Membership and Fellowship: 3 Rules for Treating Friends and Family

By Stephanie Stephens

This article reprinted courtesy of HealtheCareers, the providers of ACOG’s Career Connection online job board. Find your next job and career resources at ACOG’s Career Connection   

There you are, taking well-deserved time off and playing the back nine with your best golfing buddy. Suddenly, your buddy says, "Hey, doc. I'm having a little trouble with my (fill in the blank here). Can you help me?"

Now the line between friendship and the formal doctor-patient relationship has been crossed. How you respond will depend on many individual factors, but take solace in knowing you're not the first health care professional to be put on the spot.

In fact, some of your peers actually don't mind, because, well, they really do want to help. It is, after all, one of the reasons they—and you—do what they do!

Some even welcome the opportunity. "I routinely talk to friends and family about their health care issues," says David Nidorf, MD, emergency medicine doctor in Poughkeepsie, New York. "This may be as simple as them asking me who they should go see for a particular problem or asking for general medical advice."

Fair enough, but sometimes the inquiry doesn't stop there. "Where it gets tricky is when they ask me for specific treatments or prescriptions for medication. Or it could get tricky when they say, 'Can I ignore this weird chest pain I'm having?' In that case, if I said 'yes' and they were having a heart attack, I'd feel pretty awful."

Dr. Nidorf has established these guidelines for dispensing medical advice to friends and family:

  • Never, under any circumstances, write prescriptions for controlled substances for friends or family
  • Try not to get involved in complex or potentially serious symptoms or diagnoses
  • General advice is usually okay, but try not to get too specific

"The above rules only apply outside of the office or, in my case, the emergency department (ED)," he says. "If a friend or a friend's family member arrives as a patient in the ED, then I treat them as I would any other patient: proper history and physical, work-up, treat symptoms, and more. Some docs prefer that in this situation one of their colleagues treats their friends or friends' family, but I’m comfortable treating them myself."

A survey of the literature and a cursory survey of health care professionals proves that no one views or responds to this situation the same way. Whether it concerns a family member asking for off-the-cuff medical advice or a friend who actually wants to come in as a proper patient, individuals and organizations are divided about what’s right and wrong.

As a health care provider, you’ll need to figure out what’s right for you—and how to respond when the inevitable ask arrives.

 

1. Keep It Professional  

Many physicians know their limits and establish steadfast boundaries. "Depending on the problem and the specialty, it can be appropriate to treat a friend or relative," says Dina D. Strachan, MD, board-certified dermatologist in private practice at Aglow Dermatology in New York City. Dr. Strahan is a graduate of Harvard College and Yale Medical School.

"I haven’t turned friends or relatives away who needed help with problems such as shingles, acne, or rashes," she says. "As long as it’s not too emotionally charged, I don't find this problematic to provide my own friends and family with excellent care."

For her, the key is to treat those people in the office and to follow the same protocol followed with any other patient. "Physicians get in trouble when they get casual and don't follow the standards of practice, such as history-taking, documentation, and using insurance, or failing to collect co-pays.

"If I wouldn't do it that way for a stranger, I probably shouldn't do it that way for a family member," she says. "If it feels uncomfortable to manage someone I know, then it’s best to make a referral."

A 2014 paper, "No Appointment Necessary," in the New England Journal of Medicine agrees. "Our ethical concerns center around the provision of informal and undocumented care to these friends and family members—care outside the usual medical encounter," the authors write. They see treating these connections as simply a sticky wicket.

"We also urge providers who are involved in medical education to help trainees understand the ethical boundaries of care as part of their professional role and encourage them to refrain from treating friends, family members, and themselves," they say.

 

2. What the 'Big Guys' Say

According to an editorial opinion in AMA Journal of Ethics, these kinds of requests can be benign or they can be "burdensome." In fact, the American Medical Association states in its "Code of Medical Ethics" that “Physicians generally should not treat themselves or members of their immediate families.” As the article notes, the term "families" also inherently includes "friends."

Other professional organizations wag the same cautionary finger. They include the American College of Physicians, General Medical Council of Great Britain, Medical Council of New Zealand, American Academy of Pediatrics, College of Physicians and Surgeons of Ontario, and the College of Physicians and Surgeons of British Columbia.

So, where does that leave you?

Blogging for “Kevin MD”, Janice Boughton, MD, of Moscow, Idaho, finds the recommendation from the American College of Physicians in particular "as deeply ambiguous as the subject it addresses," she says.

"Physicians should usually not enter into the dual relationship of physician–family member or physician-friend for a variety of reasons," the sixth edition of the Ethics Manual states.

The potential does exist for things to snowball when treating friends and family—in spite of the best intentions, she explains.

"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," writes Dr. Boughton. "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."

The situation can get further off track, she says. "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. Now I'm doing something else important and for annoyance of this magnitude I really should be paid. And sometimes my familiarity really does cloud my judgment. 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."

 

3. Taking It to the Limit

There's the annoying kind of "when things go wrong," and then there's the terribly sad kind that occurred in 2010. Brandon Jacoby, age 24, died before Christmas of multiple drug toxicity—49 pill bottles close by. His father, David James Jacoby, MD, who practiced near Austin, Texas, wrote prescriptions to friends and family, who then returned some of the pills to the doctor for his and his son's use.

According to the Austin American-Statesman, the physician father "pleaded guilty to 28,750 doses of hydrocodone filled at 69 different pharmacies between early 2009 and January 2011."

The doctor is in an Oklahoma prison.

Even if things don't get that serious, what may seem like a good idea at the time, may not look that way in hindsight, cautions Chicago health care attorney Ericka Adler in Physicians Practice.

"Not all families remain close and civil at all times, in-laws and spouses may come and go, and even the best people don’t make the best decisions all of the time," she says. "For these reasons, limiting the type of treatment you provide, maintaining adequate records, following your insurance contracts, and properly evaluating patients will go a long way should you have to defend your treatment decisions."

You may have noticed some medical specialties just seem to embrace the idea more than others. Holistic plastic surgeon Anthony Youn, MD, of Troy, Michigan contemplated the propensity of fellow doctors in his field insisting on treating family members for CNN's "The Chart."  Among the reasons he cites, "To them, there is no better advertisement than showing off their 50-year-old spouse who now kind of resembles Pam Anderson."

For this skilled doctor, however, he says, "Other than removing a mole or two, I’ve never operated on my wife and I never will…. I have no desire to see her insides. I’ll leave that to another doctor."

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