Several notable medical societies have issued ethical statements discouraging physicians from treating family members and friends. According to the ethical guidelines of the American Medical Association (AMA), physicians “generally should not treat themselves or members of their immediate families.”1 The American College of Physicians (ACP) stated that physicians should “usually not enter into the dual relationship of physician-family member or physician-friend.”2 Although all of the guidelines acknowledge that there are emergent situations in which providing care for a family member or friend is not only permissible but also essential, other situations are frowned upon.
Despite these guidelines, numerous studies have shown that treating family and/or friends is a common practice among physicians.3-6 This includes both a formal patient-physician relationship4 and a more informal structure, such as the willingness to prescribe medications to a non-patient family member or friend.7,8
To shed light on this complex topic, MPR interviewed 3 experts with differing perspectives on the subject.
Physicians Should Not Treat Family Members or Friends
Katherine J. Gold MD MSW, MS, is an Assistant Professor of Family Medicine and Obstetrics and Gynecology, University of Michigan, Ann Arbor, and the lead author of “Ethical Challenges in Treating Friends and Family,”9 published in the New England Journal of Medicine.
Under what circumstances, if any, should physicians provide care to family and/or friends?
Dr Gold: I think that there are few circumstances – other than emergency situations – in which it would be appropriate for a physician to treat a family member or friend, in either an informal or formal capacity.
What do you mean by an “informal” capacity?
Dr Gold: I am referring to situations in which there is no established physician-patient relationship and a relative or friend asks for some type of medical care. Examples would include writing prescriptions, discussing a medical situation, or ordering a test. I am not talking about a very minor situation – you are on vacation and your mother-in-law runs out of blood pressure medication that she has been taking for years. She can’t reach her PCP and you agree to write a prescription for enough medication to tide her over until she gets back. That is different from diagnosing her with hypertension and writing a prescription for her, or stepping in if her own PCP is available.
What are some of the concerns about other types of of “curbside” consultation?
Dr Gold: You do not have an established physician-patient relationship. You likely will not perform a physical exam because it might be awkward. You don’t have the patient’s medical records. You may not be comfortable asking basic questions, such as inquiring about the friend’s use of substances, which may be relevant if you are prescribing a medication.
Another issue is that the treatment provided in these settings will not necessarily be documented in the patient’s record or communicated to the patient’s primary physician, which can have repercussions for the patient’s ongoing care.
One study of physicians’ informal prescribing found that physicians most frequently prescribed antibiotics to family and friends, but some also prescribed controlled substances such as opioids, stimulants, or benzodiazepines. This can have legal implications and also impede follow-up, which don’t necessarily take place in this type of informal setting.
Do these issues apply in cases of formal relationships as well?
Dr Gold: Some of them do. For example, it may be difficult to have discussions with family members about sensitive subjects such as sexual behavior or drug use, even if the person has a formal physician-patient relationship with you.
Are there other concerns in having a formal physician-patient relationship with a family member or friend?
Dr Gold: There are several. The relationship with the patient can interfere with the physician’s objectivity and impede good clinical care. The physician is more likely to have an emotional investment that can cloud his or her judgment.
I recognize that in a very small town, you may be the only physician for miles, or the only specialist in your field. But if there are other physicians available, it is preferable for your family member or friend to see one of them.
Additionally, if something doesn’t go as expected, or we make a mistake, it doesn’t only affect the physician-patient relationship but also the outside family or social relationship.
And the physician might feel a higher level of guilt if something goes wrong with family or friends than with other patients. I’m surprised how many people have said, “I’m a physician and part of the perk is that I can treat my child or spouse if I have to.” Or, “If I’m the best person to treat this condition, I should provide the care.” But if the care does not go well – for example, if the physician’s child had a major bleed or a friend had a complication – how would that physician live with the guilt afterwards?
What do you think is the appropriate role for a physician to take vis-à-vis family and friends?
Dr Gold: I think the best role is to be an advocate for a relative or friend who is ill – for example, to provide information or explain the condition to the patient, or participate in the decision-making process if the patient wishes, or perhaps speak to the patient’s physician if the patient is comfortable.
Physicians Can Treat Family Members or Friends
Antonio Abbate, MD, PhD is the James C. Roberts, Esq. Professor of Cardiology in the VCU Pauley Heart Center and vice-chair of the Cardiology Division in the Department of Internal Medicine, Virginia Commonwealth Univeristy, Richmond, VA. He is the author of “Ethical Challenges in Treating Family and Friends,”10 a comment in response to the article by Gold et al.
What are your perspectives on treating family and friends?
Dr Abbate: I think there are cultural differences in the approach to this issue. In Italy, where I come from, it is very normal to treat family members and friends. In fact, it’s not only normal, but also expected. In fact, in medical school, we were told to treat our patients as if they were our parents. This strikes me as a paradox, because how can we follow that if we can’t treat our parents?
When I came to the United States, it was a cultural shock to encounter opposition to treating family and friends. I have spent a good deal of time talking with colleagues and examining this issue and have come to the conclusion that there is no “right” or “wrong” answer to this, just different ways of looking at the same complex problem.
Do you think physicians should offer medical care to relatives or friends who are not their patients?
Dr Abbate: It is a common scenario that people ask each other at parties or other social gatherings about their professions and sometimes seek advice. “Oh, you repair roofs? My roof might need repair.” Physicians get plenty of these types of questions. I think it is okay to chat about medical issues, so long as you are not giving specific recommendations or writing prescriptions. Writing prescriptions for someone who is not your patient is unsafe and perhaps should even be illegal. But these informal settings can be great venues to advocate for healthy living, screenings, and similar things.
Do you think physicians should accept relatives or friends as patients?
Dr Abbate: I do not see a problem in doing this, but I think that there must be a real doctor-patient relationship. Treatment should take place in the office, not in other settings, and there should be a chart involved, documentation, follow-up, communication with other family members if appropriate, and all the formal structures that would apply to any other patient. This puts both people in a right framework and offers legal protection as well as appropriate clinical care.
Do you think that treating relatives or friends impairs a physician’s objectivity?
Dr Abbate: I think that it is possible to lose objectivity with many people, not only family and friends. The moment we enter the exam room and see the patient, we may have a bias about their lifestyle, characteristics, or preferences, perhaps unconsciously. Theoretically, that could put our diagnosis or treatment plan at risk. But as good physicians, we learn to take those biases into account and challenge them to arrive at a solid diagnostic approach. In the end, the literature on ethics is clear that physicians have the ultimate say in what they are and are not comfortable with. If they feel they cannot be objective, they should feel free to say they cannot care for the patient, whoever that patient might be.
I want to clarify that I am not saying that every doctor should be comfortable taking care of family members or friends, or that there may never be loss of objectivity. This is where you have to decide if you have confidence in your professionalism and objectivity. If you are concerned, then you should not treat that patient.
Do you think that physicians may be inhibited about asking intimate questions of a family member or friend?
Dr Abbate: If you feel uncomfortable asking questions about sensitive subjects, this is a clue that you should not be treating that patient.
What if something goes wrong when treating a family member or friend?
Dr Abbate: When I was being trained to practice medicine in the US, one of my supervisors told a story of a surgeon whose son had appendicitis and although the surgeon was equally qualified to operate, he asked his partner to do so because he did not want to operate on his own son. Sadly, the child died. My supervisor used this story to illustrate why it is not a good idea to operate on one’s own child. He said, “Think of how overwhelmed with grief and guilt the surgeon would have felt if his child had died during surgery that he himself was performing.” The surgeon would feel grief either way, but perhaps the surgeon felt guilty that he wasn’t the one personally performing the surgery and had instead given the care of his child over to someone else.
Kenneth Prager, MD, is Professor of Medicine, Director of Medical Ethics, and Chair of the Medical Ethics Committee at Columbia University Medical Center, New York, NY.
Do you think that it is acceptable for physicians to offer medical care to family and friends who are not their patients?
Dr Prager: I don’t see a problem in the case of very simple or relatively minor situations—for example, if a relative or friend calls me or one of my children has a chest cold and needs an antibiotic. But I would not do so in more complex or serious situations.
What about having a relative or friend as a patient?
Dr Prager: It depends on many variables, such as the nature of the relationship and the personalities of the people involved. I was the primary doctor for a number of my friends and it did not seem to be problematic. But in some cases, it can be a little more emotionally taxing, especially if the person has a serious illness. I can see where those emotions could interfere with a more objective assessment of the situation. Serving as a person’s primary internist and being the quarterback is one thing, but in the event of chronic illness, emotions can get involved and the friendship can become a hindrance. For example, if I were an oncologist, I would not want to treat one of my friends for a malignancy. But if I am an internist, conducting an annual checkup for hypertension or diabetes, I don’t see many emotionally demanding or sensitive issues that might interfere.
I do draw a distinction between treating friends – even close friends – and relatives, especially immediate family. Other than something very routine, I think it is not a good idea.
Would you feel inhibited about asking sensitive questions of your patient if he or she were a friend?
Dr Prager: I could see where asking about sexual practices might be problematic in treating a friend, but much depends on the personality of both the doctor and the patient. But I could certainly see bringing up subjects such as weight or alcohol use and even end-of-life care with a patient who is also a friend. In fact, it could even be more effective than if a different physician were raising these issues. A friend might take advice more seriously from me as a good friend than from another physician he or she feels neutral about or dislikes. Obviously this doesn’t mean that people don’t love or trust physicians who aren’t friends, only that sometimes, the word of a good friend can carry extra weight.
Ultimately, I think it is a nuanced issue and the statement of the AMA appropriately can’t be a nuanced declaration. Perhaps it’s not always a good idea to have friends as patients if there are alternatives. But there are exceptions in which a physician whose friend is a patient can offer excellent care, and good, effective communication.
- American Medical Association (AMA). Treating Self or Family. Code of Medical Ethics Opinion 1.2.1. Available at: https://www.ama-assn.org/delivering-care/treating-self-or-family. Accessed: May 25, 2018.
- Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012 Jan 3;156(1 Pt 2):73-104.
- Dusdieker LB, Murph JR, Murph WE, Dungy CI. Physicians treating their own children. Am J Dis Child. 1993 Feb;147(2):146-9.
- La Puma J, Stocking CB, La Voie D, Darling CA. When physicians treat members of their own families. Practices in a community hospital. N Engl J Med. 1991 Oct 31;325(18):1290-4.
- Evans RW, Lipton RB, Ritz KA. A survey of neurologists on self-treatment and treatment of their families. Headache. 2007 Jan;47(1):58-64.
- Reagan B, Reagan P, Sinclair A. ‘Common sense and a thick hide’. Physicians providing care to their own family members. Arch Fam Med. 1994 Jul;3(7):599-604.
- Strong C, Connelly S, Sprabery LR. Prescribing for co-workers: practices and attitudes of faculty and residents. J Clin Ethics. 2013 Spring;24(1):41-9.
- Gendel MH, Brooks E, Early SR, Gundersen DC, Dubovsky SL, Dilts SL, Shore JH. Self-prescribed and other informal care provided by physicians: scope, correlations and implications. J Med Ethics. 2012 May;38(5):294-8.
- Gold KJ, Goldman EB, Kamil LH, Walton S, Burdette TG, Moseley KL. No appointment necessary? Ethical challenges in treating friends and family. N Engl J Med. 2014 Sep 25;371(13):1254-8.
- Abbate A. Ethical challenges in treating friends and family. N Engl J Med. 2014 Dec 18;371(25):2436-7.
This article originally appeared on MPR