'common Practice of Doctors Treating Their Own Family'
Special Article
When Physicians Care for Members of Their Ain Families
List of authors.Abstruse
Background.
Picayune is known about the circumstances nether which physicians care for family unit members. We sought to examine current practice and, in detail, to learn how often family members request medical intendance or treatment, whether physicians accede to such requests, and what concerns, if whatever, physicians have about caring for their family members.
Methods.
In late 1990 nosotros distributed a pretested, structured questionnaire to all members of the active medical staff (physicians with M.D. or D.O. degrees) of a large suburban community teaching hospital. Of 691 eligible members of the medical staff, 465 physicians responded.
Results.
Of the 465 respondents, 461 (99 percent) reported requests from family members for medical advice, diagnosis, or treatment. A full of 386 (83 percent of the respondents) had prescribed medication for a family fellow member, 372 (eighty per centum) had diagnosed medical illnesses, 334 (72 percentage) had performed concrete examinations, 68 (xv percent) had acted as a family member'south chief attention doctor in the infirmary, and 44 (9 percent) had operated on a family member. In addition, 152 (33 percent) reported that they had observed another physician "inappropriately involved" in a family member's care, and 103 (22 percent) had acceded to a specific request virtually which they felt uncomfortable.
Conclusions.
Practicing physicians oft attend and care for their family members and diagnose their illnesses. They may oft experience some disquiet in doing so. For physicians, complete medical data, proper training, and sound judgment are essential when family members request handling. (North Engl J Med 1991;325:1290–4.)
Methods
In the fall of 1990, the Lutheran Full general Hospital Centre for Clinical Ethics adult a questionnaire designed to determine attitudes and activities of practicing physicians in response to family members' requests for medical assistance. No hospital or medical staff policy governed physicians' medical activities in caring for family members.
The cocky-administered questionnaire, designed to elicit anonymous responses, was pretested and so distributed to 693 active physicians on the medical staff of a big, university-affiliated teaching infirmary in a suburban community. Two of the questionnaires were undeliverable. Later on iii weeks, a second questionnaire was mailed to the physicians who had not responded, and later iii more weeks a tertiary questionnaire was mailed.
In responding to the questionnaire, physicians were asked to indicate which of their family members had asked for advice, consultation, or a second stance; the frequency of such requests; and their responses to them. Physicians were asked if they had always diagnosed affliction in family members, examined them, prescribed medication, provided prescription samples, acted as a main or consulting attending physician in the hospital, performed elective or emergency surgery, administered cardiopulmonary resuscitation, performed a Heimlich maneuver, or given immunizations. Physicians also listed what they considered the "virtually important" diagnosis they had made for a family member and the "virtually important" operation or process they had performed. Physicians were asked if they had ever refused a specific request, if they had acceded to a request that fabricated them experience uncomfortable, and if they had observed another dr. "inappropriately involved" in a family unit member's care. They were then asked to indicate why they had refused or acceded to the request or believed the observed involvement to exist inappropriate. Responses were grouped co-ordinate to empirically derived categories. The questionnaire also included four background items: age, sex, primary professional person office, and number of years in practice.
Statistical analysis was performed with ABC software. Statistical comparisons of grouping means were made with apply of Pupil'due south t-test. The chi-foursquare statistic was used to test differences in categorical variables. Physicians' participation was voluntary, and the confidentiality of their responses was ensured. The institutional review board of the Lutheran General Hospital approved the enquiry protocol.
Results
Of the 691 physicians surveyed, 465 (67 percent) returned completed questionnaires. The historic period (hateful ±SD, 45.7±xi.9 years) and sexual activity distribution of the respondents (81 percent were male) did not differ from those of the infirmary medical staff every bit a whole (P>0.43 and P>0.10, respectively). The number of respondents in various specialties ranged from 6 (for pathology) to 141 (for internal medicine). Physicians had been in do for 1 to 60 years (mean, 14.9±11.5).
Requests by Family Members
4 respondents (ane percent) reported that they had never been asked for medical advice by a family fellow member. Those who were reported as making requests included spouses (reported by 65 per centum of the respondents), children (59 percentage), mothers (50 percent), siblings (44 percent), fathers (43 percent), nieces and nephews (41 percent), and mothers-in-constabulary (forty per centum). Respondents who listed "other" family members (24 percent) were ordinarily referring to brothers- or sisters-in-law, aunts, uncles, and cousins.
Physicians' Responses to Requests
Tabular array 1.
Table 1. Services Provided to Family Members by the 465 Respondents.* Of the 461 respondents asked for communication, 265 (57 percent) reported "nearly always" providing information technology; 174 (38 percent) reported "sometimes" providing it. Physicians' responses well-nigh which services, if any, they provided to family members are shown in Table one. The respondents had performed a hateful (±SD) of 4.4±2.1 (median, 4.two) of the 12 services listed; 386 of the 465 respondents (83 percent) had prescribed medication, 372 (80 percent) had diagnosed medical illnesses requiring treatment, 334 (72 percent) had performed concrete examinations, 68 (15 per centum) had attended a family member as master physician in the infirmary, 32 (7 pct) had consulted in the hospital, 44 (nine per centum) had performed elective surgery on family members, and 17 (4 percent) had performed emergency surgery. Nineteen respondents reported that they had attended family unit members on different occasions as both primary and consulting doctor; xi had performed both elective and emergency surgery. The distribution of family members receiving intendance paralleled that of the family members requesting information technology.
In general, the proportion of respondents who provided services to family members rose with the respondents' historic period and the number of years in practice. Since beginning practice, respondents 45 years of age and older had provided more services (mean, 5.0±2.two) to their relatives than respondents younger than 45 (hateful, four.0±one.viii; P<0.001). Relatives' requests were nearly evenly distributed between older and younger physicians, although fewer older physicians than younger physicians (53 percentage vs. 64 per centum, P<0.05) reported refusing a request.
Physicians' responses were categorized co-ordinate to whether they were in primary intendance specialties (family medicine, internal medicine, obstetrics and gynecology, or pediatrics) or other specialties (anesthesiology, emergency medicine, neurology, pathology, psychiatry, radiology, or surgery). Respondents in primary intendance (n = 312) had performed a mean of 4.9 services listed in Table 1; respondents in specialties other than master intendance (n = 153) had performed a mean of 3.5 services (P<0.001). Although significantly higher proportions of master intendance respondents had diagnosed illnesses (P<0.001), examined family members (P<0.001), or prescribed medication (P<0.005), more than than one-half of the non-chief intendance respondents had provided each of these services. No significant difference was observed between the numbers of respondents in primary care and other specialties who had consulted on a family member's care in the hospital (P>0.25).
Operations and Diagnoses
Tabular array ii.
Table 2. "Most Important" Operation or Procedure Performed on a Family Member.* Xl-three of the physicians who had operated on family members specified what they considered their "virtually important" operations, listed in Tabular array 2. Procedures were most commonly performed on parents (reported past 7 physicians), spouses (seven), children (seven), and parents-in-law (four). Most of the procedures listed do not normally crave general anesthesia; many were dermatologic. Ten of the reported procedures were obstetrical, including six cesarean sections.
Tabular array 3.
Table 3. "Nearly Important" Diagnosis Made for a Family Member.* The respondents recorded what they considered to be their "about important" diagnosis requiring medical treatment. In Tabular array three, the 332 reported diagnoses are shown. The weather diagnosed ranged in severity from actinic keratosis (n = 1) to cancer (n = 27). The family members for whom these diagnoses were made were most often children and spouses.
Of the 391 respondents who answered the question, 188 (48 percent) referred the patient for whom they had made their most of import diagnosis; 82 (21 percent) diagnosed the illness and treated and and then referred the patient; and 121 (31 per centum) diagnosed the illness and treated the patient themselves. Of these 121 respondents, 10 treated family members with trivial medical conditions (e.g., ingrown toenail); 55 treated family unit members with minor medical conditions (e.g., cystitis, pharyngitis, or conjunctivitis); and 38 treated patients with major medical illnesses (e.1000., pneumonia, colon cancer, or asthma). In the 38 cases of major illness, 8 of the patients were children, half-dozen were nieces or nephews, 5 were parents, and 19 were other relatives. One respondent made a surgical diagnosis (abdominal ptosis) and operated on the patient; 17 respondents did non identify their almost important diagnosis.
Physicians' Refusal and Discomfort
Virtually respondents (262) reported refusing a family member'south request for diagnosis or handling; of these, 214 gave a reason. Some respondents (103) reported acceding to a asking about which they felt uncomfortable; 87 of these gave a reason.
Table 4.
Tabular array 4. Reasons for Refusal of and Discomfort with Requests by Family Members. Tabular array 4 shows the reasons given by the respondents for refusing a asking and for acceding to a request even when uncomfortable. The most common reasons for refusing were that the clinical problem was not within the dr.'s area of expertise (34 pct) and that examination and follow-up might be inadequate (18 percentage). Respondents who had acceded to requests that made them feel uncomfortable also cited the inadequacy of examination and follow-upward (23 pct), the absenteeism of a medical indication for the request (20 percent), and their ain lack of objectivity (20 percent).
Of the 152 respondents who had observed a dr. whom they considered "inappropriately involved" in the intendance of a family unit member, 117 reported the circumstances, which savage into iv wide categories. Respondents described individual physicians who had lost their objectivity (not performing procedures needed to investigate serious illness or pursuing care that the respondents considered futile [44 percent]); physicians who had interfered direct or indirectly with appropriate diagnostic or therapeutic measures (29 percent); physicians who had performed medically contraindicated procedures (15 pct); and physicians who had examined or followed family members inadequately (11 percent).
Give-and-take
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 frequently and by whom they were asked.
Family Members' Requests
The services family members request and the services their dr. 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 doc relatives. Conversely, many young children are just given medical intendance by their parents. Although virtually respondents reported requests from their children, we did non distinguish among children's own requests, another parent's requests for them, and the medico parent's ain wish to provide care.
Physicians' Responses
Caring for family members has advantages for patients with minor illnesses, particularly when the physician is in master intendance, although advantages for patients near the end of life have also been described.5 Recurrent problems such every bit conjunctivitis and pediatric pharyngitis are usually pocket-size, take anticipated courses, and may seem too piddling to trouble an unrelated medico about. For all patients, our medical—financial circuitous is best negotiated by a potent patient advocate, conveniently located and readily attainable, who is both altruistic and cocky-interested.
The most important diagnoses physicians gave to family members ranged from piddling 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 "well-nigh important." It is uncertain whether respondents made these diagnoses informally, as knowledgeable spouses (for case, a wife asks her physician husband near a breast lump she has found, which he and so palpates), or formally, as attending physicians (a physician daughter takes her male parent'due south blood pressure regularly, reviewing his age, nutrition, weight, medications, electrocardiogram, and family unit history).
Sources of Discomfort
The central reason for physicians' refusal of and discomfort with requests appears to be missing medical information. Near a third of the respondents mentioned colleagues who appeared to be inappropriately involved in the care of family unit members, describing the care provided as inadequate or contraindicated or reporting the obstruction of other providers' intendance. Respondents inferred that this poor quality of care resulted from their colleagues' closeness to the patient, but this inference may exist 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 than complete assessment of the quality of care.
Our information suggest that along with limiting their agile participation, physicians attempt to limit their emotional involvement in family members' intendance. Setting limits may reflect physicians' recognition of the emotional complication of having dual roles,6 physicians' difficulty in providing reassurance when a serious disease is suspected,2 or the problems anticipated when at that place is a family human relationship instead of a potentially therapeutic doctor–patient human relationship.
Who counts every bit a family member? Respondents listed only relatives, just not all relatives are emotionally close, and some people who are emotionally close are not relatives. Many physicians are devoted to others: friends, lovers, or favorite patients. Medicare's list of "firsthand relatives" includes spouses, parents, children, siblings, stepparents, stepchildren, stepbrothers, stepsisters, children-in-law, siblings-in-police force, grandparents, grandchildren, and spouses of grandparents or grandchildren. Since 1989, Medicare has non paid for patient intendance charges by immediately related physicians, their associates, or their professional corporations.four Bluish Cross—Blue Shield, which has a stricter definition of "family member," has not paid for these charges since 1976.
Is this ethics, etiquette, or merely sound judgment? The bug that arise run the gamut of modern medical ideals: when to alienation confidentiality or turn down treatment; how to obtain informed consent, assess controlling capacity, or provide terminate-of-life care; how to appeal unfair economical constraints or ensure access to care; and whom to consider equally a patient and whom as family. The care of family unit members was formerly part of medical etiquette; professional person courtesy7 was intended to allow physicians to avoid the difficulties of making medical judgments for members of their ain families.
Audio judgment is required on the part of a physician who treats a relative. Considerations include the adequacy of one's medical training to meet a relative's needs; 1's willingness to examine a relative's intimate history, perform a consummate physical exam, and, if necessary, convey bad news; the power to assess signs and symptoms objectively8 , 9; and one's ability to anticipate and negotiate family conflicts. Whether family members will receive high-quality medical care from a related md or whether they would be better off seeing someone else probably depends on the judgment of the doc, the medical urgency of the case, and the availability of medical colleagues.
Our descriptive study of family members' requests and physicians' responses has limitations. Only 465 practicing physicians returned usable questionnaires (for a response rate of 67 per centum); nonrespondents may have had different experiences. Respondents were members of the medical staff of a community didactics hospital; a national sample of physicians in different practice settings should be studied to assess the generalizability of our data. Respondents reported the frequency of requests from family members and their own actions; to verify these responses and to gather data on incidence, interviews with physicians or reviews of medical records might be useful.
These information propose that practicing physicians examine, treat, and prescribe for their family members. The data do not reveal how physicians regard family members' signs and symptoms as compared with those of other patients. The 1901 AMA code suggests that physicians may human activity "with timidity and irresolution," but our respondents diagnosed serious illnesses, prescribed powerful medications, and performed major operations. The clinical contexts of physicians' decisions virtually whether to treat family members, including the acuteness, urgency, and severity of illness and the availability of the necessary expertise are unknown but should exist carefully researched. At the least, physicians need a forum for the give-and-take of the medical intendance of family unit members, since some requests for intendance are troublesome to practitioners.
Other inquiry efforts should address what seems to be the about important clinical question nowadays: How does the doctor–patient relationship affect the quality of care when medico and patient are related? The same question should be asked of doctor–patient relationships that are close but not familial. Taking care of family members begins at dwelling; whether such care should include medical care delivered by a medico relative10 provides many opportunities for further research.
References (11)
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2. Code of ideals of the American Medical Association. Chicago: American Medical Association, 1901:15.
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3. Caveat. In: Opinions and reports of the Judicial Council. Chicago: American Medical Association, 1977.
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iv. Blue Cross and Blue Shield of Illinois. Firsthand relative services excluded. Medicare B Bulletin. Marion: Bluish Cantankerous and Blue Shield of Illinois, Dec 1990:10–1.
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5. Cranford RE. The role of the ideals consultant in personal upstanding dilemmas. In: Culver CM, ed. Ethics at the bedside. Hanover, N.H.: University Press of New England, 1990:194–206.
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6. Freeman DL. . Heal thyself. Ann Intern Med 1991; 114:694.
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8. La Puma J, Schiedermayer DL, Toulmin Due south, Miles SH, McAtee JA. . The standard of care: a case study and ethical analysis . Ann Intern Med 1988;108:121–4
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9. Tumulty PA. . What is a clinician and what does he practise? N Engl J Med 1970;283:20–4.
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10. Spock BM. . Should not physicians' families be immune the comfort of paying for medical care? Pediatrics 1962;thirty:109–10.
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Source: https://www.nejm.org/doi/full/10.1056/NEJM199110313251806
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