Medical education is in the midst of an intense interest in professionalism (1–3) as well as renewed focus on promoting and celebrating humanism in medicine (4–7). The concepts of “professionalism” and “humanism,” while not interchangeable, are nevertheless tightly linked. As eloquently articulated by Cohen (8), “Without a solid foundation of humanism to animate it, professionalism is overly dependent on good intentions, and it has little chance to prevail under the intense lure of self-interest rife in contemporary medical practice.” This perspective points toward the need for conscientious efforts among medical educators to combat this “lure of self-interest” by attracting humanistic students, fostering and rewarding humanism in trainees, providing role models who enact humanistic and professional values and behavior, and establishing a solid foundation of learning to help trainees understand why both humanism and professionalism matter. Furthermore, if self-interest is the lure, problems with boundaries and relationships represent the paths that physicians may end up taking toward that lure.

Maintaining boundaries and appropriate relationships reflects ethical principles of beneficence and nonmaleficence and is thus a key domain for ethics and professionalism education (4, 9, 10). The term boundary literally refers to “an indicated border or limit.” In medical practice the border usually divides accepted, ethical behavior from divergent or nonethical behavior. Traditionally, respect for boundaries has referred to nonexploitation of patients (e.g., sexually or financially) (2, 11). A wider, systems-based perspective, however, arguably encompasses not only boundaries on roles, behaviors, and expectations in patient care, but also the need for healthy, respectful relationships with colleagues, supervisors, and trainees in clinical, teaching, and research settings.

Ongoing occurrences of boundary violations among physicians further highlight the importance of these issues (12). State medical board records show low but consistent rates of physician reprimand. For example, in a 1998 study of physician discipline in California, 375 physicians (a rate of 0.24% per year) had received some form of disciplinary action over an 18-month period. The top reasons for discipline included physician negligence or incompetence, substance abuse, inappropriate prescribing, inappropriate boundaries with patients, and fraud (13). Moreover, unprofessional behavior—particularly irresponsibility and poor capacity for self-improvement—places physicians in jeopardy based on findings from a large case-control study of the relationship between unprofessional behavior in medical school and later discipline by medical boards (14).

For psychiatric residents, education on relationships and boundaries is particularly important given the potential vulnerability of patients with mental illness, the amount and depth of personal psychosocial information patients entrust to their psychiatrists, and common issues of countertransference and dependence in psychiatrist-patient relationships (15). Moreover, although psychiatrists-in-training encounter ethical dilemmas that are shared by trainees in other specialties, these issues may be intensified by specific aspects of training unique to psychiatric residency (e.g., managing suicidal patients) and the types of relationships between supervisors and trainees (16). Two of the six required core competencies for psychiatry training programs relate to boundaries (17). Competency in interpersonal and communication skills requires communicating effectively and respectfully with patients, families, colleagues, and other professional associates and competently working as a team leader or member. Competency in professionalism requires adherence to ethical principles; moreover, residents must demonstrate “high standards of ethical behavior which include respect for patient privacy and autonomy, maintaining appropriate professional boundaries, and understanding the nuances specific to psychiatric practice.” The Residency Review Committee expects programs to distribute to residents, and operate in accordance with, the American Medical Association Principles of Ethics with “Special Annotations for Psychiatry” as developed by APA (18). Other than this, the methods and extent of teaching on boundaries within the construct of the core competencies are not specified. One study described a training course on creation and maintenance of professional boundaries for psychiatric trainees (19). Although the findings suggested that residents explored the issues in an open and honest manner, none of the trainee participants shared any personal experiences of potentially unacceptable behavior.

Little is known about the attitudes of psychiatric residents toward training in boundaries and relationship issues. Yet, residents’ needs and perceptions regarding these domains of ethics and professionalism education may reveal important information relevant to the development of effective educational initiatives. In this study, we examined psychiatric residents’ perceived needs for education on boundaries and relationships. We hypothesized that psychiatric residents would report frequently experiencing situations involving ethical dilemmas during their training and that they would endorse the need for greater education than is currently provided on ethical issues related to relationships and boundaries.

Participants

All residents in postgraduate years (PGY) 1 to 6 (N=249) at seven psychiatric residency training programs in the spring of 2005 were invited to participate in this study. The seven sites served as a convenience sample and represented a range of psychiatric training settings. The sites were the Mayo Clinic (n=35), Medical College of Wisconsin (n=32), University of Arkansas for Medical Sciences (n=23), University of California San Diego, School of Medicine (n=54), University of Chicago Pritzker School of Medicine (n=25), University of Massachusetts Medical School (n=28), and the Walter Reed Army Medical Center (n=52). A total of 151 usable surveys were returned for an overall response rate of 61%. This analysis represents data from only six of the seven schools (N=134) due to an error in duplicating surveys.

Instrument

The survey instrument was based on a questionnaire developed at the University of New Mexico to assess views of medical students and residents regarding professionalism, ethics preparation, and the evaluation of these issues in medical education. Results of the University of New Mexico survey have been published elsewhere (9, 20, 21). The original instrument contained 124 content items in 10 domains based on the American Board of Internal Medicine definition of professionalism: attitudes, goals, learning methods, curricula, knowledge assessment, skills assessment, and educational needs concerning informed-consent topics, principles, vulnerable populations, and relationships and boundaries. Items were rated on appropriately labeled nine-point scales. In our study we added 28 questions specific to psychiatric residency training to the original instrument. The final instrument contained 149 questions in the 10 content domains, six questions regarding personal ethics experiences during training, and five demographic questions. Here we report findings concerning educational needs for issues of relationships and boundaries.

Procedure

The survey was distributed to psychiatric residents at each site with a cover letter indicating the purpose of the study, anonymity procedures, and institutional review board approval. A package of candy was included with the survey as a token compensation. Two follow-up surveys were distributed at 1-month intervals with the request that residents complete the questionnaire only if they had not already done so. Completed surveys were collected at each site and mailed unopened to the Medical College of Wisconsin for data entry and analysis. The institutional review boards of all seven sites reviewed the survey protocol and approved the study or found it exempt.

Data Analysis

For each set of related issues, nine-point scaled rating responses were subjected to repeated measures issue item (within subjects repeated measures) × school (between subjects) × gender (between subjects) multivariate analyses of variance (MANOVAs). Training level was not included in the full model because preliminary analysis showed no significant effects or interactions for postgraduate year. Correlations among issue items and the six questions regarding personal ethics experiences during training were examined. In a separate analysis, demographic characteristics of respondent groups above and below the 80th percentile of a mean composite score across the issue items were compared using chi-square or independent sample t tests.

Participant Characteristics

From the six participating medical schools, 134 psychiatric residents responded (response rate=61%; range across schools=51% to 77%). Demographic characteristics are summarized in Table 1. Ethnic composition varied among schools (p<0.02), from 50% to 95% white, from 5% to 50% African American, and from 0% to 7% Asian American.

Ethical Conflicts, Education, and Role Modeling During Training

Residents endorsed a moderate frequency of encountering ethical conflicts during training, and felt they had received a moderate level of ethics training during medical school and some ethics training during residency (Table 1). Residents reported that their overall medical education had helped somewhat to deal with ethical conflicts, that many of their supervising residents and faculty had been positive role models of ethical and professional behavior, and that they had usually been treated in an ethical and professional manner by supervising residents, faculty, and their training institution.

Education Needs on Relationships and Boundary Issues During Training (Table 2)

Residents indicated that being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, resident health care, adequately caring for patients while adhering to work-hour guidelines, performing work beyond one’s competence, mistreatment of residents, sexual/romantic relationships between faculty and trainees, mistreatment of medical students, and sexual/romantic relationships between residents and medical students should receive more educational attention than now provided, and that students introduced to patients as doctors and learning procedures on cadavers should receive the same level of educational attention now provided (issue item main effect p<0.0001, maximum Cohen’s d=0.74). The rated amount of additional attention needed to the set of issues varied among schools from the same to more overall (school main effect p<0.02, maximum d=1.00).

The pattern of additional attention needed for specific issues varied across schools (issue item × school interaction, p<0.05), with means differing by at least 1 standard deviation for being asked to work with inadequate supervision, resolving conflicts between attendings and trainees, and adequately caring for patients while adhering to work-hour guidelines. Encountering more ethical conflicts during training was associated with wanting more educational attention for all issues (r=0.15 to 0.33, mean r=0.21, p<0.08 in all cases).

Education Needs on Relationships and Boundary Issues During Practice (Table 3)

Psychiatric residents indicated that more educational attention should be provided for responding to an impaired colleague; coping with mistakes in clinical care; reporting medical mistakes; balancing one’s personal and professional life; resolving conflicts between allied health professionals; writing prescriptions for friends, coworkers, or family members; allocation of health care resources; giving medical advice to friends and family; physicians’ social and political responsibilities; interacting with patients’ families; medicine as a profession; gender bias in clinical care; being asked to falsify clinical information; accepting gifts from patients; and personal relationships with patients. In contrast, residents felt generally satisfied with the amount of current educational attention to drug company interactions, sexual harassment, confidentiality of medical records, and patient-physician sexual contact (issue item main effect p<0.0001, maximum Cohen’s d=0.89). Rated level of educational attention needed varied among schools, from approximately the same to more overall (school main effect p<0.01, maximum d=1.11). Having encountered more ethical conflicts during training was associated with wanting more educational attention for 17 of the 19 issues (r=0.15 to 0.36, mean r=0.26, p<0.06 in all cases).

Overall Preference for Additional Ethics Education

Responses to all relationship and boundary issue items were intercorrelated (r=0.22 to 0.87, mean r=0.43, p<0.01 for 425 of 435 correlations). Twenty percent of respondents indicated that topics should receive more educational attention overall, and 80% indicated that topics should receive about the same or less attention overall. Residents who wanted more ethics education and residents who wanted the same or less attention to ethics did not differ in gender, marital status, age, or year of residency. Compared to other residents, those residents who wanted more ethics education reported encountering more ethical conflicts during training (means=5.78 and 4.92, t=2.16, df=132, p<0.04, d=0.46) and being treated in an ethical and professional manner by supervising residents, faculty, and training institution less often (means = 6.15 and 6.95, t=−2.34, df=132, p<0.03, d=−0.50).

“Professionalism is the basis of medicine’s contract with society” (2). Physicians are afforded special privileges by society that must not be exploited. As the future of the psychiatric profession and as clinicians and educators, psychiatric residents must be encouraged andsupported to gain a comprehensive understanding of the principles of professionalism—including maintaining appropriate boundaries with patients and healthy relationships with colleagues and trainees.

We found that psychiatric residents expressed an awareness of the need for and a desire for more education on a number of issues related to relationships and boundaries. Clearly, trainees endorsed the importance of professionalism and boundaries education. Across all sites, psychiatric residents and fellows encountered moderate degrees of ethical conflicts during medical school and residency training, reflecting their awareness of and ability to identify such issues. They also endorsed currently receiving generally adequate ethics training during medical school and residency, identified positive role models of ethical and professional behavior, and endorsed being treated in an ethical and professional manner by supervising residents and faculty.

There was no single item that residents, as a group, felt warranted less educational attention. That residents endorsed wanting “a little more” rather than “a lot more” educational attention to these issues appears compatible with their perception of already receiving adequate training. It is possible that these matters do not register as preeminent needs relative to the many daily stressors and concerns faced during residency. Perhaps these issues do not seem as salient in the early career stage as they may later as one acquires more responsibility and accountability. Previous experiences may stimulate the desire for further education and training on ethical issues related to relationships and boundaries. Future research in this area should focus on psychiatrists’ perceived needs for continued learning on professionalism and boundaries at different levels of professional development.

Perceived Needs

Despite the perceived strengths in their education, residents desired more education on several topics related to relationships and boundary issues that occur during training. First, residents desired more education on working with inadequate supervision. Psychiatric residents who often work with minimal direct supervision may be particularly attuned to this issue. This finding may flag an unmet need in residency education for more guidance on how to manage clinical and educational roles and obligations. Second, residents wanted additional educational attention in resolving conflicts between attendings and trainees. The faculty-trainee relationship in psychiatry is complex and remains understudied (22). In a qualitative interview study, Sinai et al. (23) identified five factors that most affected the quality of the learning experience: communication, power/rivalry, individual differences, support/collegiality, and role modeling/expertise. While the supervisory relationship can be a source of immense learning and effective role modeling, disagreement or conflict with one’s attending physician can also cause stress and anxiety, and may lead some trainees to feel dismissed, devalued, or even intimidated. Residents may feel vulnerable or powerless to resolve such conflicts when they occur. Our data suggest that these issues deserve enhanced attention for both trainees and faculty supervisors.

Third, residents endorsed needing more education on resident health care and caring for patients adequately while adhering to work-hour guidelines. While navigating the daily demands of residency and meeting professional obligations, residents need to maintain their own health and well-being. Learning to monitor one’s own fatigue and stress level is a relatively recent mandate in medical education (24). This increased attention from the medical education community has led to a greater focus on resident health. One study of resident health care (25) found that residents felt that the pace and schedule of their work lives created numerous barriers affecting their ability to attend to their own health. Residents also reported that the culture of medical training discouraged sick residents from taking leave when necessary. Findings from our group have also identified several underappreciated issues related to residents’ personal health care needs, including stronger preferences for care outside residents’ own training institution for more stigmatizing illnesses (e.g., mental health issues), concerns about confidentiality, and feeling poorly informed about their personal health care confidentiality rights (26).

With respect to relationship and boundary issues that arise during subsequent clinical practice, the three most highly ranked topics for greater education were coping with mistakes in clinical care, responding to an impaired colleague, and reporting medical mistakes. This finding is important in light of a recent study demonstrating a relationship between residents’ medical errors and subsequent distress, burnout, and depression (27). Given that many psychiatric residents will encounter patient suicide (28)—an event that almost invariably leads to the resident feeling that he or she made some kind of mistake—the desire for more education on coping with mistakes is understandable. Attention to education on reporting and coping with medical mistakes would enhance this aspect of development in professionalism and may help mitigate resulting physician distress. Responding to impaired colleagues is another sensitive area for resident education—and indeed, for physicians in practice—yet it has received minimal empirical attention. One study found that residents would prefer to speak directly to an impaired resident colleague, but would report an impaired attending to their senior resident (29). The need for greater attention not only to physician impairment, but also supporting physicians’ personal health and wellness, is reflected in recent recommendations from the American Medical Association (30). The responses of the residents in our study therefore are consistent with an overall perception that physicians may not be adequately prepared to respond to impaired colleagues, and that greater self-reflection regarding distress is also needed.

Finally, residents on average perceived a need for more attention to balancing professional and personal commitments. While faculty serve as role models implicitly in this arena, explicit discussions of these fundamental issues with residents may impact their lives, particularly as they make career decisions.

Interestingly, the three lowest ranked items in terms of perceived educational needs were sexual contact between patients and physicians, confidentiality of medical records, and sexual harassment. The most difficult ethical dilemmas arise when physicians experience more conflict, have more choices between desirable and undesirable alternatives, and have more options to balance (31). It is possible that residents find relatively clear ethical “answers” when dealing with less conflicting and more clear-cut situations such as sexual contact with patients, confidentiality, and sexual harassment, and therefore desire less education in these areas.

Implications

Residents’ positive endorsement of the items in this survey lends support to the importance of providing training in professionalism. One consistent finding was the strong association between more ethical conflicts encountered and the desire for more ethics education. A closer look at the residents who endorsed wanting more versus wanting the same or less ethics education revealed no significant differences with respect to age, gender, marital status, or level of training. It thus remains unclear how the level of training affects residents’ views about topics needing more education, given the greater amount of ethics education received at higher training levels. A resident’s personality and basic interest in ethics will affect their view on these issues and on the quality of ethics training in training programs. It was interesting to note that the small percentage (20%) of trainees who strongly endorsed wanting more education on ethics not only encountered more ethical conflicts, but also felt they were treated less frequently in an ethical and professional manner by peers and faculty. Our findings highlight the importance of exposure to ethical situations as a stimulus for a desire to learn more about ethical issues and approaches.

Limitations

This study is limited by potential sampling and response bias. Results may not be generalizable to residents in varied types of programs or other geographical regions. Residents who responded to the survey may differ in attitudes from those who did not. Also, the possibility of “social desirability” bias in responses cannot be ruled out. However, the assurance of anonymity as well as the range and variability of responses across items and across programs suggest that residents provided answers accurately reflecting their genuine views. Another limitation is the broad range of questions in the instrument used, which helps provide an overview of trainees’ views and attitudes, but does not uncover underlying factors that may have influenced their responses. Future studies are needed to further assess individual variables that will affect the process and outcome of ethics education.

Even though psychiatric residents overall believe they receive adequate training on issues pertaining to relationships and boundaries, they also desire more education on specific topics. Enhanced training in these areas could have several positive payoffs. Optimizing training in professionalism and boundaries may serve to enhance patient care, heighten professional satisfaction, reduce resident distress, and contribute to effective risk management (15). Continued education and discussion among faculty regarding the importance of professionalism education and helping faculty find effective ways to supervise, teach, and mentor around issues of relationships and boundaries can help facilitate effective transmission of skills and attitudes and promote positive role modeling. Finally, education in a supportive learning environment—one that clearly and explicitly values trainees and faculty—may affect the learning of these topics in ways as yet unexplored, for instance by structuring a milieu that is safe for conflict resolution, providing a framework of mutual respect, and modeling how to treat one another in a caring, ethical, and professional manner at the system level.

Manuscripts authored by an editor of Academic Psychiatry or by a member of its editorial board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the Editor is recused from any editorial decision making.

Drs. Lapid, Moutier, and Green Hammond declare no competing interests. Dr. Dunn receives grant funding from the National Institute of Aging and from the Greenwall Foundation. Dr. Laura Roberts’ work is funded through the Research for a Healthier Tomorrow-Program Development Fund, a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin. Disclosures of Academic Psychiatry editors are published in each January issue.