Figure 5.1. The role of boundary clarity and engagement in deepening the physician-patient relationship in the medical context.
Never forget that you defecate, micturate, and fornicate the same as your patients do.
SIMON AUSTER (OFTEN EXPRESSED WITH MORE COLORFUL, CRUDE WORD CHOICES)
ONE AFTERNOON, I was staffing the urgent care clinic at a Veterans Affairs hospital and walked into an exam room to see a man in his 60s who was concerned about a rash on his penis. He looked apprehensive as I entered. When I said my name was “Dr. Weiner” (pronounced “Wiener”), his expression turned incredulous, he glanced at my name tag—presumably to verify that what I was saying was true—and then burst out laughing. Although his reaction reminded me of teasing I endured as a child, I could see that here it was coming from a different place. This was unpremeditated. He wasn’t trying to entertain an audience, although the intern accompanying me looked amused. Rather, his response to my name in the context of his medical complaint was a stress reliever. Realizing what was going on, I felt some pleasure at how my name had actually been therapeutic, and also laughed. It would be easy to talk with this guy. We clicked.
To engage is, literally, to connect, like two railway cars that are latched together. Once linked, they function as a single unit. For the connection to work, the two cars must have the same destination. Also, they should be at the same level above the track, or the latches won’t intersect. One car can’t be looming above the other. And, when they do connect, they should come together gently with a satisfying “click” rather than a jarring “clack.” Once engaged, each is affected by the movement of the other, such that a tug is felt as a pull and vice versa.
When I am introduced to new patients, I expect to engage, and usually that’s what happens. After flipping through notes, looking up labs, or hearing a resident’s presentation, I get to meet the person, who may be lying on an exam table, sitting in a wheelchair, or waiting on a bench against a wall adjacent to the physician’s desk. Sometimes they are alone, sometimes with family, close friends, or a caregiver. One thing I like about meeting patients is that the purpose of the interaction is clear. I’m not walking in there wondering why we are conversing, as I often do at social events or cocktail parties. The railway car analogy applies: we’re going on the same journey, which is their journey. And we’re going to be at the same level. Of course I have expertise, which is why they’ve sought me out, but it doesn’t elevate me. In my own mind I think of my medical training as a tool kit that I carry. I dip into that kit as needed, but the interface with the patient is always me—Saul—not the algorithms, protocols, and technical language that can dazzle and confuse laypersons while putting me on a higher plane. Finally, as we do engage, I will take care that the contact is gentle and not bruising to them, as they are exposed and vulnerable.
My impression is that most patients are eager to engage—but don’t expect it. What they expect is a detached professional interaction that feels safe, if a bit impersonal. They have come to talk with a stranger about their hemorrhoids, depression, nasal congestion, erectile dysfunction, chronic pain, or simply fears of some lurking condition. When telling a doctor about an intimate and embarrassing problem, they assume the physician has heard similar stories a thousand times before and will take it in stride. I care for older veterans who exude masculinity, and I’m still struck by how openly they talk with me about sexual problems or drop their trousers to show me a diaper they’re wearing because of incontinence. Patients count on health care providers not to humiliate them by recoiling in surprise or laughing inappropriately, and I think the vast majority of physicians understand and meet that expectation.
But detached professionalism is not as good for patients or their doctors as engaged interaction, as it lacks the affirmation and partnering of minds that comes with real human connection. Nevertheless, it is a widely accepted communication style for collecting medical information inoffensively, having an orderly conversation to arrive at a care plan, and closing out a visit. Patients find it generally unobjectionable, and many physicians find it familiar, safe, and efficient. They evolve a style that is serviceable in nearly any clinical situation.
When the role of “professional” dominates medical encounters, however, they become scripted, which wears physicians down over time, even though they are the ones adopting the persona. It’s tiresome putting on a facade all day. It’s also less fulfilling not to open oneself to the experience of real connection. As a result, in contrast to other relationships, physicians often find that while relating to patients they are giving, but not getting back. They become prone to see their work as a labor, or sacrifice, and to view each encounter as one more job checked off a list, rather than as a satisfying interaction. As a result, they may be less attentive to patients than they could be, even regarding patient care as a burden—in contrast to the way they might feel helping a friend—which is a recipe for burnout.
I’ve heard physicians say that they don’t have time to engage, particularly with the short, back-to-back visits that are so common in office-based practice. This comment gives me the impression that they are not describing engagement, or at least not as I understand it. Engaging is the surest way to maximize the value of the time spent with someone. Engaging isn’t an additional task; it’s a way of relating in which neither party is holding the other at a distance.
It’s hard to describe an abstract concept like engagement in a way that leads to a shared understanding about what, exactly, it means. I intend it to mean something quite specific. For those who think visually, the difference between detached professionalism and engagement can be understood by diagramming what engagement looks like, starting first within the medical context. In figure 5.1, physician and patient each occupy a space that is circumscribed by a boundary that defines who they are—their values, beliefs, hopes, fears, preferences, even their physicality. The space within which they interact is also circumscribed by a boundary; one that encompasses the medical context, inclusive of the norms of the profession including all acceptable activities, whether “standard of care” or experimental, for which there is evidence of effectiveness or potential effectiveness.
Figure 5.1. The role of boundary clarity and engagement in deepening the physician-patient relationship in the medical context.
Note that the boundaries of the two individuals are in contact, indicating that each of them is experiencing directly who the other one is. This is a natural state that occurs anytime two individuals are open to engagement. The dashed concentric circles illustrate how as the degree of engagement increases—for example, the extent to which there is a sharing of values and experience—more of the self of each individual is encompassed. As long as the interaction stays within the medical context, broadly speaking, increased engagement deepens the therapeutic relationship. Any interaction that falls outside the medical context, such as financial or romantic indiscretions, or renegade treatments that are unacceptable even when both parties consent to them would constitute a “professional boundary violation.” Another type of harm, which is further discussed below, occurs when the physician encroaches on the patient’s personal boundaries. Such intrusions, while remaining within the medical context, include badgering a patient for being overweight or pressuring them to have a procedure they feel uncomfortable about. Such tactics, while potentially well intentioned, indicate that the physician is disregarding what may be going on inside the patient. Hence the physician must neither stray outside of the medical context, broadly defined, nor impinge on the patient’s personal boundaries. This is not as hard as it sounds: If the physician remembers why they are there, can avoid being someone they are not, and has respect for the person who has come to them for help, they are ready to engage. If that person is able and ready to trust, the two spheres will naturally draw together and lightly touch, as if there is a small amount of gravitational pull.
Figure 5.2. “Arm’s length” care, in which a physician lacks boundary clarity and holds the patient at a distance.
In contrast to engaged interaction, detached professionalism can be visualized as a physician holding a patient at arm’s length, as seen in figure 5.2. Note also that the boundaries of the physician are now shown as porous. This is to illustrate a physician who is not clear about who they are, at least in the medical context. My impression is that such a lack of clarity about self is the major reason physicians hold patients at a distance. Such physicians are hesitant to connect or are prone to withdraw at the slightest provocation because they simply aren’t sure how to react to certain situations, so they adopt a persona. For instance, had I not been clear about personal boundaries, I might have appeared poker-faced or simply looked uncomfortable and vaguely offended in response to the patient laughing when he heard my name, a seemingly professional but aloof response. Fortunately, I recognized that a brief twinge of indignation I felt came from negative past experiences and that this patient’s response to learning my name was a stress reliever, not a put-down. So I laughed along with him. The capacity to differentiate “what’s me” from “what’s you” is the essence of boundary clarity—of knowing who you are in a particular setting. If you don’t have it, you feel vulnerable because you don’t know what to think or do, which generates a sense of insecurity and defensiveness.
Boundary clarity is also what enables a physician to respond to suffering based on their patients’ needs rather than their own discomfort. This was concisely captured in the satirical classic about becoming a doctor, House of God, in the dictum, “The patient is the one with the disease.” It may sound harsh, but it’s a useful reminder to the physician that what they are feeling reflects their internal response to what they are witnessing rather than what the patient is experiencing. While the physician must do whatever they can to alleviate a patient’s suffering, getting caught up in that suffering as a consequence of a failure to recognize interpersonal boundaries will actually impair care. Thus, when a patient’s sobs cause a physician personal discomfort, it is important for that physician to recognize that although the patient’s distress is a result of the patient’s situation, the doctor’s own distress comes from within, an expression of their individuality, not the patient’s suffering. It may be a caring response to the patient’s distress; it may also reflect the physician’s fears—fears of experiencing a similar hardship, of losing control, or of tarnishing the image they have of themselves. Or it may be a direct response to the recognition that the physician has unwittingly hurt the patient. Each of these situations calls for a different response—the first, an expression of sympathy; the second, self-reflection; the third, an apology.
Physicians who cannot make such distinctions generally hold patients at arm’s length in the face of the suffering, rather than engaging. This was well illustrated in an essay in the New England Journal of Medicine by a mental health professional with a spinal cord injury who described how both a lack of boundary clarity and a lack of engagement by his physicians affected his care. He learned to withhold unpleasant information about his experiences with disability because their reactions were not helpful. He observed: “Expressing the emotions that accompany living with my disability evokes varied responses, but seldom has a physician responded by becoming more engaged or more determined to understand how my experience of disability can inform medical treatment.” In essence, in an attempt to manage their own dysphoric responses to the patient’s plight, his physicians kept a safe distance.
Boundary clarity is essential in interactions with patients who push boundaries, meaning they attempt to exert their will on the physician rather than share what they believe and seek what they want through respectful interaction. These are the patients whom physicians tend to identify as “difficult,” sometimes labeling them as demanding, manipulative, seductive—terms often used to self-justify a physician’s retreat from patients when they don’t know how else to respond to them. Even as these interactions can provoke frustration, the physician who is clear about personal boundaries will remain open to engagement, respectfully asking questions to clarify why their patient is upset, unafraid of where the conversation may go. They will also provide fair warning about when the visit must end so that their patient can decide if this is how they want to spend the remaining time. Staying engaged is possible because the physician with boundary clarity doesn’t take the patient’s behavior personally and remains clear about their own values and priorities, and so is not offended or threatened if challenged. The patient, in turn, may find the physician’s calm, unperturbed questioning and logic-based responses frustrating if they perceive the interaction as a power dynamic and are seeking to exercise control. However, it also provides them with an opportunity to begin to relate on healthy and constructive terms and hence has direct healing potential.
I’ve found that patients who try to push through boundaries respond in one of two ways when their physician is clear and firm about theirs: Either they stop the shenanigans and begin to interact openly and positively as they come to trust the physician, or they flee and find another doctor whom they can destabilize. The latter occurs if they are too distrustful to show who they really are, which is often a person frightened because they are unable to define their own boundaries and hence cannot let down their oppositional facade. In such instances, the physician will have lost a patient they probably could not have helped anyway.
There are rare situations in which a patient’s challenging of boundaries should prompt even physicians with clear boundaries to intentionally disengage. These are instances in which the patient is not just pushing the physician’s boundaries but is operating outside of the medical context, as when they exhibit physically threatening behavior or there is unequivocal evidence that they are seeking controlled substances for the purposes of diversion. I say “unequivocal” because I have seen too many patients suspected of such motives who were simply narcotic addicts, which is a problem within rather than outside of the medical context, and hence calls for a caring, engaged response.
As noted, harm to patients occurs when the physician is not respectful of a patient’s boundaries. At the extreme, telling a patient that one finds them sexually attractive represents a total disregard for why they came to see you and, therefore, who they are. It is also outside of the medical context within which all clinical interactions must remain. The more common types of boundary violations can subtly contribute to the unintended infliction of shame or humiliation in the medical encounter, as in the example in chapter 4 of several physicians pestering a standardized patient about being overweight when he’d repeatedly indicated that he wanted to talk about another, unrelated, medical problem. For whatever reasons, they couldn’t keep their preoccupation with his weight to themselves, which made him feel bad—even though he was just an undercover actor. Figure 5.3 illustrates such disruptions of a patient’s boundaries, which occur within the clinical context.
As seen previously in figure 5.2, the physician’s boundaries are again porous, indicating that, like the physician who holds patients at a distance, these “boundary-insensitive” doctors are also unable to reliably distinguish what’s going on in their heads from what they are observing. They differ in that their lack of boundary clarity leads them to badger or pressure patients rather than to pull back. This occurs when they feel strongly about something, such as their opinion that a patient needs to work harder at losing weight. They are not aware that their behavior is insensitive or even disrespectful. Because the underlying problem is a lack of boundary clarity, these are often the same physicians who hold patients at arm’s length when they are not being patronizing or bossy.
Figure 5.3. Intrusion on the patient’s domain when a physician lacks boundary clarity in the medical context.
Although the description above can give the impression that engaging with boundary clarity is very complicated, I think it is most helpful to think of it as a natural state. Engagement is simply what happens when two people are unselfconsciously interacting without a need to control the conversation in order to feel okay about themselves. This doesn’t mean that they talk about anything on their minds. Engagement always occurs in a particular setting and context that both parties are mindful of. Engaging with a lover in a romantic restaurant or with a patient in an exam room are completely different scenarios, but within their respective parameters each is a real human connection. The boundary clarity that prevents an engaged interaction from becoming hurtful is assured when the two parties are respectful of each other, meaning that both refrain from trying to impose their wills, including their values or beliefs, on the other. Over time, this leads to increasing trust.
What makes engaging with boundary clarity so healing? In the immediate moment it is the affirmation. One afternoon when I was with Simon at the supermarket and the cashier asked her employer-mandated question, “How are you today?” He replied, “Do you really want to know?” She looked up, a little surprised, but when she saw that he was not being sarcastic or challenging—just asking a reasonable question—she replied, “Yes, I do.” I don’t recall what he told her, but Simon is almost always having a good day, and he briefly shared a few thoughts with her. She looked visibly pleased.
In the longer term, such sincerity leads to trust. Whether a customer at the checkout counter, friend, or physician, one comes to trust a person who is both open about who they are and respectful toward you, meaning that they don’t pull rank on you, or attempt to exercise power, humiliate, or judge. You learn that if you look to them for advice, it won’t be colored by any sort of agenda other than being helpful to you. This enables you to speak honestly, putting into words thoughts that you never fully articulated even to yourself, which initiates a process of positive change.
Consider a man who comes to the doctor every few weeks for help with managing several poorly controlled chronic conditions. He doesn’t adhere to his medications because he is preoccupied with the chaos in his life. Relationships with his spouse, children, neighbors, and coworkers are distracting and volatile. The physician sometimes wonders whether they are doing any good for the patient but nevertheless welcomes him each time he comes to the office. Each visit they talk briefly but openly about what is going on in his life. He complains about various family members but rarely talks about himself. One day the physician asks him what he thinks he can do to help himself, since he can’t make his family change. He acknowledges that he feels out of control in his own life and observes that skipping his medications is a symptom of “not having my act together.” His doctor suggests referring him to a counselor, and he agrees that would be a good idea. Arriving at a place where he could talk about himself didn’t happen right away but played out over several visits. His capacity to open up, listen, and accept help emerged out of an earned trust that his physician is a caring and nonjudgmental person who only wants the best for him. Unfortunately, physicians in training these days often have so little patient continuity that there are few opportunities to foster such therapeutic relationships even if they could do so.
As we begin to participate in the medical workplace, we are taught to adopt a “professional demeanor.” Demeanor is defined as a person’s “outward manner.” Is our demeanor consistent with who we are, or is it a persona? Whereas the former should not interfere with engagement, the latter will. A persona, defined as an “individual’s facade or front” entails holding others at arm’s length (figure 5.2) while giving the impression that one is not. In lieu of one’s natural self, one substitutes a variant. It’s useful to reflect on whether you adopt a persona and, if you do, what purpose it serves and whether you’d like to change.
Adopting a persona is, in fact, sensible in situations where engaging is demonstrably unwise. For instance, if you discover that the attending physician on your third-year clerkship rotation bases grades on how much they are flattered, I would recommend flattering them as long as you don’t cross a line you are not comfortable crossing. You are in a situation where someone who lacks respect for boundaries is in a position of power over you, which is not a time to engage. Expecting you to meet their psychic needs is disrespectful of who you are, as a student enrolled in an educational program with career goals that depend on an objective assessment of your performance. Hold that person at arm’s length while simultaneously pretending you are doing just the opposite. Adopt the persona.
On the other hand, as soon as rounds are over and you enter the room of one of your patients, you are now with a vulnerable person who needs human connection, no matter how grumpy or irritable they seem. Can you switch from portraying a persona to engaging within the medical context? And if the patient is emotional, whether they are expressing grief or anger, can you maintain clarity about your boundaries without pulling back? You may find the opportunity to talk with a real patient about their real life issues as a breath of fresh air after dealing with a high-maintenance supervisor. You get to be yourself again, and expend effort on an interaction that is meaningful.
Then, when you get home at the end of a long day, how do you relate to the people in your personal sphere? With your friends, do you engage and respect boundaries? What about your family? And, if you grew up with a parent who reminds you of your self-absorbed, boundary-violating attending, how has that shaped you? Are you wary of engaging generally? Do you end up in intimate relationships with boundary violators because their behavior, while disturbing, feels at least familiar? And when you get into conflicts with intimate partners, family, or friends, do your emotions compel you to lash out, perhaps disrespecting their boundaries? Or do they say that you are cold and hold them at a distance? Most of us have some of these issues, depending on the circumstances. Do you know what yours are?
The ideal is that we initially approach interactions with an openness to engage, a clarity about our boundaries, and a respect for the boundaries of others. This ideal applies equally to the personal and professional spheres. What you’re engaging about, of course, greatly differs. As illustrated in figure 5.1, engagement in clinical interactions occurs exclusively within the medical context, whereas engagement in the personal sphere occurs outside that space. But that doesn’t mean that you are any less you in the medical context than you are with your friends at a Saturday afternoon brunch (assuming you’re not adopting a persona with them). The boundary issues in the professional and personal spheres are also more similar than different. With patients it entails knowing, for instance, not to nag them to do things they don’t want to do even if you think they should, and responding based on reason rather than emotion when you feel they are giving you a hard time. So too with friends and loved ones!
In reflecting on your own capacity to engage and to do so with boundary clarity, a good place to start is with personal relationships, as those are where we first learn what we gain and lose by connecting with others and develop a pattern of response. Think first about when and with whom you engage positively. I’m referring to relationships in which you are open, are neither deferential nor patronizing, and don’t have to tiptoe, meaning you can comfortably disagree without hurt or anger. That’s possible because neither of you tries to impose views or beliefs on the other, indicating a mutual respect for personal boundaries.
Now think about what you are not prepared to share with these individuals, as a way of assessing how engaged those relationships really are (see “Degree of engagement” in figure 5.1). In college I was not prepared to disclose to close friends that I had a panic attack because I feared they would think less of me. Looking back, I don’t recall any indication that they would have. An inability to trust close friends not to judge me cut off a resource that I could have turned to while feeling miserable. At the extreme, we hear of close family and friends who are shocked following a suicide, unaware of the pain the person had concealed. I think this is what the poet and writer Henry David Thoreau was referring to when he said, “The mass of men lead lives of quiet desperation.”
Just as we may hold those who care about us at arm’s length out of fear, we also, all too often, direct negative emotions toward them. If you find yourself succumbing to outbursts with intimates—be they parents, siblings, friends, or romantic partners—you may be blaming them for what you’re feeling inside (a lack of clarity about one’s own boundaries), or attempting to make them miserable too (a disrespect for their boundaries). These behaviors parallel those described in figures 5.2 and 5.3.
It’s hard to say exactly why we have the relational issues that we do, but our parents, teachers, and peers in childhood have much to do with it. Collectively, during our most formative years, they create the only world we know. As illustrated in chapter 1, these early interactions have a lasting effect. I’ve had an easier time with boundary clarity in professional relationships than with immediate family. In my case, the challenges probably have their origins in the way adults and classmates related to me while I was growing up with a learning disability. Sometimes I respond with indignation to a benign comment from my wife or daughter that reminds me of things my mother or a teacher said when I was a child (for example, calling me irresponsible or lazy when I was actually just bewildered and confused) that led to insecurity and defensiveness. I’ve found that boundary clarity entails recognizing that the emotion I’m experiencing in response to an interaction often reflects my issues, not the other person’s behavior. Recognizing that feelings—especially strong ones—need to be analyzed before acting on them is the biggest challenge to achieving boundary clarity in the personal sphere. Sharing with my family what I am feeling inside, but without implying they are responsible, is a way of engaging positively. It’s something I’ve been learning and practicing.
Young adulthood is when most people struggle to define their boundaries, that is, to figure out their values and preferences. At such a vulnerable stage, what they need are people who they can safely bounce ideas off of, knowing that those individuals have their best interests at heart, and no other agenda. Many future physicians, however, grow up in families where their parents have a plan for them. It’s hard to find your voice when people you are close to only want you to listen to theirs. Imagine trying to seek your father’s advice about whether to become a doctor or pursue a career in music, when he has said for years that he expects you to become a physician or an engineer. The fact that he regards your career as something he chooses for you reflects a lack of boundary clarity. Lacking clarity about what are your decisions—not his—he may try to push you around in other ways too. You can’t trust him as an unbiased sounding board who has only your interests at heart, although no doubt he thinks he does. Hence, you don’t engage him in conversation regarding big decisions. Not being able to talk about your dreams and aspirations with someone who looms as large in your life as a parent can leave you questioning whether there is anyone you can trust.
If someone comes along, on the other hand, who you appreciate is an unbiased listener, it can be an eye-opening and healing experience. Not only is their feedback of practical value, but you learn that there are individuals who don’t have an agenda other than to help. If you’ve not engaged with anyone like that before, it can be hard to recognize them even when they are standing in front of you. So, you may keep a distance. It’s a vicious cycle, as you can only determine if someone is trustworthy by fully engaging and seeing what happens. Many people are absolutely trustworthy under most circumstances, but if you are incapable of trust, even those relationships will remain superficial.
Even if you don’t have these issues, it’s important to appreciate that many of your patients do. I meet patients who give off a vibe of suspicion as I enter the exam room. Others exhibit distrust more indirectly. They may seem agreeable with everything I’ve discussed for the care plan but then not follow through after they leave because they don’t have confidence in what they’ve been told. How does one gain their trust?
Physicians who have good “bedside manner” can win trust in the short term simply by appearing trustworthy. Exuding reassuring confidence, they may convince patients to listen to them and do what they say even if the plan is not well thought out. But such a paternalistic style should not be confused with actual trustworthiness. Just like the physician dad who believes the best thing for his daughter is to become a physician even if her heart is not in it, physicians who believe they know best try to compel rather than to engage. Oftentimes I’ve heard a resident say a patient is “noncompliant” (which implies that a patient’s job is to do as they are told) when in fact they are declining something they don’t want, or simply are unable, to do. This reflects a lack of appreciation that the boundaries that delineate the patient incorporate both their individual preferences and their life situations. It also reflects a failure to recognize that the doctor works for the patient, not the other way around.
A trustworthy physician, in contrast, remembers that—like themselves—their patient is at the center of a complex life with many competing priorities that are all a part of who they are. Instead of trying to compel their patient to “comply” with anything, they’ll respect those boundaries and seek a care plan their patient wants and can follow—one that is hopefully a step forward from whatever they are doing now. Rather than thinking of their patient as “not compliant,” the trustworthy physician notes only that they are not adhering to a care plan, which calls for gaining the patient’s perspective. They will find out, for instance, why their patient wants to leave the hospital before they are medically ready to do so, starting with the premise that they must have their reasons. Those reasons may be either shortsighted and misinformed or driven by competing priorities of great import. Either way, the physician will meet the patient where they are and respond honestly. They will not disengage because the patient seems to be imprudent in their choices.
In fact, it’s at times when patients do the opposite of what you think is essential that they need you the most. I recall an Army veteran in his 30s with a serious bone infection that required intravenous antibiotics who insisted on leaving while he still had a fever “because I have to go pay some bills.” The intern suspected the patient wanted to get high and told him he’d have to sign out against medical advice (AMA). To expect an addict to take your advice, however, and ignore intense cravings is not respectful of where they’re coming from. This man had developed substance abuse problems after returning from two tours of duty in Afghanistan, where he experienced trauma. The fact that he felt a need to lie to us rather than just say, “Guys, I really need to get high,” is an indication that we did not have his trust. What he needed most is a doctor who doesn’t just give advice that he can’t follow, but who cares about him. In this case that meant getting him oral antibiotics to take with him and encouraging him to come back as soon as those “bills” were paid. I think he knew that we knew what was going on and appreciated us for it, as he did return and was able to talk about his addiction during the readmission. We were able to get him into a drug treatment program.
When I was a resident and got paged that a patient wanted to leave AMA when we thought they were not ready to go home, I had them sign the paperwork. It always felt like a breakdown in the relationship between the patient and the care team that was, basically, the patient’s “fault.” Before they left, I’d explain all the reasons why they should stay, but I can’t recall convincing anyone. Now I question the whole approach. The fact is, they have their reasons too, or they wouldn’t be leaving. Heroin withdrawal, for instance, is a compelling reason to go get some heroin if you’re the one in withdrawal. The fact that the patient has an addiction is just a part of who they are. As their physician, my job is to create a safe place where they can be open about it, so that we can work collaboratively in their best interest, whether to stay or go. From a medical-legal standpoint, I can document in the chart why they left and the extent to which I conveyed the risks. I can also explain what I did to mitigate the risks, like giving them Narcan, to reverse a possible overdose, to take with them.
The notion that success is actually about helping patients get the best possible care under the circumstances of their lives and preferences requires focusing on what makes them tick rather than on their not taking your sensible advice. When a patient declines a screening colonoscopy after learning how it can save them from a common and horrible cancer, the question is why they’ve made that decision, not how do I change their mind. Based on my research audio recording these discussions, many physicians either nag patients to get the test or stop bringing it up when a patient has said “no thanks” at previous annual checkups. A colleague of mine, however, recently described how after she had asked a patient annually why he didn’t want the test, without receiving any satisfactory explanation for several years, he revealed that he had been sexually abused while living on a Native American reservation as a child. His wife was present at the visit and learned about what had happened at the same time as his physician. The man agreed to enter therapy for a history of sexual trauma, and a couple of years later the wife commented about how positively her husband and their marriage had changed. He also got a colonoscopy. This physician wasn’t thinking of her patient as someone who didn’t “comply” with her, but as an unsolved mystery that warranted continued exploration. It was not about her but about him. That’s boundary clarity, and over time it led the man to trust her with a painful secret.
Perhaps the most contentious area these days where a lack of boundary clarity may undermine trust is opioid prescribing. Such lack of clarity can lead both to inappropriate prescribing and to withholding of opioids. On the one hand, a patient who is more likely to be harmed by than to benefit from escalating opioids may guilt-trip their physician into putting them on a higher dosage. The physician knows it’s not a good idea but doesn’t know how to assert that they are not personally comfortable escalating a treatment when the risks outweigh the benefits. In this situation the physician is allowing the patient to infringe on their boundaries.
On the other hand, physicians have also been forcibly weaning patients off of long-standing dosages of narcotics, causing havoc in the lives of individuals who were functioning well, when there is no evidence to support such action. There haven’t been any studies to date showing that forced opioid reductions decrease morbidity or mortality, so this practice isn’t evidence-based. Then why are physicians doing it? It’s possible some are just misinformed. But it also may that they are reacting, unwittingly, to their own fears about getting in trouble rather than to a measured assessment of their patients’ needs. Recently I saw a man who came into the urgent care clinic with his wife because chronic pain from an old back injury had flared since his doctor insisted at two prior visits on weaning a high narcotic dosage the patient had been taking for years. He worked as a forklift operator, never drank, didn’t use recreational drugs, and had no history of obtaining narcotic prescriptions from anyone else. He supported his family and sent money back to parents in Mexico. The patient’s wife vouched that he was missing work and at risk of losing his job. I restarted him on his original narcotic dose. Before writing the prescription, I ran the plan by the patient’s physician, who was down the hallway, to confirm that I wasn’t overlooking any information and that he did not object. I also documented how I’d concluded the benefits outweighed the risks.
I admit that increasing that dose of a potentially addictive pain medication made me uneasy. My unease, however, was not that I might be doing the wrong thing for the patient, but that I might get in trouble if there was a bad outcome. I’ve learned, however, that unease alone isn’t sufficient reason not to respect a patient’s wishes. One should not just react to what one is feeling inside without objectively looking at the situation. This patient had been functioning well, and now his quality of life and livelihood were compromised because of his doctor’s unilateral decision. It appeared I could undo some of the harm with a stroke of the pen and protect myself legally by documenting my rationale in the medical record. I recognized that my unease wasn’t related to anything the patient had said or done or any clinical research I knew of. It was probably the same unease that influenced previous doctors to pull the rug out from under this man. This was about them, not him.
I acknowledge that weaning patients off of narcotics without their consent can be attributed to factors other than a lack of boundary clarity. In some practice settings physicians are scrutinized or even penalized if their patients are on narcotics. Others may simply be ignorant of the lack of evidence, assuming that if starting patients on narcotics for chronic pain is bad, then getting them off narcotics must be good. A significant cause seems to be judgmentalism, as physicians often characterize patients who request narcotics as “drug seeking.” All of these factors influence physicians’ behavior. However, I do think we underestimate the extent to which we react to people, whether in the personal sphere or in our physician role, based on emotions that have little to do with the facts at hand. That represents a lack of boundary clarity, and it makes us less trustworthy.
Your clinical skills are almost certain to grow during the course of your training and in the early years of your career. After taking care of hundreds and then thousands of patients, you will develop strong pattern recognition and reliable intuition about what actions to take, particularly when caring for patients who are very ill. But how do you grow as the person who is the physician acquiring these skills, so that those you care for benefit not only from your technical abilities but from who you are? Your well-being matters too: most people who choose medicine as a career indicate, often in their medical school applications, that they seek meaningful interactions with patients. And yet so many hold patients at arm’s length, unaware of what they’re doing. All they know is that their work is more depleting then fulfilling. How do you avoid this rut?
First, by not blaming your lack of connection with patients on “not enough time,” the extensive use of technology in health care, or the electronic medical record. While I agree those are all problems, they are not the cause. Openly engaging with people is not conditional on anything. You can’t chalk it up to being too busy.
Second—and this gets to the core—engaging with a diversity of people coming to you with a wide range of health needs requires attention to your own triggered emotions and how to interpret and respond to them. Self-awareness does not come easily, and the culture of medical training doesn’t make it easier. Throughout your training and into your medical career you learn to suppress whatever you are feeling, whether it is fatigue, frustration, anxiety, or self-doubt, by adopting a matter-of-fact, even-keeled external demeanor. There is the sense that your medical career is happening to you rather than that it is in fact yours. The default is that over time you become an unobjectionable, technically competent task completer at risk for burnout.
To avoid this common pathway, you must acquire and maintain a perspective on what you are going through that requires balancing two realities. On the one hand you have, in fact, joined an all-consuming social system similar to the military, with conventions and expectations from peers and superiors about how to comport yourself moment to moment, and even what to think. On the other hand, you must remember what being a physician is all about: caring for people who are sick, worried about their health, or becoming increasingly dependent on health care as they age. Some are jerks, some are nice, some are lost, and some are confused—just like the doctors who care for them. There are reasons for their attitudes and capabilities, which you’ll likely never know. They are wealthy, middle-income, and poor. They may look bored or indifferent, but they rarely are. They’ve come to see you, often at personal cost or inconvenience, because they trust that you are their best bet at getting the help they need.
When you are with a patient in a hospital or exam room, it’s no longer about the medical tribe that you’ve joined; it’s two people working together to solve the patient’s problems. What do you feel as you walk into that room and start a conversation? Are you rushed, anxious, fearful, or frustrated that you don’t have much you can offer, given the patient’s condition? Impatient because of the circuitous answers to your questions? Burdened by responsibility? Distracted by other things you need to do, personal and professional? All of these feelings are common and normal, but they’ll less likely distract you if you have one other: a desire to connect in some way, even if briefly. It’s a natural state that you’ll get to if you can strip away the impediments: pretensions, presumptions, insecurities, illusions, and anxieties that incline physicians to hold their patients at a distance.
Early on, my “physician-hood” consisted mostly of the skills and expertise that I acquired through education and clinical training. I often compartmentalized my interactions with patients from those with other people. Over time, however, there has been a significant shift in perspective. Now, when I walk into a patient’s room, I’m reaching out to someone to form a connection. The “me” I’m introducing is inseparable from the one who can’t cook but can wash dishes, can’t find anything in grocery stores but enjoys the interactions with the stock clerks who help, and frets over every new ache and pain. Some may say that you can’t get to this point until you are first comfortable with the technical aspects of being a doctor. I acknowledge that it’s harder because, early in your training, you are prone to feel like an imposter. The best antidote, however, is to value the parts of yourself that predate your medical training and that can be such a comfort to your patients. You may still be “wet behind the ears” in terms of acquiring clinical skills, but at least you can give them the chance to interact with someone who—while still learning the basics—engages with them. There is nothing fake about that.
An openness to engaging isn’t something you compartmentalize into your work or personal time, as it’s your way of relating generally. I’ve found that neighbors, friends, colleagues, people in my wife’s congregation, employees, and occasionally even bosses come looking for medical advice, often about sensitive, private matters. I take it as a sign that they regard me as approachable and safe. It usually starts with an e-mail or voicemail, or someone whom I vaguely know pulling me aside at a community event. I once had an employee call me from an emergency room because he was having a bad trip after smoking some marijuana and needed someone to calm him down. Just as remarkable as that call was the fact that there was nothing awkward about seeing each other the next day at work when he was back to his usual professional self. Just as patients are people, people can be patients. We are all in flux. When I got the flu and had a panic attack during a time my wife was abroad, I realized I would be comfortable calling many of the same people who had turned to me when they were in trouble.
If you can acknowledge your own humanity, you can more easily see others’. An indication that you are engaging is that you ask fundamental questions you otherwise might overlook or suppress. You see beyond what tests to order, pills to prescribe, or procedure to do, and notice the bigger picture. When I saw a patient recently in urgent care with a common cold who had survived two tours of duty as a soldier in Iraq and works as a data analyst, I asked him: “Is there something else on your mind, aside from a cold?” I learned that his PTSD symptoms were acting up, making him more anxious, and that someone he knew had gotten really sick from the flu, which triggered some feelings of panic. I recognized that the fact of his coming to see me was the real puzzler for me to sort out, not how to treat cold symptoms.
When I asked the resident who saw the man first why they hadn’t asked the question, they replied that they had thought about it too, but didn’t want to appear judgmental by inquiring why he bothered to come in. I wonder if they felt that way because it had not occurred to them that there may be some underlying reason other than just “worried well.” Ironically, their fear of coming across as judgmental reflected that they were judgmental. If they’d given the guy a bit more credit—the same credit they’d probably accord their friends or themselves—they might have asked what was going on.
Medical training narrows your perspective about what matters during a clinical encounter. You’re taught a lot of expert knowledge and reminded repeatedly, starting with multiple-choice testing, to apply that knowledge to patient care. So, when a patient comes in with upper respiratory symptoms, you focus on the symptoms, not on the person who has them. With such a narrow focus you don’t form a human connection, and hence are likely to miss whatever is going on around those symptoms. A staggering 45 percent of people who commit suicide saw a primary care physician in the prior 30 days. I’ve come to appreciate that the safest way to be sure that I don’t hurt my patients, and that I do help them, is by quickly forming connections so that I have every opportunity during the encounter to pick up on something I wouldn’t want to miss.
And yet, when I’m observing physicians, all too often I see them holding patients at a distance. My research and quality improvement team, which listens to about a thousand audio-recorded visits a year, often has the same impression. What they notice most are the questions doctors don’t ask when they hear patients say things like, “Doc, I’m supposed to be taking that medicine twice a day.” It’s not clear why they are not engaging, but my sense is that there are quite a few reasons, depending on the situation, including the following:
• They are task-focused rather than person-focused. In the example above, all they’d hear is that their patient is taking a medication twice a day, not the indicator that this is actually not happening. If it were their own child or parent instead, I posit that they’d ask, “What you do mean you are supposed to?”
• It hasn’t occurred to them. For instance, when a patient has a cold, there isn’t much to engage about, so it seems, so they focus on small talk while entering data into the computer.
• They don’t know how. They hold everyone at a distance, including their families and spouses, unaware of what they’re doing. They don’t know what engaging is. This is likely due to a lack of clarity about personal boundaries.
• They’ve been taught by example to adopt a persona with patients rather than connect as who they are.
• They’ve learned that when they do engage with people, things can go sour fast. They are unaware that this is due either to a lack of clarity about who they are (that is, knowing what is inside versus outside the personal boundaries that define them at a point in time), or a lack of respect for other people’s boundaries.
• They feel that engaging with patients is going to be draining, consumes too much time, and isn’t necessary. They are unaware that this perception reflects a misunderstanding of what it means to connect with people during even brief interactions.
• They would like to engage but are fearful of making themselves vulnerable.
Which of these, if any, apply to you? I think the last is a bigger factor than most physicians would acknowledge. A sign is that you withdraw in emotionally charged situations. When you’re with a patient who starts to cry, can you sit there, aware that you are feeling all sorts of emotions—such as sadness, fear that what happened to them could happen to you, a sense of helplessness—yet remain calm and open, and not retreat into a persona? If the answer is no, I urge risk taking: avoid avoiding such situations. If you’re experiencing emotions that pull you back in the face of suffering, instead let them wash over you—accepting that they are coming from within you, not from your patient—and remain open and in touch with yourself, perhaps by paying attention to your breathing. Also, be kind, thoughtful, and helpful to the person who is crying.
Physicians may retreat from the suffering they witness by focusing on medical facts so that they don’t have to engage directly with the patient. I recall an extreme example when I took the place of another attending, supervising a team on the medical wards. The patient was a man in his 70s with emphysema so severe that he was kept alive with Bilevel Positive Airway Pressure (BiPap), a tightly sealed mask that forced air into his lungs with each breath. Even on the highest settings it was evident that he was gasping for air. It turned out he’d been in a miserable state for days and lung tests showed this was his new baseline. His present and future life looked like hell.
I asked the residents if they agreed with my assessment, and they nodded that they did. I asked if they had talked to the patient about withdrawing care, and learned that no one had. No one could tell me why. My conversation with the patient was straightforward. After introducing myself, I asked a few questions to be sure he was capable of understanding what I wanted to talk about. As the machine made whooshing sounds, forcing air in and out of his lungs, he nodded to each in a manner that indicated his mind was working fine. After explaining his medical situation, I asked him in about three different ways if he wanted us to remove the mask and put him on narcotics so that he would not feel air hunger but would soon die. Each time, without hesitation, he nodded “yes.” We called his family, discussed the plan, arranged for them to come in right away, took him off the machine after putting him on a morphine drip, and allowed him to die peacefully within a few hours.
How long did these physicians in training, and their attending physician, watch this man suffer without meaningful hope of recovery? Why did they stand by rather than engage in what turned out not to be a particularly difficult conversation? I don’t know for sure, but I suspect it was a response to fear of what they would feel by having this end-of-life discussion.
Regardless of the reason for not engaging, the remedy is the same: step outside your comfort zone. You needn’t wait for extreme situations like the one illustrated above. In nearly every patient encounter there is an opportunity to connect within the medical context in a way that acknowledges our shared human experience. Start by looking at the epigraph to this chapter. Repeat it to yourself, replacing the medical jargon with visceral, crude language that strips away pretensions that any of us are other than flesh and blood with needs and desires. Let it sink in. Now you are ready to engage.
Questions for Reflection and Discussion
On Engagement
1. To what extent do you fully engage in various types of interactions, as the author describes the term? How many of your patient interactions are a boost to your mood or, at least, feel satisfying?
2. What parts of yourself do you show your patients, and what parts do you generally conceal? How might you behave differently when giving bad news to a friend (versus a patient) that your friend (or patient) has a serious illness or that a loved one has died? What are the pros and cons of any differences in how you respond to friends and patients—for your patients and for you?
3. Do you feel your patients are benefiting from the distinct qualities that make you the unique person you are, or is that uniqueness not really a part of the way you relate to them? Do you feel you are interacting with patients in a manner that gives you a window into what makes each of them unique? Are many of your interactions rewarding? If so, in what ways?
4. If an adult patient came to see you with symptoms of a mild upper respiratory infection, missing work to do so for the third time in two years, would you wonder why they were seeking medical care, knowing that you just provide reassurance and over-the-counter medication recommendations for the common cold? What might be some underlying reasons for these visits? Would you ask? How might you frame the question?
5. Have you seen patient care situations in which difficult conversations were postponed at a cost to the patient’s comfort or well-being because of a reluctance to engage? (The example of the patient with terminal end-stage emphysema kept alive on BiPap is an example.) If so, how might these situations have been approached differently so as to better serve the patient?
6. What are the implications of the epigraph at the start of this chapter for how to think about your patients’ foibles, odors, and eccentricities? Can you think of a patient with whom you felt a strong sense of shared humanity? Can you think of patients who seemed “other” to you? What are the implications for how you interacted with each of them? Can you think of more engaged ways of interacting with patients who seem un-relatable?
On Boundary Clarity
1. When are you best able to be clear about boundaries, as the author describes the term, and when do they break down in your personal and professional interactions, leading to conflict, making assumptions about the other person, or distancing?
2. Are there certain types of patients who “get under your skin,” making you cringe when you see their names on your appointment calendar? Consider what might be going on during your interactions with them, utilizing the framework described in this chapter. Is it that you can’t engage with them? Do you struggle with maintaining boundaries when they make incessant demands? How might you alter your behavior so that these encounters become opportunities to model healthy interaction and to provide them a brief respite from the chaos that is likely present in their other relationships?
3. Have you ever felt resentment that a patient didn’t show appreciation after you significantly helped them? If so, why do you think their show of gratitude is important to you? Does the doctor-patient relationship include an expectation that patients make their doctors feel good too? Could their indifference reduce your investment in their care? What if you learned from a patient’s family member that the person actually does appreciate you but just isn’t able to show it?
4. If a patient asked you a question about yourself that you were uncomfortable answering, how might you respond? Could it change the way you relate going forward? If so, how? Might you now hold them at more of a distance? If so, what—if any—are the implications for their care?