Robin Thicke and Pharrell Williams weren’t talking about the physician–patient relationship when they sing about “blurred lines,” but, personal interaction is the constant that connects that song to our professional experiences. We should never assume we know what is best for someone else or that we should interpret what they say rather than listen.
Few professions allow conversations to move rapidly from introduction to inquiry about an individual’s most intimate, private information. The patient interview involves vulnerability and is relational by nature. As with all relationships, delineation of boundaries and committed respect for the borders are essential to successful, healthy encounters. Performing artists, with singers as a subset, can present unique challenges we should understand.
We can review literature about provider–consumer boundaries and then describe what we consider some of the unique challenges of working with vocalists and other performing artists.
What Is a Physician–Patient Boundary?
This generally refers to the conditions that define and clarify the limits of a fiduciary relationship. This is a relationship in which one person (a patient) entrusts his or her welfare to another (a physician), who receives compensation for delivery of services (JAMA. 1995;274:1345–1346).
What Are the Ethical Foundations that Govern the Need for Boundaries?
Boundaries always exist for protection of all participants. There is a continuum between a boundary crossing and a frank violation. A crossing is a planned or principled deviation from usual, accepted practices. A violation is an unethical and harmful deviation from the standards of care (Am J Psychiatry. 1993;150:188–196).
What’s Different about Performers?
Obviously, performers are generally like any other patient in many ways. However, their personalities and backgrounds have unique implications for their interactions with healthcare providers.
1. Identity intertwined with talent: Some performers equate having a bad performance with being a bad person.
2. Emotional association: A great deal of performing requires emotional intelligence and it is designed to stir the emotions of both the performer and the audience. This creates a degree of vulnerability that can influence factor 1.
3. Lack of awareness: Most artists are not trained to recognize mental health issues or to seek help. They may not see a reason to share symptoms of depression or anxiety with their doctors.
4. Wide exposure to feedback: Artists often receive anonymous, frequently negative, feedback. It can feel like they are offered up for public criticism and consumption.
5. Creativity and psychopathology: There are competing views, but there is a possible predisposition toward addictive behavior and substance abuse (Lancet. 1995;345:138–139; Indian J Psychiatry. 2018;60:168–174; Cogn Neuropsychiatry. 2014;19:359–377). Adverse developmental events in childhood that often foster people pleasing behavior (Prog Brain Res. 2018;237:225–242).
6. Mobility: They may have multiple residences, be traveling on tour, and often documentation of medical history may not be available.
As we understand potentially influential factors in the development of the performer, we must also examine healthcare providers and some of the predilections we bring to the table.
Personality Traits of Physicians
Although the process continues to evolve, the training of medical students and residents can involve and even promote maladaptive behaviors (Physician Exec. 2013;39:14–16,18,20; CMAJ. 2012;184:1980; Acad Med. 1999;74:1327–1333):
- Competitiveness: this can begin in primary school with a focus on test scores and grades.
- Type A Behavior: Briggs-Meyer evaluation confirms this.
- Social Isolation: Physicians continue to work on work–life balance and how the commitments to work overshadow social interactions.
- Identity with Vocation: The commitment to work can overshadow our humanity.
- Safety Seeking and PTSD Symptomatology: Risk aversion is present, but can negatively influence decision making.
- Emotional Dissociation: Consider cadaver dissection as the introduction in most medical schools.
The Makings of a Perfect Storm
In the quest to understand our imperfect humanity, we have to consider how a physician who feels socially isolated might be tempted by adjacent fame. The mystique of a talented artist could become a stumbling block for a physician who is not mindful of the professional codes that protect the physician–patient relationship.
While provisions such as seeing patients during off hours to avoid waiting room chaos are reasonable, the forces acting on these encounters can be formidable and must always be recognized and respected. The role of managers, producers, agents and directors should also be recognized, though their respective roles should never eclipse the centrality of the patient’s well being.
- Is what I’m doing part of accepted medical practice? Define your boundaries and communicate them and keep them.
- Is a deviation from standard truly unavoidable? Be honest with yourself. Find your core principles.
- Is what I’m doing solely in the interest of the patient? Develop a clear mind of discernment.
- Is what I’m doing causing me stress, worry, or guilt? Listen to that voice of caution.
- Have I sought the counsel of a friend or colleague? Identify a professional mentor/confidant and build your support network.
- If someone publicized this event, would I be comfortable explaining my choices and actions?
Dr. Sims is an associate professor of otolaryngology at the University of Illinois in Chicago.