Northern Constellations 2019

May 4, 2019

James Goertzen MD MClSc CCFP FCFP

Assistant Dean, Continuing Educational Professional Development

Brent Kvern MD CCFP (University of Manitoba)

Miriam Boillat MD CCFP (McGill University)

Teresa Cavett MD CCFP (University of Manitoba)

I am a recipient of a NOAMA Grant for a medical education research grant.

I have no financial or personal relationships to disclose relevant to this presentation.

1. Apply physician-patient boundary concepts to preceptor-learner relationships.

2. Describe preceptor-learner boundary crossings and risk factors.

3. Identify strategies to assist preceptors in developing optimal professional, educational and personal relationships with their learners.

Physician-Patient and Preceptor-Learner Boundaries

Case Discussions

Preceptor and medical student (tables)

Preceptor and medical student (tables)

Preceptor and resident (large group)

Supporting Learning Post Workshop

Workshop Evaluation & Feedback

Confidential and respectful discussion

Mutual and mindful learning environment

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Boundaries create our therapeutic relationship with a patient along with clarifying roles and expectations for both

physician and the patient.

Boundary transgressions include a range of behaviors and include boundary crossings and boundary violations.

Boundary crossing is a departure from usual practice with our therapeutic relationship with a patient. They are not exploitive

and may at times be helpful to the patient.

• Therapeutic touch in the clinical setting

• Physician self-disclosure

• Establishing dual relationships (patients as friends)

• Attendance at events (shows, social, business)

Boundary crossings may be unavoidable and happen to all physicians in their therapeutic relationships with patients.

Important for physicians to recognize boundary crossings and consciously take responsibility for maintaining therapeutic

boundaries to protect both patient and physician.

Boundary crossings become boundary violations

when there is harm to the patient.

INSERT PICTURE

• Self-disclosure that is not for purpose of helping the patient

• Probing for patient information that has no relevance to clinical care

• Complaining to the patient about some of the challenges of being a physician

There is an inherent power imbalance

in the patient-physician relationship.

Boundary violations jeopardize the patient-physician relationship and are a breach of a patient’s trust.

• Boundaries create our educational and professional relationship with learners along with clarifying roles for both preceptors and learners.

• Boundary transgressions include a range of behaviors and include boundary crossings and boundary violations.

There is an unequal power dynamic in preceptor-learner relationship.

Potential for exploitation due to power dynamic.

Boundary considerations often not clear cut matters of right & wrong.

The Grey Zone includes boundary straddling and crossing behaviors.

Key with managing boundaries is ensuring best interests of learner.

Boundary crossing is a departure from usual practice with our learner educational relationship. They are not exploitive and may

at times be helpful to the learner.

Boundary crossings may sometimes be a conscious decision on part of the preceptor with intention of assisting the learner with their clinical independence, professional development or professional

identify formation.

IN OFFICE, HOSPITAL, OR ACADEMIC SESSION

• Preceptor self-disclosure such as medical mistake

• Establishing dual relationships (professional and personal)

OUT OF OFFICE IN THE COMMUNITY

- Dinner invitations

- Shared recreational activities

Balancing closeness and distance is necessary in all relationships.

Appropriate preceptor collegial & social interactions (closeness) can assist learners with their professional development.

Professional identify formation is supported as learners integrate into the values and aspirations of their professional community.

Within the preceptor-learner relationship, boundary considerations are often not clear cut matters of right or wrong.

The Grey Zone is dependent upon many factors and requires careful exploration of a number of issues keeping in mind the best

interests of the learner.

Inappropriate closeness between preceptor and learner may compromise the preceptor’s ability to be objective and fair with

their of completion of evaluations.

If preceptors favour certain learners for personal rather than academic reasons, a perception of favoritism or discrimination may

occur within a group or team setting.

Boundary crossings become boundary violations when there is harm to the learner.

• Inappropriate touching in the clinical or educational setting

• Self-disclosure that is not for the purpose of illustrating educational concepts or assisting the learner with their professional development

• Probing for learner personal information that has no relevance to educational context

• Boundary violations may result from life difficulties with either preceptor or learner.

• As a result of the power imbalance inherent in preceptor-learner relationships, trainees may find it difficult to negotiate boundaries or recognize boundary crossings.

• Boundary problems often arise from behaviors that place the preceptor’s personal goals or needs ahead of the learner.

• Embrace the importance of professional boundaries through open discussions with preceptors and learners.

• Model boundary setting with learners as it will support skills in their development of appropriate physician-patient boundaries.

• Recognize factors that place preceptors and learners at risk to become involved in intimate relationships with each other due to problems in their own relationships or emotional vulnerability.

• Consult a colleague when faced with a possible concerning preceptor learner boundary challenge.

• Preceptor

• Sarah (Third year medical student)

You are preceptor for Sarah, third year medical student on a Phase 2 placement. Sarah attends your clinic business supper meeting held at the clinic at your invitation. You routinely invite medical students and residents to these meetings to assist with physician leadership development and practice management. As the meeting ends, you invite Sarah to join several other colleagues and yourself for a post meeting beverage at a nearby pub.

1. What is educational goal with this invitation? What are the benefits to Sarah in accepting the invitation?

2. What might be the impact on Sarah’s clinical rotation if she turns down the invitation?

3. Does it make a difference with the invitation if you are a male or female preceptor?

4. How would you define appropriate boundaries for preceptor-learner socialization?

• Preceptor (Recent graduate in third year of practice)

• Jason (Forth year medical student on four week rotation)

You are a recent graduate and have agreed to supervise Jason, a forth year medical student on a four week rotation. Jason is an older student fairly close to your age. You and your partner are experiencing difficulties. It seems natural to review clinical cases with Jason over a cup of tea at the end of the day. Recently you shared some of your marital difficulties with a goal to help Jason understand that being a doctor doesn’t automatically mean a happy home life.

1. Why would you characterize this as a boundary crossing or violation?

2. Where, if at all, did you go wrong?

3. How could this have been handled so the learner feels safe?

• Preceptor

• Resident (Second year resident on eight week rotation)

You have been supervising residents over 10 years. You enjoy working with residents and feel that residents enjoy working with you. In fact, residents seem to gravitate to your office at the end of clinic to speak with you about some of their challenging clinical situations and achieving work-life balance. Lately, one resident seems to spend more time in your office than others and often stays after others leave. He divulges that his is having difficulties in his personal life and asks you for advice.

1. Is this a boundary crossing or boundary violation between preceptor and resident?

2. What might be your role (as preceptor) in this situation?

3. How would you respond to the resident’s request for advice with his personal life?

4. How might you set boundaries with this resident? How might you set boundaries with future residents?

• Important to clarify the boundaries of preceptor-learner relationships.

• Power differential exists within preceptor-learner relationships.

• Boundary concepts from physician-patient relationships apply to preceptor-learner relationships.

• Effective preceptors prioritize the needs and interests of learners when developing professional, educational and personal relationships with their learners.

• Galletly C. Crossing professional boundaries in medicine: The slippery slope to patient sexual exploitation. MJA 2004.

• Plaut SM, Baker D. Teacher-student relationships in medical education: Boundary considerations. Medical Teacher 2011.

• Professional responsibilities in PGE. Toronto: CPSO 2011.

• Professional responsibilities in UME. Toronto: CPSO 2012.

• Dekker H et al. Medical students’ and teachers’ perceptions of sexual misconduct in the student-teacher relationship. Perspect Med Educ 2013.

1. Apply physician-patient boundary concepts to preceptor-learner relationships.

2. Describe preceptor-learner boundary crossings and risk factors.

3. Identify strategies to assist preceptors in developing optimal professional, educational and personal relationships with their learners.

We do not learn from experience.We learn from reflecting on experience.

John Dewey