Setting Boundaries With Patients:  A Guide to Effective Communication in Direct Care

In the world of Direct Care, the connection with patients is uniquely close-knit, which can lead to remarkable health outcomes, and strong patient-physician relationships. 

However, this closeness necessitates clear boundaries to ensure that both parties maintain a professional relationship. 

This article provides essential strategies for you to navigate this delicate balance.

Why Do We Need to Talk About Setting Boundaries with Patients?

Setting boundaries in a healthcare setting can be challenging. Your extensive training and desire to help can lead you to become so involved that you overlook your own limits and the necessity of maintaining a professional distance. 

This deep engagement is commendable and often crucial for empathetic care, but without clear boundaries, it can lead to burnout and blurred lines that might compromise the care process. 

Establishing boundaries is not just about protecting yourself; it's about sustaining the ability to provide high-quality care sustainably and ethically.

Setting Boundaries with Patients: The Radical Candor Framework

Kim Scott wrote a book called Radical Candor, which presents a framework for communicating and giving feedback to others. Many insights from the book can be applied in healthcare, particularly within the patient-physician relationship.

Essentially, she introduces two main axes: Care Personally and Challenge Directly.

Care Personally‍

This axis emphasizes the importance of showing genuine personal care and concern for the individuals you interact with. It’s about acknowledging and respecting the feelings, aspirations, and well-being of others.
When you care personally, you invest emotionally in the people around you, creating a relationship of trust and openness. This is crucial in healthcare, as it fosters a safe environment where patients feel valued and understood.

Challenge Directly‍

Challenging directly involves communicating openly and honestly, even when the feedback might be difficult. It’s about not shying away from tough conversations and being clear and specific with your feedback to prevent misunderstandings. In healthcare, challenging directly, when done respectfully, helps individuals change their lifestyle for the better, follow your prescriptions, and adhere to orientations, which can also improve outcomes.

Together, these axes advocate for a balance where one can be both empathetic and assertive—caring deeply for the individual while also daring to point out mistakes and push for positive changes.

Setting Boundaries with Patients: Practice Scenarios

Here’s how you can apply this framework through four common scenarios that you may encounter:

Handling Overdependence

Patients can sometimes develop an overreliance on you for both major and minor health issues, expecting immediate responses at all times. 

Applying Radical Candor, you might address this by expressing genuine concern for the patient's well-being: "I see how important this is for you”, while also setting clear boundaries about availability: "Let's discuss appropriate times for non-emergency calls". 

This approach shows care while directly addressing the issue.

Managing Unrealistic Expectations

Some patients might have expectations about treatment outcomes that aren't aligned with medical realities. 

Here, caring personally means acknowledging their hopes or fears "I understand why you would want this outcome", while challenging directly involves providing clear, factual information about what can realistically be achieved and why certain treatments might or might not be appropriate.

Dealing with Non-compliance

When patients do not follow treatment plans, it's crucial to express concern for their health "I am concerned about your well-being when you miss your medication", and directly challenge their behavior by outlining the consequences of non-compliance "Skipping your medication can lead to serious health complications".

Discussing Sensitive Health Issues

Conversations about sensitive health topics require high levels of empathy, paired with straightforward dialogue. 

Care personally by showing empathy and support: "I can see this is difficult for you", and challenge directly by being factual and clear about the health implications and necessary actions "It’s important that we address this issue directly to manage your health effectively".

In each of these scenarios, the Radical Candor framework helps maintain professional boundaries while ensuring that the patient feels supported and understood. It promotes a balance where you are neither too detached nor overly involved, helping to foster a healthy relationship that benefits both you and the patient.

Insights About Setting Boundaries With Patients: A Seasoned Physician's Perspective

Meet Dr. Grace Torres-Hodges, a leading podiatrist and a fervent advocate for the Direct Primary Care and Direct Specialty Care models. With a deep commitment to improving patient access and autonomy, Dr. Torres-Hodges has reshaped her practice to align closely with the needs of her community.

Dr. Torres-Hodges is also an accomplished author, having penned Private Practice Solution: Reclaiming Physician Autonomy and Restoring the Doctor-Patient Relationship. 

How do you manage professional boundaries and communication in a small community where you personally know many of your patients?

I am very familiar with this question, especially because I practice in my hometown. A lot of the people I take care of are individuals I grew up with, including my former teachers. When you're seeing many of your high school teachers and doctors who treated you when you were younger, who are now retired and are my patients, you definitely have to set boundaries.

"The ability to clearly communicate what my role is as your doctor needs to be very defined and straightforward, not ambiguous. It shows respect for yourself and for the patient. I respect their time, and they respect mine. And it starts with me talking to my patients."

If you respect someone, you know not to call them at a certain time. I have never not given my personal cell phone to patients, particularly my surgery patients, in all 24 years of my practice.
Communication is key. These are soft skills that I think sometimes have not been taught to some doctors. But it's just people skills that you have to have. If you don't know how to do that already, you're not going to do well in direct care.

What sets Direct Care apart from traditional insurance-based medicine in terms of patient interaction and quality measures?

Unlike insurance-based medicine, where you have to meet benchmarks with the number of visits done on a certain day as a quality measure, in Direct Care, my main priority is: my patient feels better. Number two: my quality assurance is top-notch.

If I'm getting referrals from them, if they are speaking well of me, telling me about my service with friends and family, that's quality. If you're spending a lot on marketing, I think you need to let your work speak for itself.

What strategies do you implement in your practice to balance availability, and affordability for your patients?

One of the big things you always have to remember is that it's not about you; it's about the patient you're trying to cater to. As far as communication goes, you want to be available for your patients, and I think immediately reducing the number of patients you see per day makes the doctor more available. When you're seeing 26 patients a day over a four to five-day week, you don't have the bandwidth for that.

When you make your prices transparent, it makes it very affordable. People may say, "Oh no, it's much more expensive," but I challenge them to show me where. In Direct Care, you're giving the patient a choice because they can budget, make a payment plan, or even barter.

How has your perspective on healthcare changed as you've gained more experience?

I think, maybe it's an age thing, as I get older, I realize that I'm not always going to be the one taking care of others; eventually, I will be the one being taken care of. You want to make sure that care is in place, not just for you, but for the next generation as well.

Also, I think it's exciting to be in this field right now. It's fun, but there's a lot of work to be done. It's never easy when it's something that is meaningful.