New and Evolving Dimensions in the Pediatrician-Family-Patient Relationship: Maintaining and Managing Boundaries: Clinical Report Free

There is an inherent power differential in the pediatrician-family-patient relationship. Pediatricians, like other physicians, hold power over patients (and their families) because of the diagnostic and treatment knowledge and skills they possess as well as the privileged socioeconomic and educational status they experience.¹ Some patients and their families may also first meet a pediatrician at a time of illness, which can further create a sense of powerlessness and vulnerability. This power differential underscores the essential role of trust in the pediatrician-family-patient relationship.

Boundaries within the pediatrician-family-patient relationship primarily exist to prevent the exploitation of the patient’s or family’s dependency on the pediatrician, to maintain patient safety, and to protect the trust necessary for a healthy and healing relationship with the pediatrician. Accordingly, boundaries in the medical profession have been defined as “the parameters that describe the limits to the fiduciary relationship in which one person (a patient) entrusts his or her welfare to another (the physician).”² Boundaries, in essence, denote limits and separation. They can help protect and respect space, attitudes, and experience.

Abuse of these parameters signifies a lack of respect for the patient and family and their vulnerability. It can be damaging to a patient’s intrinsic moral worth or dignity, ability to trust, and physical and emotional well-being. In fact, central to considerations of whether an action constitutes an abuse of power within the pediatrician-family-patient relationship is the degree to which the action compromises a pediatrician’s fiduciary responsibilities to the patient and family, including the preservation of the patient’s and family’s trust, respect, and dignity.

Boundaries within the pediatrician-family-patient relationship also serve to protect a pediatrician’s objectivity. Objectivity is recognized as “intrinsic to the healing end of medicine” and “necessary for proper diagnosis and treatment.”^3,(p87) Several biases and cognitive shortcuts can contribute to a loss of objectivity and cause a disregard or discounting of certain aspects of the clinical evaluation,^4,5 threatening the accuracy and soundness of a pediatrician’s clinical judgment and placing the patient at risk of physical or emotional harm. Although there is a place in medicine for emotion and sentiment—compassion is an essential virtue in medicine—these must exist in tension with objectivity to ultimately achieve the goals of medicine.³ 

Breaches of professional boundaries within the pediatrician-family-patient relationship exist on a continuum.⁶ At one end of the continuum are minor breaches, or boundary crossings. Boundary crossings are nonexploitative; carry only a small potential for having a negative effect on a pediatrician’s responsibilities toward preserving patient trust, respect, or dignity; and have a low risk of physical or emotional harm to the patient. In addition, there is minimal risk that a pediatrician’s objectivity is compromised. An activity that could be characterized as a boundary crossing may even be associated with some benefits. Therefore, boundary crossings may be justifiable in certain circumstances when their perceived benefits outweigh their potential risks; however, potential boundary crossings should always be carefully scrutinized and promptly reflected on regarding their impact on the patient’s trust and vulnerability as well as the pediatrician’s objectivity. At the other end of the continuum are major breaches of the pediatrician-family-patient relationship. Major breaches, or boundary violations, represent an exploitation of the power imbalance and are not acceptable, as they significantly compromise a patient’s trust, respect, or dignity; undermine or call into question the capacity for objectivity; and/or carry a high risk of physical or emotional harm to the patient. Avoiding boundary violations is fundamental to the practice of medicine.⁷ 

The 2009 policy statement, “Pediatrician-Family-Patient Relationships: Managing the Boundaries,” offers guidance for pediatricians in navigating several key scenarios regarding professional boundaries, including accepting gifts, dual relationships, and romantic relationships with patients or caregivers. That guidance remains relevant today. This current clinical report complements the 2009 policy statement by providing additional guidance for navigating new and evolving dimensions of the traditional pediatrician-family-patient relationship: issues related to advocacy, self-disclosure, and social media.

To advocate is “to defend or serve (a cause) through action” or “support, recommend, or speak in favor of a person or thing.”⁸ Advocacy is a process in which stakeholders make their voices heard on issues that affect their lives or the lives of others. Advocacy by physicians can manifest in many ways within and outside the clinical setting.⁹ For instance, advocacy by pediatricians within the clinical setting can include ensuring quick access to subspecialty consultation for a patient in need of further diagnostic work-up or ensuring access for all non-English–speaking patients at one’s practice by improving interpreter access. Advocacy by pediatricians outside the clinical setting can be similarly diverse, including, for example, improving voting access in a local community or lobbying a state legislature to impose taxes on sugar-sweetened beverages.

Physicians have obligations to advocate within the clinical setting to provide high-quality care to their patients, such as advocacy to improve systems of care that impact patient outcomes. These obligations to advocate can extend beyond issues pertinent to individual patients or groups of patients and include issues affecting the health of populations.⁹ This broader obligation to advocate for population health follows from society’s social contract with the medical profession: in exchange for “monopoly use of knowledge, practice autonomy, and the right to self-regulate… the medical profession is expected to promote society’s health.”⁹ Although some argue that such advocacy is not mandatory¹⁰ or may simply be aspirational as it becomes more distant from factors that directly influence an individual’s health,⁹ responsibilities to advocate for societal health have been integrated into the medical profession. The American Medical Association’s 7th Principle in its Code of Ethics states “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”¹¹ Similarly, the American Academy of Pediatrics Committee on Bioethics states that pediatricians have responsibilities “to address issues of advocacy for child health and the effective use of health care and public health resources.”¹² 

What is less clear, however, is the appropriateness of advocating for issues related to societal health (or, more specifically, pediatric population health or public health) within an individual patient-family clinical encounter. Consider the following scenario:

Wearing a pin with the intent to make its message visible to others is a form of advocacy. In this scenario, wearing a United for Kids: We Shall Overcome pin—a modification of the 1960s era pin associated with the civil rights movement that employed the words “United: We Shall Overcome” surrounding an image of interracial shaking hands—can be an opportunity to draw attention to racially motivated violence against historically marginalized communities and raise awareness of structural racism in US society, including its effect on the health of children of color.¹³ It can also communicate solidarity and allyship. Therefore, wearing a United for Kids: We Shall Overcome pin in the clinical setting could be viewed as an opportunity for physicians to fulfill their obligations to advocate for child and public health.

Whether or not this scenario represents a breach of the pediatrician-family-patient relationship depends on its potential to 1) exploit the power differential in the pediatrician-family-patient relationship and compromise a patient’s (or their family’s) trust, respect, or dignity; 2) undermine or call into question the physician’s capacity for objectivity; and/or 3) carry a risk of physical or emotional harm to the patient. It is unlikely that wearing such a pin compromises a physician’s capacity for objectivity. On the contrary, it may signal a commitment to being more attentive to disrupting individual- and system-level biases within the health care encounter. Though wearing such a pin may carry some risk of emotional trauma to patients or families that have experienced racism or suffered from generational trauma from systemic racism, it can also be a powerful way to communicate solidarity and allyship with patients.

It may be argued, however, that wearing such a pin will make some patients or families uncomfortable by exploiting the power differential between physicians and patients/families and generating the perception that patients or their families must adopt the same position taken by the physician if they want to remain patients. However, the salience of this argument depends on the message being conveyed and the physician’s intent. Conveying messages within a clinical encounter that reflect consensus positions within pediatrics on issues related to an individual’s health or pediatric population health and that are intended to educate the patient or family about such issues are an appropriate form of advocacy within the pediatrician-family-patient relationship, whether communicated in conversation or on a pin. A pin that reads United for Kids: We Shall Overcome is this type of message: it is a positively valenced message about overcoming racial injustice and discrimination that is in alignment with a consensus AAP position.¹¹ Messages that are directly related to the health of the individual patient in the encounter are most appropriate, but given physicians’ responsibilities to also promote societal health, messages that are discernibly pertinent to consensus positions within pediatrics related to population health or public health more generally also represent an appropriate form of physician advocacy within the clinical encounter. As such, pins that read FluVaccine✓,^13,14 Protect our Children: End Gun Violence,¹⁵ or Clean Air: It’s Up to Us,¹⁶ would also be appropriate. Messages that do not clearly relate to the health of the individual patient in the encounter or to pediatric population health or public health more generally and/or in which there is not professional consensus on an issue with some relationship to pediatric population health or public health (eg, Blue or Vote) have potential to exploit the power differential within the pediatrician-family-patient relationship. As such, messages with these characteristics should generally be avoided. In the current polarized environment in which several medical issues have been politicized, such actions require particular attention.

Wearing a United for Kids: We Shall Overcome pin in a clinical encounter is, therefore, a justifiable means to fulfilling physician obligations to promote societal health by combating racism. Racism is an important societal issue for which there is professional consensus regarding its effects on child and public health. There is the potential that wearing a United for Kids: We Shall Overcome pin will have a direct positive impact on individual patients and caregivers by visibly advocating against racism while carrying low risk of undermining a physician’s capacity for objectivity.

Consider another scenario:

Communicating this sponsored event to the caregiver in this scenario is an appropriate form of advocacy, because it relates to a consensus position on an issue of child or public health regarding the importance of bike helmet use for injury prevention,¹⁷ it is rooted in the physician’s obligation to promote the child’s health and public health, and it has the potential to positively impact the health of the individual patient in the encounter (who is at an age where he may be learning to ride a bike). Given the physician’s intent to promote the individual child’s health, and assuming there is no financial conflict of interest for the pediatrician (it is important to note here that selling bike helmets or other health-related products in the office would require separate consideration, given that it “presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own”¹⁸), conveying information about this event has little potential to exploit the power differential in the pediatrician-family-patient relationship or undermine or call into question the capacity for objectivity. It also represents an effort to minimize, not heighten, the risk of physical or emotional harm to the patient. This form of advocacy, therefore, does not breach pediatrician-family-patient boundaries.

Physician disclosure of information about themselves during a clinical encounter with patients is controversial. Physician self-disclosure can expend valuable time during the encounter and shift the focus of the encounter from the patient’s needs to the physician.¹⁹ In addition, physician self-disclosure is often non sequitur and unrelated to any discussion in the encounter.¹⁹ The impact of physician self-disclosure on outcomes such as patient satisfaction^20–23 and compliance with medical recommendations^24,25 remains unclear.

Physician self-disclosure can also expose patients to physician biases and vulnerabilities that may undermine trust in the relationship as well as a physician’s ability to be objective.²⁶ This, in turn, can increase the risk of harming a patient. For these reasons, “personal disclosure related to social, cultural, religious, or other demographics” is considered by some to be a boundary crossing.²⁷ 

It is important, however, to recognize the potential benefits of physician self-disclosure in a clinical encounter. Self-disclosure can deepen therapeutic relationships with patients, build trust and rapport, communicate a shared humanity, and be an effective means in which to respond to suffering.^26,28–30 In particular, physicians who have, themselves, at one time been patients—and for pediatricians, perhaps their child has been a patient—have an opportunity through self-disclosure to provide “insight…[gained] in one role from the experiences [had] in another.”²⁸ This type of self-disclosure about an illness or a health care experience, even something as ordinary as a pediatrician’s experience having their own child vaccinated,³¹ can convey a shared understanding and empathy with patients that has the potential to have a positive impact on the individual patient’s health and/or the pediatrician-family-patient relationship.

As such, the appropriateness of physician self-disclosure in a clinical encounter hinges on several factors. One such factor is the physician’s intent. Self-disclosure done with the intent to benefit the patient by building trust and rapport is more easily justifiable.²⁸ Important here, however, is not only being truthful with oneself about intent—it can be easy to disguise motives that are selfish rather than altriustic²⁶—but also balancing this intent with insight into its impact, namely how the self-disclosure may be received by the patient, as well as how it may affect one’s capacity to remain objective. If there were uncertainty around intent for disclosing information about oneself in a clinical encounter, it would be prudent not to do so.

A second factor is the context in which self-disclosure is used. Self-disclosure should not be used indiscriminately, gratuitously, or without tact. It is important to match delivery of information in a clinical encounter to the preferences of the patient or caregiver. If the patient or family is interested in the physician’s personal perspective or self-disclosure seems consistent with the patient’s or family’s communication preferences, it may be appropriate when utilized in small, measured amounts and in ways clearly connected to the patient’s benefit. Physician self-reflection is required to know how much to share and when to limit further disclosure as it no longer is for the patient’s benefit.

Consider the following two dialogues between a physician and an adolescent patient (modified from real encounters¹⁹):

Patient: I’m six feet, and the nurse just told me I was 204 pounds on check-in.

Physician: Is that up a little bit for you weight-wise?

Patient: … it might be up a few pounds … I used to be 190 pounds during football season… I just haven’t …

Physician: See, ’cause I’m weighing more like 172, 173, and I’m six foot … and I don’t play football like you but I do still run…. I’m still doing the 5 and 10 and 15Ks. The half-marathons and …

Patient: So … I’m 30 pounds heavier than you?

Physician: Right now, yeah.

Physician: … I live with it myself.

Patient: Oh, you’re kidding me?

Physician: Absolutely.

Patient: So what I’m saying to you is … what you have? The exact same thing?

Physician: Exactly.

Patient: Oh, my gosh!

Physician: Exactly.

Patient: What a coincidence.

Physician: Basically … the acids in the stomach are coming back up. That’s the reflux. And that really irritates the lining of the esophagus.

The self-disclosure by the physician in Dialogue 1 is non sequitur and shifts the focus of the encounter from the patient to the physician. Although the physician is, perhaps, intending to utilize self-disclosure to develop rapport, the physician instead insinuates competition with the patient. This potentially undermines any attempt at building rapport in a way that benefits the patient. This self-disclosure, therefore, constitutes a boundary crossing of the pediatrician-family-patient relationship.

In Dialogue 2, however, it is more apparent how the physician’s use of self-disclosure may benefit the patient. Her self-disclosure may deepen the therapeutic relationship with her patient, for instance, by communicating a shared humanity and experience around the patient’s recent diagnosis. The self-disclosure is also not used gratuitously but rather to help communicate empathy and share information about the diagnosis with the patient. If the physician in this scenario does not believe her self-disclosure undermines her capacity to remain objective and is consistent with the communication preferences of the patient, this type of self-disclosure is appropriate and does not represent a breach of the pediatrician-family-patient relationship.

Today, 9 in 10 Americans use the internet,³² and the majority of Americans have looked for health information online.³³ Social media has also become a staple of American life,³⁴ with nearly half all adults in a recent survey stating it is appropriate to contact their physician about a health issue through social media.³⁵ Although this accessibility and use carries with it the potential to promote health equity, health-related social media may also exacerbate disparities if its design and content do not account for user group factors, such as socioeconomic status, health literacy, culture, and social media access.³⁶ It is nevertheless clear that the democratization of scientific and medical knowledge through increased accessibility to online health and medical information has transformed the role of patients and caregivers in the pediatrician-family-patient relationship.³⁷ Compared with past generations, today’s patients and caregivers are accustomed to new ways of social interaction and communication and have new expectations regarding physician availability and accessibility of health information.

These new expectations create challenges for the pediatrician-family-patient relationship. One particular challenge is responding to friend requests from patients or caregivers. Consider the following scenario, adapted from a published narrative³⁸:

As discussed in the clinical report “Ethical Considerations in Pediatrician’s Use of Social Media,”³⁹ accepting friend requests on personal social media accounts from patients or their caregivers blurs traditional pediatrician-family-patient boundaries. Foremost, entering into a social media relationship with a patient or caregiver is akin to having a dual relationship with them: one that is professional, as the patient’s doctor, and the other, that is more personal over social media. This social media relationship may involve the patient or caregiver having access to other elements of the physician’s personal social media profile and posts (and vice versa), which creates the potential for exposing patients and caregivers to physician biases and vulnerabilities that may undermine a physician’s ability to be objective and increase the risk of harming a patient. For this reason, accepting friend requests from current patients or their families represents, at a minimum, a boundary crossing in the pediatrician-family-patient relationship. When it is difficult to avoid this breach, such as may be the case for pediatricians who are one of only a few pediatric practitioners in a rural community (where they may have relationships that have developed outside of the office with people for whom they also provide a medical home), it is critical that pediatricians remain cognizant of the potential risks it carries for patients and families in their practice and strive to minimize those risks.

One way to minimize these risks is to have a public professional social media profile in addition to a private personal profile.⁴⁰ Professional social media profiles can be means to share information about the physician’s professional interests and experiences and educate patients regarding specific health topics. These professional profiles can also provide some limited information about physician personal interests. Physician professional social media profiles that contained educational information or professional information with some limited “healthy” personal information (eg, personal interests in hiking and reading), in fact, were perceived by patients as professional.^41,42 Accepting friend requests from current patients made to a physician’s professional profile can be an appropriate way to connect patients to this information while upholding commitments to preserve patients trust and physician objectivity by maintaining professionalism standards.

In the above case, however, the parent making the friend request is the parent of a past patient. Accepting friend requests of family members of past patients to personal social media profiles can be an “opportunity and a privilege” to learn from family members, convey support and compassion, and empower their voice.³⁸ Given there is no ongoing professional relationship, there is also no risk of undermining a physician’s objectivity in the care of the patient. However, given the past professional relationship between the physician and the patient, there is some potential that the parents may perceive some elements of the physician’s social media profile or posts as incongruous with their conception of and experience with the physician. This, in addition to the power differential between pediatrician and family that still exists, could have a negative impact for families, such as complicating their bereavement. Therefore, physicians should not initiate friend requests of patients or families and should only accept friend requests of family members of past patients to personal social media profiles after serious consideration of the potential risks. Accepting friend request of family members of past patients is perhaps best done through a professional social media profile.

1. Boundary breaches exist on a continuum. Physicians should only consider taking actions that constitute minor breaches, or boundary crossings, after assessing their potential risks and benefits and determining that the action is likely to result in a net benefit for the patient and pediatrician-family-patient relationship. Boundary violations are major breaches and should be avoided as they significantly compromise a patient’s trust, respect, or dignity; undermine or call into question the capacity for objectivity; and/or carry a risk of physical or emotional harm to the patient.

2. Advocacy within the clinical encounter is most justifiable when the advocacy message is child-focused and represents a consensus issue on pediatric population health or public health and clearly relates to and seeks to promote the health of the individual patient in the encounter.

3. Physician self-disclosure within the clinical encounter can expose patients to physician biases and vulnerabilities that may undermine patient trust in the physician and compromise a physician’s ability to be objective. However, physician self-disclosure may also deepen therapeutic relationships with patients and communicate a shared humanity. Use of self-disclosure within the clinical encounter is appropriate when done with the intent to benefit the patient and when utilized in small, measured amounts and in ways clearly connected to the patient’s benefit.

4. Accepting social media friend requests from current patients or their families on physician personal social media accounts represents at a minimum a boundary crossing in the pediatrician-family-patient relationship, although it may be acceptable if the request comes from families of former patients. Accepting friend requests from current patients or families through physician professional social media accounts can be an appropriate way to connect with patients while maintaining professionalism standards and upholding commitments to preserve patients trust and physician objectivity.

Douglas J. Opel, MD, MPH, FAAP

Douglas S. Diekema, MD, MPH, FAAP

Naomi Tricot Laventhal, MD, FAAP, Chairperson

Gina Marie Geis, MD, FAAP

Carrie Henderson, MD, FAAP

Deborah S. Loeff, MD, FAAP

Mary A. Ott MD, MA, FAAP

Sara Taub, MD, FAAP

Douglas J. Opel, MD, MPH, FAAP

Maria de Brito McGee, MD, – American Academy of Child and Adolescent Psychiatry

Douglas S. Diekema, MD, MPH, FAAP – American Board of Pediatrics

Kavita S. Arora, MD, MBE, MS– American College of Obstetricians and Gynecologists

Nanette Elster, JD, MPH – Legal Consultant

Anjie Emanuel, MPH