Not just a patient: The dangers of dual relationships

Physicians who practise in rural areas are confronted with the challenge of treating patients who are, at the very least, acquaintances.1 They may be neighbours, members of the same faith community, or sit across the table at board meetings. The rural physician may have as a patient her mechanic, or child's teacher. With these patients the physician has a dual relationship. Fellow citizens of a small community may be both patient and friend. The physician may be both doctor and customer. This reality presents special challenges for the rural physician. She has an ethical obligation to provide care to under-serviced patients. To fail to do so may leave the potential patient without a physician. On a practical level, refusing to treat any person with whom the physician has non-clinical contact may eliminate most of the potential patient population, especially if the town is remote and the physician lives where she practises. Despite this reality of rural practice it has long been recognized that dual relationships pose a threat to appropriate medical care by causing boundary violations and interfering with patient autonomy. If all patients receive the "best standard of care" then all can expect similar treatment. Boundaries dictate that, in return, the physician may only expect appropriate financial reward. A dual relationship may lead either party to expect or receive "special treatment." This expectation may never be verbalized. Equally possible is that one person may perceive that special consideration is expected, or is being offered, even when that is not the case. At the office this may be demonstrated by offers of, or demands for, unusual flexibility in time, place and length of appointments5 or waiving fees for non-insured services. Outside of the office the physician may receive, or expect to receive, favours such as products or services at a reduced price.5 If expectations beyond those normally arising in a doctor-patient interaction exist and are not met, then clinical and non-clinical relationships can both be damaged. If the physician meets the special expectations of one patient, relationships with other patients may be damaged. If the physician cannot answer all these questions with an unequivocal "No" then she must consider carefully initiating or continuing the doctor-patient relationship. The slippery slope from minor boundary crossings (an inevitability in rural practice) to major boundary violations is greased by rationalizations. Thought