During the course of a physician’s career, there will be times when he is called upon to take care of a family member. There may even be times when he will actually take care of himself. An article published in the New England Journal of Medicine in 1991 reported that 99% of the 465 surveyed physicians had been asked for medical advice from family members. I was surprised that it was not 100%. That same survey showed that 83% had prescribed medications for a family member, 72% had done a physical exam, 15% actually serve as a family member’s primary care provider, and 9% had actually done an operation on a family member.
I once was called by my wife to meet her at the emergency veterinarian’s office because one of our dogs, a whippet, had run into some lawn furniture and had a large chest laceration. When I got to the facility, the veterinarian told me that the dog would die and she did not have the skills needed to fix the wound. I went to the sink to scrub and my wife advised the vet to let me operate; it would be better for all concerned if the dog were to die in my hands. Luckily, I was able to clean and close the wound. The lung, although visible, was still covered by pleura so there was no lung injury or pneumothorax.
Although this incident was on a canine, not a human, the dog was considered a family member. Would I have done the same thing if I was in a similar situation with my wife or daughters? Of course I would. In an emergency situation, I don’t think anyone would criticize a physician taking care of a family member, but what if it is not an emergency?
When I was doing my residency in general surgery, my father presented to the hospital with acute cholecystitis. When it came time to remove his gall bladder, I planned to scrub on the case; it was my dad and I wanted to be involved with his care. The attending surgeon, one that I had personally asked to take care of my father, took me aside and, gently, told me to sit this one out. Of course, he was right but I was too inexperienced at the time to know it.
Treating oneself or a family member raises some ethical questions relating to maintenance of professional objectivity, informed consent, and patient autonomy.
In medical school, we are told that, in general, it is unwise to routinely take care of family members. For one thing, a family member may not be willing to tell us all of the symptoms and signs because they may be embarrassed. If we need to do a physical exam, we may be unwilling to follow our usual course of care for the same reasons. Without a good history and physical exam, then we may not be giving the family member the optimal care we are able to give.
Of course, for minor injuries, cold symptoms, headaches and the like, it is reasonable to treat until another physician becomes available. When my daughters were growing up, it was a common event for me to treat sprained fingers, small cuts and abrasions, even the occasional sore throat.
The American Medical Association (AMA) has an ethics opinion which addresses this issue of self-treatment or treatment of immediate family members. In the opinion, the AMA states, “Physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems.”
When treating family members and friends, there may come a time where it becomes difficult or impossible to maintain the objectivity needed to provide optimal care. Most advisory opinions state that physicians must treat loved ones and friends just like any other patient that comes to their practice. This means they must take a good history and physical exam and they must have a proper medical assessment—known as a differential and plan, and they must document this in writing in some form of medical records. In an emergency situation, it may not be practical to do the proper medical documentation, but there is no reason that this documentation cannot be done at a later time.
In documenting the encounter with a family member patient, the record should include the chief complaint (the reason for the care provided), the relevant physical exam findings, the clinical impression (a differential diagnosis), a plan of care which may include a plan for future diagnostic testing, and, the identity of other people who may be witnessing the care. Since this record out of necessity may be hand written, it would be wise to write legibly.
In the non-emergent setting, it may be that the wisest action would be help the relative or friend find another appropriate care-giver.
Controlled substances are a totally different scenario and most states prohibit a physician from prescribing controlled substances to themselves, family members, or others that they may have a close personal relationship with unless there is an “immediate need.” In many states, controlled substances can be prescribed but it must be limited to a 72 hour window—this is the case for Texas. For Tennessee, my home state, the physician is precluded from prescribing controlled substances for family members except for emergencies. Since “emergency” is not clearly defined, it would be wise to just not write these prescriptions.
The bottom line is that the physician may treat a family member, close friends, or even himself out of necessity, but, he should transfer that care to another physician as soon as it is practical to do so. Even if care is given out of necessity, state laws may make it a requirement to, at least, take a focused history and perform an appropriate physical exam and document the findings in a written record. Based on the history and physical, a treatment plan should also be documented. In some states, appropriate diagnostic testing may be required. If the physician does not do these things, he may end up having his medical license suspended or revoked. He may also be subject to fines or other disciplinary actions to be determined by his licensing board.
It has been said that a physician who takes care of himself has a fool for a patient. For best care, get another physician to care for family and friends.
Dr. Weiman is the author of two books, Medical Malpractice and Fundamental Issues In Health Care Law.
Dr. Weiman’s website is www.medicalmalpracticeandthelaw.com