.ca and
search for continuing medical education and
CPSO-recognized courses. Or contact
Meghan Edmiston, 519-661-2111, ext. 88929; or
[email protected].
• or the CPSO poli