When physicians are off-duty, they are regular people in the community with friends outside of work. These friendships can become complicated during visits to the doctor, especially in a rural community. One physician’s talk with a patient made a lasting impression about the boundaries of the physician-patient relationship, and it is one of my favorite lessons from Hinton that helped me to connect more strongly with my patients.
The rural physicians I’ve met usually want to be not only in a practice where they can maintain and use a broad range of clinical skills, but also in a town where they can enjoy the lifestyle of a rural community. It was common to see physicians biking on the trails, skiing on the slopes, or watching a local performing arts production. It was only natural that the physicians would befriend people in town through such pastimes. That’s part of the rural medicine experience.
So while rural physicians and patients enjoy a relatively high degree of familiarity through those social activities in town, such chumminess could complicate a clinical encounter. Should the physician even take on their friends as patients in the first place? What happens when there are questions about smoking, drinking, lifestyle, or drug abuse? What would be the best way to navigate through complicated medical or social issues when you might see the patient at an outing after clinic? Being friends can blur the line of the physician-patient relationship.
I discussed this issue with JS, and he shared what he observed when one physician skillfully handled a complicated patient with multiple health issues. The quote has been one of my favorites from my time in Hinton:
I’m your doctor, not your friend – but I’m on your side.
This quote is good because it sets parameters on the physician-patient relationship. Ultimately, the physician ought to address health concerns brought to them by their patients. Whereas friends may tiptoe around sensitive issues or give unconditional support to poor decisions, physicians aren’t necessarily bound by such expectations of “being nice”. Their patient encounters may require talking about or doing things that are unpleasant.
I was really squeamish watching my preceptor suture a patient’s nail directly to the nail bed because of a bad laceration, and this basic thought dawned on me:
I’m going to hurt my patients.
I was highly aware of this notion when I started practicing taking ABGs and starting IVs. You want to avoid inflicting pain on anyone – especially as a learner! – but those procedures were a necessary step in the grand scheme of caring for the patient. Having that context to justify the pain was one of the many instances that helped me to be comfortable with being uncomfortable. Being “nice” and worrying about upsetting the patients wasn’t going to help them – I had to work through my hesitancy to begin to be medically useful.
One issue that physicians contend with is difficult conversations. Patients expect the doctor to talk about quitting smoking and exercising regularly, which can provoke guilt and frustration. But physicians can go deeper than that: they are in a position to ask probing questions to uncover underlying issues. Sometimes patients will answer; sometimes they won’t. I don’t think that I’ve felt the weight of silence as heavily as I did in some of these encounters. But more often than not, patients will reveal some of their deepest and darkest secrets, and I was humbled to be part of some very intimate conversations.
But why would they be that transparent with us? They expect that we, as health care providers, will use the knowledge to make health decisions to improve their health. And again, I wouldn’t have reached that depth if I didn’t work up the nerve to ask the tough questions.
A special kind of relationship exists between physicians and their patients. Physicians have the power to help and to reassure on health-related matters. I’m glad that I don’t have an obligation to do whatever patients think makes them feel good – I will proceed and advise in a way that best helps their health in their situation.
There’s a difference between when a friend and a doctor says, “Don’t worry about it.” It’s a profound privilege and responsibility to have that trust from another human being. I want to treat that relationship delicately so I do it right. After all, I’m on their side.
Chris Le, Almost MD 
hey chris, this is an awesome blog post that I will definitely remember! thanks for sharing! Im in chiropractic school and eventually might end up practicing in a rural area so I take your advice to heart!
As a psychotherapist I completely understand how these lines can become blurred. Good luck to you!
My doctor surprised me a few weeks ago when I took my young daughter to an appointment for her. He entered the room, bee-lined over to me and threw his arms around me. I rather stupidly blurted out, “What’s this?!” before I realized he was hugging me. He also signed his after-visit summary, “Lots of love, Firstname”
I’m a touchy-feely person by nature with tons of male friends, so getting hugs from men who aren’t married to me doesn’t bother me, nor does it bother my husband when I get them. My doctor and I are close to one another in age and we get along well. I like him and trust him more than any other doctor I’ve ever had. I sense that, had we met under other circumstances, we could have been good friends.
That said, the hug surprised me. It strikes me as a little risky, in this litigious culture, for a male doctor to initiate a “hey, how you doin'” hug with a female patient. (“This patient is distraught” hugs are another matter.) I genuinely don’t believe that the hug (or the after-visit summary note) was meant to be amorous, so he has nothing to fear from me, but I’ve seen good men fired from their jobs for “sexual harassment” that consisted of much lesser offenses.
I discussed it with one of those aforementioned male buddies after it happened, who offered, “It could just mean that he’s coming to think of you as a friend.” “Well, that’s a problem,” I said. “He’s not my friend; he’s my doctor.” The way I see it, friendship is about mutual vulnerability and support. The doctor-patient relationship may be intimate—perhaps more intimate than most friendships are—but the vulnerability is almost always one-sided, the support one-directional. Furthermore, we don’t socialize outside of the walls of his office, and I never let myself forget that when he sees me, I’m work to him. Maybe pleasurable work (I hope), but work just the same. That isn’t “friendship” to me. There’s nothing mutual about our relationship.
There’s also the fact that it’s already happened early on in our relationship (and will almost certainly happen again) that he has refused a course of treatment that I wanted, or I have refused to follow his instructions. When things like that happen, I really don’t want one of us to be able to say, “I’m asking you to do this as your friend.” I’d rather we both try to evaluate the situation objectively and not emotionally.
So I guess the point of all that is, some of us patients don’t really want to be friends with our doctors, either. At least, not while they are still our doctors.
Thanks for sharing, Proserpina! You are very insightful in pointing out the fine line of familiarity that separates professional conduct and friendly contact. The idea of being a doctor and not a friend continues to help me build my clinical confidence, and I hope that the concept helps you build a healthy relationship with your doctor.