Scenario

One of my colleagues has been concerned about a friendship she is developing with a patient’s family and wonders if she needs to set professional boundaries. When this patient was gravely ill, she visited him frequently at home until his death. During these visits, she became friendly with the entire family, particularly with the patient’s sister. In fact, they became very close.

Now the sister has asked my colleague if she would accept her and other family members as patients. Should she explain to the sister that her feelings of friendship toward her might preclude a professional relationship? Can she accept the woman’s family members as patients and continue the friendship? In general, to what extent should friends, relatives, and acquaintances become patients?

Commentary

The negotiation of boundaries in patient care can be a difficult process in many circumstances. Perhaps the thorniest negotiation is the one alluded to in this case scenario—how does a physician decide if a friend should be accepted as a patient? It is one of the more complex challenges a physician faces.¹ A physician has to consider several issues before agreeing to see a friend as a patient. If these boundary issues are not addressed before the agreement is made, there is a risk that the physician could eventually feel resentful or exploited, and the patient could feel confused, betrayed, or even mistreated. The following list of questions is intended as a guideline for physicians contemplating accepting a friend as a patient.

Can I be as good a diagnostician with this patient as I would be with a patient who is not a friend? When treating a patient-friend, one might either underevaluate or overevaluate a symptom because of the underlying friendship. For example, if the patient-friend complains of atypical chest pain, the physician might go overboard with the work-up because of anxiety about missing something serious. Or, if a friend needs a painful or uncomfortable procedure, the physician might be reluctant to recommend it.

Can I tell this patient-friend that I cannot answer health-related questions outside the office? At a party or other social gathering, friends often prod a physician to sit down a minute while they describe the pains they have been feeling, and ask the physician if it’s something to worry about. Physicians who can’t tell a friend that they are not comfortable talking about medical situations in a social setting and that those questions should be addressed in the clinic or hospital may have a difficult time giving the best level of care. Telephone calls at home or consults in the grocery store should be discouraged as well.

Can I ask questions that might make my patient-friend feel embarrassed or uneasy? There are many questions about drinking, unsafe sex, and other health-risk behaviors that can be awkward to address with any patient. Negotiating the boundary between respect for patient privacy and the physician’s need for information in good medical practice is a challenging role for most physicians. It is even more challenging when the patient is a friend.

Can I perform examinations that might make the patient-friend feel embarrassed or uneasy? Rectal, pelvic, and breast examinations may be difficult to perform on a friend but are an essential part of good medical care. But physical exposure might make either the doctor or the patient very uncomfortable if a friendship predates the physician-patient relationship.

Can I deliver difficult news and information to my patient-friend? Even if the physician has gathered enough courage to ask sensitive questions about such things as sexual practices or to perform a physical examination of sensitive areas, there are still challenges ahead in conveying the results of testing for sexually transmitted diseases. For instance, a physician needs to be certain that, if the situation arises, he or she could tell a patient-friend about a human immunodeficiency virus–positive status.

Can I say no to inappropriate requests? Patient-friends may make requests that a physician might feel conflicted about, such as filling out forms for questionable disabilities or writing a prescription for another family member. With a patient-friend, it is important for physicians to ask themselves if they can say no when requests are made that would otherwise not be agreed to. For instance, if a patient-friend asks for antibiotics without an office visit, the physician needs to be comfortable telling the patient that he has to be checked in the office before a decision to treat with antibiotics can be made.

Will I blame myself if something goes wrong while I’m caring for a patient-friend? It is difficult to anticipate the answer to this question. Even physicians with the best imaginations cannot necessarily anticipate exactly how they will feel when something bad happens to any patient under their care. It is important to remember, however, that in all medical practices, medical mistakes and bad outcomes happen. The question is, are you more likely to blame yourself and feel a sense of shame if you make a mistake with a friend? For example, if you reassure your patient-friend with atypical chest pain, and then he dies suddenly, what are you going to feel? How are you going to handle the other family members’ reactions to the situation?

Are you clear about your ability to maintain confidentiality? When a friend is a patient, other family members may be equally well known to the physician. In this case, the physician may find it unusually difficult to maintain patient confidentiality. For example, if the husband of the patient recently seen by the physician asks during a tennis game what you thought was going on with the headaches his wife was having, would it be difficult to maintain patient confidentiality? If a spouse, parent, or adult child assumes that, since the patient is such a good friend of yours, you might be inclined to share information freely, would you be able to say no, you can’t?

Do you have someone with whom you can talk about these patient-friend issues? Carl Whitaker, one of the fathers in the field of family therapy, talked about the importance of therapists having what he referred to as a “cuddle group.” This group would provide therapists with access to other therapists to talk with about the struggles and challenges of managing difficult patient situations. It is important for physicians to have other physician colleagues who can be trusted to discuss a variety of problems, including the dilemmas presented by treating friends as patients.

Are you in a rural setting? Physicians practicing in a rural setting may not have an alternative to having friends as patients. When a physician is the only physician available, the need for clarifying the boundaries of the doctor-patient-friend relationship is exceedingly important. The physician who has trouble setting limits because of the pull of friendship certainly will be more vulnerable to burn out. By carefully identifying exactly what the physician can do for a friend in the doctor-patient role and in the friend-friend role, the physician can guard against feeling overextended.

In this scenario, the physician’s responses to these questions may indicate if this patient would be a good addition to her practice. If the physician does not feel comfortable taking this friend as a patient, the ability to say no is again important.² The physician in this situation may need to say, “I know we have developed a close connection during the course of your brother’s illness and his death, and it seems in many ways natural that I would offer to care for you as your physician. However, I don’t believe, in light of the friendship that we’ve developed, that I could give you the level of care you deserve. I have a trusted colleague, however, whom I know you would like and who would provide you with excellent care. I’ll give you her name and number, and I hope you’ll be able to follow up with her.” By providing a referral to a recommended colleague, the physician can maintain a sense of doing what is best for the patient and perhaps continue the friendship, free from the double role of friend and physician.