I am a junior faculty member in an academic family medicine practice. My colleague informed me that his father, a renowned physician, recently moved to the area. My colleague's father has reviewed my curriculum vitae and would like to establish care with me. Should I accept him as a patient? If so, how should I approach his care?
There may be no higher professional honor than being asked to care for a colleague, a “very important person” (VIP), a friend, or a family member. However, these requests can be problematic if they are not addressed properly. The following strategies can help physicians avoid pitfalls when faced with these situations, keeping in mind that all cases are different, and you must use your best judgment in choosing a course of action.
CARING FOR COLLEAGUES
When deciding whether to care for a colleague, it is important to first consider if you feel comfortable assuming this role1 and if care can be provided objectively.2 As a junior faculty member, you might be uncomfortable caring for a more experienced colleague because of a real or perceived gap in medical knowledge and skill. If you feel uncertain about accepting a colleague as a patient, suggesting that another physician or even another hospital system provide care is appropriate.1
When receiving a request from a colleague for medical care, be wary if the request is informal or takes the form of a “curbside consultation.” Physicians who request nonurgent medical care tend to select colleagues with whom they have a professional or social relationship.3 Prospective physician-patients often do not reveal their complete medical history in curbside settings,2 particularly if the history includes substance abuse or psychological disorders.4 They may also feel anxious or embarrassed about their symptoms and delay seeking care.4 If you accept a request to care for a colleague, it is advisable to arrange a formal office visit at a later date for a complete medical history and physical examination. This approach may become even more important depending on the seriousness of the condition for which the colleague seeks care.
Ground rules for legal, ethical, and financial concerns (Table 11,2,5–10 ) should be discussed early in the physician-patient relationship to avoid misunderstandings.1 After a formal relationship has been established, your colleague may have difficulty adopting the role of patient because he or she must relinquish full control of medical decision making.3 It is important to include your colleague in formulating the treatment plan, but you should still provide formal treatment recommendations.2 You should also offer your colleague the option to obtain a second opinion early in the relationship.4
|Consider whether care can be provided objectively2
|Maintain confidentiality; do not assume that any information can be shared because of a familiar relationship
|State early on that potentially embarrassing aspects of the history or physical examination may need to be addressed to provide optimal care1
|Consider whether to accept gifts, depending on the situation; be aware that inappropriately accepting or declining gifts could damage the relationship5
|Do not allow the location of care to compromise the quality of care5
|For colleagues who request care of their child, clarify their role; encourage them to be the parent and not the health care professional for their child7
|Clarify the cost of care at the outset, as colleagues may underestimate these costs1
|Be aware that professional courtesy (i.e., not charging fees for services) may affect the relationship by fostering a sense of indebtedness in the colleague toward his or her physician2
|Recognize that obtaining payment from a friend or family member establishes a professional relationship8
|Document all encounters in the same way as for patients who are not colleagues, VIPs, friends, or family members; even informal consultations can result in malpractice claims9
|Be aware that some state medical boards prohibit caring for friends and family members10
|Avoid excessive tests and consultations
|Avoid offering special privileges, such as bypassing the office staff or answering service to reach the physician directly
|Set clear expectations that medical advice will be rendered in appropriate settings (e.g., during an office visit)6
|Consider arranging a second opinion
|Strike a balance between overly simplistic and overly detailed treatment recommendations with colleagues1
|Avoid the “chairperson's syndrome” in which medical trainees are excluded from a VIP's care5
|Consider listing “physician's child” in the medical record to alert health care professionals if the patient is a physician's son or daughter 7
|Discourage the practice of ordering tests for one's own child7
Finally, you should strive to strike a balance between avoiding assumptions about your colleague's knowledge of his or her condition and insulting him or her with overly basic information.1 When providing care in this scenario, for example, it can be helpful to ask if your colleague is considering (or has already considered) a diagnosis. This may help alleviate feelings of anxiety he or she may be experiencing, and to gauge the presence of denial if a serious illness is diagnosed.
CARING FOR VIPs
“VIP syndrome” occurs when influential or famous persons, such as politicians and celebrities, receive special treatment as patients. This often happens during inpatient admission, and can involve providing the VIP patient with a private room, granting access to the most experienced physicians, or changing usual procedures to avoid discomfort or inconvenience for the patient.6 Although it is unrealistic to expect that the setting for care will be exactly the same for a VIP as for other patients (e.g., when accommodating the security needs of a prominent politician), medical care must not be compromised as a result.5
Special treatment afforded to VIPs can adversely impact the relationship of the patient with the medical staff, particularly if the person was in a position of power (e.g., a hospital executive) before seeking medical attention, and can lead to a paradoxical increase in the risk of substandard care.2 For example, providing special privileges in the outpatient setting, such as arranging for tests and consultations that would not normally be ordered, and allowing the VIP to contact you directly instead of following established office communication protocols, could compromise care by generating unnecessary workups and delaying treatment of urgent medical concerns.
CARING FOR FRIENDS AND FAMILY MEMBERS
Most physicians receive requests for medical advice from friends or family members at some point in their careers, and many diagnose and treat their friends' and family members' illnesses.11 Similar legal, ethical, and financial implications apply to caring for friends and family members as for colleagues and VIPs. These considerations may be especially pertinent in situations when a colleague is requesting care for his or her child or parent, and has to transition from the more formal role of physician to the more intimate role of parent or adult caregiver.7
You should respect the patient's autonomy and confidentiality, avoid deferring potentially uncomfortable aspects of the history and physical examination, and maintain appropriate documentation. In other words, you should take the same approach to friends and relatives who seek clinical advice as you would with any other patient, making sure to provide them with the same professional expertise and judgment.8
In addition, be sure to set expectations in advance that a professional relationship will be established. You can accomplish this by seeing the patient in the context of an office visit, charging a fee, and maintaining awareness of the inherent conflict between being both a physician and friend or family member.8 If you are not comfortable providing medical advice or taking care of a friend or a family member, it is appropriate to say, “I would feel better if you asked your doctor about this.”8 Finally, it is important to refer to state medical board policies regarding the care of friends and family members. Some states have specific policies that limit or forbid this practice.9