Patients may push boundaries in a number of ways. Unreasonable demands or expectations or a blurring of the lines of the physician-patient relationship can occur. There are many other ways in which patients can challenge boundaries. There are many reasons why patients challenge boundaries.  These may include seeking support, attempts at shifting the power differential, discomfort with the patient role or health care environment, looking for special favors, embarrassment, distrust or self-advocating among others. Mental health, cognitive or substance use issues may also contribute.

Regardless of the reason, checking our biases first and then utilizing some of the following approaches may help develop the therapeutic relationship and allow the patient to receive appropriate care.

It is important to spend some time developing rapport with patients and learning how to make connection.  Finding the balance between being personable and professional is the goal.  When the conversation begins to migrate away from the patient’s issues and starts to focus on you this may be a time to re-establish boundaries and redirect the encounter.

Be transparent in expected norms around doctor-patient relationships. Utilize evidence-based diagnostic and treatment recommendations rather than emotional responses to make care decisions.  Let the patient know it is important that they receive the most appropriate care.

When appropriate, explore potential reasons for their behavior with the patient. Reinforce how joint decision making will GIVE the patient a modicum of control.

Acknowledge the uniqueness of a doctor-patient relationship and how this can be unfamiliar or uncomfortable at first.  Emphasize your professional role in the relationship.  Talk about the patient, not yourself – redirect the patient when they try to bring the conversation back to you.

You may need to impose structure returning to the health care issues at hand and continuing to use evidence-based and clinical experience to guide your decisions.  Sometime you may have to rely upon and share protocols about appropriate physician-patient interactions.  Learn to set limits and be explicit.  Remember to keep you and the patient safe and consider inviting a chaperone for any sensitive exams or conversations.