‘Rules are important’: Boundaries can ensure quality care, promote clinician wellness
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Technologic advances such as online patient portals have given patients unprecedented access to their health care providers.
Prior methods of communication — such as on-call pagers — allowed clinicians to maintain some separation between patient care and personal or professional responsibilities.
However, current technology allows patients to ask questions of their physician at any time, often with the expectation of a timely response.
A paper published in JCO Oncology Practice addressed this challenge using a hypothetical case vignette, and the authors outlined the need for clear expectations regarding clinician communication with patients.
“Things have moved quickly — and in very positive ways — but there has never been any sort of guidelines or frameworks as to how this should be implemented, and where the borders or boundaries lie,” co-author Monica S. Chatwal, MD, assistant professor of medicine and a genitourinary medical oncologist at Moffitt Cancer Center, told Healio. “In any situation, rules are important. They help people feel safe and in control.”
Healio spoke with Chatwal about the ethics of sacrifice and balance, what institutions can do to help clinicians communicate effectively with patients while still respecting boundaries, and how providers can use available resources to promote their own wellness.
Healio: Why is it important to establish guidelines that address new channels of patient-provider communication?
Chatwal: Technologic progress has advanced very quickly. Without clear rules as to how to communicate through these technologies — particularly portal messages, text messages, cell phone calls and even social media — it becomes very tricky as to what the social norms should be in that setting. It becomes especially challenging when you have a patient you know very well — sometimes even outside the clinical setting. When discussing medical issues or cases with these individuals, the physician might feel another level of responsibility to that patient, and it can become a bit tricky in terms of delineating the lines between professional and personal relationships.
Healio: Can you discuss your paper’s key recommendations?
Chatwal: This paper was a companion piece to a paper we wrote for the ASCO education book after a presentation at the annual meeting earlier this year. It also reflects work being done by the ASCO ethics committee. In both circumstances, we’ve talked about how to determine one’s personal responsibility to each patient, but we also emphasized that there should be some kind of overriding institutional framework to provide flexibility. There is a lower limit of what’s expected and, if someone decides that they want to go beyond that, it’s perfectly reasonable. Many physicians feel comfortable sharing their personal contact information, and some have been able to manage that very well. But there can be circumstances where it can lead to some problematic situations. It’s valuable to have clear expectations about the timing, frequency and appropriate mode of communication.
Healio: What are “resilience resources” and how can they support appropriate patient-provider boundaries?
Chatwal: Some interventions and resources effectively promote physician well-being and resilience. These include mindfulness training, stress management, communication skills and other types of strategies to reduce burnout. However, that isn’t enough, and we all recognize that. Another aspect of this is recognizing and learning to set appropriate boundaries — not just professionally but also personally.
Another key component is the support that institutions give us in terms of feeling empowered and comfortable making those decisions. Sometimes physicians feel if they aren’t giving out direct contact information or if they’re not replying immediately every time, they’re letting a patient or institution down. Essentially, it’s one’s personal responsibility to determine what is appropriate for them. However, when there is nothing at the institutional level outlining what is appropriate, it can be much more difficult and can add to the sense of anguish and discomfort about the situation.
Healio: Is there anything else you’d like to mention?
Chatwal: One of the critiques I’ve seen of this paper was a commentary saying that by restricting our modes of communication, we may be creating more of a rift or more disparities. Some patients may not be able to access certain forms of technology, which I understand. There is a correct means of communication for each patient, and we have to figure that out. Having some level of expectation is important, just like anything we do in life. If the patient knows a physician is giving them their cell phone number, it’s helpful to outline the specifics of what times and under what circumstances those calls are appropriate. It helps everyone feel more in control.
Reference:
For more information:
Monica S. Chatwal, MD, can be reached at monica.chatwal@moffitt.org.
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