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It happened again...

OldPsychDoc

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    Boundaries issues: In the 5.5 years I spent in the community of my residency program, I only once ran into a patient outside of hospital or clinic. Now, in a much larger metro area, it seems that 2 or 3 times a year it is happening to me, and now this month it has happened to me twice, and more specifically, in my own church.

    I think it may be that the church I attend, though not large, is very active in outreach to its corner of the metro area, making it attractive and welcoming to folks like the mentally ill and marginalized. Also by chance, my outpatient clinic is located less than a mile from the church--so, all in all, my patient base is somewhat skewed toward our quadrant of the metro. In addition, one of our leaders is on the staff of a major shelter for homeless women & families--which seems to have a fairly substantial overlap with our clientele at the hospital and clinic. Still, I don't advertise myself, and I certainly don't seek patients among my co-parishioners!

    So last Sunday I look up, and there in the next row is this nice chronic schizophrenic lady that I see about twice a year in clinic. She recognizes me and asks me, "Am I seeing you tomorrow?" Well, I have no idea, and politely tell her so, bid her good day in a superficially social way, and that's that. Next day in clinic, sure enough, she had an appointment. She tells me that she used to know the pastors in their previous church, and wanted to get back to going to church. I gave her my usual spiel that I wouldn't divulge that she was my patient unless she specifically gave me permission, and that she shouldn't try to transact "doctor business" at church, etc. She agrees, understands, etc...no problem. So tonight I'm in a church small group in a friend's home--and guess who's there...

    I certainly don't want her to feel bad about appropriately pursuing relationships in the church of her choice, but neither do I want to change my style, or have to stop being a part of activities that bring balance and sanity to my life. Nevertheless, it feels somewhat uncomfortable in the more intimate setting, where more personal information gets shared, where my family's present, etc. Again, she's a nice enough person, and only an occasional med refill patient, but this seems to happen to me regularly. What if it were a more antisocial bipolar? Or a really intense borderline? I know several of them who live within a mile's radius of the church as well...

    So anyhow--just thought I'd toss it out there to let you all kick the question around a bit. Am I making too big a deal of it? Too little? I grew up in a small town where the FPs all were a part of the town's social fabric--church, school, grocery store, golf course, etc. How different is that?
     
    I grew up in a small town where the FPs all were a part of the town's social fabric--church, school, grocery store, golf course, etc. How different is that?

    I'd say, very different. I would be interested to hear what other people say about this, but my opinion is: Your profession is the most intimate branch of medicine.

    FPs and other primary care fields deal with less sensitive topics, or at least they deal with them at lot less often. You can visit your FP for something like an AIDS test, but you can at least lie about it to others and say you got your tonsils checked. I feel like the dynamic is completely different.

    And it is because of this different dynamic that you can't share a beer with your shrink. As you insinuated, sharing details with some patients could mean putting you and your family at risk. I think it's best to draw one line and keep consistent with all patients, whether it's a guy with mild depression or a bipolar pt with awful antisocial tendencies

    I also think it's bad for your clients. A goal of psychiatry is to allow your patients to live their lives with as few disturbances (social and occupational) as possible due to their mental illness. There is a lot of societal stigma around mental illness, and so 'outting' a person's dysfunction to the world can harm them. I don't think it matters if that's through a voluntarily divulgence of information. It's not fair to her as I'm sure she trusts you and would jump at the chance to chat to you in public about her condition. And given enough time around her, she'll let it slip some how. Another difference from family medicine: you can trust a reasonable adult to decide for themselves if they want announce to you in a grocery store that their hemorrhoids are doing better. But can you say the same about your pts?

    I am sorry to hear of your bad fortune OldPsychDoc, it sounds like you might have to switch churches. In addition to your own sanity/safety, I think you shouldn't risk putting her in a position like that. Good luck to you!
     
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    Faebinder

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      Unfortunately, I predicted this a long time ago. I firmly believe you have to "live" in an area different than where you practice.... My definition of different is an area where if you were to be admitted to psychiatry, you'd end up being admitted to a different hospital in a different county. My reason is secondary to not wanting truly vindictive dangerous patients knowing where I live.


      On the other hand, you are not doing anything wrong. If anything, this acts like a reminder to you that you need to be a good physician while your patient is involuntarily in your ward, so that people in the community like you outside the hospital. Don't be ashamed of being her psychiatrist outside... you did nothing wrong. She is depending on you not to judge her as "abnormal" or "unacceptable" when many other do.

      Stick with it, stay within patient/doctor boundries, be nice.
       
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      kugel

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        Afraid you probably do need to change churches.
        And I don't mean change to another branch of your church.
        You need to change religions.
        Change to one that caters to the rich and famous and powerful. Preferably one that openly espouses a revulsion to psychiatry and demonizes psychiatrists. To be sure that the antipsychiatry view is not just a matter of political correctness, choose one that has an arm of the church that actively encourages violence against psychiatrists.
        And just to be sure that there is really no chance that anyone in the church has any interest in general mental health, make sure that it's one that only lets people into the upper levels of the church after they have given millions to the church AND are completely indoctrinated in the belief that ancient aliens began our world by exploding a nuclear ("nucular" for immediate past Presidents) bomb inside a volcano.

        That way, you have little chance of running across a psychiatry patient from a public mental health clinic - except for the alien conspiracy part.

        Tell Cruise and Travolta that I said, "Hello."
         

        Therapist4Chnge

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          Unfortunately, I predicted this a long time ago. I firmly believe you have to "live" in an area different than where you practice.... My definition of different is an area where if you were to be admitted to psychiatry, you'd end up being admitted to a different hospital in a different county. My reason is secondary to not wanting truly vindictive dangerous patients knowing where I live.

          Unfortunately that often doesn't work too well. I worked in a different county and in a specialized setting, but I've run into more former patients within walking distance of my (former) residence than anywhere else. I lived in a popular part of one of the cities, so short of moving to suburbia or the sticks....I was stuck. Thankfully I worked with a non-violent population so it was never an issue of safety, though the prevelence of Cluster-B traits made it rather uncomfortable at times.

          OPD, depending on the size of your congregation, you may be okay for regular services, but I wouldn't go back to the small group setting.
           

          OldPsychDoc

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            Afraid you probably do need to change churches.
            And I don't mean change to another branch of your church.
            You need to change religions.
            Change to one that caters to the rich and famous and powerful. Preferably one that openly espouses a revulsion to psychiatry and demonizes psychiatrists. To be sure that the antipsychiatry view is not just a matter of political correctness, choose one that has an arm of the church that actively encourages violence against psychiatrists.
            And just to be sure that there is really no chance that anyone in the church has any interest in general mental health, make sure that it's one that only lets people into the upper levels of the church after they have given millions to the church AND are completely indoctrinated in the belief that ancient aliens began our world by exploding a nuclear ("nucular" for immediate past Presidents) bomb inside a volcano.

            That way, you have little chance of running across a psychiatry patient from a public mental health clinic - except for the alien conspiracy part.

            Tell Cruise and Travolta that I said, "Hello."


            Thanks for that GREAT advice. I never considered that angle. :rolleyes:

            (BTW--in all seriousness, a church switch isn't an option. Mrs. OPD & I have been part of this group for almost 15 yrs, excepting a break to go out of state for residency, so it is our primary social network. Ultimately it will be easier to transfer the patient to a colleague if it comes to that, and assuming she continues to attend regularly.
            Again--not so much asking for y'all's advice as wanting to provoke a little discussion here...)
             
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            billypilgrim37

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              This seems like one of the few great reasons to transfer to a colleague. You would do the same if a family member came to see you, and many people incorporate their brothers and sisters in Christ to be essentially family. I imagine most people would understand that you would prefer to have her as a personal colleague (personal in the church fellowship sense) than as a patient. Or at least, that's the sort of spin you could go with. ;)
               

              Doctor Bagel

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              1. Attending Physician
                Thanks for that GREAT advice. I never considered that angle. :rolleyes:

                (BTW--in all seriousness, a church switch isn't an option. Mrs. OPD & I have been part of this group for almost 15 yrs, excepting a break to go out of state for residency, so it is our primary social network. Ultimately it will be easier to transfer the patient to a colleague if it comes to that, and assuming she continues to attend regularly.
                Again--not so much asking for y'all's advice as wanting to provoke a little discussion here...)

                Good, I was getting sad thinking about you changing your church since it sounds like an important part of your life. I'm new to this, but my thought is that it running into patients will happen, and you can't hide out from life to avoid it. I grew up in a town of about 40,000 people that doesn't have a ton of restaurants, grocery stores or even churches. If you were a psychiatrist in that town, the odds are pretty good that you might attend church with a patient, run into them at walmart and see them out at dinner at a restaurant. It wouldn't be feasible for either the patient or the provider to change their habits to avoid this. So I guess you have to establish boundaries like you mentioned above with the knowledge that you will have some out of the office interaction. I'd be curious to hear how psychiatrists there deal with it.

                And about psychiatry being more intimate than other fields of medicine, maybe, but I'm not sure. An STD can be more stigmatizing than a mental illness, and oncologists probably have lots of pretty intimate interactions with patients. I'm not convinced that the boundaries need to be different for us, but again, I haven't even started residency.
                 

                billypilgrim37

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                  I'm not convinced that the boundaries need to be different for us, but again, I haven't even started residency.

                  The fact that we're trained/generally predisopsed to even wonder whether boundaries ought to be different for us is the first indicator that they probably should be.
                   

                  Faebinder

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                    Afraid you probably do need to change churches.
                    And I don't mean change to another branch of your church.
                    You need to change religions.
                    Change to one that caters to the rich and famous and powerful. Preferably one that openly espouses a revulsion to psychiatry and demonizes psychiatrists. To be sure that the antipsychiatry view is not just a matter of political correctness, choose one that has an arm of the church that actively encourages violence against psychiatrists.
                    And just to be sure that there is really no chance that anyone in the church has any interest in general mental health, make sure that it's one that only lets people into the upper levels of the church after they have given millions to the church AND are completely indoctrinated in the belief that ancient aliens began our world by exploding a nuclear ("nucular" for immediate past Presidents) bomb inside a volcano.

                    That way, you have little chance of running across a psychiatry patient from a public mental health clinic - except for the alien conspiracy part.

                    Tell Cruise and Travolta that I said, "Hello."

                    :laugh:
                     

                    OldPsychDoc

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                      Afraid you probably do need to change churches.
                      And I don't mean change to another branch of your church.
                      You need to change religions.
                      Change to one that caters to the rich and famous and powerful. Preferably one that openly espouses a revulsion to psychiatry and demonizes psychiatrists. To be sure that the antipsychiatry view is not just a matter of political correctness, choose one that has an arm of the church that actively encourages violence against psychiatrists.
                      And just to be sure that there is really no chance that anyone in the church has any interest in general mental health, make sure that it's one that only lets people into the upper levels of the church after they have given millions to the church AND are completely indoctrinated in the belief that ancient aliens began our world by exploding a nuclear ("nucular" for immediate past Presidents) bomb inside a volcano.

                      That way, you have little chance of running across a psychiatry patient from a public mental health clinic - except for the alien conspiracy part.

                      Tell Cruise and Travolta that I said, "Hello."


                      Been thinking about this some more, kugel.
                      Is there a book or something I could read? Or some kind of test to take?
                      And if I do join, do *I* get to be rich and famous and powerful, too?
                      :D
                       

                      kugel

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                        Been thinking about this some more, kugel.
                        Is there a book or something I could read? Or some kind of test to take?
                        :D

                        If you can read a book, or if you can pass a test (ANY test, even an eye test, or if you can spell "IQ" on the IQ test), then you should probably not join. Such a group seems unlikely to truly be seeking those who can accomplish either.

                        But it's just an imaginary group. So nothing to worry about.
                        ....right?
                         
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                        whopper

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                          I'm not a religious type of guy, though I do have a spiritual view on the universe. I attended church my last year of residency, mostly because my wife nagged me into doing it. However after getting into it for about 1 month I actually started liking it. There were a lot of nice people at the church and the pastor was a sincerely good man. He cared, tried to do the right thing and just that made me like going. It didn't convert me, but it was affirming to my faith in humanity.

                          I told the church upfront that I could not have any connection to them in terms of mental health other than answering general questions. I was thinking that someone from the church may end up in the crisis center. Didn't happen.

                          Since I've moved to Ohio, I haven't attended church. I don't got the time.
                           

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                            Kind of along the same topic, should patients seek out psychiatrists that practice a distance away from where the patient lives? Would it be unusual for a patient to drive 30-60 minutes away from their home city to see a psychiatrist in another city just to ensure (as George Costanza would say) worlds don't collide?
                             

                            Saluki

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                              Kind of along the same topic, should patients seek out psychiatrists that practice a distance away from where the patient lives? Would it be unusual for a patient to drive 30-60 minutes away from their home city to see a psychiatrist in another city just to ensure (as George Costanza would say) worlds don't collide?

                              I guess I don't think that's reasonable.... It's good to have boundaries, but at the same time, running into a patient at the grocery store or book store shouldn't be that huge of a deal... And if anyone should be doing the driving it should be the psychiatrist- why should the 500 hundred patients be driving an hour away from where they live rather than the psychiatrist choosing to live further away if he's concerned that boundaries are going to be an issue?
                               

                              Prime2000

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                                I guess I don't think that's reasonable.... It's good to have boundaries, but at the same time, running into a patient at the grocery store or book store shouldn't be that huge of a deal... And if anyone should be doing the driving it should be the psychiatrist- why should the 500 hundred patients be driving an hour away from where they live rather than the psychiatrist choosing to live further away if he's concerned that boundaries are going to be an issue?

                                The psychiatrist may not care as much as the patient. Some patients might take comfort in knowing their psych doc is in another city.
                                 

                                swanny

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                                  Given your account, I'm amazed this hasn't happened more often. I have had contacts with many patients outside of my office over the years. I have had several professional interactions with people who attend my church. If they approach me (i.e. Can I see you for treatment?) I refer them to others, as I feel the boundary issue is difficult. I have not had any patients show up at my church-but I suspect that if I did, I would consider referring them to someone else. That would require some exploration and discussion with the patient. I have had some coworkers ask to see me, and I have consistently referred them elsewhere. I have had a number of patients who have contact with my children (primarily through school). This is a little harder to avoid, and I generally don't refer them away. I usually let them know that I live in their area and that my children attend school with them, and we talk about it. Often times, the patients make the connection before I tell them. Most of the time, the contacts are peripheral. However, my daughter has an ongoing friendship with one of my patients-but isn't aware that I see her friend, as the patient hasn't disclosed, and I wouldn't break confidentiality. I see a number of patients when I'm out in the community-many of them I end up seeing repeatedly (through school, scouting or sports functions). These contacts don't seem to be nearly as odd.


                                  I suspect that your situation is more disconcerting because it's occurring in church (as opposed to the grocery store, school, or other community settings). Church contacts seem to be more intimate and long term than those in other settings, and we tend to be more revealing of our problems and feelings in small groups, like Bible studies. As with everything in psychiatry, I think it's important to talk with the patient and explore her reaction to it. She may be much less discomfited by the issue than you are. However, your concerns, if they persist, may mean that you should refer her to someone else. Naturally, you might have more boundary concerns with a psychotherapy or BPD patient than for a quarterly med check patient-the relationship and interactions are quite different, and each patient's needs ought to be considered individually.
                                   

                                  Psychintern2006

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                                    For me safety is the number one concern, after that it is not much of a concern.

                                    I will admit your interaction is little too intimate viz. at a friends house/ family being involved.

                                    Memo :
                                    I have to get my home phone De-listed.

                                    I am curious in the dynamics here - probably she feels safe being around you in a similar way she feels Lord protects her. Thankfully she is not a borderline.

                                    Will be interesting and educating to see how you dealt with this situtation, if you are still alive :laugh:
                                    Best
                                     

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                                      I live in a smaller town (about 50-60K), about 1/2 hr drive to the next dinky place (4k) and not much other than sagebrush.

                                      I run into my patients all the time, and their boundaries are often poor. That doesn't stop me from shopping at my regular store where 2 patients are checkers, but I do avoid the video store where the more clueless, slightly borderline IQ patient works. Not for myself, but for their protection. The checkers might say that "I need to get back in and see you doc, I am having some difficulties," and I just tell them to call the office. The low-IQ patient will start talking as if it was another session, so for her protection, I don't go there.

                                      As for OldPsychDoc, clearly it interferes in your life, and referring to another psychiatrist is appropriate if there are others available. Whether it is sufficient is something you will have to wait and see. Even if someone else sees him, you still know. If that affects your interaction in church and especially in the group, then you might be stuck.

                                      Also remember that strict boundaries is a psychodynamic, rather than behavioral concept.


                                      (PS: On the ie-spell check, Oldpsychdoc comes up as "altruistic" :) )
                                       

                                      whopper

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                                        A buddy of mine was in law school and did pro-bono work for a battered women's shelter (which was strange because he was a womanizer, but he swore to me he'd keep his sexual thoughts outside of work. I specfically told him for his sake (and for the sake of these women) to never do anything sexual with them. Trust me this guy's sexual life was interesting and ought to be a thread....).

                                        He told me he one day represented a woman, and helped her in getting a restraining order against her husband. The judge ordered in her favor.

                                        As he was going down the elevator, feeling smug because his side won, the husband ran into the elevator, and the door closed.

                                        The husband told my friend he was going to kill him, said he knew my friend had no way to prove he made the threat, and told him he would find out where he lives, plan it out, and get him while he least suspected it.

                                        My friend just a few days later bought 4 guns.

                                        I've always wondered what I'd do if a patient took it to that level. I've never had one do that yet. In residency, the first year I wondered what would happen, but after a few days of weirding myself out, I figured "why worry about it all the time when it might not even happen? I'll cross that bridge if I get to it."

                                        Since working in forensics, I entered a new level where patients are more dangerous and antisocial vs regular patients in clinical practice. The same thing occurred, and the same resolution occurred. Several of my colleagues however, and they swear its not because they work in the field, well most of them happen to own guns and practice at the range.
                                         
                                        A buddy of mine was in law school and did pro-bono work for a battered women's shelter (which was strange because he was a womanizer, but he swore to me he'd keep his sexual thoughts outside of work. I specfically told him for his sake (and for the sake of these women) to never do anything sexual with them. Trust me this guy's sexual life was interesting and ought to be a thread....).

                                        He told me he one day represented a woman, and helped her in getting a restraining order against her husband. The judge ordered in her favor.

                                        As he was going down the elevator, feeling smug because his side won, the husband ran into the elevator, and the door closed.

                                        The husband told my friend he was going to kill him, said he knew my friend had no way to prove he made the threat, and told him he would find out where he lives, plan it out, and get him while he least suspected it.

                                        My friend just a few days later bought 4 guns.

                                        I've always wondered what I'd do if a patient took it to that level. I've never had one do that yet. In residency, the first year I wondered what would happen, but after a few days of weirding myself out, I figured "why worry about it all the time when it might not even happen? I'll cross that bridge if I get to it."

                                        Since working in forensics, I entered a new level where patients are more dangerous and antisocial vs regular patients in clinical practice. The same thing occurred, and the same resolution occurred. Several of my colleagues however, and they swear its not because they work in the field, well most of them happen to own guns and practice at the range.

                                        :whoa:
                                         
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