Cover Story
Family Affair
By Cathy Madison
Physicians now more than ever are questioning the wisdom of treating themselves or their family members.
My father was a surgeon who kept it simple. Our medicine cabinet contained only aspirin, rarely administered. He prescribed easy-to-remember home remedies: cold water for fevers and burns, hot water for scrapes and sore throats, forced fluids and bed rest for colds and flu. When we were kids, this seemed to work just fine. But when he was visiting me as an adult and severely injured his hand while trying to break up a dog fight, then asked me for my sewing box, I began to question the wisdom of physicians caring for their families and themselves.
Apparently the question of when and whether to treat oneself or one’s loved ones is still a good one. Although the practice has long been discouraged and the trend is toward stronger mandates against it, physicians say they wrestle with it throughout their careers. And the basic issues—compromising one’s professional objectivity, failing to probe sensitive areas, stretching beyond one’s areas of expertise—remain ethical considerations.
Treating Your Kids
Those considerations can demand painful decisions when it’s your own child who needs care. “A parent/child relationship is different from a doctor/patient relationship,” says Mark Eckman, M.D., an infectious disease specialist who recently retired from St. Mary’s Duluth Clinic. The son of a family physician, he was about 10 when he caught his finger in the brake of his dry-land Flexible Flyer as it barreled down a hill.
“It tore my fingernail off. My mother looked at it and took me to my dad’s office. I had to wait until all the paying customers were taken care of,” he recalls. “I’ve tried not to care for my own children because of those experiences.”
Sometimes, he admits, it is convenient and economical for a physician-parent to step in. He was willing to swab a sore throat and take it in for a culture, but he stopped short of giving a shot, which he finds invasive. He won’t refill birth control prescriptions when his daughter runs out and has forgotten to make a doctor’s appointment—and may forget again.
Like many physicians, Eckman fears missing or downplaying a problem. Once his teenaged daughter was horsing around at a friend’s house and hurt her toe. “She showed it to me, and I said let’s see how it feels tomorrow. Then she went and got an X-ray, and it was indeed fractured,” he says.
“Physicians are just as inclined as anybody to be in the denial business. I’ve seen them explain away chest pain as gastroenteritis or esophageal irritation of one form or another, when in retrospect it was coronary artery disease,” says C. Richard Guiton, M.D., an internist who retired a year ago after working for three decades in downtown St. Paul. “When you look at your family from a medical point of view, you put in a bunch of what I might call filters. You don’t want them to be ill because they’re your family, so you may minimize their complaints.”
Guiton says it is always tempting, especially with children, to intervene in order to alleviate the discomfort of an acute fever, for example, or to try to expedite treatment. Although diagnosing an ear infection may be a simple matter, then what? “I’m always reluctant to order antibiotics myself,” he says. “If a child has an allergic reaction, I’d have an extraordinary sense of guilt. Physicians are always second-guessing what they do and how they do it anyway.”
Joseph Sockalosky, M.D., a pediatric endocrinologist at Children’s Hospital and Clinics of Minnesota in St. Paul, agrees that caring for one’s family is simply not a good idea. It’s not necessarily a problem in relatively minor circumstances, he says; he looked in his own children’s ears and prescribed medications many times when they were young. But no longer.
“I’ve chosen not to do even that simple a thing for my grandchildren. I don’t want to be looked on as their doctor. I want to be their grandfather,” he says. “I don’t think it’s likely that one can separate one’s emotional involvement with a family member from one’s objective professional judgment. There’s a certain natural tendency to err on one end of the spectrum or the other—to
ignore the possibility of something serious going on, or to overreact and treat or do unnecessary testing. It’s hard enough to form those kinds of judgments for patients you don’t have deep emotional attachments to.”
Sometimes just being involved gets tricky. When Sockalosky was a resident and his baby spiked a high fever, the baby’s pediatrician called him to disclose the findings and ask whether he thought a spinal tap was in order. “I had a chance to voice an opinion, but I didn’t want that privilege,” he says.
The rules have since changed, making it more difficult for him to play any role in the care of family members. Sockalosky once referred a grandchild to a respected colleague in his specialty. Because of confidentiality and privacy laws, his colleague couldn’t discuss the case with him without express permission from the child’s parents. “I don’t for a moment want to make it sound like it’s easy to divorce yourself totally from having any role,” he says.
A Common Practice
Although caring for family may not be a good idea, it is widespread. In a 1991 study reported in the New England Journal of Medicine, 99 percent of 465 staff physicians in a large suburban community teaching hospital reported fielding family requests for advice, diagnosis, or treatment, and the vast majority provided it, with 72 percent doing physicals, 80 percent diagnosing illnesses, and 83 percent writing prescriptions for family members. More telling, perhaps, is the fact that 22 percent of physicians acceded to requests that made them uncomfortable. The American Academy of Family Physicians also cites widespread self-treatment, ranging from 52 percent to 84 percent of physicians claiming to do so, and treatment of “nonpatients” (those outside a standard office relationship) that nears 100 percent. The most common medications prescribed in those situations: antibiotics, antihistamines, and contraceptives. In an unscientific online poll, Minnesota Medicine found 31 of 54 respondents said they had treated a family member.
“There’s no law against it,” Rob Leach, executive director of the Minnesota Board of Medical Practice (BMP), points out. Although a medical license does authorize treatment of family members, the practice is universally discouraged. In truth, though, it has created few problems for the BMP. The prescription issue occasionally surfaces, Leach says, especially when controlled substances are involved, but so far no official policy has been necessary.
Official policies, such as that of the American Academy of Family Physicians, merely adopt the American Medical Association’s Council on Ethics and Judicial Affairs’ opinion, which outlines the issue in surprising detail. (The policy is online at www.ama-assn.org/ama/pub/category/print/8510.html.) “Physicians generally should not treat themselves or members of their immediate families,” it says, because personal feelings cloud professional judgment, situational discomfort may afflict both doctor and patient, sensitive information may be suppressed, and physicians may overestimate their medical knowledge. Privacy and confidentiality as well as the vulnerability of a child to parental authority all play a part.
Yet the opinion provides an out. “It would not always be inappropriate to undertake self-treatment or treatment of immediate family members,” it states, noting emergencies and isolated settings. “There are situations in which routine care is acceptable for short-term, minor problems.”
Wiggle room is what Thomas Schmidt, M.D., calls it. As chief of patient safety for Park Nicollet Health Services, one of the country’s largest multi-specialty clinics, he realizes that “emergency treatment in the boondocks” is sometimes appropriate. Aside from this common-sense caveat, the organization’s formal policy prohibits its 960 physicians from treating themselves and family members—and states specifically which family members it covers.
Park Nicollet’s policy went into effect in December 2006 after “lots of chatter,” Schmidt says. “It took some time to get there, probably too long. Issues came up at least two or three times a year, often enough in the last three or four years to have to create a policy.”
At Park Nicollet and elsewhere, those issues have included physicians submitting bills for treating family members, ordering tests and expecting them to be supplied gratis, and peeking at family members’ medical records. Often payment issues are at stake; Medicare will refuse to pay a claim if patient and physician share a family name, for example. Medicare regulations also say that in nonprofit settings, what is provided for some—such as pro bono care—must be provided for all, which means that the age-old concept of “professional courtesy,” whereby a physician treats another physician’s family member for free, has become obsolete.
A Fine Line
Having a policy in place may relieve the angst that naturally occurs when a physician attempts to treat someone close to him or herself, even if that person is not an immediate family member. Several years ago, physicians at Abbott Northwestern General Medicine Associates, for example, adopted a policy that prevents them from treating each other’s family members as well as their own.
Making It Policy
More and more, large health systems are creating policies about treating one’s family members or oneself. In September 2005, the Clinical Practice Council of the 850-physician Allina Medical Clinic adopted a policy regarding self-treatment or treatment of immediate family members. Like many such policies, it endorses the AMA’s policy and says that physicians and providers should not treat themselves or family members “except in narrowly defined situations.” It also defines immediate family members as a:
- Former or current spouse/domestic partner,
- Natural and adoptive parent, child, or sibling,
- Step-parent, stepchild, stepbrother, or stepsister,
- Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law, or
- Grandparent or grandchild and their spouses/domestic partners.
According to Allina spokesperson David Kanihan, instituting such a policy was never hotly debated nor considered a high-priority issue. “We knew the AMA had a policy, so we thought it would be appropriate to have one as well,” he says.—C.M.
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Being asked to treat someone close to you is extremely stressful for physicians, Kathy Ayaz, M.D., one of the group’s 13 internists, explains. Dealing with such requests is not addressed in medical school; new doctors have to figure out for themselves how to handle them. “From my first year in practice, I had to put my foot down. I don’t ever treat family members. They ask questions—my mom does it all the time, and I suppose that’s a natural thing—but there’s a real ethical line you shouldn’t cross,” she says. “My family members do respect what I say, but they’ve had to be trained. They go to their own doctors.”
Ayaz contends that a primary care physician is often in a more awkward position than a specialist because he or she knows a little bit about everything, so any health question is fair game.
But specialists find themselves in equally difficult situations. Orthopedic surgeon James House, M.D., who teaches at the University of Minnesota, points out that his expertise has often been valuable in obtaining proper care for family members, even if he doesn’t do the surgery himself.
When his 3-year-old granddaughter caught her finger in the door and ripped the soft tissue, he dripped lidocaine into the wound, spiraled some Steri-Strips, and reconstructed her thumb in half an hour while she sat on the kitchen table. Hauling her off to the ER would have been far more traumatic, he says. (He is a hand specialist.)
“It’s a fine line; but basically, I think it’s not unethical to do it,” he says of treating family members. Yet he, too, fears making a wrong diagnosis, mistaking the arm pain of a heart attack for tennis elbow. He diagnosed his wife’s Lyme disease but had another doctor treat her.
Ayaz has written prescriptions for family members, although after more than two decades of practice she can count them on one hand. The fact is that even in rural Minnesota, there are few, if any, “boondocks” situations in which there is no physician available. Representatives from both the Minnesota Academy of Family Physicians and the Minnesota Board of Medical Practice say that current economic realities force physicians in rural communities to practice in groups, albeit small ones. Although a vacation might require a physician to write an emergency prescription for a loved one, everyday life, even in small towns, seldom does.
Another reason why physicians are reluctant to prescribe for family members and other nonpatients is the increasing complexity of record-keeping for insurance as well as future care purposes. Paper trails are essential; even physicians who determine that it’s easier or more convenient to write their own prescriptions need to get them into the medical record. Otherwise, says attorney Cinda Velasco, J.D., subsequent physicians will have to rely on the patient’s memory and history to determine which antibiotic was prescribed, whether it was taken, and whether it worked.
Velasco, who specializes in risk management for the Minnesota Medical Insurance Company, a medical malpractice insurer for more than 12,000 physicians in Minnesota, Iowa, Wisconsin, Nebraska, and North and South Dakota, echoes the standard line: She discourages self and family treatment but recognizes that it happens. She can’t recall any malpractice cases that have resulted; issues that arise generally involve narcotics prescriptions, which is a licensing issue. But she implores physicians to avoid emptying their sample cabinets when a family member needs meds.
“That’s the sort of thing that I don’t want them to tell me they do,” she says. “It tends to be a physician who is trying to help, trying to do the right thing. But I believe it’s a risky practice.” Beyond record-keeping, the ultimate concern is whether the emotional connection one has with one’s family will cloud one’s professional judgment.
Where that old admonition, “physician, heal thyself,” is concerned, judgment may indeed be murky. After the dog fight all those years ago, I helped my father thread the black thread from my sewing basket through the needle he’d sterilized with a match. He sewed up his hand and held it over his head the rest of the day and night, swearing under his breath and wincing in pain. In the end, his hand healed just fine, but if I had it to do over, I would have told him that a physician who treats himself has a fool for a doctor and a bigger fool for a patient and taken him to a doctor. MM
Cathy Madison is a freelance writer in Minneapolis.