Comment

www.thelancet.com/oncology Vol 15 December 2014 1423

6 WHO. Prevention of cardiovascular disease: guidelines for assessment and management of cardiovascular risk. Geneva: World Health Organization, 2007.

7 Rabe KF, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: gold executive summary. Am J Crit Care Med 2007; 176: 532–55.

8 Poon D, Anderson BO, Chen LT, et al. Management of hepatocellular carcinoma in Asia: consensus statement from the Asian Oncology Summit 2009. Lancet Oncol 2009; 10: 1111–18.

9 Wee JT, Anderson BO, Corry J, et al. Management of the neck after chemoradiotherapy for head and neck cancers in Asia: consensus statement from the Asian Oncology Summit 2009. Lancet Oncol 2009; 10: 1086–92.

Blurring of boundaries in the doctor–patient relationship

Ghi

slain

& M

arie

Dav

id d

e Lo

ssy/

Cultu

ra/S

cienc

e Ph

oto

Libr

ary Oncology is a specialty that can be enormously

rewarding but is fraught with many challenges. Young oncologists have to master dealing with anxious patients who are facing a life-threatening disease; conveying the true prognosis; discussing the complexity of modern treatments; and explaining the unavailability of some drugs, the side-eff ects of treatment, and likely therapeutic aims. Evidence-based courses have been shown to help oncologists to communicate all these issues in a clear, honest, and empathic manner while maintaining realistic hopes about probable clinical outcomes.1 However, getting closer to the emotional needs of patients and their families can put doctors at psychological risks unless they have skills to navigate the boundaries between personal and professional involvement.

Burnout in young oncologists (<40 years of age) in Europe and among oncology fellows in the USA is high (>34%) and can lead to them leaving the profession.2,3 Various factors including diffi culties in maintenance of a healthy work–life balance and having had insuffi cient training in communication and management skills can be associated with burnout; however other ethical, moral, legal, cultural, and philosophical concerns within the practice of modern medicine have received insuffi cient attention, in particular the blurring of professional boundaries. Such blurring can occur when a patient with life-threatening disease has a need to believe that their oncologist cares personally as well as professionally and might happen inadvertently when the doctor’s behaviour is ambiguous enough to be misinterpreted. For example, is a hug, rather than a brief touch on the hand, from a young male doctor an appropriate response to the tears of a young woman told that she has breast cancer? Even the choice of clothes the doctor wears and manner of their introduction to vulnerable patients can convey overt or subtle messages

with unpredictable interpretations. The correct etiquette in terms of work attire and forms of address when greeting patients has undoubtedly varied over time, in keeping with changing societal and cultural norms, but no fi rm universal rules exist.4,5 Although most patients might prefer to be called by their fi rst names after a more formal introduction, doctors who permit patients to address them by their fi rst names, through a genuine belief that this approach helps the patient, might also fi nd themselves in danger of falling prey to ambiguities that blur other professional boundaries. It is perfectly possible to show kindness, care, concern, and empathy while maintaining the use of a professional title such as doctor. Adherence to some boundaries implies professional distance and respect and should not be confused with cold, indiff erent, detachment.

Professional boundaries are not always well defi ned and get increasingly complicated when a patient starts to be seen as a friend; some actions are obvious violations (eg, sexual involvement), whereas others are less clear-cut, such as having a dual relationship (social and professional) with a patient, acceptance of gifts, some forms of physical contact, and use of informal language. Occasionally boundary transgressions occur owing to misguided assumptions that the behaviour is helpful or through honest misunderstandings; other actions exploit the vulnera bility and dependency of patients because of the inherent power diff erential within the doctor–patient relationship. For people working in clinical settings, some of these areas have always been challenges to negotiate appropriately, but modern technology has also introduced new challenges.

The burgeoning use of social media potentially makes it hard for any individual doctor to maintain a truly private personal life. Although social networking has enhanced opportunities for benefi cial individual and

Comment

1424 www.thelancet.com/oncology Vol 15 December 2014

group interactions in both personal and professional domains, it has also created risks and problems within the doctor–patient relationship. Social media websites or blogs can all leave a digital footprint and might lure an incautious young oncologist into various problematic situations. Despite privacy settings, anonymity is easily breached and most people forget that indiscreet photos and comments might be accessed by patients or their families. The eff ect of some online content could have dire consequences for the public perception of the medical profession in general and an individual’s career. Any professional whose online behaviours violate or challenge societal expectations could also be vulnerable to dismissal or other sanctions.6

Results from an anonymous online survey during August, 2014, of young European oncologists (done to provide data for a European Society for Medical Oncology [ESMO] workshop), showed some of the risks to the doctor–patient relationship through blurring of boundaries. The survey comprised 20 statements probing what responders felt was appropriate in general for doctors to do and another 20 statements probing what individuals did personally. 338 responses were received from oncologists aged 25–45 years in 56 diff erent countries (205 [61%] women, 133 [39%] men). Their mean age was 34 years (SD 4·2) and most were medical oncologists working in university hospital cancer centres. Most respondents (113 [55%] of 205 women and 89 [67%] of 133 men) felt that if doctors were too empathic then they could not make objective decisions. 113 (58%) of 196 female oncologists and 80 (62%) of 130 male oncologists reported it diffi cult to be truthful about prognosis if they liked the patient. Despite these fi ndings, about a third of respondents had treated friends with cancer and a quarter had treated their own family members. Most oncologists allowed patients to address them by their fi rst name, and 125 (64%) of 196 female respondents and 70 (54%) of 130 male respondents either sometimes or often permitted patients to hug or kiss them when greeting or saying goodbye. 178 (55%) of 326 respondents had often or sometimes given patients their personal mobile phone numbers and 23 (12%) of 196 women and 24 (18%) of 130 men had accepted patients as friends on Facebook. 32 (16%) of 196 women and 36 (28%)

of 130 men accepted social invitations from patients who were still undergoing treatment. These results need replication, but are troubling if representative of present practice.

Various professional organisations such as the General Medical Council and British Medical Association in the UK and American Medical Association in the USA have published guidelines on the use of social media.7 However, few oncologists had ever received any training about how to handle risks and boundaries in the doctor–patient relationship more generally, and more than 80% would like specifi c training in these areas. Changes in societal norms and expectations about doctor–patient interactions and best online practice make a blurring of professional boundaries more likely. Without more evidenced-based training in how to deal with these issues, harnessing the opportunities while remaining aware of the risks, young oncologists are unsurprisingly experiencing burnout.

*Lesley Fallowfi eld, Valentina Guarneri, Mehmet Akif Ozturk, Shirley May, Valerie JenkinsSussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Brighton BN1 9RX, UK (LF, SM, VJ); Department of Surgery, Oncology and Gastroenterology, University of Padova, Istituto Oncologico Veneto IRCCS, Padova, Italy (VG); and Medical Oncology Clinic, Antakya State Hospital, Hatay, Turkey (MAO)l.j.fallowfi eld@sussex.ac.uk

All authors contributed to the development of the online survey and writing of the paper. VJ, SM, and LJF analysed the data. We declare no competing interests. There was no funding for this Comment, but European Society for Medical Oncology Young Oncologists provided support to send out and collate data from the online survey. The authors are grateful to the European Society for Medical Oncology and to colleagues at Sussex Health Outcomes Research & Education in Cancer who assisted with design of the survey and analysis of data.

1 Fallowfi eld L, Jenkins V, Farewell V, Saul J, Duff y A, Eves R. Effi cacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 2002; 359: 650–56.

2 Banerjee S, Califano R, Corral J, et al. Professional burnout in European young oncologists: a European survey conducted by the European Society for Medical Oncology (ESMO) Young Oncologists Committee. Ann Oncol 2014; 25 (suppl 5): abstr 1081O_PR.

3 Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are getting into? J Clin Oncol 2014; 32: 2991–97.

4 Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med 2007; 167: 1172–76.

5 Moore R, Yelland M, Ng SK. Moving with the times: familiarity versus formality in Australian general practice. Aust Fam Physician 2011; 40: 1004–07.

6 Jain SH. Practicing medicine in the age of Facebook. N Engl J Med 2009; 361: 649–51.

7 Farnan JM, Snyder-Sulmasy L, Worster BK, Humayun JC, Rhyne JA, Arora VM. Online medical professionalism: patient & public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013; 158: 620–27.