Border crossings: on the boundary of the physician-patient relationship.

Physicians are trained to divorce personal feelings from professional duty and to avoid those patient encounters in which we playa dual or compromised role. Yet in practice, especially in those encounters where the physician-patient relationship is our chief therapeutic tool, emotion and conflict often arise. Rather than fearing their intrusions, we should understand them to be inevitable, informative, and indispensable means to the provision of high-quality patient care and professional selffulfillment. Sunday at dusk. I am driving back from Boston after a conference for teachers in family medicine. In Portsmouth the road rises sharply above the Piscataqua River, where its industrial mouth forms a natural border between New Hampshire and Maine. Suddenly I realize that this 1-95 bridge-perched on the margins of a wider world and my adopted home and between the lights of higher education and the shifting shoals of private practice-spans more than a geographic frontier. Though my eyes lock on the center line, my mind veers to thoughts from the final workshop, an exploration of ethical boundaries in patient care. How cleanly we wove through the familiar snares: news of an associate's sexual impropriety, favors parceled to special patients, promises we make but cannot keep, the dangers of self-disclosure, and encroaching demands of work on family life. All cases were perfunctorily dispatched by my seasoned colleagues while I lay mired in the first scenario: a physician has just examined his neighbor's child for bruising. On questioning, the boy alleges that his father struck him. \Vhat must the physician do? For me, the answers are not academic. Tomorrow I will address a grand jury on behalf of my