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Success Story: Professional Boundaries

I am a psychiatrist in private practice. In early 2003, I was unexpectedly and angrily confronted in my office by the relative of a patient I had treated. I didn’t have any previous contact with this relative, so I was completely taken aback by the confrontation. I learned, however, that my patient was jailed and charged with a major violent felony. The relative’s concern was that the patient’s actions resulted from him consuming alcohol in addition to the Xanax I prescribed.

After a tense discussion, followed later that day by an angry telephone call, I phoned the relative’s home with the intent of diffusing the situation by injecting an element of humor. What is now apparent to me is that there was nothing humorous about the situation. My response was inappropriate, unprofessional, and ultimately symptomatic of what I would learn to be my own challenges in understanding and respecting professional boundaries.

In addition to the inappropriate response to my patient’s situation, some of my office practices were problematic. For almost six years, I had been conducting meetings for a 12-Step, relationship-focused Fellowship, and my patients attended these groups. Although I had consulted with both 12-Step friends as well as psychiatric colleagues and mentors, I ignored their resonating advice -- that the meetings, although well intentioned and attended, created professional conflicts of interest and violated boundaries I was unwilling to recognize at the time. Rather, my own opinions and desires seemed to be the only driving force. When these events erupted, I was advised by an attorney with the Massachusetts Board of Registration in Medicine (the Board) to contact Physician Health Services (PHS).

After completing questionnaires and several interviews with Drs. Luis Sanchez and Judith Eaton, I was advised to enter into a two-year behavioral health monitoring contract with PHS. I knew I needed help, and I sought it freely and voluntarily, without any reservations. The elements of my contract were as follows: monthly meetings with my associate director, Dr. Eaton, and my hospital chief; weekly meetings with a monitor of my choice in my specialty; on-going therapy and medication with my psychiatrist; monthly attendance at the Physician Health Peer Support Group; as-needed visits with my own primary M.D.; and attendance at PHS-recommended educational courses. My monitor, hospital chief, and psychiatrist all submitted quarterly, written reports to Dr. Eaton. I was advised to immediately cease all of the 12-Step meetings I conducted. I was free to continue my own, personal 12-Step work, and to talk about 12-Step ideas with my patients, as long as meetings did not take place in my office or with my oversight.

In December 2003, under the advisement of PHS, I attended a four-day course at the Vanderbilt University Medical Center’s Center for Professional Health in Nashville, Tennessee, on critical issues and common pitfalls of prescribing controlled substances. In October 2003, I independently took a one-day training in the prescribing of buprenorphine, a new treatment for opiate dependence. I became DEA credentialed for this therapy, and quickly attained the maximum 30 patients in treatment. Drs. Eaton and Sanchez responded with unfailing support to all requests with respect to credentialing renewals and verification of compliance with my PHS contract. After reviewing my responses, and with the support of PHS, the Board closed my pending case without action. My support group peers were a kind, living mirror to me. My monitor was my angel. No other word even begins to convey my esteem of, debt to, and gratitude to her.

Over the course of my two-year contract, I performed all of the required activities with very few missed appointments. I became much more open to routine consultation with my monitor, my psychiatrist, and Dr. Eaton. Even though I did no in-patient work at the hospital where I have by choice held only courtesy privileges, I felt more than ever a part of the department and medical staff there. I consulted more freely with the laboratory staff about routine testing and urine toxic drug screening and with all of my PHS support colleagues about my experiences treating patients with buprenorphine. With the help and advice of my support team, I relocated my office from a mixed-tenant, general professional office building -- in which I was the only remaining physician -- to a nearby, larger, entirely medical and allied health care professional medical center. Also as a result of the prodding of my team, I replaced my office staff, recruited years earlier when I had much less confidence setting standards and leading a team, with a new, more qualified and well-suited staff. With the sole exception of Medicaid managed care, I was successfully recredentialed by six major managed care plans, including two of the most important. On my appeal and with the help of PHS, these plans reversed their initial decisions to deny my credentials. I was accepted as a contracted provider by an alternate Medicaid carrier. I am expanding my office clinical staff. I am even contemplating re-applying to the main Medicaid carrier. I have incorporated into my office routines and documentation practices numerous suggestions of multiple health plans as well as of the Board and my malpractice carrier. I defined and strengthened boundaries and treatment requirements with all of my patients, but particularly with uncooperative, improperly motivated, high-risk patients. I realized that I need to become more teachable and open and willing to change -- in all of my professional decisions and actions. I know I still need to improve my time management and workload regulation skills, and be more aware of my sleep, exercise, and relaxation needs. After 22 years in practice in Massachusetts, I will soon apply for membership in the Massachusetts Medical Society.

In addition to acknowledging PHS, I must also express gratitude to two other indispensable sources of support in my quest for growth. At no cost, my malpractice carrier provided the services of a superb, highly qualified attorney to assist me with proactive risk management, the numerous administrative and credentialing appeals I faced, and realistic, professional patient boundaries. In addition, my 12-Step friends, groups, and sponsor, and my self-defined higher power have given me the skills, humility, and faith to finally become a functional, peaceful member of my professional and personal worlds.

Yet PHS was the integrating milieu that made the past two years the most rewarding, valuable, and enjoyable of my 37-year professional journey since medical school graduation. I am eager to pass along to colleagues the gifts given to me.

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