Observations Yankee Doodling

Doctors treating their families

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g4281 (Published 26 June 2014) Cite this as: BMJ 2014;348:g4281
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, and associate editor, BMJ
  1. dkamerow{at}aafp.org

Common, often harmless, sometimes dangerous and wrong

It began for me when I was a boy in the 1950s. My sisters and I would troop over to the house next door where our uncle, a general internist, jabbed us with the Salk polio vaccine. He wasn’t our regular doctor—we had a pediatrician whom we saw regularly for checkups and ear infections—but we sometimes got our injections from him. In retrospect, I’m not sure why we went there for the shots: Convenience? Vaccine scarcity in the early days of polio immunizations? Low (no) cost?

It continued throughout my childhood. Even though he did not regularly see children, our doctor next door was often where we went for acute illnesses. I remember him treating an ingrown toenail, diagnosing chickenpox, and injecting antibiotics for what was likely cellulitis.

It continues today. I am often consulted by family for medical advice and even care, despite the fact that I am a non-practicing family doctor who only teaches part time. How should I respond?

Medical authorities provide some guidance. The American Medical Association says that “physicians generally should not treat themselves or members of their immediate families.”1 The reasons cited include the doctor’s possible lack of professional objectivity, potential failure to probe sensitive topics or perform an intimate examination, and possible feeling of obligation to perform care for which he or she is unqualified. Also, there is concern about lack of continuity of care, patient autonomy, and informed consent when doctors treat family members.

Other countries have similar policies. The UK General Medical Council’s Good Medical Practice says, “Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship.”2 Canadian authorities state that “physicians should generally refrain from treating themselves or family members.”3

Despite these relatively clear policies against it (more about exceptions in a minute), what little evidence there is states that most doctors do indeed often treat their families. One survey of 465 doctors in a US community hospital setting found that virtually all had been asked for medical advice by family members. More than 80% had diagnosed medical illnesses and prescribed drugs for family. Fifteen percent acted as a family member’s attending physician in a hospital, and 9% had operated on a family member.4

A survey of 492 faculty and staff doctors at a US medical school focused on medical care of their children. Three quarters (74%) reported usually treating their children for non-febrile acute illnesses, fewer for febrile illnesses, and 65% stated they prescribed drugs for their children. When asked why, the overwhelmingly most popular response was convenience.5

Anecdotes about horror stories reinforce the policies against treating family members, especially for serious problems. For example, there is the story about the surgeon who performed major trauma surgery on his grandson, who then died, or tales of plastic surgeons remaking their wives’ appearance as walking advertisements for their skills.6 Yuck.

Most of the policies proscribing physicians’ treatment of their family members do have exceptions, though. Emergencies are clearly an acceptable justification for physician action, no matter what the relationship, as is true isolation, such as during a wilderness trip. But what about urgencies rather than true emergencies? How about relative isolation, such as a family trip to the beach or to a foreign country, where doctors are available but inconvenient or expensive?

Then there are exceptions related to the severity of the problem and the longevity of treatment. The American Medical Association’s policy says that “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.”1 The question, of course, is what is “short-term” and “minor”?

Convenience—either the doctor’s or the family member’s—is unquestionably a major motivator for physicians’ treatment of family members, especially their own children. It is 10 pm, or Sunday, and your daughter has a fever and is pulling at her ear. Or it is Monday morning and your son has a sore throat and a cough and you have to decide whether to send him to school. Do you examine your child and treat accordingly?

I think that treatment of family members is acceptable if four criteria can be fulfilled. Firstly, the complaint and likely treatment are within a doctor’s training and competence. You have to feel comfortable with the problem. Secondly, the problem is acute, minor, and likely to be short lived (fever, sore throat, twisted ankle) or chronic and well known (hypertension needing an urgent prescription refill). Thirdly, the care provided is at the same level of quality as would be performed in the office setting. Thus, you have to have an otoscope at home to diagnose and treat otitis media, and you have to examine the patient before prescribing antibiotics. If you don’t prescribe drugs over the telephone to patients, you shouldn’t do it for your family members. Finally, the doctor (or patient) should ensure that a record of the care is transmitted to the primary care doctor for continuity.

Perhaps our best role with family members is solely as a patient advocate and adviser.7 Sometimes, though, serving as their doctor is probably all right.

Notes

Cite this as: BMJ 2014;348:g4281

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not peer reviewed.

  • DK is a former US assistant surgeon general.

References

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