Boundaries

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I can't remember when I first met Kimberly.^⁎ She had transferred to my small liberal arts college from a larger university and quickly had joined our circle of friends. Throughout college, we were certainly friendly, but not close friends at first; Kimberly didn't seem to socialize much outside of class. After graduation, she moved to the East Coast for her graduate studies, and I started medical school in California. We managed to keep in touch periodically despite both being entrenched in graduate school.

With my own sense of adventure, I too decided to move east after my internal medicine residency, taking a position as an academic hospitalist in New York. I took pride in my observational skills and good instincts and felt invincible as a physician. I was fortunate to have Kimberly as a friend in a new city and, over the next year, we shared many adventures together. I continued to notice that Kimberly was quiet and not completely open and forthcoming, but I attributed it mainly to her reserved personality. Until I found a note from Kimberly in my email one morning, just before seeing my first patient of the day: “I don't think you know this, but I have lupus in my kidney. I have been close to needing dialysis, so I am going to China for a kidney transplant. I will probably be gone for a few months.”

My jaw dropped. Slowly, it started to make sense. How could I have missed the hints? The clues had been there: she was thin and a bit pale, she didn't eat or drink much, she avoided alcohol, and I had seen her out of the corner of my eye taking pills (phosphorus binders, of course!) with meals. She spent a lot of time away from school with her family. She had paused as if to say something when I mentioned that I was thinking about leaving my internist position and returning to nephrology fellowship. Perhaps I had seen these things, but I could not consciously acknowledge illness in my friends and personal life.

I felt horrible. It was humbling to realize that while I credited myself as being an astute clinician, it had not crossed my mind that a close friend was ill. Was there something I could have done to help her, as either a friend or a physician? With our similar ancestral background, would I have been a match? If I had been her primary care doctor, how would I have advised her? If I had been her nephrologist, how would I have advised her? These questions remained unanswered, unanswerable. Kimberly was halfway across the world. It was only her prolonged absence while she traveled for her transplant that forced her to reveal her diagnosis. In her personal life, she had chosen to keep her health problems confidential, even from her friends.

Certainly, as physicians we have all heard uncomfortably intimate stories from strangers at dinner parties of their own health care experiences and ailments. With our friends, coworkers, colleagues, and acquaintances, there must be some boundary which balances personal privacy and sharing experiences. How much should we know about the health of our friends, and how much do we, as physicians, even want to know outside of the appropriate office and hospital settings? And what about sharing in the other direction? Would physicians benefit from being more forthcoming with their own experiences? Seemingly, the boundary might vary among patients: some patients may find comfort in understanding a doctor's personal experience with disease, while others may not be interested in this form of empathy.

A few months later, Kimberly returned with her new kidney. I tried to respect her privacy and let her share her experience abroad as she saw fit, not asking too many questions about her transplant. Over the next year, our friendship continued to strengthen, perhaps in part because her secret of having progressive lupus nephritis was no longer hidden. The boundary that had existed earlier had been relaxed. I learned about her cyclophosphamide therapy and her attempts to be on transplant lists in different areas in the United States to increase her chances of receiving a kidney. Kimberly was also particularly supportive when I announced my decision to return to the West Coast for nephrology fellowship training.

Despite the distance, Kimberly and I continue to be close. Perhaps now, as a nephrologist, I am more understanding of her plight than our friends in different professions. I do occasionally inquire about her kidney, but realize that her chronic disease and transplant experience need not define her as a person, as we have shared many other experiences. Most recently, I was a bridesmaid in her wedding.

This experience has changed the way that I think about patients. I benefited both personally and professionally from Kimberly sharing her story with me. In medical training, I became accustomed to “self-inflicted” diseases that are a result of smoking, obesity, or drug and alcohol abuse. I realize now that this way of seeing illness was a way to cope with everything I saw as a student, resident, and internist and it was a form of denial that serious illness could affect me. Kimberly's illness brought home to me the knowledge that disease can afflict anyone, at any time.

At the time of Kimberly's kidney transplant, I had not yet started my nephrology training, and was much less informed regarding options for end-stage renal disease. Even now, however, not one patient has asked my opinion about transplants abroad. Having known Kimberly's plight, I'm not sure exactly how I would respond. As a friend, I have been supportive of the decisions that Kimberly has made, particularly as I observe how she has thrived, continuing on her journey of life, since her return from China. I know it doesn't always turn out this way, and I know that such transplants are surrounded by serious and complex ethical issues. Is it wrong to have two answers for this question—one for friends, and one for patients? I realize now that this will be a lifelong challenge: to consciously and subconsciously set limits between my personal and professional life, and hope that when boundary lines are crossed, I have not done a disservice to any of the parties involved.

• ⁎ Name has been changed to protect her identity.