Imagine yourself in this scenario: You’ve been experiencing a fever, a cough and shortness of breath for a week, and you think you might have pneumonia. What are you most likely to do:
Order a chest X-ray on yourself;
Curbside a colleague to listen to your lungs and treat you if needed;
See your regular physician.
How do you decide when treatment of yourself, family and friends is appropriate? Do you have a set of guidelines to make these decisions? If so, are you comfortable with them? Our intent is to help you reflect on this issue by increasing your awareness of other physicians’ practices and by increasing your knowledge of ethical and legal guidelines for prescribing for yourself, relatives, friends and colleagues. We hope this adds clarity and comfort to your decision-making process.
Treatment of family, friends and self is widespread among physicians, with antibiotics, antihistamines and contraceptives among the most commonly involved medications.
Once a physician has treated a family member or a friend, it may be more difficult to deny care to that person in future situations.
Ethical and legal guidelines provide some guidance but leave a lot of area open for physician interpretation.
Other factors that might affect a physician’s decision include the need for an exam, the severity of the condition, the requested treatment and the convenience.
To get yourself thinking more about this topic, imagine what you would do in each of the following clinical scenarios and why:
You are on a beach vacation with your family. A relative begins complaining about a toothache, and you suspect he has a tooth abscess. He would like you to prescribe antibiotics. How likely are you to do that?
Your 8-month-old infant has had three days of fussiness and fever up to 102 degrees. You think she has an ear infection. How likely are you to look in her ears and treat her if needed?
You are visiting a colleague who is two weeks postpartum at home. She is breastfeeding and thinks she has a yeast infection. How likely are you to treat her and her baby?
A family member calls from out of state, where she is visiting family. She has a cough and requests a narcotic cough syrup. How likely are you to call this in for her?
Your neighbor does not have health insurance and thinks he has the flu. After a history and an exam, you agree with this diagnosis and think he is dehydrated. How likely are you to give him intravenous fluids at home?
You are at a dinner party, and an acquaintance corners you to ask your advice about some migraines she’s been having. How likely are you to offer your medical opinion?
Treatment of self and non-patients (defined as people treated outside a standard office relationship, usually without documentation) is common practice. Self-treatment has been reported with percentages ranging from 52 percent to 84 percent of physicians.1–5 Treatment of non-patients is even more widespread, with some studies reporting nearly 100 percent of physicians engaging in this practice.5–7 The medications most commonly used in these situations are antibiotics, antihistamines and contraceptives.
Guides for the gray areas
Most physicians are not aware that ethical guidelines on the treatment of non-patients do exist.1 Section E-8.19 of the AMA Code of Medical Ethics (available online at http://www.ama-assn.org/ama/pub/category/8510.html) states that “physicians generally should not treat themselves or members of their immediate families” because their professional objectivity may be compromised in those situations. Exceptions are allowed for “short-term, minor problems” or “in emergency or isolated settings.” The American College of Physicians (ACP) Ethics Manual (available online at http://www.acponline.org/ethics/ethicman.htm) similarly asserts that “physicians should avoid treating themselves, close friends or members of their own families.” It goes on to comment that “physicians should be very cautious about assuming the care of closely associated employees.”
Some state medical boards take these positions a step further. North Carolina requires that the “physician must prepare and keep a proper written record of that treatment,” and the Medical Code of Virginia specifies that “records should be maintained of all written prescriptions or administration of any drugs.”
In addition, some insurance providers, including Medicare and Blue Cross Blue Shield, ban payments for the care that physicians provide for immediate family members, even in an office setting.
Legal considerations and laws should also be taken into account when deciding whether to treat non-patients or yourself. Once a physician begins treatment, a patient-physician relationship is established. From that point on, the physician is liable for the interaction and its consequences. The scope of federal law for written prescriptions is limited to controlled substances. It states that a prescriber must have a bona fide patient-physician relationship, including a written record of it. At a minimum, state law follows federal statutes. However, some states (Massachusetts, for example) further require documenting a medical history and a physical exam before prescribing any medication.
The bottom line for ethical and legal guidelines: Don’t treat non-patients except in cases of minor problems or emergencies. Document what you do. Stay away from prescribing controlled substances.
Of course, this leaves a lot of area open for physician interpretation of each situation. In addition to the ethical and legal issues above, other factors that might affect your decision to treat yourself or non-patients are:
The type of relationship and emotional closeness you have with the person being treated;
Your areas of expertise or training;
The need for an intimate history or exam;
The severity of the condition or diagnosis;
The medication or treatment requested;
What would you do?
Let’s go back to the clinical scenarios listed above. Are your answers still the same? The case involving narcotics should be clear-cut, but the rest fall into a gray area. In these situations, every physician might interpret minor problems and emergencies differently. Here’s how one of the authors, who encountered each scenario, handled them:
You suspect you have pneumonia. The author’s regular doctor was not available. She felt that she could not be objective when dealing with her own care, and she saw a colleague in the office setting. The visit was documented.
Your vacationing relative has a toothache. The author felt that the tooth abscess was a minor problem and decided it was convenient to give her family member an antibiotic when away from home in a somewhat isolated setting.
Your infant might have an ear infection. Though some physicians might feel comfortable treating their child, the author did not treat her 8-month-old. She felt that the emotional closeness of the mother-child relationship might compromise her medical judgment. If this scenario occurred at night or on the weekend, then some physicians might be more willing to treat their children given the convenience issue, though it is important to consider setting boundaries.
In addition, consider whether there are certain family members you would never treat, or others you would treat under particular circumstances. The issue of precedent within the family should be given real thought. If a physician sets up the expectation that family members will be treated, it may be more difficult to deny care. Physicians may want to frankly discuss with their family the circumstances under which they might consider treating them – or simply say that they will never treat family members.
Your colleague thinks she has a yeast infection. This decision could vary depending on a physician’s gender and relationship with the colleague. The author did treat her colleague and the baby because she felt that it was a minor, easily treated problem. However, because treatment might involve examining the breasts, other physicians might have been uncomfortable and declined treatment.
Your family member wants a narcotic cough syrup. No gray area here. As mentioned above, this would violate the law.
Your neighbor thinks he has the flu. Here’s another situation in which a doctor’s circumstances could shape the decision. The ailing neighbor presented the author with a more complicated, higher risk situation. She opted not to treat him at home. However, another physician did treat this non-patient outside the office, and the non-patient improved and was appreciative. The factors that prompted the second physician to do this were the financial situation of the patient and convenience for the patient not having to wait for hours in an emergency room.
An acquaintance seeks medical advice in a social setting. It is a common and sometimes troublesome situation for a physician to be asked for medical advice by a non-patient (or even a patient, for that matter) in a social situation. Rarely does a physician have enough information about the situation to provide specific advice. One might choose to give general information about the medical condition then refer the patient to his or her own physician for more thorough advice. A physician could frame that conversation by saying, “Here are some things you might want to talk about with your physician ….” Or the physician could opt not to give any information, citing ethical or legal reasons why it would be unwise.
In all of the above situations where care is provided, the physician should document what took place, even if the treatment was minor.
Comfort and clarity
Clear-cut answers are rare when someone you’re close to is hurting and you have the power to ease their pain. Thinking about these situations before they pop up can make it somewhat easier to set your personal guidelines. Weigh the ethical questions and opinions with state and federal laws. This will help you make comfortable, well-thought-out decisions. In turn, the clarity and comfort of your personal guidelines can inspire students and colleagues as they form their own approach to these questions.