My lapse in judgment

It was early into my first clinical year and I was still being eager, traipsing up into the wards and asking for patients who would want to have a chat with me. A young gentleman was recommended, so I tiptoed into the shared room he was in.

He was on the far side of the room, and with the separating curtains in place by the time I could see him I was already in front of his bed and had made eye contact. And by eye contact I genuinely mean in its singular form, for he was missing an eye. I had no prior knowledge of his story so reminded myself not to react or make a point to highlight it, but truth be told I was taken aback ever so slightly. It was not because it bothered me, it was just something I had never encountered before. I wondered whether it was rude to only look at his one eye whilst talking, or if I should shift my eye contact between that and the empty space where the other would have existed, just like if I was conversing with someone who had two eyes. In hindsight it was a pretty trivial thing to be worried about, but for a fresh medical student who was only a month or two into her first clinical rotation it seemed important. Being overly conscious of patients’ conditions and disabilities is still a problem I struggle with, and there is a fine line that exists between acknowledging and respecting their difficulties, and overcompensating to the point of being insulting. Entering a conversation with the conscious effort of trying to create a sense of normalcy and making someone feel comfortable whilst simultaneously venturing into a thorough history of their past takes finesse. I am still stumbling my way through it and can only hope I have never unintentionally offended anyone.

So, I still haven’t addressed why the title alludes to a moral mistake on my behalf. We had a very long conversation and whilst I cannot remember exactly all that was said I can remember how it felt. It felt nice. We were of a similar age, so conversation flowed freely with no generational gap or sense of distance. We empathised with each other, and I shared almost as much of my life as he did. It was not a doctor-patient relationship, it wasn’t even a medical student-patient relationship. At the end of the day it felt like I had made a new friend and I think he felt so too. Because then came the oh so dangerous question, “Can I add you on Facebook?”

It may not seem like a big deal to many people, what’s in a friend request? It was an innocuous question, meant to consolidate our budding friendship and a symbol of the connection we made. The only problem is, it complicates what should strictly be a professional relationship. Clinican-patient distance is an important feature of the job designed to protect both parties. It creates barriers that allows the focus to be on providing good healthcare without letting other confounding factors to infiltrate. It is why many doctors choose to utilise pseudonyms on their social media accounts or keep their accounts vague, in order to make it harder to find. Being friendly is not the same as being friends, and although it may sound harsh and uncaring it is vital to being a good doctor.

Once a label of friendship has been implied it is easy to feel the pressure of certain obligations that can muddy a previously clear-cut relationship. The patient may now view certain services as a given, or expect extra effort the doctor may not usually provide. The doctor may have an emotional attachment that clouds their clinical judgment, or feel certain pressures to perform. Consultations may occur outside clinic hours in informal environments, without a documentation of notes to be legally utilised as evidence if needed. The patient’s perspective of the doctor’s professionalism may be unduly affected by what they see of their social lives. Or finally, it might just be awkward. Imaging your best mate knowing all of your embarrassing medical anomalies and vulnerabilities.

And so I added him on Facebook. Huh, you’re thinking, all that preaching and you turn out to be a complete hypocrite. I know I know, not the best confession to admit to. Part of the reason we were even in that situation was likely because I was so friendly and voluntarily shared my own stories. I had even thought to myself, if we hadn’t met in such circumstances it would be nice to be friends. So it shouldn’t come as a surprise how hard it is to reject such requests, particularly for someone who is so inexperienced dealing with these uncomfortable interactions.

In that moment I was wholly unprepared to be faced with such a question, so in a state of panic and to avoid ruining a great conversation with harsh rejection I agreed. Twenty seconds later, profiles had been shared and friends were made. I walked out feeling a little uneasy, but assured myself it was a harmless action and that I would face no repercussions. And I haven’t. To this day we remain background Facebook friends, never having spoken or interacted again. It is exactly the same as many other acquaintances I have on my account, aware of each others existence and sometimes an acknowledgement of the relationship through a “like,” but nothing more. It is a perfect example of how it is more likely for people to be genuinely friendly than to have ulterior motives behind their advances, but then where do you draw the line? How do you know where your relationship with someone is going to end up? Chances are they themselves may not have even thought about it and neither of you have considered intentionally letting it affect the professional relationship. You never know until it happens, and that’s the scary part. An innocent relationship can quickly turn sour, so for the sake of preventing the minority it is just easier to remain steadfast in your resolution.

It is even harder when your life-long family and friends seek advice. I know of doctors who remain unmoved, and kindly ask their friends to arrange a formal consult at their clinic. Which is definitely the right thing to do, especially if it is not a simple question. I haven’t had to confront such situations and am undecided how I would precisely phrase such a response, but I’d like to hope I’d be able to handle it or at least know where to refer them. I am worried about what happens if my parents need medical care, and how difficult it might be for me to stand back and allow experts to take control without trying to micromanage each step of the way. But we will cross that bridge when we come to it. For now I am going to work on maintaining my distance, which remember is not about being cold and unfeeling, but feeling enough to know what is best.


25 thoughts on “My lapse in judgment

  1. I think all professionals suffer from being asked for their advice from friends, friends of friends, family, friends of family, and generally. Only you can know what’s the appropriate tesponse in that particular situation.

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  2. It must be touch to respond to family and friends when you are asked for medical advice. How to be judicious when someone else is not? More so you’re dealing here with strangers who become acquaintances. That’s hard, too, especially on the job. I learned something about that as a college teacher with most of my students adults or nearly adults. Interaction and relationship-building are encouraged, though somehow all that’s supposed to remain academic as well. How good a friend am I supposed to become with a student? I’ve been on the high and low of that, which might imply there’s a good place in between. But I think you’ve handled it in your conclusion: “For now I am going to work on maintaining my distance, which remember is not about being cold and unfeeling, but feeling enough to know what is best.” I think you have it just right.

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    1. Yes, it’s a struggle so many people deal with on a daily basis. And there’s no rules or guidelines to direct you towards an objectively correct answer. Sometimes we just have to stumble through it and hope our own judgement is good enough. It sounds like you’ve had much experience with this question and I am sure all of your students have appreciated your thoughtfulness 🙂 I can only hope with time I will figure out exactly how I want to approach this issue and feel more comfortable with navigating those complex relationships.

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  3. You are likely right about the distance but to me it shows that you are compassionate and have a kindness that I hope that you don’t lose. He wasn’t your patient but instead someone who struck up a conversation with as a person and obviously you had some things in common. As a young nurse probably before your birth I once climbed into bed along side of a dying female cancer patient (who was my patient) and cried with her. She was alone and afraid and I held her. I would do the same thing today. Doctors were thought of as “God” back then and nurses were afraid of them. I was not. In fact I watched a young man in ICU (I was not a nurse on that unit at the time but went in to see what was going on) die because the nurse in charge decided on her own that the man would be dead before the Dr. could get to the hospital. He did have a small arterial bleed. This was apparent as every time his heart beat there was a small amount of blood that would shoot a few inches into the air. He was drunk and was flirting with all the nurses, he was in his early 20’s. I fought with the nurse for an hour to at least let the Dr. make that decision and he lived for a couple of hours after that. She would not make the call. I was always fighting with the other nurses. I could give you so many examples of similar situations. If that would have been my patient I would have gone around the charge nurse. Eventually I did anyway and I was not liked by any of the other nurses. I think that the best doctors have amazing compassion. I am privileged to see a world renown physician that treats me for an extremely difficult and painful disorder. I have been in remission for years now. This man is one of the most compassionate people I know. He is involved in at least two to three pharmaceutical trials at all times. People come from all over the world to see him. He is always running a minimum of two hours late for our two appointments per year. Why – because he won’t leave a patient until they have all their questions answered. I would never think of betraying this kind man by doing anything inappropriate and my guess is that this man you befriend would not either. Why – because his respect for you is probably so deep. Also he has probably shared his experience with all those he loves about the compassionate Dr. who just wanted to visit with him. I think you will be an amazing Dr. God Bless. Love Joni PS please don’t feel like you need to post this comment as it is very long and your blog is most likely meant for interns and currently practicing medical personnel. I just really wanted you to know that I don’t think you did anything wrong. I will always regret not calling someone to help that young man who died three hours after he arrived. His short life will always haunt me.

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    1. Joni, I have such a deep respect for your compassion and kindness towards your patients. Doctors are not gods and would be nowhere without the rest of their team, nurses are often the ones who know the patients the best and in many instances treat the person better than the doctor themselves. I admire your sense of morality and passion and I am sure your patients felt the same. I am glad you have such a wonderful doctor who deeply cares about you far beyond being simply a patient to treat. I appreciate all of your kind words and insight from your many years of experience. I do hope to be able to always have time to make for people and never leave anyone feeling abandoned or cruelly dealt away. I understand and am afraid of the immense load of work interns have, that often means they are headless chickens running around the hospital with barely a moments to breathe let alone spend extra time with patients than necessary. The way that hospitals are run can sometimes make it simply impossible to do so, which is something I fear. I can only wait and see for myself once I start working. I do hope that I can stand by what I preach and not become the type of person I dislike.

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      1. Thank you for your long and thoughtful comment. I think the fact that you are already so aware, sharing with others, and the incredible kindness and gratitude you have for your father speaks for itself. I think everyone who meets you will be blessed in some way. It may be a genuine smile, a slight reassuring touch of a hand or a kind word to a frightened family member but it will be there. Thank you again for your generous words and may you continue to be a blessing to others. Love 💕 Joni

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  4. Thanks Helen for dropping over and checking out my post, Stop!

    An interesting scenario you write about here. I think it is wonderful you took time to chat and get to know the patient as you describe. A couple reflections I have relate to this.

    I once traveled along with my wife to Toronto in 2007 for a conference on Narrative inquiry…. My wife was a counselor and a researcher in British Columbia’s University of Victoria at the time. I recall the keynote address by a Medical Doctor from Columbia University. She described her research and work she and some of her team was dong to have medical staff develop a better understanding and rapport with patients….. to help in recovery and treatment etc. They had hired the Canadian novelist Michael Odantaje to come for a period of time ( 3 months I believe) to observe as well as give lectures, seminars etc to the practitioners and their relationships with patients on the importance of stories! Exactly what you described you were doing… i.e. …. the importance of truly listening and getting to know the person and the story of the person that you are trying to help. It seems you are onto something here.

    On the ethical side of the question of developing a “frriendship” per se, it’s good you ponder this. There is a well known Canadian Doctor Brian Goldman who also acts as a journalist with a weekly podcast, and he has talked about this and other similar ethical question in some of his weekly podcasts. I’ll add a link to his general site on CBC… https://www.cbc.ca/radio/whitecoat He’s very inspiring to listen to and maybe you would find something helpful or useful there yourself. His cover a wide range of topics in regards to medicine.

    Thanks again for reading my reflection about my reaction and insomnia to the recent crises and violence that was arsing between the US and Iran. May you keep up your good work of helping people. also, good luck in all your endeavours ….

    ,Cheers, Bruce W. (from northern Vancouver Island on the west coast of Canada)

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    1. Hi Bruce, thank you so much for reading and taking the time to write this. I think the work that your wife has done is extremely important, and it is a shame that as doctors work their way up the hierarchy sometimes things like this can be forgotten. They become jaded, cynical and lose touch with what it means to connect with a patient.

      Thank you for the recommendation! I’ll make sure to give Dr Goldman a look, I can already tell there are some very interesting pieces of his. Good luck to you too and I hope you have a lovely day 🙂

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  5. Interesting post, I think having boundaries is healthy but it’s also understandable to want to connect with people in a genuine way. FB and social media has created this situation of ambivalent boundaries and privacy.

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  6. This is the time to encounter these challenges so you can learn to be better prepared. As a counsellor, I have to quickly form a very intense bond with my clients in order to do good work, and that is often misinterpreted by them as friendship. I find saying things like “I”m sorry, it’s against the rules” takes the onus off yourself so it’s less of a personal rejection, and it helps them start to think of the professional boundaries also inherent in this relationship. It’s complicated and I think everyone struggles before finding their way.

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    1. Thank you for the advice, yes I do think letting them know it is somewhat out of our control and rule of the profession would lessen blow, and hopefully I won’t feel as bad saying that. It definitely is difficult and because I am so inexperienced it makes me feel uncomfortable. Hopefully I eventually find a way around it!

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  7. It’s easy to cross the Doctor-patient line. As your career moves forward there may even be times where you create a strong bond with patients. It’s hard not to in all honesty. You are human and it’s hard to just treat another person/patient as just a number. It’s good you have that humanity about you just be safe about it.

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  8. Seems to me that the breach of action was an ethical one and not a moral one. Morality is such that in good nature we encourage the exchange you had with your patient. In professional settings as a clinician – you are ethically bound to the separation. It is required to bolster an arena of discovery and healing, needed to remove the emotional fog of humanity in your diagnoses and treatment.

    The fact that you recognized the mistake and no longer replicate it demonstrates your growth. We all are presented to learn with each opportunity that we fall. When we get up and do it again, plan to fall again until you make the realization of self – with self-honesty like you did.

    You can feel your soul in your writing and I look forward to seeing more. There are many fortunate patients that are yet to know you Doc !

    Liked by 1 person

  9. I found your post really interesting and insightful. I have a friend who is a dermatologist and I am always super sensitive about saying anything to him that might even vaguely suggest I’m looking for his advice. I am always mindful that his off-time is sacred and like you point out, that there needs to be clear boundaries around that.

    Interestingly I ended up watching a video presented by Donald Miller this week and he was advocating not being friends with your customers too. Here’s the link if you are interested.
    https://www.businessmadesimple.com/video/should-you-be-friends-with-your-customers/?inf_contact_key=75c1adf979568117c69fbdea0bf531d1dcd31c885f4ab1b34be5363d83ed1062

    Thank you for a thoughtful and interesting article.

    Liked by 1 person

    1. You are such a considerate friend, but I am sure he would not mind at all, especially if you actively trying to avoid it! Don’t feel like you have to be careful with your words, the fact that you are aware of it makes me think you would never cross any lines 🙂 And thank you for the recommendation!

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