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(This article was originally posted on the Div 42 email group and is re-printed with the author’s permission – Ed.)
When we moved here from an urban university area, we wondered if people would even make use of our services, given the lack of anonymity in a small city (BTW, we don’t like to be called a town). What we discovered was that most people treated us just like they did their primary care physicians. Merchants and service people let us know they were glad we’d decided to practice here. Patients greeted us on the street and in stores with “Hi, Doc.” And, most importantly, they used us the way they do their family docs. That is, when they perceived a need, they came in. When an “episode” was resolved, they thanked us, paid their bills, and let us know they’d be back next time there was a need. They also referred their family members and friends. One of the gratifying things about practicing here is that we’re seeing second and even third generation patients from the same families. There are also patients with whom we’ve worked for two weeks and others with whom we’ve worked intermittently for over 20 years.
As others have pointed out, there is simply no way of being an active member in a community like ours if one completely avoids dual relationships. We’re not stay-at-home types, and we’ve both been quite active and visible locally. I remember once sitting in a board meeting of a local nonprofit (aren’t they all) arts agency. As I looked around the room, I realized that five of the other seven board members present had been seen in our office. Most were and still are friends, a status that emerged after treatment. Generally speaking we make it clear that we do not socialize with patients while they’re in active treatment. And yes, there have been cases of post-treatment friendships in which our new friends have re-entered treatment. We talk about that when it occurs, and we and our patients make informed and mutual decisions about whether to continue or refer. Occasionally former patients wanting to re-enter treatment will come to us and ask for referrals because they prefer to see someone else now that we’ve become acquaintances or neighbors. We’re never offended by that healthy insight. In fact, we work to make it easy for people to do that.
The point of all this is that if one establishes an enduring reputation for practicing ethically and responsibly in an area where most everyone knows most everyone else, people will trust you to help them make informed decisions and protect their vulnerabilities and rights. Yes, there are those patients who have problems with boundaries, but one learns, usually from painful experience, to recognize them fairly early and act accordingly. But there are a whole lot more folks who accord us the same respect and trust they do their family docs, and they expect the same respect and professionalism from us. I like the notion that dual relationships per se are not the problem, but if a clinician becomes engaged in a dual relationship, the burden of proof is on that clinician to assure that there is nothing remotely exploitive in the duality.
When we first started practicing here, fresh out of grad school, we looked for the same kinds of definitive, inviolable rules and ethical principles most new professionals do. As time has gone on, we have matured and become more confident in our case-by-case judgment, and our patients have also become more confident in us. That means that we sometimes go to funerals and weddings and holiday parties and anniversaries, and that we sometimes do not. To date, I am not aware of a single incident where our approach has failed us, although, as I’ve mentioned, we were much more conservative and cautious in our early years.
Dave Grundel can be reached at www.drsgruendel.com
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