Physicians, dentists, and other health professionals rarely talk about when physicians advocate or interfere in their family member’s healthcare. I strongly suspect we have all encountered this emotionally-charged subject. And what is the best way to navigate through issues of providing or advocating a loved one’s medical care as a medical professional?
Ethical Dilemmas Have Always Been a Part of the Practice of Medicine
- Think of a time when you may have been tempted to provide medical care for your extended family member, your own child, or the child of a close friend or relative.
- Imagine a family member who is asking for your medical opinion or advice.
- Consider when your patient has a clinician in the family who is questioning your medical decision-making.
These ethical dilemmas have been a part of the practice of medicine for thousands of years, and continue today to spark conversation and debate.
Physicians Can Advocate or Complicate What’s Best for a Loved One’s Medical Care
Do we treat family members differently than our other patients? You’ve likely heard Hippocrates’ phrase regarding physicians: “First do no harm” (Primum non nocere). Do we always strive to follow this mantra?
The first code of ethics for physicians was advanced by the American Medical Association (AMA) in 1847 based on the work of the physician and ethicist Thomas Percival. In 1803, he wrote:
“Officious interference, in a case under the charge of another, should be carefully avoided. No meddling inquiries should be made concerning the patient; no unnecessary hints given, relative to the nature or treatment of the disorder.”
Treating family members differently than other patients blurs the boundary between our role as an advocate for our loved one’s medical care and our role as a provider. This presents a challenge in our ability to deliver appropriate, confidential, and safe care.
The American Medical Association (AMA) states in its current code of ethics that these physician-family relationships cause problems and should generally be avoided. They also recognize the limited circumstances when it is permissible to provide care.
Pediatricians Change Normal Routines When Treating Other Physicians’ Children
Wasserman published a paper in the journal Pediatrics over 30 years ago entitled “Healthcare of Physicians’ Children.” The group surveyed physicians practicing in an academic center in Vermont on how they handled pediatric care for their own children. They especially noted the relationship between survey respondents as physician parents and the child’s pediatrician of record.
They discovered pediatricians obtained less social and psychologic history of children in physicians’ families, and were less likely to document the data they received in the medical record. Pediatricians also changed the normal routine when these children were admitted to the hospital, and interacted with the families more frequently.
Physician parents were more likely to self-refer their children to subspecialists without notifying the primary pediatrician. An alarming finding was that physician families came in less often for acute care visits and tended to wait an inappropriately long time in ultimately seeking care for their ill children.
Another statement from this paper surprised me. It was the recommendation to add “Physician’s Child” to the patient’s problem list in the medical record to alert providers of the inherent risks and boundary issues that may present themselves in this group.
Can Patients Be Harmed When Physician Family Members Intervene?
In 2012, authors Bramstedt and Popovich published a case report describing interference by medical family members of 2 separate hospitalized adult ICU patients. In both cases, physician family members significantly and negatively impacted the care of a loved one.
One of many thought-provoking points made was:
“Without clear roles for the clinician-relative and the attending physician, there is the potential for patient harm and even resource allocation issues (e.g., unfair allocation, waste of scarce resources). We argue these roles cannot be shared by the same person without interjecting bias (active or passive) into clinical decision-making.”
Best Care Guidelines for Medical Providers When Advocating for Family Members
This paper includes a table of suggested guidelines to help medical providers provide the best care in a highly charged environment. The guidelines state:
- Clinicians should not write drug or procedure orders for their hospitalized relatives. Unless they have authorization, clinicians should not access the medical records (paper or electronic chart), including laboratory or imaging studies, of their hospitalized relatives. History and physical examinations should be conducted without any family members present.
- Patient information should not be disclosed to clinician relatives (or any family member) unless the patient has given permission or unless the patient cannot give permission due to a lack of decision-making capacity.
- The medical team should discuss the clinical situation and treatment options directly with the patient. The clinician-relative should not be a formal medical intermediate or interpreter. Frustrated clinician-relatives should be offered the services of an Ombudsman and/or ethicist, and patients offered a second opinion or hospital transfer (if clinically stable).
- Employ behavior contracts for disruptive family members that explicitly state inappropriate behaviors such as interfering with treatment plans, viewing the patient’s chart, writing orders, etc. Consequences for breaking the contract include restricting visiting hours and supervised visitation (Security personnel present).
Benefits of Having Standards and Boundaries in Place When Advocating for a Loved One
We all have experienced this phenomenon in our practice of medicine. Thankfully, standards, codes, guidance, and boundaries are available to help us navigate this complex and potentially emotionally-charged issue.
Applying these concepts to our own personal and professional relationships requires thoughtful reflection and likely some discomfort. However, there are positive outcomes of doing so:
- There’s the confidence that comes with clarifying and articulating your own values.
- There’s a feeling of competence when using skills necessary to advocate for your loved one as an informed family member.
- There’s a feeling of relief when you refrain from complicating or even jeopardizing your loved one’s care with your own medical treatment or interference by setting boundaries.
Learning these skills and behaviors will help you to practice safer, more complete, confidential care for all of your patients. As promised, here are 5 ways to advocate, instead of complicate, your family members’ healthcare.
5 Ways to Best Advocate For Your Family Members’ Healthcare
- Be honest with yourself about not being able to provide objective care for your loved ones, though it’s tempting to help, or to do it out of obligation and convenience.
- GO ALL IN to advocate for your loved one’s care while still being ONLY a caregiver or support person for them, not their clinician or subspecialty referral contact.
- Create or locate a list of defined boundaries that help you care for your patients who have care providers in their families, then apply those same boundaries to yourself! You may find this to ultimately be a liberating activity for your conscience.
- Be consistent! Use the same standards for safe, patient-centered, timely, efficient, equitable care for ALL your patients.
- Stick to your ideals and values. Don’t be discouraged if you didn’t get everything exactly right.
Your singular approach to living and providing healthcare is what brings meaning and purpose to your life and work. It defines you as the unique human and provider you are!
In a future blog post, I will share the experiences of people for whom a parent was their treating physician or provider growing up and their reflections on how it impacted them. Stay tuned!
Dr. Julie Lindower, MD MPH, is a newborn intensive care doctor at the University of Iowa Stead Family Children’s Hospital in Iowa City, Iowa. She views her work as an intentional effort to help create an environment in which children and their families can be healthy and live meaningful lives. She especially enjoys sharing the vocation of medicine with health professions students, who bring her a sense of hope for our collective future. You can find her on Instagram at @jlindowe.
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