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The Management of Troubling Feelings Toward Patients
Arch Fam Med. 1999;8:272-273.
PERHAPS THE MOST IMPORTANT aspect of "Time and Tide"1 is the fact that it is being published in a mainstream medical journal. This is a reflection of an evolution in the culture of medicine in the United States, where the presence of uncomfortable, disruptive, and "unacceptable" feelings toward patients can be acknowledged. Doing so is of course not an end in itself. Hopefully, it is a starting point in a process of self-awareness that ultimately will improve one's work by minimizing the effect of such unruly feelings on the physician-patient relationship.
It would be difficult to argue with the motivation for this trend toward acknowledging and discussing "forbidden" feelings. The process, however, is not without pitfalls. Naive preaching to physicians to "get in touch with your feelings" ignores the complexity of the mechanisms individual practitioners and the profession as a group have employed to cope with the enormous stress of caring for ill and suffering patients.2 Some physicians, like some people, have limited psychological resilience. To force them to give up the safety of a technical, biomedical approach to their work, and at the same time to demand that they acknowledge confusing feelings toward patients, can cause more harm than good. By way of analogy, experienced family practitioners and psychotherapists alike are cautious with some patients about stirring up primitive feelings that could possibly lead to more disorganization and lack of functioning.
Given these caveats, I still believe "Dr Tide's" struggles with his feelings toward his patient, and his sharing this with his colleagues (including the readers of this journal) is a positive step. The literature on professional boundary violations and sexual misconduct would suggest that his behavior is an example of how to avoid such feelings being translated into action.3-4 Physicians who end up sexually abusing their patients tend to fall into 2 categories.
- Repeat offenders. These are usually sociopaths who have slipped through the credentialing filters and who coldly, consciously, and repetitively exploit their patients. Dr T. clearly does not fit in this category.
- Isolated incidents. These are usually decent but troubled individuals, and the sexual misconduct is actually a later step in a series of boundary violations. The first violation is most often excessive self-revelation (based on the physician's, rather than the patient's, needs), followed by extending the length of appointments, scheduling the patient as the last appointment of the day, inappropriate touching and hugging, home visits to help with a "crisis," and socializing outside the office. A typical scenario is a middle-aged physician who is recently divorced, socially isolated, drinking too much, with some disappointments in his career, who becomes overinvolved with a patient whom he is trying to help deal with her grief over a loss in her life. (I use these pronouns because the most common pairing is a heterosexual male physician and a heterosexual female patient, but every permutation of gender and sexual orientation occur.)
Dr T. could have fit into this category, but he avoided it and, in doing so, demonstrates several admirable traits: (1) He was troubled by his feelings from the beginning and never rationalized them. He thus avoided the slippery slope of confusing his needs and those of his patient. (2) He never shared his feelings with the patient. (3) Rather than loosening the boundaries with the patient, he became scrupulous in observing them. (4) He sought help from colleagues (not from the patient!) in dealing with his fantasies and feelings.
The response of his office mates—a brush-off with anxious winking—shows the pressure to keep such feelings "in the closet." The next step, reaching out to Old Edward for advice, was a wise one. First, he takes his pain seriously and allows an open discussion of embarrassing feelings. His comments, starting with "She's a metaphor," confront Dr T. with the fact that his own conflicts are blurring his ability to see the unique individual who is in his office. They further stimulate him to reflect on the problems in his own life that fuel his disturbing fantasies. But he is careful about boundaries: admitting troubling feelings and trying to make sense of them is fine, but acting on them violates the patient's trust and the physician's integrity. Edward allies himself with the more mature side of Dr T. by informing him that the duty of friendship would require him to report Dr T. to the medical board for such behavior.
Is Old Edward just a wise, seasoned colleague, or a formally trained mental health professional? Does it matter? Up to a point, probably not. Indeed, the very brief but very effective "therapeutic" techniques that Old Edward employs are a model of the kind of counseling techniques that a family physician could realistically use in a busy practice. However, if these feelings continued to cause trouble, the next step would be more formal counseling or psychotherapy. For one thing, this would keep the boundaries clear with Old Edward, by not putting an undue burden on their friendly and collegial relationship.
If Dr T. learned more about what in him stimulated such strong erotic feelings toward his patient, he could then use his emotional reactions to patients to enrich his work with them. I encourage primary care residents to develop a decision tree to deal with strong feelings (including attraction, anger, avoidance, and guilt) toward patients. The first decision point is, "Is this feeling, or at least the intensity of it, what a majority of relatively healthy physicians would experience, or is it idiosyncratic to me?"
If the former, the physician needs to develop a differential diagnosis of why this patient elicits such a response in generally caring physicians—clarification of which will determine the clinical approach. If the latter, the response yields no useful data about the patient. Instead, it points to the need for the physician to understand more about this emotional reaction, whether it be through introspection; informal discussion with colleagues like Edward; formal processes structured to enhance such awareness, eg, a Balint group5; or formal psychotherapy. Such processes take time; in the meantime, the physician can learn from professionals in the theater who master the technique of "making an adjustment" when they need to portray an emotion different from what they are personally feeling.
I suspect that in the scenario involving Dr T., most colleagues would note some fleeting feelings of attraction and perhaps envy, but this would be experienced as background noise that was not particularly pressing. Some might go further and suspect a forced element in this picture of youthful contentment, particularly since the patient seems at the moment to be socially isolated and without a passion for a possible career trajectory. The intensity of Dr T.'s response makes impossible the more sophisticated kind of assessment of what both parties bring to a charged moment in the physician-patient relationship. However, the prognosis is bleak only when the physician is unaware that his or her response is problematic and cannot distinguish between his or her own conflicts and the patient's needs.
Our society is debating the seriousness of boundary violations in public life, including those of the highest elected officials. There is no question that physicians must be held to the highest standards. Like everyone else, we are entitled to privacy in our personal lives. However, boundary violations within the physician-patient relationship are unacceptable. Dr T. gives us a practical example of how to deal with all-too-human feelings and temptations in a way that protects the privileged status of the trust that patients place in physicians.
AUTHOR INFORMATION
Corresponding author: M. Philip Luber, MD, Department of Family Practice and Community Medicine, University of Pennsylvania Health System, 2 Gates, 3400 Spruce St, Philadelphia, PA 19104.
M. Philip Luber, MD
Philadelphia, Pa
REFERENCES
1. Neher JO. Time and tide. Arch Fam Med. 1999;8:270-271.
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2. Luber MP. Overcoming barriers to teaching medical housestaff about psychiatric aspects of medical practice. Int J Psychiatry Med. 1996;26:127-134.
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3. Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship. JAMA. 1995;273:1445-1449.
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4. Simon RI. Sexual exploitation of patients: how it begins before it happens. Psychiatr Ann. 1989;19:104-112.
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5. Balint M. The Doctor, His Patient, and the Illness. New York, NY: International Universities Press; 1957.
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