Being a ‘good’ doctor: Understanding and managing professional boundaries is challenging and can lead to stress and burnout

Objective The aim is to increase the understanding of non-sexual boundary challenges and potential personal and professional impacts on doctors and medical students. Method We examined peer-reviewed and grey literature and published commentary and cases from Australian health practitioner boards and medico-legal insurance companies. Key ideas relating to the objective of our study were subsequently framed into a narrative. Results Compared to ‘sexual’ boundary crossings, the literature examining ‘non-sexual’ boundaries is scanty, fragmented, and difficult to find. There are gaps in knowledge around the prevalence and consequences of non-sexual boundary challenges and crossings, although the safety and wellbeing of health professionals and patients are of concern. Non-sexual boundary crossings may represent a ‘slippery slope’ to boundary violations. Opportunities for doctors and medical students to access relevant training appear limited. Conclusions We identified several categories of boundary challenges based on context, the nature of the existing relationship, and the type of behaviour. Non-sexual boundary challenges may be related to stress, burnout, and risk for future boundary violations. Future research to investigate the impacts on doctors and medical students in maintaining professional boundaries in their relationships with patients and colleagues, their specific training needs, and the effectiveness of training in reducing work-related stress and burnout is needed.


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rofessional boundaries have been defined as the 'edge' of appropriate professional behaviour, maintaining the expected and accepted psychological and social distance between health professionals and patients. 1This distance protects patients from the power differential 2 and helps preserve the relative objectivity of medical decision making. 3Boundaries also refer to the limits on acceptable interactions between the health professional and their patient.Interactions with the patient should arise from and be directed towards meeting their medical needs, be within the scope of the health professional's expertise, and contextually appropriate.Acceptable boundaries can also be understood with Corresponding author: LA Lampe, School of Medicine and Public Health, University of Newcastle College of Health, Medicine and Wellbeing, Level 3 Education Building, John Hunter Hospital, New Lambton Heights 2305, NSW, Australia.Email: Lisa.Lampe@newcastle.edu.aureference to the health professional's usual practices, including location of consulting and hours of practice. 4e doctor-patient relationship has long been regarded as fiduciary in nature, in that doctors are expected to put the patient's needs before their own and avoid conflicts of interest. 5There is a wide agreement in the literature that, as the individual with greater power in the relationship, it is the health professional's responsibility to establish and maintain appropriate boundaries.

Aims
The main purpose of our literature review was to synthesise information about non-sexual boundaries and develop a new understanding of the topic to support planned research.We sought to understand more about types and impacts of non-sexual boundary challenges.

Data sources and methodology
A broad search (peer-reviewed, professional, and grey literature) was conducted using the keywords above.The search was hampered by association of the term 'professional boundaries' with different meanings including interprofessional scope of practice or, as in the current review, professional relationships.Although the primary focus of the review was on doctors and medical students, there was a much larger literature derived from the nursing, psychology, and social work professions which was included where the research team considered the findings to have relevance for doctors and medical students.A search of the codes of conduct published by peak or certifying health professional associations in Australia (including medicine, dentistry, physiotherapy, occupational therapy, chiropractic, and pharmacy) was conducted.Finally, the websites of medical defence associations in Australia were searched for publications concerning professional boundaries.There were no exclusion criteria.
A qualitative approach based on thematic analysis was adopted.Categories of non-sexual boundary challenges were developed through an iterative process involving consideration of suggestions in the literature and interpretations of the literature by the research team.The literature on impacts of non-sexual boundary crossings was synthesised into a narrative.

Categories of non-sexual boundary challenge
We developed 10 categories of non-sexual boundary challenges presenting the risk of boundary crossing or violation.Category names reflect common usage in the literature or descriptive names developed by the researchers.Table 1

Impacts of boundary drift, crossings, and violations
In an influential and widely cited article, Gutheil and Gabbard 6 described a psycho-therapeutic framework for understanding professional boundaries.This seminal article distinguished 'boundary crossings' from 'boundary violations'.Since then, 'boundary drift' has been described, 2 as contemplation of a potential boundary crossing, or a behaviour that is close to the boundary.
In a boundary crossing, the health professional engages in an interaction with a patient that is outside of indicated therapeutic interventions or the professional's usual practice.Boundary drift and boundary crossings may not necessarily be intentional nor cause harm to the patient.However, harms may be subtle, including loss of objectivity, conflicts of interest, distorted patient expectations, or a perception of patient exploitation.They may increase the risk of future boundary violations (the 'slippery slope'). 7undary violations, by accepted definition, cause or have the potential to cause harm to patients and involve a behaviour that prioritises the health professional's wants or needs over the patient's. 8In the medical profession, even the perception of a boundary crossing can harm a doctor's reputation. 9In health settings, the focus on boundary violations and crossings has traditionally been on sexual transgressions.However, many nonsexual categories of boundaries are described in the literature, mainly according 'special' patient status, providing clinical favours to non-patients, dual and multiple relationships, accepting and receiving gifts, physical contact, self-disclosure, and social media interaction.
Various influences on boundary crossing behaviour have been described, including the health professional's own emotional vulnerability, 'moral weakness', exploitative character traits, and ignorance. 4,10undaries in different contexts, locations, and specialities Some practice contexts may offer particular challenges to maintaining boundaries, including rural, remote, or isolated practice, where social relationships outside the professional one are common and often unavoidable, thus creating 'dual' or 'multiple' relationships with a patient. 11Other contexts include doctors in highly specialised practice or specialities with relatively small numbers of practitioners, whose expertise may be sought out by friends, family members, or colleagues.It has also been suggested that as the population ages, doctors in specialities such as oncology and palliative care may increasingly come across patients with whom they have existing social, collegial, or family relationships.
Professional boundaries also apply to roles not directly concerned with patient care, for example, in relation to medical and non-medical colleagues ('corridor consultations' and requests for prescriptions), and teaching and mentoring of students and junior colleagues.There is limited research on professional boundaries in relationships such as supervisortrainee, faculty-student, and mentor-mentee.A potential for boundary violations arises from the power differential in the faculty-student (and supervisor-trainee) relationship which resides in the teacher's (or supervisor's) professional status and responsibility for evaluating the student's (or trainee's) skills, and the student's vulnerability and dependence on the teacher for guidance and pass/fail grading.

The connection between boundary challenges and burnout
Burnout has been described by pioneering researchers in the field as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job. 12arly research identified key characteristics of burnout as emotional exhaustion, cynicism, reduced personal accomplishment, and depersonalisation. 13[16] Boundary violations have been referred to as an 'unrecognized risk for burnout'. 17The prevalence of burnout in doctors is uncertain, in part due to inconsistencies in  19 Higher levels of stress and burnout have been reported in younger doctors and in some specialities; gender associations are less consistent. 16ere is a close connection between stress and burnout, 16 and negotiating boundary challenges can be stressful, particularly in the absence of training and guidance. 20Most health professional codes of ethics and codes of conduct forbid some boundary violations explicitly, such as sexual relationships.However, there is little guidance in the literature and professional codes of practice regarding nonsexual boundary challenges.Many commonly encountered situations in professional settings may be complex and associated with ambiguity concerning boundary lines; the uncertainty in how to respond can exacerbate the associated stressfulness. 21Likewise, it can be difficult to refuse the request of a friend, family member, or colleague for a script or 'corridor consultation'.Training has the potential to increase skills and confidence but is generally lacking at both undergraduate and post-graduate levels.
Peak psychology bodies appear to have given most consideration to guidance on professional boundaries.The Australian Psychological Society (APS) complements its 'Code of Ethics' with a series of 28 Ethical Guidelines, which apply the

Table 1 .
18tegories of non-sexual boundaries and potential impacts methodology and definition of the syndrome.In the Australian National Mental Health Survey of Doctors and Medical Students,18rates of reported emotional exhaustion were high, especially in doctors under 30 years of age (47.5%).A recent review estimated a 21%-35% prevalence rate with significant increases since the COVID-19 pandemic. research