Blurring of boundaries in the doctor–patient relationship

"Juggle the different hats we wear": enacted strategies for negotiating boundaries in overlapping relationships

Despite agreement that teaching on professional boundaries is needed, the design of health profession curricula is challenged by a lack of research on how boundaries are maintained and disagreement on where boundaries should be drawn. Curricula constrained by these challenges can leave graduates without formal preparation for practice conditions. Dual role or overlapping relationships are an example: they continue to be taught as boundary crossings amidst mounting evidence that they must be routinely navigated in small, interconnected communities. In this study, we examined how physicians are navigating overlapping personal (non-sexual) and professional relationships with the goal to inform teaching and curricula on professional boundaries. Following constructivist grounded theory methodology, 22 physicians who had returned to their rural, northern and/or remote hometown in British Columbia, Canada or who had lived and practised in a such a community for decades were interviewed in iterative cycles informed by analysis. We identified four strategies described by physicians for regulating multiple roles within overlapping relationships: (a) signalling the appropriate role for the current context; (b) separating roles by redirecting an interaction to an appropriate context; (c) switching roles by pushing the appropriate role forward into the context and pulling other roles into the background; and (d) suspending an interfering role by ending a relationship. Negotiating boundaries within overlapping relationships may involve monitoring role clarity and role alignment, while avoiding role conflict. The enacted role regulation strategies could be critically assessed within teaching discussions on professional boundaries and also analyzed through further ethics research.

To be or not to be in the social media arena? The perspective of healthcare providers working within adolescent and young adult oncology in Switzerland

Background Given that social media is quickly penetrating clinical practice, it is essential to explore how these technologies can be used to improve patient-centered care. This is particularly important for healthcare professionals caring for adolescents and young adults (AYA), amid whom the use of social media is nearly universal and whose medical and psychosocial needs are often underestimated by the pediatric or adult oncology settings in which they are treated. Objectives To examine the perspectives of various medical professionals on the emerging role of social media in AYA oncology. Methods Three focus groups were performed with Swiss healthcare professionals involved in the care of AYA patients with cancer. The focus groups were analyzed using thematic coding. Results Healthcare professionals caring for AYA cancer patients in Switzerland are reluctant to step into the social media sphere because they find it difficult to navigate professional boundaries in an unfamiliar space where different contexts collapse. Nurses and younger healthcare professionals who tend to have a more intimate relationship with AYA, often lack virtual mentorship to know how to maintain online professionalism. Adolescents and young adults cancer-related social media presence was unknown to our participants which resulted in missed occasions to inform, educate and care for this often underserved population of cancer patients. Conclusions More practical guidance is needed to help healthcare professionals with how to integrate social media into clinical practice. Setting up fruitful collaborations between medical institutions and existing AYA support groups online might be the best way forward.

What lies beneath? Experiencing emotions and caring in oncology

Medical encounters - while often viewed as centred on conveying clinical knowledge - are also sites of emotion and for exerting emotional labour by healthcare professionals. The temptation to view these encounters as largely 'technical' - an exchange of knowledge or information - can marginalise the complex emotions often experienced by healthcare professionals, and negates the critical work done in these encounters. Drawing on in-depth interviews with 22 Australian medical oncologists, this article explores the experience and meaning of (their) emotions in medical encounters, and the manner in which emotional labour is performed by medical oncologists. Emotions, as it emerges, are central to the 'management' of encounters, ensuring professional sustainability and in 'achieving' clinical outcomes. Here, we broaden understandings of emotionality in oncological work, focusing on emotions as central to the production and enactment of professionalism, relationships and identities across professional careers. We illustrate how the performance of emotional labour reflects a dialectic between notions of 'professionalism' and 'feelings' - which in practice are co-existing and intermingling dimensions of oncology relations - manifested in the practice of 'bounded caring'.

How do trainee doctors introduce themselves to patients?

Objectives

To identify how trainee doctors introduce themselves to patients.

Design

Survey.

Setting

Chelsea and Westminster Hospital, London.

Participants

One hundred trainee doctors, of mixed grades and specialties.

Main outcome measures

Introducing oneself by name, using their professional title ‘Dr’, use of the term ‘trainee’.

Results

All 100 participants introduced themselves by name to patients, with 63% using only their first name, 18% using only their last name and 18% using a combination of both. 67% mentioned their specialty and 18% mentioned their training grade. 85% identified themselves as a doctor, but only 22% used their professional title (Dr), and only 6% introduced themselves by name, grade, specialty and title. 80% varied the way they introduced themselves to patients, depending on several factors including the clinical situation and patients' characteristics/features. 56% said that they had changed the way they introduced themselves over time, and 42% deliberately avoided the term 'trainee' during introductions. There was no association between trainees’ age, gender or specialty and their comfort in describing themselves as ‘trainees', but the more junior trainees were more comfortable using this term than the senior grades (p<0.0001). Overall, 76% disliked the term ‘trainee’, for various reasons.

Conclusion

All doctors in this study introduced themselves by name but the majority did not specify their training grade or trainee status, predominantly because they believed it could trigger anxiety around their competence or undermine confidence in their abilities.

Reconsidering the role of language in medicine

BACKGROUND

Despite an expansive literature on communication in medicine, the role of language is dealt with mostly indirectly. Recently, narrative medicine has emerged as a strategy to improve doctor-patient communication and integrate patient perspectives. However, even in this field which is predicated on language use, scholars have not specifically reflected on how language functions in medicine.

METHODS

In this theoretical paper, the authors consider how different models of language use, which have been proposed in the philosophical literature, might be applied to communication in medicine. In particular, the authors contrast the traditional, indexical thesis of language with new models that focus on interpretation instead of standardization.

RESULTS

The authors demonstrate how paying close attention to the role of language in medicine provides a philosophical foundation for supporting recent changes in doctor-patient communication. In particular, interpretive models are at the foundation of new approaches such as narrative medicine, that emphasize listening to patient stories, rather than merely collecting information.

CONCLUSION

Ultimately, debates regarding the role of language which have largely resided in non-medical literatures, have important implications for describing communication in medicine. In particular, interpretive models of language use provide an important rationale for facilitating a more robust dialogue between doctors and patients.

Changing medical relationships after the ACA: Transforming perspectives for population health

American health care has undergone significant organizational change in recent decades. But what is the state of core medical relationships in the wake of these changes? Throughout ACA-era health care reform, the doctor-patient relationship was targeted as a particularly important focus for improving communication and health outcomes. Recent developments however have shifted the focus from individual-level outcomes to the wellbeing of populations. This, we argue, requires a fundamental rethinking of health care reform as an opportunity to renegotiate relationships. For example, the move to population medicine requires that the very concept of a patient be resituated and the scope of relevant relationships expanded. Medical relationships in this era of health care are likely to include partnerships between various types of clinicians and the communities in which patients reside, as well as a host of new actors, from social workers and navigators to scribes and community health workers. To address the upstream determinants of population health, providers must be increasingly willing and trained to collaborate with community stakeholders to address both medical and non-medical issues. These community-based partnerships are critical to providing health care that is both relevant and appropriate for addressing problems, and sustainable. Approaching health care reform, and the focus on population health, as a fundamental reworking of relationships provides scholars with a sharper theoretical lens for understanding 21st century American health care.

A Qualitative Study of Medical Oncologists' Experiences of Their Profession and Workforce Sustainability

BACKGROUND

Medical oncology is a steadily evolving field of medical practice and professional pathway for doctors, offering value, opportunity and challenge to those who chose this medical specialty. This study examines the experiences of a group of Australian medical oncologists, with an emphasis on their professional practice, career experiences, and existing and emerging challenges across career stages.

METHODS

In-depth qualitative interviews were conducted with 22 medical oncologists, including advanced trainees, early-career consultants and senior consultants, focusing on: professional values and experiences; career prospects and pathways; and, the nexus of the characteristics of the profession and delivery of care.

RESULTS

The following themes were emergent from the interviews: the need for professional reinvention and the pressure to perform; the importance, and often absence, of mentoring and feedback loops; the emotional labour of oncology; and, the impact of cascading workload volume on practice sustainability.

CONCLUSIONS

Understanding professional experiences, career trajectories and challenges at the workforce level are crucial for understanding what drives the oncological care day-to-day. The results indicate that there are considerable potential tensions between the realities of professional, workforce demands and expectations for patient care. Such tensions have real and significant consequences on individual medical oncologists with respect to their futures, aspirations, satisfaction with work, caring practices, interactions with patients and potentially therapeutic outcomes.