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.
Have you ever provided medical care to a non-patient family member or friend?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.