Ben Hoban is a GP in Exeter.
Like everyone else, our practice put up a clear plastic screen at reception during the COVID-19 pandemic to protect the receptionists. It had its downsides, of course: even though it was unavoidable, building barriers never feels like a friendly thing to do, and at a time when access had already become much more remote, it may have added to people’s frustrations when they were frightened and trying to get help. Social distancing meant keeping at least two metres away from other people, although having a screen at reception and using Personal Protective Equipment (PPE) during consultations allowed this requirement to be waived. It is therefore worth reflecting that despite their drawbacks, barriers designed to separate people did also bring them together by making closeness safe.
It is not just viral transmission that can make closeness hazardous. We did consider taking the screen down again after the pandemic, although everyone was used to it by then, and the receptionists had occasionally been grateful to have something between them and an angry patient, however flimsy; we decided in the end to install a permanent screen with an intercom system. The danger in a consultation is usually more subtle, lying in the various misunderstandings that can arise between two people who do not always know each other, when one of them is unwell and must expose themselves physically or psychologically to the scrutiny of the other. We all have a sense of personal space around both our body and our inner self, whose invisible boundary we guard carefully against intrusion.
Boundaries in medical care are therefore not primarily a mechanism for creating distance between people, but for making safe the physical or psychological closeness that effective care requires.
Personal boundaries are rarely fixed, however. Consider how the need for physical space around us can disappear entirely in a crowd, or on a busy tube train, simply through a cognitive reframing of what we are doing: not touching strangers, just being in a space with particular conditions, where different norms apply. When doctors make physical contact with their patients’ bare skin, examination gloves can be a useful hygiene measure, but they are also symbolic, drawing our attention to a similar re-framing. The same applies to purely verbal contact. Most patients seem to appreciate a bit of small talk when they are collected from the waiting room, but would expect a more formal tone during the consultation, especially if it involved an intimate examination. Boundaries in medical care are therefore not primarily a mechanism for creating distance between people, but for making safe the physical or psychological closeness that effective care requires. They achieve this partly through the context of language, rituals, and symbols that together emphasise the otherness of doctors. A boundary represents not just the line separating one entity from another, however, but also the point of contact between them.
How then do we achieve this contact?
It is natural, and in many situations unavoidable, to make assumptions about people based on first impressions and our own past experience. To recognise someone as an individual with their own particular concerns and needs is more difficult, requiring us to exercise some degree of empathy, to see the world through their eyes while still recognising it as their world and distinct from our own.1 Without the closeness that comes from this act of identifying with another, communication cannot progress beyond the superficial and concrete; and without the distinction that preserves our separateness from each other, closeness can tip over into familiarity. Working at this boundary can be risky: it takes trust for a patient to grant us access to their inner world, but also for us to enter. We trust people we see as competent and consistent in carrying out their role, whether as doctors or patients, and who invite trust by acknowledging the same qualities in us and taking seriously our needs as well as their own.2 The patient and their doctor may have an asymmetric relationship, but it is still a reciprocal one.
Tolstoy’s line about happy and unhappy families comes to mind: all effective consultations are alike, but each ineffective consultation is ineffective in its own way.3 Heartsink, transference, and combativeness all represent different challenges, and yet all of them are essentially boundary phenomena, arising through the absence of one or more of the elements that make up the border between us, and characterised by an inability to achieve both the necessary closeness and separateness.4-6 Doctor and patient face each other across a gap which is either impossibly wide or dangerously narrow, projecting onto each other what they have been trained to see: diagnoses that make sense; authority figures who know what to do or need to be shown that they don’t; and a world that often feels random and frightening, in which their needs are unlikely to be met. How can they carry out their respective roles effectively or safely when the boundary between them is faulty?
A boundary represents not just the line separating one entity from another, however, but also the point of contact between them.
Barriers to healthcare are also plentiful outside the consulting room. The systems we build to manage access in general practice can often feel like barriers themselves, full of rules that seem arbitrary and work-arounds that invite gaming.7 Ultimately, though, what is at issue is not a particular structure or process, but whether these things function as barriers or boundaries, and whether they enable care or merely control activity. Do we really see ourselves and the service we offer through the eyes of our patients, and do we recognise their competence as much as we want them to recognise ours? If we want people to trust us, it is essential that we approach this in a way that goes beyond the merely expedient or technically adequate, and that we learn to trust them too.8 In order to meet their needs, we must see the person as well as the patient; we must allow them to see us as people ourselves; and we must do this in a context that still makes clear the distinctness of our roles. If we are to remain professionally effective and safe, we do not need more barriers, but instead, care that combines closeness with separateness; that is what boundaries are for.
Deputy Editor’s note – see also: https://bjgplife.com/touch-matters-touch-covid-19-the-physical-examination-and-21st-century-general-practice/ and https://bjgplife.com/shaking-hands-again/
References
1. John Goldie, On becoming: Empathy at the deep end, BJGPLife.com 4 February 2026
2. Daniel Sokol, Trust equation is a tool to build confidence in medicine, BMJ 2026; 392 doi.org/10.1136/bmj.s163
3. Leo Tolstoy, Anna Karenina, first published 1877
4. Mark Rickenback, Reframing the “heartsink” feeling can help doctors find a resolution, BMJ 2024; 385 doi.org/10.1136/bmj.q1427
5. Abigail McNiven, Amy Dobson, Katie Read and Sharon Dixon, ‘My patients are “gunning for a fight” that I don’t want’: reflecting on feeling dismissed and conflict- expectant consultations, British Journal of General Practice 2025; 75 (754): 234-236. doi.org/10.3399/bjgp25X741561
6. Paul E. Goldberg, The Physician-Patient Relationship: Three Psychodynamic Concepts That Can Be Applied to Primary Care, Arch Fam Med. 2000;9:1164-1168
7. Jennifer Voorhees, Simon Bailey, Heather Waterman and Kath Checkland, A paradox of problems in accessing general practice: a qualitative participatory case study, British Journal of General Practice 2024; 74 (739): e104-e112. doi.org/10.3399/BJGP.2023.0276
8. Charlotte AM Paddison and Theo Georghiou, Implications of skill-mix change in general practice: secondary analysis of data from the GP Patient Survey, British Journal of General Practice 23 February 2026; BJGP.2025.0360. doi.org/10.3399/BJGP.2025.0360
Featured photo by Claudia Soraya on Unsplash
