The Intimacy of Longitudinal Care and Boundaries

As part of the Longitudinal Ambulatory Care Experience (LACE) program at UC Riverside School of Medicine, I’ve had the opportunity to volunteer at free clinics that focus on education and patient support. Many of these free clinics serve vulnerable communities that lack meaningful access to basic healthcare amenities, especially undocumented and homeless populations.

As a volunteer on the Lung Health Committee at one clinic, I worked to help patients through the difficult process of smoking cessation. One of the biggest lessons I learned is that rather than give patients a lecture on the dangers of smoking, it’s more effective to get to know them to understand the underlying context of their behaviors. As I spoke with patients about their lifestyles and habits, I found that smoking was related to very intimate portions of their lives. I ask questions about their life at home, the stressors they have, the triggers that cause them to smoke, how they relax, and their social support. Smoking cessation isn’t merely deciding to “stop smoking” – most patients already know that. Smoking cessation is an uneven road, that requires a team-based effort that encourages longitudinal (long term) care for continual reflection and success through regular check-ups. Ultimately, it requires robust patient connection, good rapport, and trust.

The very first patient I developed a longitudinal care plan for was “David.” (Note: names and identifying details have been changed to protect patient privacy.) He was an indigent man who had recently relocated to the Riverside area and was referred to the lung health committee as part of his triage. He shared that he smoked to get away from the stress in his life and not having anyone to speak to. David had smoked a pack a day since the age of 15 and was never able to quit for long. I reassured him that the committee would be there for him, but to qualify for smoking cessation supplements he would first have to document his daily smoking habits for two weeks and then be reevaluated. We made a plan in which David wasn’t going to quit smoking fully, but rather, cut down gradually on his daily number of cigarettes. When asked how many he could quit for the next two weeks, David said he could try to quit smoking three fewer cigarettes a day. To finalize the visit, David was referred to counseling, shown breathing exercises, and given a smoking cessation kit that included sunflower seeds, packs of gum, and toothpicks, and was remined of my affirmation that our committee would always be there for him.

David took us up on our offer. For the next six months, David not only updated us on his smoking habits, but also on his general well-being. We were David’s sole source of social support, and he would spend nearly the entire clinic speaking with the committee. If we happened to be seeing another patient, there was always another lung health committee member available to keep him company.

As the weeks went on, David divulged more about his life, including that he had been physically assaulted by his father, run away as a teenager, and had often drifted between jobs and cities ever since. Learning more about David’s background deepened our connection with him, making us feel like he was a close friend to care for and protect. David’s uneven access to housing contributed to many problems in his life—possessions being stolen, constant feelings of insecurity, and persistent loneliness. He once confided he was afraid of not surviving the upcoming winter, and that the job offer he was hoping for could mean life or death for him. David said if we didn’t see him at the clinic one day, it meant he either got the job or died in the cold. This news put the whole committee on alert so we referred him to social services for information on free winter housing.

David’s smoking cessation journey was temperamental. In his first follow up, he’d made little progress, indicating in his log that some days he still smoked two packs per day. When asked what happened, he admitted that he sometimes lost himself in his anxiety and would keep smoking until the pack ran out. David said he felt better after talking about these issues and vowed to try harder. On the next visit, he had improved, just as he’d promised. After qualifying for his Nicorette gum, his success continued and he lowered his daily cigarette intake by half over the next few months.

Through my experience with David, I believed I’d found my purpose in medicine. I better understood how the power of motivational interviewing and collaborative community medicine could initiate change despite years of trauma. I looked forward to volunteering in the clinic to hear updates from David. My team praised him during his victories and comforted him in his lows. We were amazed at how far he had progressed since his first visit.

However, with time, David became too comfortable at the clinic. Sometimes he came over to our committee before going through triage, which was the required process. He would often take up the entire table which made it difficult to see smoking cessation patients. We gently corrected him, but it became clear he had difficulty recognizing boundaries. This lesson came to a head when we were notified that David had been harassing a volunteer. His behavior was absolutely inappropriate and the clinic leaders responded by separating him from the volunteer at all times. I was shocked at his actions; —it almost felt like a betrayal by a friend.

Shortly after the incident, David accepted a job offer and told us he would be leaving the area soon. I fought mixed feelings. The disappointment I felt with his behavior interfered with the joy I felt in the success of his smoking cessation and employment journey. I was elated that he’d found a job and could finally find security, but I was also relieved he would no longer improperly interact with the clinic workers. Ultimately, it was an important lesson for me in maintaining boundaries. I had become too close to my patient and too emotionally invested in his care. Through the months we spent together, I should have reassessed my boundaries and affirmed my professional purpose working with David.

The experience also forced me to recognize my privilege. Growing up, I had a stable environment. David did not. He didn’t learn about proper boundaries and appropriate ways to express himself like I had. I also needed to remind myself that David was not a friend. He was a patient — one whom I failed to regulate my emotional attachment to. My experience with him represented a critical developmental step in my journey to becoming a physician —one not explicitly taught within the medical curriculum.

Though it has been years since David left the free clinic, I hope he is well and continues to benefit from what he learned there. My experiences with the lung health committee helped mold who I am as a medical student. It’s helped me to develop my own way of connecting with patients in order to provide them with the best care possible. I learned the importance of boundaries in a physician-patient relationship, and the importance of regulating emotional attachments. Moving forward, I will continue to build professional patient relationships and work to bridge health inequities in my community and with my future patients.