Treating Loved Ones and Yourself : When to Step Aside

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01/02/2018
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Almost every doctor has a story about how the course of a loved one’s illness has influenced the direction of their career, often in the hope of being able to one day change the outcome of their disease. When we finally find ourselves in a position to use our expertise for the benefit of those closest to us, we must consider the possibility that we may not be the best person for the job.

What does SMC advise?

The Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG) states that doctors may not treat people close to them for psychiatric issues, or when it involves the prescription of controlled or potentially addictive substances.

The ECEG goes on to say that doctors may provide those close to them with “routine continued care for stable conditions, minor conditions, or in an urgent/emergency situation”.1 Doctors are then cautioned that if they choose to provide further care, they should guard against allowing the nature of their relationship with the patient to compromise the quality of treatment.1 Several other medical organisations, such as the American Medical Association and the General Medical Council, advise much more strongly against treating one’s close friends or family.2,3

What are the risks?

Although it is common for doctors to treat, and even operate on, those close to them,4 this sometimes takes place without a full understanding of the risks involved.

The first hurdle encountered is information gathering. The doctor may assume that he already knows a friend’s or family member’s history based on their social interactions, or may be uncomfortable asking them sensitive questions. Similarly, patients may not be comfortable disclosing intimate medical information to a friend or relative, in particular one who is in frequent contact with the rest of their social circle, such that a breach of confidentiality might have disastrous social implications.

The physical examination may also be incomplete due to sheer mutual embarrassment.

Some of these “consultations” take place informally at social events – which may seem convenient, but be warned that history-taking and examination are unlikely to be complete because of the lack of time and privacy. There may be no documentation of the clinical findings, which compromises follow-up care. Doctors should be extremely cautious about suggesting or prescribing treatment based on these encounters,and mindful of the ethical and legal implications of such prescriptions.

Perhaps the most obvious problem with treating close friends or family is the loss of professional objectivity, which may compromise even the most experienced doctor’s clinical acumen. A doctor may, understandably, be reluctant to consider an alarming diagnosis in a loved one, or conversely may be so anxious and emotionally invested that he/she over-investigates a minor symptom. Doctors may also be tempted to rely more on intuition than evidence when treating those close to them, and may find it difficult to allocate limited resources impartially.

This is a controversial and frustrating issue, because doctors often believe strongly that they are in the best position to treat those they care about. They may feel personally responsible for the safety of their loved ones, particularly because they are acutely aware of the imperfections of the healthcare system. The problem is that one is often not aware of the extent to which one’s judgement is compromised in such situations.

The relationship between the doctor and a close friend or relative can also be coercive. For instance, a child may feel unable to question a physician parent’s recommendations or to voice his/her distress.

Many of us may turn to our families and friends for support when there is a problem at work; in contrast, the doctor who treats those close to him risks alienating part of his social circle, should there be a poor outcome. His patient may also have limited recourse to legal restitution, due to fear of damaging relationships and/or the social pressure to not take action against the doctor.

Deciding whether to treat someone you are close to

Answering these questions should allow us to better understand the wisdom of the decision to treat a close friend or family member:5

  • Am I trained to address this medical need?
  • Am I too close to obtain intimate history and to cope with bearing bad news if need be?
  • Can I be objective enough not to overtreat, undertreat or give inappropriate treatment?
  • Is my being medically involved likely to cause or worsen family conflicts?
  • Is my relative more likely to comply with an unrelated physician's care plan?
  • Will I permit any physician to whom I refer a relative to treat that relative?
  • Am I willing to be accountable to my peers and to the public for this care?

If doctors decide to take family members or close friends as patients, the hazards of an out-of-office consultation can at least be eliminated by scheduling a formal clinic visit. There should be a low threshold for referral to a colleague should a minor illness become more serious or prolonged.

Sometimes, the doctor may be the best, or the only, qualified person to provide treatment for a loved one.

In these situations, it may be useful to discuss management plans with a colleague and pay particular attention to documentation so as to provide an objective record of clinical findings.

The doctor may find it difficult to refuse requests for treatment from those close to him/her. It is perfectly acceptable to make reference to the ECEG and other guidelines when politely declining to treat someone. Remember that there are other ways to be helpful, such as offering to be present for clinic visits or by texting afterwards to find out how things went. Doctors can be excellent well-informed patient advocates, even if we leave the formal medical care to colleagues who are able to temper compassion with equanimity.

Self-treatment: concerns and consequences

SMC’s guidelines expressly forbid self-treatment for psychiatric issues and self-prescription of addictive or controlled drugs.1 Doctors are permitted to treat themselves for minor or stable conditions and in emergencies,1 but many continue to do so for more serious problems. This may be the most expedient course of action, but it is probably not the safest.

Self-treatment invariably circumvents the rigorous process of history-taking and examination, which can lead to delayed or missed diagnoses. Doctors who self-treat must rely on themselves to prompt lifestyle modifications and ensure adequate follow-up in the management of their own chronic medical conditions. Many of us have also seen colleagues self-administer drugs that they have only anecdotal evidence for (since the privacy of self-treatment means that we do not have to hold ourselves to the same standards as when we treat patients). Doctors cannot remain completely objective when diagnosing or treating themselves, which may not be apparent to them and could result in delays in seeking help.

Some doctors self-medicate because they fear that their licence to practice may be jeopardised by a formal medical diagnosis, particularly of psychiatric problems. However, SMC’s current application form for the renewal of a practising certificate does not demand disclosure of any or all psychiatric and medical history, but only that which may impair performance. It is also particularly dangerous to self-treat for mental health issues because it usually means bypassing psychotherapy and counselling in favour of drugs, which can lead to worsening mental health issues and even substance addiction.

Unfortunately, doctors are also reluctant to both take time out of their own schedules and to bother busy colleagues, and are sometimes even afraid of being ridiculed for asking for help. We need to extend the compassion that we have for our patients to our colleagues, so that doctors are allowed to be patients too. This is a kinder and more effective route than treating ourselves, and it will allow us to provide better care for our patients as well

References

  1. Singapore Medical Council. Ethical Code and Ethical Guidelines (2016 Edition). Available at: https://goo.gl/ss8fRT.
  2. The AMA Code of Medical Ethics’ opinion on physicians treating family members. Virtual Mentor 2012; 14(5):396-7.
  3. General Medical Council (UK). Treating family members. Available at: https://www.gmc-uk.org/ guidance/10247.asp.
  4. La Puma J, Stocking CB, LaVoie D, Darling CA. When physicians treat members of their own families. N Eng J Med 1991; 325(18):1290-4.
  5. La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA 1992; 267(13):1810-2.
  6. Gold KJ, Goldman EB, Kamil LH, et al. No appointment necessary. Ethical challenges in treating friends and family. N Eng J Med 2014; 371(13):1254-8.
  7. Montgomery AJ, Bradley C, Rochfort A, Panagopoulou E. A review of self-medication in physicians and medical students. Occup Med 2011; 61:490-7.