There are some situations for which medical school simply doesn't prepare you. Consider Thanksgiving dinner, when Aunt Myrtle buttonholes you about a recurring rash that's been bothering her. Or the sideline consult that one of the parents at your kid's football game wants to have, right after her son lands awkwardly trying to catch a pass.
When you're a physician, informal requests for information are simply part of the conversational landscape. Sometimes those requests are a quick and easy way to help someone out with a bit of information, a simple clarification, or a reassuring affirmation. Other times they can escalate and become annoyances: A simple question can result in a follow-up phone call and more requests. And, in a worst-case scenario, they can present ethical landmines [sic] that may tempt physicians to cross professional boundaries.
How do you address or deflect such requests? Unfortunately, there are no easy answers. It depends a lot on you, your boundaries, and the situation.
The American Medical Association (AMA) Code of Medical Ethics is clear, however: "Physicians generally should not treat themselves or members of their immediate families." The statement goes on to provide an extensive list of good reasons why, including personal feelings that may unduly influence medical judgment, difficulty discussing sensitive topics during a medical history, and concerns over patient autonomy. Black-and-white though that guidance may be, queries from family and friends are often far more opaque. Friends and loved ones don't just seek treatment; often they ask for informal second opinions, help navigating the medical system, help with referrals, interpretation of medical language, or simply factual information, among other things. What's more, while the AMA may discourage doctors from treating their family members, it really doesn't help you deal with Aunt Myrtle as she doggedly pursues your opinion over pumpkin pie.
Hey, Doc, Do You Mind if I Ask You...?
Given the breadth of questions friends and family may ask, doctors simply can't respond with a stock response, says Gregory Eastwood, MD, interim President of SUNY Upstate Medical University, in Syracuse, New York. Rather, you need to be thoughtful and prepared. "This whole area of giving incidental advice can easily escalate," he says. "There's not a clean line between answering a question or giving a piece of advice and taking care of somebody and taking responsibility for their care."
While most doctors are wary of friends' and family members' requests for prescriptions, they may be less attuned to the dangers posed by providing advice. Physicians need to know when "helping out" approaches the point of duty of care, Dr. Eastwood says, which could establish a physician-patient relationship with all of the legal and ethical obligations that go along with it.
Michelle Berger, MD, an Austin, Texas-based ophthalmologist, says friends, family, and casual acquaintances typically ask for her medical advice or help 2 or 3 times a month. "You're out socially or at a party, and if people find out you're a physician, they have questions."
People don't understand the implications of their requests, she says. She recalls one mother who texted her pictures of her son's black eye and couldn't appreciate why Dr. Berger said she couldn't diagnose the child's injury without examining him. Friends are often equally befuddled when she refuses to write them an "emergency" prescription because they've run out of contact lenses. "They don't understand what the laws are. In our state you have to have an exam and a chart in the office and an established physician-patient relationship."
Dealing with out-of-town family members can be particularly challenging, she says. When a relative recently called about a problem another family member was experiencing, Dr. Berger had to explain that without examining the woman, she couldn't diagnose or treat the problem. "I tell them, 'I wouldn't want to do any harm,'" she says. "Most people understand and accept that. You have to be as polite as you can, but you have to know what your personal boundaries are and where you can go and where you can't."
Digging Yourself Into a Hole
Rebecca Jaffe, MD, a Delaware family practitioner, views the matter in practical terms: While answering a quick initial question might be okay, the chances that it will require follow-up questions and information means a simple request from a friend or family member is likely to snowball. "When family and friends come to you, it's usually because they trust your opinion and your ability to navigate this very complex medical system," she says. "There are times I wish I could offer more help, but once you put both feet in the water, it's hard to get yourself out." Instead, she routinely directs advice-seekers to 2 or 3 reliable sources for medical information.
Taking such an arms-length stance can be helpful in some cases, Dr. Jaffe says. "I've had neighbors who say, 'My kid sprained her ankle in a soccer match. Should I go to the clinic or wait it out?' I tell them, 'You're going to need to use your own common sense.' Sometimes -- especially in the case of a non-relative -- that works very well because they don't call a second or third time."
Nevertheless, politely dealing with a neighbor's medical request might be a lot easier than brushing off a family member's. "I try not to give too much medical advice, even to my parents," Dr. Jaffe says. "I see my role as an advocate: to help them synthesize information when they have questions. When my mother calls and says, 'I'm short of breath and I don't know what to do,' I walk her through all the things her doctor has talked to her about: Have you taken your blood pressure and pulse? Do you know how many times you're breathing per minute?
"I'm only reminding her to do what her doctor said, but he said it very quickly along with a lot of other information. By repeating those questions, it helps her distill the information. If she has questions beyond that, I tell her, 'Mom, it's time to call your doctor.'"
Some physicians are reluctant to give impromptu medical advice for fear of potential lawsuits. While Dr. Jaffe admits she sometimes "uses the legal card as an excuse," practically speaking, few doctors face legal consequences from providing friends and family members with advice, says Robert Olick, JD, PhD, an Associate Professor of Bioethics and Humanities at SUNY Upstate Medical University. Although some friends and family might sue over "bad advice," most wouldn't dream of it. That said, Olick cautions physicians to make sure listeners comprehend the limitations of their relationship and their advice. You'll help ensure mutual understanding by adding caveats along the lines of, "I'm not your doctor and I haven't examined you, so I can only offer an educated guess," or "This isn't my area of expertise, and I recommend you talk to your doctor about this."
But lawsuits aren't the only pitfalls doctors should consider. When informally fielding questions, physicians need to be careful not to violate patient privacy. They also need to understand that what may begin as a small request can lead to more intense involvement and situations that can be inconvenient and damaging to the relationship.
Here's an example: One gastroenterologist (who requested to remain anonymous) remembers when a family member asked for his help in securing an appointment with a sought-after specialist for her adult son. He obliged by setting up the appointment, only to discover the son didn't want to see the specialist and resented his mother's involvement. "I made a false assumption that the son wanted the appointment," the doctor recalls, "and then I felt silly in the eyes of my colleague I couldn't help wondering what he must have thought about me. It was embarrassing."
On another occasion, a professional acquaintance asked the gastroenterologist to recommend a primary care physician. He happily passed along the name of a highly qualified doctor. A week later, the same person called, inquiring about a specialist for his wife. Then came a third call and a third request. "I began to feel a little bit used," the doctor recalls. "I was functioning as a primary care physician who was connecting these individuals with specialists, and that was something I really shouldn't have been doing."
Play It Straight Down the Middle
Of course, as the AMA guidelines suggest, the greatest danger of helping out a friend or a family member is that it might impair a physician's judgment or color the nature of the relationship, or the interaction might result in bad medical decisions, says Arthur Caplan, PhD, Director of the Division of Medical Ethics at NYU Langone Medical Center in New York.
"When somebody asks you about a rash at a party, you're not in a diagnostic mode," Caplan says. "You don't say, 'Take off your shirt; I want to see what else you've got.'" It's not wrong for physicians to want to help, he says, but they have to be constantly mindful of what they don't know about a situation. "Never leave a person with the feeling that you've settled the problem simply because you spoke with them at a party or a picnic."
Friends and family members aren't inherently wrong to seek your advice, of course. You're a trusted source, and they're faced with a baffling array of questions. As complex -- and often conflicting -- information propagates the Internet, it's no surprise that they ask for help in deciding what to believe. And as deductibles and copays skyrocket, it's understandable that they seek your opinion before rushing off to their own doctors.
Questions are appropriate and to be expected, Caplan says, but doctors have to wrestle with themselves in determining how to respond if they're to act responsibly and ethically. "When close friends and family ask for medical advice, that's always a matter for introspection, and at the end of the day, it's not resolved by codes of ethics but by considered individual judgments."
References 1. American Medical Association. Code of Medical Ethics Opinion 8.19: Self-treatment or treatment of immediate family members. Issued June 1993. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/ opinion819.page Accessed March 3, 2014. Reprinted from Medscape Business of Medicine, 2013 WebMD, LLC