Clinical and professional boundaries

Author: A Consultant Orthopaedic Surgeon

The poem Mending Wall by Robert Frost depicts two neighbours at the end of each winter, rebuilding the wall between their farms¹.  Each year they question the need for the wall between friends, with no livestock, only crops, and each time concluding, “Good fences make good neighbours”.  The wall serves as a metaphor for boundaries within a society or institution, to safeguard member’s autonomy and facilitate healthy collaboration.

Similarly, a river’s banks are its boundaries. These give water its depth and consistent direction of flow.

Professional and clinical boundaries exist within medicine and hospital institutions to protect both patients and staff.  They provide predictability and consistency, while ensuring that those in a position of power and trust act in the best interests of both our patients and colleagues.  Where and when a power differential exists, it is up to those in positions of responsibility to maintain these boundaries and prevent harm.

Having been involved in both sides of disciplinary processes, I attended a professional boundaries course.  It made me question many assumptions, and reflect on the perspectives of others and our own vulnerabilities. The course lasted three days: intense, draining and reflective.  The themes discussed were evidence-based and common, yet largely unknown among senior and junior colleagues in the departments I had worked in.

A consistent theme was that authority and responsibility can lead to myopia, sometimes reinforced by years of practice (we are all ‘busy’), and it is only when events or circumstances conspire that an individual is forced (and often has the time) to step back, reflect and hopefully improve.  Avoidance and denial of responsibility were consistent themes during the course among the doctors (including myself), dealing with difficulties that had occurred in the workplace.  Each course participant had ‘a story’ and we each acted as observers and ‘story listeners’, noting a sequence of events that often ended with the group commenting: “...And at what stage did that decision seem like a good idea?”

Many of the following themes I recognised to a greater or lesser extent in my own professional and personal life, but at work I was surrounded by colleagues exhibiting similar traits and potentially ‘at risk’, because they were unaware.  You may recognise some of the following…

Self-disclosure

Self-disclosure (from a doctor) can help build trust and rapport, both with patients and colleague³.  The doctor who has experienced a surgical procedure or illness may use this experience in a positive way to reassure an apprehensive patient.  However, self-disclosure that manipulates or achieves self-indulgence or personal gain is not acceptable.  Trust makes people vulnerable.  Our captive audiences may feel obliged to listen to long monologues that are of no interest or purpose.  There was a reflective story during the course about a senior surgeon who spent the first five minutes of each consultation talking about fishing – when questioned as to whether this was appropriate, he replied: “…But everyone loves fishing”.

Cognitive distortion²

These are feelings that are irrational or exaggerated.  They are evidence-based, validated and known responses that can occur before, during and after significant events:

1. Mind reading. The doctor assumes that they know best.  This phenomenon is more common with experienced practitioners who are ‘busy’.  Omissions and misinterpretation arising from assumptions made during the consultation (or a discussion with or about a colleague) can lead to harm.  The importance of being present, being aware and listening with curiosity to what each patient or colleague is actually saying (rather than your own internal voice speaking over the person), has benefits for clinical care and collaborative working.
2. Personalisation.  An inability to see what is obvious and around you is the “It’s all about me” phenomenon.  This can be used to blame other people for your own actions.  With this, there is an assumption that the actions of others are based around you.  This is common in a hospital setting where entrenched differences can persist and escalate: “This only happens to me” and “These people were out to get me anyway”. A perspective can develop where individuals blame others for the consequences of their own actions.  We find personalities who struggle to accept responsibility.
3. Emotional reasoning. Decisions are made based on feelings, rather than logic or evidence.
4. ‘Should’ statements.  These are ideals and rules where the affected individual has fixed and unreasonable expectations for others’ behaviour, what they ‘should do,’ and becomes agitated, angry or irrational if they object.
5. Entitlement.  An attitude can develop whereby individuals feel that due to their knowledge and expertise, that certain rules or behaviours do not apply to them, because they ‘know what they are doing’ and have worked hard for many years.

Professional and personal values⁴

What are solid professional and personal values?  During the course we created two separate lists, which with a healthy outlook we were told should present like two marginally overlapping circles of a Venn diagram.  Some separation should exist and the circles not completely overlap, as the risk is that one subsumes the other.  On the other hand, complete separation and circle size asymmetry indicates an unhealthy imbalance and dissonance between our behaviour at work and at home. It was discussed that it can be career-saving to have a mentor in the work environment and/or place for discussion where problems and pressure can be shared. 

New possibilities: reflection, acceptance and making reparation

We are all vulnerable.  A denial of vulnerability is well-recognised in surgeons (along with money, prestige and perceived popularity). Is it acceptable for a surgeon to be perceived as vulnerable within a hospital peer group?  Arguably, our current culture has made us more vulnerable through reinforcing expectations of individualism.

Apology, responsibility and making reparation are essential to people learning and moving on from each individual situation.  Make a plan, speak to colleagues, obtain feedback directly, and record their feedback and answers to your questions.  Do so openly and do not answer back or justify when they speak – simply listen and take notes.

‘Who I am is what I choose to be’ was one of the take home messages that resonated with me.  This is not predetermined and as surgeons we are not locked into a specific personality type – we can choose to change, develop, exercise control and improve.

Key tips:

1. Select three words that you would hope colleagues would use to describe you and aspire to those words.  My choices were skilled, approachable and professional. 

2. Find a mentor as a consultant.  Someone who can give you honest feedback and who you trust. 

3. Create your own questionnaires with regards to all aspects of your working life and regularly ask a range of colleagues to complete these with you face to face,  but let them speak! 

4. Listen – don’t be the first to speak.  Let others direct the conversation and you’ll often be surprised where the conversation travels.

5. Be aware that your words and actions matter and can affect others – people tend to minimise this in their own minds. Consider fault and responsibility separately.

References

1. ‘Mending Wall’, The Poetry of Robert Frost. Robert Frost. Edited by Edward Connery Latham.
2. The Clinic for Boundary Studies. www.professionalboundaries.org.uk
3. Disclosure of illness by doctors to their patients. A qualitative study. Klitzman R, Weiss J. Patient Educ Coun. 2006.
4. Good Clinical Practice. www.gmc-uk.org/guidance