By J.L. Puma, C. B. Stocking, D. LaVoie, and
New England Journal of Medicine, October 31, 1991
STORIES have been told about physicians who treat their own family members, but to the best of our knowledge, this practice has not been studied. Family members may benefit; they may avoid the inconvenience and expense of an office visit and gain an especially caring, available expert who is able to interpret medical language and help them maneuver through medical systems. Physicians may also benefit; accustomed to caring for patients and surrounded by books, tools, and pharmaceuticals, they may consider attending to ill family members a natural and rewarding opportunity.
Ethical questions have been raised, however, about physicians who treat members of their own families. McSherry found incomplete physical examinations, medical records, and immunizations to be undesirable consequences of physicians' treating their own children.1 The 1901 code of ethics of the American Medical Association (AMA) noted that a family member's illness "tends to obscure [the physician's] judgement and produce timidity and irresolution in his practice."2 In 1977, a revised admonition was dropped by the AMA with other "outmoded matters of medical etiquette."3In 1989, fearing financial abuse by unscrupulous providers, Medicare barred payment to physicians who care for "immediate family members."4
In this study, in an attempt to understand current practice, we asked these questions: Which family members request advice, diagnosis, or treatment? How do physicians respond to such requests? Which, if any, requests make physicians feel uncomfortable? And under what circumstances do physicians refuse requests from family members for medical assistance?
(Jump to the discussion)
To understand current norms, we gathered empirical data on which family members ask physicians for advice, diagnosis, or treatment and how physicians respond to these requests. We also attempted to understand the dilemmas inherent in this practice. In general, physicians reported providing services to relatives in proportion to how often and by whom they were asked.
Family Members' Requests
The services family members request and the services their physician relatives offer are probably different. Family members may request care that requires a complete history and physical examination, new knowledge, or facilities that are unavailable, thus sometimes embarrassing and frustrating their physician relatives. Conversely, many young children are simply given medical care by their parents. Although most respondents reported requests from their children, we did not distinguish among children's own requests, another parent's requests for them, and the physician parent's own wish to provide care.
Caring for family members has advantages for patients with minor illnesses, especially when the physician is in primary care, although advantages for patients near the end of life have also been described.5 Recurrent problems such as conjunctivitis and pediatric pharyngitis are usually minor, have predictable courses, and may seem too trivial to trouble an unrelated doctor about. For all patients, our medical—financial complex is best negotiated by a strong patient advocate, conveniently located and readily accessible, who is both altruistic and self-interested.
The most important diagnoses physicians gave to family members ranged from trivial to grave. The breadth of these diagnoses and the relatively narrow range of operations performed suggest that personal, psychological, and familial factors contributed to the assessment of "most important." It is uncertain whether respondents made these diagnoses informally, as knowledgeable spouses (for example, a wife asks her physician husband about a breast lump she has found, which he then palpates), or formally, as attending physicians (a physician daughter takes her father's blood pressure regularly, reviewing his age, diet, weight, medications, electrocardiogram, and family history).
Sources of Discomfort
The central reason for physicians' refusal of and discomfort with requests appears to be missing medical information. About a third of the respondents mentioned colleagues who appeared to be inappropriately involved in the care of family members, describing the care provided as inadequate or contraindicated or reporting the obstruction of other providers' care. Respondents inferred that this poor quality of care resulted from their colleagues' closeness to the patient, but this inference may be scientifically unjustified. Comparative process and outcome evaluations of care provided to patients who are family members and to those who are not would permit a more complete assessment of the quality of care.
Our data suggest that along with limiting their active participation, physicians attempt to limit their emotional involvement in family members' care. Setting limits may reflect physicians' recognition of the emotional complexity of having dual roles,6 physicians' difficulty in providing reassurance when a serious illness is suspected,2 or the problems anticipated when there is a family relationship instead of a potentially therapeutic doctor–patient relationship.
The entire article can be read here.
Thanks to Gary Schoener for this information. Our Ethics Committee is currently working on a vignette that relates to this article.