Case Study 1
An ENT physician schedules his wife for a nasal reconstruction procedure that he will perform at his surgery center. Upon learning this, the facility manager calls the physician to discuss concerns about the appropriateness of him performing this procedure on his wife. The physician says he is "the best at this surgery in the city" and that he wants to ensure his wife receives first-rate care that he can oversee.
Case Study 2
A family practice physician in a rural setting often treats her staff and their family members for free. She sees her medical assistant’s 12-year-old son for an upper respiratory tract infection. The physician opts for conservative treatment and makes no record of the visit. Three days later, the patient presents to the ER with shaking chills and pneumonia. A prolonged hospitalization follows.
ANALYSIS
In the first case, the physician is unaware that his actions represent a concern outlined by the AMA Code of Medical Ethics1 that state, "When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment."
In the second case, the patient survives but has an expensive and extensive hospital stay. The physician struggles seeing the medical assistant every day and feels guilty. Six months later, the physician feels the medical assistant's performance is poor, but is hesitant to fire her as there may be a risk of litigation in the future.
BACKGROUND
A classic New England Journal of Medicine article2 highlighted that 99% of physicians had requests for advice, diagnosis, or treatment of family members or friends, and 83% prescribed medicine for a family member.
The AMA and the American College of Physicians (ACP) have clear ethics statements that medical care can be complicated by preexisting social and emotional relationships. The AMA states that this kind of care should be avoided except in emergency situations or in shortterm, minor problems. In these situations, the AMA notes that physicians have a further responsibility to:
- Document the care provided and convey relevant information to the patient's primary care physician.
- Recognize that if tensions develop in the professional relationship with a family member, such difficulties may be carried over into the family member’s personal relationship with the physician.
- Avoid providing sensitive or intimate care especially for a minor patient who is uncomfortable being treated by a family member.
- Recognize that family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician.
The ACP Ethics Manual (7th Edition) notes that treating family members, friends, and employees "adds another layer that may complicate what would become the professional patient–physician relationship." Instead of providing direct treatment in these situations, the ACP recommends that "A physician in these circumstances, however, could serve as an advisor or medical interpreter and suggest questions to ask, explain medical terminology, accompany the patient to appointments, and help advocate for the patient."
MOTIVATIONS FOR PROVIDING CARE
Treating patients is an honor, a challenge, and a responsibility. There are reasons why treating friends and family is attractive. The fee might be waived, there is convenience, and a pre-existing trust. Sometimes your involvement can lead to better outcomes, and provide a personal touch and close attention that may alleviate anxiety and support better patient adherence. But, these positives also come with certain risks.
CONCERNS AND RISKS
1. Confidentiality—We recognize that in smaller communities, you might truly be the best provider for your staff. But be aware that office records might be easy for a coworker to peruse whether electronically or in a paper form. HIPAA violations might occur. If you are treating employees, then there should be a strong confidentiality policy in place. Your policy should be consistent and well communicated to the whole staff. Everyone should be confident that confidential care can be delivered just as with any patient. The patient should be charged, and records should be maintained.
2. Diagnostic reasoning—We practice best in situations when we have the calm diagnostic decision making of a sage clinician. Professional relationships with your patients are usually
fiduciary in nature. When you care deeply about someone, this might tilt your clinical acumen one way or the other. A small lymph node after a URI might lead to a lymph node biopsy because of an affection bias, whereas normally, you might have waited three months. And the opposite may be true. You might suggest waiting on chest pain when normally you would send someone to the ED with the same complaint. Personal feelings may compromise the objectivity of the clinician and make the delivery of sound care a challenge.
3. Documentation—You should do the same documentation for family members or staff as you would for any patient. When possible, you should treat the person in the office. If
there is an emergency situation, then you should communicate any actions taken with the person's provider. The natural tendency to “curbside” treat and either not or insufficiently document can result in serious diagnostic oversights, medication and prescription errors borne out of informal and quick assessments, and a minimization of serious illness that could possibly lead to preventable harm.
4. Medical samples—Dispensing samples of prescription medicine requires prescriptive authority. Employees should only receive samples on the authority of the physician or an advanced
practice provider who has such authority. Distribution of samples should be documented in the medical record. This should be discussed with staff and there should be a “no tolerance” policy in terms of dispensing sample medications without the proper authority.
5. Embarrassing illnesses—Employees/family members might present with STDs, injuries from abuse, or other ailments that they don't want others to know about. Would you have concerns in dealing with this? Will you be able to perform the complete physical exam necessary with someone you see every day? More importantly, will you ask the necessary questions to properly diagnose and treat the person?
1 www.ama-assn.org/delivering-care/ethics/treating-selfor-
family
2 N Engl J Med. 1991 Oct 31;325(18):1290-4
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 1Q22 Copiscope.
