Reexamining the call of duty: Teaching boundaries in medical school

Although healthy physician-patient boundaries are essential to medical practice, published research on how to teach this important topic to medical students is lacking. Physician-patient boundaries, the interpersonal limits placed on behavior within a clinical relationship, protect providers and patients alike, and they represent a key component of professionalism. However, these boundaries may be difficult to teach and frequently are not presented as part of the formal curriculum, except in communicationfocused specialties such as psychiatry and palliative care. Medical students may be particularly susceptible to boundary concerns due to the inherent ambiguities of their role within the medical team. In this Perspective, the authors present the adapted, anonymized case of a medical student who encountered a boundary issue during a clinical rotation. Following a brief review of the limited published literature regarding the teaching of boundaries during medical school, the authors define key concepts, including the clinical frame, boundary crossings and violations, fiduciary duty, and dual relationships. Next, they provide examples of common boundary challenges that arise during the course of undergraduate medical education and later during clinical practice. The authors present factors that may contribute to boundary concerns, including characteristics of providers and patients, and they describe some of the potential consequences of boundary violations. They propose a curriculum for teaching medical students about boundaries, providing concrete suggestions for how to do so at both the preclinical and clinical levels. Before closing, they apply insights from the Perspective to the example case.