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Letter to the Editor

A Case of a Patient/Physician Boundary Issue in Rural Practice and Measures to Avoid or Maintain Dual Relationships

Pravesh Sharma, MD

Published: April 23, 2015

A Case of a Patient/Physician Boundary Issue in Rural Practice and Measures to Avoid or Maintain Dual Relationships

To the Editor: Physicians deal with some of the most intimate and sensitive issues in patients’ lives and are bound by confidentiality to protect the healing space of the physician/patient relationship. The trust embodied in the physician/patient relationship is that of a fiduciary relationship wherein the clinician holds a superior position of power relative to the patient.

Perhaps the most important principle of this relationship is the obligation of primum non nocere or to "first do no harm." The concept of relationship boundaries helps to identify and avoid situations in which harm or exploitation of the patient might occur.1

Professional boundaries are described as the edge or limit of professional behavior appropriate for a physician’s interaction with a patient. Many commentators have defined the professional boundary as solely within the context of the clinical setting, but this definition may be inadequate for clinicians who live and work in rural or small town settings where chance encounters outside of the clinic routinely occur. Additionally, while boundary violations have focused primarily on sexual boundary violations, a more nuanced understanding of nonsexual boundary issues has also developed in recent years.1 These nonsexual boundary violations may occur outside of the clinical context where a dual relationship may be invited by the patient or the clinician and may not necessarily involve sexual encounters. Business relationships, friendships, and community engagement may all give rise to these dual relationships.1,2


Case report. Dr A is a psychiatrist in a small town. The hospital where he works is the only major psychiatric facility in the town. Being among the few psychiatrists, Dr A would bump into his past and present patients whenever he would go to the shopping mall, gym, or church or attend a parent-teacher meeting for his son. A few days ago, he found out that his wife’s coworker is his patient too. Recently, Dr A visited a car dealership with his friends to buy a new car. The sales representative who was dealing with Dr A happened to be his patient. It was obvious at once that Dr A and the sales representative knew one another. The sales representative offered a substantial discount on the car of Dr A’s choice. Seeing this, Dr A’s friends, who were unaware of the exact nature of Dr A’s and the sales representative’s relation, also wanted to be offered a good deal. This landed Dr A in a complicated situation in which he must face either a breach in patient-doctor confidentiality or a setback to his friendship with his peers.


The above-mentioned case is a common scenario that a small town physician faces every day. On the one hand, there is awkwardness to this situation, and on the other, there are a few ethical dilemmas. Many physicians aim to avoid these nonsexual, postwork relationships because of the fear of the patient’s confidentiality being at stake.3 However, in a smaller geographical settlement, the members of the community are more dependent on each other to meet their basic needs. In addition, the longer a physician lives in a small community, the more unavoidable and inevitable these overlapping relationships become.4

The concern among physicians with these encounters is that patients might get a glimpse of their personal lives, which could put them in an uneasy situation. However, a few physicians find these overlapping relations acceptable and propose that, being a responsible member of a community, the physician has a duty to nurture the community in which he or she lives. These participations may even become an opportunity for effective role modeling for the community.5 A physician may prevent awkward situations by undertaking the following measures.6,7

Educate the patient. A physician may use a clinical visit with the patient as an opportunity to discuss the unexpected encounters they may have outside the office. If the physician and patient are not comfortable with the nonsexual, dual relationship, they may choose to end the doctor-patient relationship. If that is not the case, the physician could provide the patient with the options of either acknowledging or ignoring one another outside of the office. It should be made clear that the physician cannot participate in any conversation regarding the patient’s treatment in public.

Refer to someone else. Physicians charge for the services provided to their patients. Anything beyond this service would be considered as a physician’s own need, which may interfere with the physicians’ ability to be empathic and objective toward the patient. In that case, the physician should refer that patient to a colleague.

Talk about it. Dual relationships are one of those topics that we do not like to talk about aloud. Initiatives should be taken in residency programs to have a discussion among the residents and students to create an environment of self-awareness. Immediately seek supervision from the senior physician if entering into an overlapping relationship. A physician should find another physician with whom to talk about any such dilemma in clinical practice but keep the patient’s confidentiality secured.

Self-awareness. Physicians should ponder on their personal and professional needs. They should be aware of their own weaknesses and prejudices. Physicians should not challenge their personal and professional limits.

Honor confidentiality. If a physician chooses to go into a dual relationship, he or she should be very careful regarding the confidentiality of the patient. For example, since Dr A’s wife is a friend of one of his patients, he needs to make sure that the confidentiality of the patient is not compromised if they all happen to meet at the same time in public. However, every attempt should be made to avoid those meetings. In such situations, a few physicians would call the patient directly and engage in mutual problem solving.8

Good documentation. It is imperative to document the conversations held with the patient regarding contact outside the office. It is also important to document any dual relationship a physician enters into as well as rationalizations to do so.

Physicians may refrain from entering into multiple relationships if such contact reasonably affects their objectivity, confidence, and effectiveness in performing their functions as a physician or risks exploitation or harm to the patient. Discussing the issues of outside office contacts, and acknowledging doctor-patient relationship confidentiality and ethical dilemmas associated with it, during the first visit with the patient is always helpful.


1. Gabbard GO. Boundary violations. In: Bloch S, Green SA eds. Psychiatric Ethics. 4th ed. New York, NY: Oxford University Press; 2009:251-266.

2. Nadelson C, Notman MT. Boundaries in the doctor-patient relationship. Theor Med Bioeth. 2002;23(3):191-201. PubMed doi:10.1023/A:1020899425668

3. Smith D, Fitzpatrick M. Patient-therapist boundary issues: an integrative review of theory and research. Prof Psychol Res Pr. 1995;26(5):499-506. PubMed doi:10.1037/0735-7028.26.5.499

4. Simon RI, Williams IC. Maintaining treatment boundaries in small communities and rural areas. Psychiatr Serv. 1999;50(11):1440-1446. PubMed doi:10.1176/ps.50.11.1440

5. Scopelliti J, Judd F, Grigg M, et al. Dual relationships in mental health practice: issues for clinicians in rural settings. Aust N Z J Psychiatry. 2004;38(11-12):953-959. PubMed doi:10.1080/j.1440-1614.2004.01486.x

6. Schank JA. Ethical issues in rural counselling practice. Can J Counsell. 1998;32(4):270-283.

7. Brownlee K. The ethics of nonsexual dual relationships: a dilemma for the rural mental health professional. Community Ment Health J. 1996;32(5):497-503. PubMed doi:10.1007/BF02251048

8. Schank JA, Skovholt TM. Dual relationship dilemmas of rural and small community psychologists. Prof Psychol Res Pr. 1997;28(1):44-49. doi:10.1037/0735-7028.28.1.44

Pravesh Sharma, MD

Author affiliation: Department of Psychiatry, Texas Tech University Health Sciences Center, Lubbock.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Acknowledgement: Dr Sharma thanks Cheryl Erwin, PhD, JD (Center for Ethics, Humanities and Spirituality, Departments of Medical Education and Psychiatry, Texas Tech University Health Sciences Center, Lubbock), for her invaluable support and suggestions in preparing this letter. Dr Erwin reports no conflicts of interest related to the subject of this letter.

Published online: April 23, 2015.

Prim Care Companion CNS Disord 2015;17(2):doi:10.4088/PCC.14l01752

© Copyright 2015 Physicians Postgraduate Press, Inc.

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