The Risks of Treating Family Members and Staff
Eric Zacharias, M.D.
COPIC Department of Patient Safety and Risk Management
Case Study 1: An ENT physician schedules his wife for a nasal reconstruction procedure that he will perform. Upon learning this, the surgery facility manager calls the physician to discuss concerns about the appropriateness of him performing this procedure. The physician says he is "the best at this surgery in town" and wants to ensure his wife receives top-notch care.
Case Study 2: A rural family practice physician often treats her staff and their family members for free. She sees her medical assistant’s 12-year-old son for an upper respiratory tract infection. The physician opts for conservative treatment and makes no record of the visit. Three days later, the patient presents to the ER with shaking chills and pneumonia. A prolonged hospitalization follows.
ANALYSIS
In the first case, the physician is unaware that his actions represent a concern outlined by the American Medical Association’s (AMA) Code of Medical Ethics1 which state “When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment.”
In the second case, the patient survives but has an expensive and extensive hospital stay. The physician
struggles seeing the medical assistant every day and feels guilty. Six months later, the physician feels the medical assistant's performance is poor, but is hesitant to fire her as there may be a risk of litigation.
BACKGROUND
A classic New England Journal of Medicine article2 highlighted that 99% of physicians had requests for advice, diagnosis, or treatment of family members or friends, and 83% prescribed medicine for a family member. Prominent medical organizations have released ethics statements that medical care can be complicated by preexisting personal relationships. The AMA states that this kind of care should be avoided except in emergency situations or in short-term, minor problems. The American College of Physicians (ACP) Ethics Manual (7th Edition) notes that treating family members, friends, and employees “adds another layer that may complicate what would become the professional patient–physician relationship.” Instead of providing direct treatment in these situations, the ACP recommends that physicians “…could serve as an advisor or medical interpreter and suggest questions to ask, explain medical terminology, accompany the patient to appointments, and help advocate for the patient.”
CONCERNS AND RISKS
Confidentiality—We recognize that in smaller communities, you might truly be the best provider for your staff. But be aware that office records might be easy for a coworker to peruse whether electronically or in a paper form. HIPAA violations might occur. If you are treating employees, then there should be a strong confidentiality policy in place. Your policy should be consistent and well communicated to the whole staff.
Diagnostic reasoning—We practice best in situations when we have the calm diagnostic decision making of a sage clinician. Professional relationships with your patients are usually fiduciary in nature. When you care deeply about someone, this might tilt your clinical acumen one way or the other. A small lymph node after a URI might lead to a lymph node biopsy because of an affection bias, whereas normally, you might have waited three months. Personal feelings may compromise the objectivity of the clinician and make the delivery of sound care a challenge.
Documentation—If you decide to see family members or staff, you should complete the same documentation as you would for any patient. When possible, you should treat the person in the office. If there is an emergency situation, then you should communicate any actions taken with the person’s provider. The natural tendency to “curbside” treat and either not or insufficiently document can result in serious diagnostic oversights, medication and prescription errors borne out of informal and quick assessments, and a minimization of serious illness that could possibly lead to preventable harm.
Embarrassing illnesses—Employees/family members might present with STDs, injuries from abuse, or other ailments that they don't want others to know about. Would you have concerns in dealing with this? Will you be able to perform the complete physical exam necessary with someone you see every day? More importantly, will you ask the necessary questions to properly diagnose and treat the person?
1 www.ama-assn.org/delivering-care/ethics/treating-self-or-family
2 N Engl J Med. 1991 Oct 31;325(18):1290-4.