Ethics - When a patient happens to be your neighbor

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LimbicResponse

Analyzing your every move
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I saw a patient in an emergency setting seeking help for her heroin addiction. Patient did not go through with treatment offered and decided to continue her addiction for the time being.

Unfortunately, the patient happens to live on my block. She has seen me a couple of times walking home (likely knows where I live), and has recognized me, and said hello a few times. During our last encounter, the patient mentioned how she appreciated my concerns during the time that I saw her as a patient and if I would be willing to talk to her some more as a friend to come drop by her home. I dismissed the request, but I feel that we will inevitably continue to see each other throughout my residency since I mostly walk everywhere and she lives on my block.

I was wondering what are the ethics behind this decision, and what advise you would have in this situation?

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This is not a good situation. The year I started residency, there was a resident kicked out of my program engaging in several boundary violations. She did not keep a healthy boundary with a patient and this guy lived in her apartment complex.

She chose to live in the bare bones, piece-o-crap complex that was around $300 month that was on the wrong end of town. WTF she was thinking I don't know. She must have some type of money issues. I don't know. This guy decompensated and beat her up because she knew right where she lived.

No she wasn't kicked out for getting beaten up. She was kicked out for doing ridiculous things like write up 5 H&Ps or 7 progress notes before she even came to work and simply put them in the chart and put a patient's name on it, without even seeing the patient. Another problem the guy who attacked her, she was playing nicey-nicey with him outside of work.

My point is that psychiatrists, though it's never written, need to keep a few steps away from patients to help assist us in keeping our boundaries.

I do see some patients here and there but try not to get in too-in-depth a conversation with them because it's very embarrassing for some people to admit they have a psychiatrist, and when I see them, I see them with coworkers, friends, or family, so I keep it polite and brief. If it's someone I've forensically seen or the person has severe mental illness and I see they still have signs of it, I'll try to keep completely away.
 
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When I first moved to my current job, I sublet somebody's apartment for 2 1/2 months to give myself more time to find something I liked. In the first month at my new job, I noticed that a patient had the same address (in my temporary complex) and my first urge was to refuse to see him, schedule him an appointment with someone else in the group, and write him refills to last until that appointment. That response was based on past experience in a community clinic with patients who were much more ill than the population I treat now and I realized that it was a bit of an over-reaction and I did see the patient. However, psychiatry presents some conflicts and some risks that are more severe than other fields and outside contacts need to be limited as much as they can be.
 
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...I realized that it was a bit of an over-reaction and I did see the patient. However, psychiatry presents some conflicts and some risks that are more severe than other fields and outside contacts need to be limited as much as they can be.

I don't see that as an overreaction because there are too many examples of the randomness of life coming back to bite people. If I see a potential conflict, even if a remote one, I am much more likely to err on the side of caution because I don't want to increase the odds of something happening down the road. I've dealt w. enough pts w. co-morbid borderline personality dx to know there is no such thing as "too cautious" in certain circumstances.
 
The last time I had a resident realize that their new patient lived in their building; I spoke with the patient and made a switch. The patient was greatly relieved to be given the chance to switch being unsure if this were an option. It seems that the only thing worse than having a patient live in your building is having your psychiatrist live in your building.
 
The first psychiatrist I saw was the father of a school acquaintance of mine when I was a child (early high school). I was very uncomfortable with it, mainly because the kid was one of the "cool" kids and he helped out in his dad's office after school and would see me there. At the time, I didn't realize I had other options. This was back in the days when you called your HMO and they gave you a name of a person to see. It definitely was not on purpose. I went over to his house several times while I was his patient; the father wouldn't talk to me when I would go over, but his wife, who was the nurse practitioner who actually prescribed my meds would talk to me. It was a bit awkward. Although, the ineffectiveness of his treatment was a far bigger problem than any social awkwardness. And I realized that when I complained about the father's treatment many years later to mutual friends that it may have gotten back to the son, so the problems with that set-up sort of continued over time. I was also talking about my sexuality to the psychiatrist (only the first time I saw him), which was something his son had teased me about, so that caused some awkwardness, as well.

In general, it would have been good to have had my "own" person to talk to, where I didn't feel ham-stringed by all the things that could have gotten out into the community. But I only saw the father the first time; his wife did all subsequent appointments. But she wasn't someone I could talk to, either. Didn't get therapy until many years later—this particular practice I was at in high school didn't believe in talk therapy.
 
If there were other options that doctor shouldn't have even picked you up as a patient and told you go to elsewhere due to the conflict of interest. The fact that you had to go to this guy's home was even more of a boundary violation.

IMHO one of the only justifications for this guy taking you up would've been if he was one the only person that could've taken you in the general geographic area, then if he did, to specifically state the potential problems, tell you there were other doctors that could've seen you, and go from there if you agreed to it.

While I did private practice, I did see a few children. I refused to see anyone below age 15 years, and I told all of them I wasn't a child psychiatrist and only would see them on specific conditions. One of the main things was that they were all on a waiting list to see a child psychiatrist that was on the order of 6+ months, I would see them in the meantime and they came into my office with me declaring full-well that they were better off with a child psychiatrist and they were only seeing me because we all agreed I was the next best thing given the situation.
 
If there were other options that doctor shouldn't have even picked you up as a patient and told you go to elsewhere due to the conflict of interest. The fact that you had to go to this guy's home was even more of a boundary violation.

IMHO one of the only justifications for this guy taking you up would've been if he was one the only person that could've taken you in the general geographic area, then if he did, to specifically state the potential problems, tell you there were other doctors that could've seen you, and go from there if you agreed to it.

While I did private practice, I did see a few children. I refused to see anyone below age 15 years, and I told all of them I wasn't a child psychiatrist and only would see them on specific conditions. One of the main things was that they were all on a waiting list to see a child psychiatrist that was on the order of 6+ months, I would see them in the meantime and they came into my office with me declaring full-well that they were better off with a child psychiatrist and they were only seeing me because we all agreed I was the next best thing given the situation.

At the time, that part of it did not seem unethical to me at all, nor did it to my parents, I don't think. I think we just sort of regarded it as a strange coincidence. There were reasons it made me uncomfortable, but it didn't occur to me that I could have spoken up or that I shouldn't have just dealt with it. I can see now how it was detrimental. I can remember my parents calling the HMO. I think that's how you did it back then. They were desperate to get me in somewhere, but I lived in an area where there would have been many, many providers, so if it had occurred to any of us that it was a bad idea, we could have tried someone else (at least, I think so, not exactly sure how that insurance worked). I didn't even know there were child psychiatrists. And still in reflection, it wasn't that I knew his son that bothered me the most about the treatment—not even close. The treatment was quite cursory.
 
Imagine this: you are the only psychiatrist in a small community. Some of your patients live with you and you have no other option. You see your patients at the gym, you play soccer with and against them, you work with them, etc.

Then there was that time where I realized half way through that one of my patients was on the opposing roller derby team and I might have accidentally broken her nose...

Talk about weird, ethical situations...
 
At the time, that part of it did not seem unethical to me at all, nor did it to my parents, I don't think.

A problem there is most lay-people don't know the standards, and the psychiatrist should educate the patients and their families, but in this case (as in many others) the doctor apparently did not. It's actually quite shocking the lack of compliance to guidelines I see from so many doctors. I sat in my wife's OB appoinment when she was pregnant with our first child and the OB didn't do a heck of a lot of things such as explain what was going on and merely just wrote a script and went off to the next patient.

My wife had a pregnancy induced rash that was serious to the point where she scratched herself till she bled. The first-line treatment is a topical antihistamine or corticosteroid. The OB, without explaning anything or even checking out the rash wrote for methylprednisolone (addendum: oral that is), on a high dosage with a slow taper down and didn't mention anything else including that if you stop the meds you could go into adrenal failure, or risks/benefits of being on a corticosteroid while pregnant.

The wife and I decided right then and there to get a different OB.(Addendum, and this particular one actually did spend the time to explain things to us. I intentionally didn't tell the first one I was a doctor because several docs all of a sudden do their jobs the way they're supposed to do it not not otherwise when they find out the patient is a doctor or lawyer.)
 
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A problem there is most lay-people don't know the standards, and the psychiatrist should educate the patients and their families, but in this case (as in many others) the doctor apparently did not. It's actually quite shocking the lack of compliance to guidelines I see from so many doctors. I sat in my wife's OB appoinment when she was pregnant with our first child and the OB didn't do a heck of a lot of things such as explain what was going on and merely just wrote a script and went off to the next patient.

My wife had a pregnancy induced rash that was serious to the point where she scratched herself till she bled. The first-line treatment is a topical antihistamine or corticosteroid. The OB, without explaning anything or even checking out the rash wrote for methylprednisolone (addendum: oral that is), on a high dosage with a slow taper down and didn't mention anything else including that if you stop the meds you could go into adrenal failure, or risks/benefits of being on a corticosteroid while pregnant.

The wife and I decided right then and there to get a different OB.(Addendum, and this particular one actually did spend the time to explain things to us. I intentionally didn't tell the first one I was a doctor because several docs all of a sudden do their jobs the way they're supposed to do it not not otherwise when they find out the patient is a doctor or lawyer.)

Funny. I do the same thing.
 
I do see some patients here and there but try not to get in too-in-depth a conversation with them because it's very embarrassing for some people to admit they have a psychiatrist, and when I see them, I see them with coworkers, friends, or family, so I keep it polite and brief.

I think I'd die with one leg in the air if my Psychiatrist struck up a conversation with me outside the office. Not because I'm ashamed of seeing a Psychiatrist, but for me I like to think of Psychs as just magically appearing when it's appointment time, and where they go, and what they do after that I don't really know, nor do I care to.
 
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