Navigating Appropriate Boundaries When Patients Ask You To Be Their Trusted Physician

Many podiatrists now refer to themselves as physicians. I guess the word physician is a little more dignified than simply calling ourselves foot doctors or podiatrists. I have always preferred to call myself a podiatrist so I wouldn’t have to explain later that I was actually a limited form of physician and wouldn’t have to hear, “So, you’re not actually a ‘real doctor.’”    Despite my efforts to be identified as a podiatrist, many of my patients, friends and medical colleagues thought of me as a physician. This was all well and good until I was called upon occasionally to be a patient’s trusted physician. I was not prepared with the education or experience to fulfill that role. Still, many patients, friends and colleagues placed me in that awkward position.    Brendan Reilly, MD, recently published his memoir called One Doctor. Dr. Reilly is an internist in his mid-60s who teaches at Dartmouth College and practices as a general internist. Dr. Reilly talks about the heavy burden and responsibility of being a patient’s one trusted doctor. He also talks about the challenges of that role in light of healthcare reform. The obligation to adhere to evidence-based standards of care often conflicts with the needs and desires of his patients who are often approaching the end of life.    Dr. Reilly gives the example of his mother, who is in her 90s, with Alzheimer’s dementia and a cardiac pacemaker that is interfering with the natural process of death, which should involve slowing of the pulse and respiration, leading to the end of life. He could not ask her physician to disable the pacemaker because it would conflict with the standard of care.    He gives many examples of the real challenge of being a trusted physician. The book is one of the best I have read and I would advise any caregiver to own a copy to use as a moral compass as we negotiate the coming changes in our health system.    A podiatrist should know and understand the role of a trusted physician. There will be times when a patient sees us as the most trusted and understanding doctor available. This will become more crucial as changes in healthcare evolve into “population health.” Many patients will no longer have the ability to choose one doctor to discuss their concerns and life decisions with them.    It is important to establish boundaries. As podiatrists, our medical advice to patients needs to be confined to matters that pertain to our scope of practice.    One of my first experiences being used as a trusted physician occurred when a young man who had become a quadriplegic after a car accident came to my office to chat. I had helped him with pressure ulcers caused by contractures. He asked if he could talk with me about his plans and then let me know he was considering suicide.    I knew right away that his problem was out of my scope but talking as his friend, I suggested that he consider some alternatives since he had a bit of a tendency to screw things up. I asked him to consider the consequences of surviving the attempt. I also contacted his primary care doctor, who arranged medication and therapy for his depression.    I saw my former patient a few months ago in a coffee shop. He rolled in riding in a state-of-the-art motorized wheelchair that reclined with a breath toward a sensor switch and was equipped with a cellphone and computer tablet.    My former patient and friend had finished college, and is working as a rehabilitation counselor, helping disabled workers return to work. He reminded me of the talk we had about suicide and thanked me for reminding him that he may screw it up.    The boundaries are very important. Many physicians of all types have been caught in the web of a patient with dependent gratification issues. When the doctor feels the need to get out of the relationship, the patient and state medical board can twist the story to implicate the well-meaning doctor in a boundary violation. This can result in medical malpractice and license suspension.    Be cautious when a patient singles you out to be his or her trusted physician. It can be a rewarding experience but the podiatrist and the patient should know the limits of the relationship.    My favorite memory of a patient compliment was when an elderly lady told me how much she liked my care and told me she wished I was a real doctor. Dr. McCord retired from practice in 2008 at the Centralia Medical Center in Centralia, Wash.