The yellow-, red-, and green-striped gift bag containing the present lay on my office desk among the stacks of charts and assorted papers. Curious as to the sender, I looked at the card that came with it. “Oh no, not again.” It was from my patient Ms. Emalee, next on my schedule. Among her myriad medical problems—diabetes, hypertension, obstructive sleep apnea—was intractable knees and back pain for which she used narcotics chronically. On her current visit I’d planed to perform a random drug test, to ensure she was actually taking the medications and that she did not use illicit drugs. But now the gift, although this was far from her first—she often brought fruits, baked goods and other presents for everyone in my clinic. After she learned I got married and hinted she was looking for “something special” for me, I’d entreated her not to worry. She had looked at me as if I were from a different planet and then declared I was “like family now,” adding “you better believe you getting something from me, don’t matter you snucked off ‘n’ got married without telling no one.” Now I wondered: What if her test results indicated a problem? Would her act of kindness make it difficult for me to do my job, such as refusing to prescribe further narcotics or even discharging her from my practice?
The question of boundaries with their patients is one issue that small-town doctors face. Often for lack of convenient alternatives, country doctors not only have to take their friends on as patients, but their patients quickly establish themselves as friends. It seems to challenge the reader to consider that in small towns, where privacy is shunned and familiarity with neighbors prized, maybe physicians’ closeness with their patients is exactly what they need to render care with true understanding and deep compassion.
When I entered Ms. Emalee’s room, she looked up at me expectantly and asked if I liked her present. I told her I had not opened it. Sensing her disappointment, I quickly added that I was waiting to get home, before opening it with my wife. The explanation seemed to satisfy her. “Smart man,” she said, “I’m sure she’d love it.” Ms. Emalee’s knees and back still hurt, but her pain medications were helping. No, she did not have significant side effects from the medications, such as constipation or drowsiness. I also asked if she ever sold her pain pills, but that seemed to annoy her. “You keep asking me that foolish question every time I comes here and I keeps telling you no, I does not sells my medicines. Don’t you even trust me?”
I apologized, but reminded her it was the law and my job to ask. At the conclusion of the visit, I told her I’d like a sample of her urine for a random drug test. “Whatever you say, doc,” was her sarcastic reply. Then she informed me they were having a birthday party for her mother—who was also my patient (as were her two sons, a daughter, a sister, and brother-in-law). Her mother was turning eighty. Her family would be greatly honored if my wife and I could come. Not sure how to respond, I promised to get back with her.
(Excerpted from Who We Are—Synopsis, The Country Doctor Revisited)
Boundaries between physicians and patients are usually different in rural areas than in larger metropolitan areas. Students are often caught in a double bind when they learn in medical school that physicians cannot be friends with their patients, but see in rural areas they usually are. As Dr. Onime states, “Patients often quickly establish themselves as friends… and that closeness may be what is needed to render care with true understanding and deep compassion.” What do you see as the benefit and downside of “dual-relationships” –friend and doctor to the same person? How do the professionals on your rural rotation negotiate this? Physicians often feel like they live in a fish bowl, especially in small towns where everyone knows everybody’s business. How do your preceptors draw the boundaries? Some professionals relish being the heart of the town and others prefer much more privacy. Imagine yourself as a small town practitioner, what would you do?