It is a very odd thing that most doctors, especially ones who really love what they do, provide advice and sometimes treatment to family members and good friends. It is also held to be true that this is a bad practice. How do we reconcile this?
In 1847 the AMA published its first “code of medical ethics” which covered many subjects and, though short, is dense and diatribe-like. It seemed to me, when I read through it, that it was mainly concerned with discouraging various forms of quackery, which was rampant in the relatively unregulated environment of the early 19th century in the United States.
We physicians were enjoined to “unite tenderness with firmness and condescension with authority” and our patients were reminded that they needed to do what we told them and not fuss and argue with us. Physicians were required to be always available to sick patients, to get consultation when necessary, to treat those who could not afford to pay. In turn, patients were told to avoid seeing more than one doctor because we might disagree and then there would be dissension within the profession. Physicians were to be of superior moral character, not advertise, not have patents on surgical instruments, be cheerful and treat each other and each others’ family members for free. It was noted that if we were to treat our own family members, we would be apt to be timid and irresolute.
The American College of Physicians published its 6th ethics manual last year and said this about treating family and friends:
Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons. The patient may be at risk of receiving inferior care from the physician. Problems may include effects on clinical objectivity, inadequate history-taking or physical examination, overtesting, inappropriate prescribing, incomplete counseling on sensitive issues, or failure to keep appropriate medical records. The needs of the patient may not fall within the physician’s area of expertise . The physician’s emotional proximity may result in difficulties for the patient and/or the physician. On the other hand, the patient may experience substantial benefit from having a physician-friend or physician–family member provide medical care, as may the physician. Access to the physician, the physician’s attention to detail, and physician diligence to excellence in care might be superior.
Which leaves me ethically stranded about where I was before. It is wonderful to be able to provide medical care to friends and family. When I look at what a patient has to go through when they have any one of a number of very common symptoms, a rash, vaginal itching, urinary discomfort, an upset stomach, a productive cough, and the eventual outcome, often an unnecessary antibiotic after a wait of several hours, with almost no history taken and precious little planned followup, I cringe. Can I do better than that for someone I know well and love? Yes. I can.
It is not uncommon that the easy problem that I can take care of in no time leads to another problem and then I may not be available. Then I have treated the patient but left no easily accessible record to help the next care provider figure out what’s going on. And sometimes I give really good advice, but the patient doesn’t believe me because I’m not really their doctor. Then they do some wrong thing and come back to me for advice when that doesn’t work and I am annoyed because they didn’t listen to me in the first place and I’m now doing something else important and for annoyance of this magnitude I really should be paid. And sometimes my familiarity really does cloud my judgement. I don’t insist on actually seeing them and miss a very important piece of information that I would never have ignored in a patient in my office.
I have provided hospice care for close friends and family. I think that worked out very well, and I can’t imagine standing by watching communication snafus worsen the pain of dying. And yet it was pretty tricky. My heart strings were pulled and decisions really were more difficult than they would have been had I not been so intimately involved. My children have not had much experience with being doctored in the way that has become standard in our culture. But much of what is now done in doctors’ offices has traditionally been the job of a mother, including managing the countless colds and tummy troubles that plague children and the inevitable bumps, bruises and lacerations. When I meet the children of physicians, they speak proudly of how their physician parents hydrated them, placated them, benignly neglected them. It is what is most often done, at least with really healthy children. I have traded uncomplicated medical care of close friends for jars of honey or gratitude or just the satisfaction of knowing that the right thing was done, all so far with no ill effects.
I have also refused to treat people close to me for issues that were complex or required prescriptions for controlled substances, or when my relationship with them was one which made the blurring of roles a bad idea.
I salute the American College of Physicians for the final two sentences in the paragraph about treating those with whom one has a prior relationship. They didn’t have to recognize that care of family and friends can be “substantially benefi(cial)” to both the patient and the physician. I can just imagine the arguments that may have accompanied this as the document was written. It is as deeply ambiguous as the subject it addresses.
Janice Boughton is a physician who blogs at Why is American health care so expensive?