Boundary Crossing in Medicine: Out of the Closet

No Better ExerciseIn the September 25, 2013 JAMA column “A Piece of My Mind”, Dr. Gordon Schiff wrote a piece called Crossing Boundaries—Violation or Obligation? about being reprimanded for giving his patient $30 for a prescription. The article apparently struck a nerve — he received over 150 responses to his article. Here he describes what has happened since the publication of his commentary.

It was as if they had been given permission to come out of hiding–validation rather than condemnation for simple acts of human kindness that they had secretly committed. In response to a recent JAMA commentary I had written, I received a deluge of emails, many describing acts of helping patients including: providing rides or taxis home, giving money to help pay for medications, helping patients get jobs or even employing them or their family members in their offices, and striking up an occasional friendship with a patient. Although mindful of issues related to professional-patient boundaries, these physicians and others who wrote me in support expressed their gratitude that someone had articulated and validated their caring instincts and actions.

After being called on the carpet for acts that were deemed “unprofessional boundary crossings,” I began to explore the history, attitudes, and what I sensed (and later documented) were striking geographic, institutional, and personal variations in what professionals do, and consider acceptable. I had worked most of my career as a general internist at a Midwest public hospital and came to a Boston academic center where I found a different culture and norms related to “professional-patient boundaries.” Actions my public hospital colleagues and I regularly took to help needy patients were questioned as inappropriate and unprofessional.

There are many reasons for caution in crossing lines to avoid confusing professional with personal relationships. But as I note in the JAMA commentary, and the deluge subsequent emails confirm, many physicians (and patients) yearn for meaningful caring relationships that treat the whole patient, which at times may entail crossing lines and even taking risks when the particular situation calls for a more human response. As pointed out by Martinez (ref 1) and others we need to reframe the construct of profession-patient boundaries from that of a “slippery slope,” to a more patient- and context-centered one that weighs risk and benefits for that particular patient and situation.

And beyond the particular patient and situation, physicians must modestly grapple with ways we more meaningfully can stand alongside our patients. Every time we say “it’s not my job” we risk losing a bit of our humanity. (ref 2) And we risk overlooking opportunities to act in solidarity with those we care for, and whose needs, granted, often seem overwhelming. This suggests a need to ponder what I would term the “burn-out paradox.” While it would seem that further overburdening caring professionals with even more responsibilities is a sure-fire recipe for more burnout, numerous studies and commentaries have noted the opposite. The best antidote for feeling overwhelmed and burned-out is to focus on our relationships with patients and the rewards of working with them to improve their health and lives. (ref 3) It is our job to care for the whole patient, and even take occasional risks in crossing boundaries to help in small and bigger ways. 

What do you think about this issue? We are eager to keep this important discussion going in the comments section below. 



1.  Martinez R. A model for boundary dilemmas: ethical decision-making in the patient-professional relationship. Ethical Human Sciences and Services. 2000;2(1):43-61.

2.   McCullough M. An ethicist’s journey as a patient: are we sliding down the slippery slope to sloppy healthcare? BMJ quality & safety. 2011;20(11):983-985.

3.    Gunderman R. The Root of Physician Burnout. The Atlantic Monthly. Aug 27 2012.


Gordon Schiff

Gordon Schiff MD is a general internist and Associate Director of Brigham and Women’s Center for Patient Safety Research and Practice and Associate Professor of Medicine at Harvard Medical School. In 2006 he was selected by Modern Healthcare as one of the top “30 People for the Future” in medicine. 




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