Boundaries
Professional boundaries relate to the way you behave in your role as a doctor.
The term encompasses a range of areas of your work: time, place and space, money, gifts, services, clothing, language, self-disclosure, and physical contact. You might cross a boundary because you think it could benefit your patient. However, if crossing the boundary could have a negative impact and potentially cause harm, this is known as a ‘violation.’
Patient safety is paramount. Doctors must not use their professional position to establish or pursue an improper emotional or sexual relationship with a patient or someone close to them. They must treat patients with dignity and protect them from harm posed by another colleague’s conduct.
Developing awareness and responsibility around patients’ cultural and religious concerns is important to understanding boundaries such as touching or social invitations.
Doctors who get into trouble around boundaries often confuse their personal life with their professional life.
It is critical that you maintain a fiduciary relationship with your patients. It involves trust and duty – the patient places trust and confidence in the professional who has a duty to act in the best interest of the patient.
Breach of this trust undermines not just the doctor–patient relationship, but the public’s trust in the profession.
Disclosing personal information about yourself to the patient can bring you closer, which may have advantages in terms of encouraging the patient to talk about themselves. However, excessive disclosure radically changes the dynamic. In most examples where sexual boundaries are violated, the doctor has provided an excessive amount of information about themselves.
The blurring of personal and professional lives is increasingly played out online. The simplest approach is to have separate personal and professional social media profiles, with the highest level of privacy on personal sites.
Violating professional boundaries can lead to long-term psychological issues for patients because:
- the problems they initially sought help for still remain
- the original problems have been made worse
- additional damage is caused by the breach of trust
- their ability to approach/trust other professionals is impaired.
Patients may feel confused and, in extreme cases, even suicidal. The doctor will face disciplinary enquiries and professional sanction, including in the worst cases being removed from the medical register. Colleagues, other patients, the employing organisation, friends, and family may also be affected.
Why are boundaries important?
Boundaries keep doctors and patients safe. The professional relationship must be upheld as patients need professionals to behave with integrity and do their job.
Who violates boundaries?
Multiple offences committed by psychiatrists against patients are relatively uncommon. Assessment and rehabilitation experts report that doctors at all stages of their careers might violate boundaries. Higher rates have been observed in people who are further ahead in their professional careers.
The majority of transgressions seem to be committed by clinicians experiencing personal and professional stress, sometimes with additional trauma. It is important to address personal stress and burnout as early as possible and to talk with colleagues and mentors if you are worried or are experiencing problems.
What should I do if I become aware of developing feelings towards a patient?
It is normal to have a range of feelings towards patients. Sometimes called ‘countertransference,’ these are ethically neutral occurrences. The key skill is clearly identifying these feelings, sharing them with a colleague or mentor, and taking appropriate action. Problems arise when feelings are acted on.
It is worth reflecting with a mentor or supervisor how these feelings developed, as there may be important lessons about working with patients or any personal/ professional issues you may have.
What should I do if I have already overstepped a boundary with a patient?
Both GMC guidance and general professional ethics require openness and accountability. If you believe you have crossed a boundary and risk causing significant harm to a patient, consider being open about this with colleagues. As a matter of integrity, apologise to those concerned. It is important also to contact your professional association, defence organisation and the GMC.
Can practitioners who have transgressed ever be safe to work again?
There is evidence from Gabbard and others in the USA to suggest that rehabilitation is possible for some practitioners. The key issue is identifying contextual and risk factors and developing rehabilitation plans in light of these factors.
The GMC will always take action on improper relationships and its decision-making will always be informed by the remedial action taken, level of insight and specific circumstances of the transgression. Openness and honesty following a transgression are key.
I am concerned about a colleague – what can I do?
If you have concerns about a colleague, take appropriate steps without delay. Please refer to the GMC’s and the Royal College of Psychiatrists’ guidance listed under References.
- Gabbard G, Lester E (1995) Boundaries and Boundary Violations in Psychoanalysis: 59. American Psychiatric Publishing.
- Gabbard GO, Myers M (2008) The Physician as Patient. American Psychiatric Publishing.
- General Medical Council (2013a) Good Medical Practice. GMC. (PDF)
- General Medical Council (2013b) Maintaining a Professional Boundary between You and Your Patient. GMC. (PDF)
- General Medical Council (2013c) Doctors’ Use of Social Media. GMC. (PDF)
- Royal College of Psychiatrists (2013) Vulnerable Patients, Safe Doctors: Good Practice in our Clinical Relationships (2nd edn) (College Report CR180). Royal College of Psychiatrists. (PDF)
- Subotsky F, Bewley S, Crowe M (eds) (2010) Abuse of the Doctor– Patient Relationship. RCPsych Publications. (PDF)
The content on this page is also available as a downloadable help sheet (PDF).
