A Yawning Gap in Medical Education
Medical training prepares students for clinical challenges, not professional ones.
It happens at the end of every course I teach on professional boundaries. One after another, the surgeons, internists, therapists and others trying to salvage their careers come up to me and say essentially the same thing: “I wish I had known earlier what I know now.”
There are two reasons why they didn’t learn about boundaries sooner. The first is on them. Like virtually all medical professionals, they simply did not believe they were at risk earlier in their careers. In fact, the same people who end the class wishing they had understood boundaries sooner begin the course convinced that they have nothing to learn. Refusing to take responsibility for their violation, they tell me the board is just over-reacting or a disgruntled patient is simply out to get them. They haven’t done anything wrong and they don’t need to waste time learning to avoid violations in the future.
But it’s not just individual practitioners who resist the need for education. The institutions responsible for educating them are equally to blame. Asked to consider a boundaries course, medical schools inevitably reply that there is simply no room in the curriculum for non-clinical training. And it’s certainly true that medical students and residents have their hands full learning what they need to know to get a license. But that’s all the more reason to make sure they know how to protect that license once they are out in the real world. Considering how much students pay for medical training and how much they sacrifice to become doctors, don’t they deserve at least a little help learning how to survive a career in medicine?
Some schools and hospitals do offer a cursory lecture or two on rules and ethics, but these are woefully inadequate. In moments of stress—whether from passion or exhaustion—we are all likely to forget or ignore any rules we may have learned. In its excellent publication, “Challenges of Professional Boundaries (for Medical Students),” the Texas Medical Association puts it this way:
“Physicians are trained to function effectively and cope with the numerous stresses that come with the responsibilities of their position. When additional personal stressors occur, normal coping mechanisms may become strained. As a part of being human, physicians and students may become vulnerable to poor judgment and/or decision-making. They also may be at greater risk for succumbing to invitations of needy patients.”
There is, of course, no way for medical students, or anyone else, to avoid these “additional personal stressors,” but there are proven ways to prepare oneself. The article below, Protection Plans Help Prevent Violations, describes the way PBI graduates do just that. But most of the practitioners who attend our classes have already committed a boundary violation, seriously harming their patients, their institutions and themselves in the process—not to mention their family and friends. In an ideal world, they would have been prepared for the challenges they faced before any damage had been done.
Simply offering such training is not enough. Because no one believes they are at risk until it’s too late, few if any medical students or residents are going to voluntarily attend classes designed to reduce their violation potential. That’s why I strongly believe that professional boundary training should be a mandatory part of medical training.
The time devoted to this training needn’t be extensive. In their first year of school, medical students could take an introductory course, focusing on the boundary issues most common to those just starting out (see below). Then periodically throughout their training, as their experience and exposure to risk grows, students and residents could revisit the subject, discussing with mentors and each other challenging situations they’ve actually faced. To help break through students’ sense of invulnerability, these classes should also include case histories of students, residents and young physicians who have been disciplined for violations.
And there is no reason this attention to professionalism needs to lapse after the initial years of medical training. States could ensure that the education continued throughout the careers of all medical professionals by including boundary education in the CME credits required for license renewal. Again, the commitment could be modest; just a few hours of CME-approved courses every few years.
I recognize that teaching medical students and others about professional boundaries is not a panacea. I don’t expect that the kinds of educational initiatives I am advocating will extinguish the need for remedial courses like those we teach at PBI. But given the amount of damage I have seen boundary violations inflict over the years, I know how valuable any reduction in violations would be—both for physicians and patients. As anyone who cares for the sick and injured knows all too well, the best medicine is preventative.