The doctor is (always) in: Treating oneself and one’s familyCategories: President’s Message Comments: 7 comments
Then your son comes up.
“My ear hurts when I touch it.”
A quick exam reveals typical otitis externa.
“You’ve got swimmer’s ear. Not surprising with all the time you’ve spent in the water this summer.”
“Can you make it better? It really hurts.”
The nearest urgent care is more than an hour’s drive. And even if you make the trip, by the time you are done, the pharmacy will be closed. Treating swimmer’s ear is not part of your everyday practice, but it is fairly simple with little potential for complications. You call in some drops to a nearby pharmacy, pick up some ear plugs and the rest of the vacation goes swimmingly (sorry about the pun!)
Did the practitioner/parent in this scenario do the right thing? This was a minor, acute illness that most likely required one-time treatment. The “patient” started therapy faster than he would have if the family had sought medical attention from an unrelated practitioner. It made life easier for several people. I think most physicians and physician assistants would agree that Dr. Mom (or Dad) acted appropriately.
The NC Medical Board would also consider the conduct described above to be generally acceptable. While the Board’s current position statement on treatment of self and family cautions against treating family members, it recognizes that it may be appropriate or even necessary to do so for minor, acute illnesses, and in emergencies. One thing that would improve the encounter described in the example: the creation of a brief note indicating the date, patient’s name, chief complaint, therapy recommended and drugs prescribed. Creating such a record would ensure full compliance with the Board’s position statement.
The Board is currently reviewing the rather awkwardly entitled position statement, Self-treatment and treatment of family members and others with whom significant emotional relationships exist. A Board task force I established to head up this review held a public meeting in late June, during which it received comments and suggestions from interested parties. All position statements of the Board are reviewed on a regular basis in an effort to keep the Board’s guidance as clear and up-to-date as possible. (One of my personal goals for the task force: Come up with a new title that is both clear and concise!)
If you didn’t attend the task force meeting or submit written comments, it’s not too late to tell the Board what you think. Look for instructions on taking a brief, anonymous online survey on treating self and family at the end of this article.
The Board’s licensees confront the possibility of diagnosing and treating immediate family, loved ones or themselves on a daily basis, in situations that often are far more complex than the vacation scenario described in my example. Invariably, deciding to treat someone “in the family” (I use the phrase broadly to include romantic interests, in-laws and perhaps even close friends) raises questions.
Does the personal relationship between practitioner and patient bias medical judgment? Does doing a cursory, one system exam, if an exam is done at all, prevent the patient from receiving more thorough medical care that might uncover other problems? Should it ever be OK to prescribe controlled substances to yourself or to family? Is it appropriate to treat chronic conditions or give preventive care? When treating family, will the practitioner be more inclined to treat outside of his or her area of training/practice and, thus, be more likely to provide substandard care? What happens if there is a bad outcome?
Then, too, there is the problem of over-diagnosis. A colleague of mine recently underwent several biopsies due to a troubling blood test, which turned out to be falsely elevated. My colleague drew the test on himself not because of symptoms, but out of curiosity and expediency. The result was unnecessary cost, discomfort and anxiety.
The answers to these questions, like many things in medicine, are complicated and, to a large degree, subjective. If you ask 10 of your colleagues you are likely to get 10 different perspectives. There is wide diversity of opinion even among the members of the Board. That’s why, when the time came to review the Board’s self-treatment position, I knew a quick and quiet internal discussion would not be sufficient.
About a dozen guests, most of them representing professional organizations for physicians, physician assistants, nurse practitioners and pharmacists, attended the task force meeting at the NCMB’s offices in Raleigh on June 28. The task force will consider their suggestions, as well as comments from readers of this article and the results of the online survey, as it proceeds. The group hopes to present a revised draft of the position statement to the Board no later than November.
I know there are some licensees of this Board that believe —some of them vehemently—that medical boards have no business telling licensed, competent physicians and PAs who they can treat and under what circumstances. But the NCMB didn’t invent this dilemma. In truth, medicine has been grappling with it for a long time.
The American Medical Association first addressed the subject of treating loved ones in 1847 in its initial “Code of Medical Ethics,” which advised the physician against the practice because “the natural anxiety and solicitude which he experiences at the sickness of a wife, a child, or anyone who by the ties of consanguinity is rendered peculiarly dear to him, tend to obscure his judgement and produce timidity and irresolution in his practice.” And you have no doubt heard the famous comment of Sir William Osler (1849-1919), who said, “A physician who treats himself has a fool for a patient.”
The NCMB adopted the original version of its position statement on self treatment in 1991 and it has been reviewed and/or modified several times over the years, most recently in 2005. If you are not familiar with the position statement, it is published below.
As best the Board’s administrative staff can tell, the NCMB was among the first state medical regulatory boards to adopt a formal position on self treatment. But it seems the Board’s thinking was timely. In 1993, the AMA issued its Opinion 8.19, Self-Treatment or Treatment of Immediate Family Members. Like the NCMB’s existing position statement, the AMA opinion cautions against treating oneself or one’s immediate family members, except in certain circumstances, such as emergencies or when no other qualified practitioner is available.
As part of its work to support the NCMB’s task force on self treatment, Board staff conducted an informal survey of medical regulatory authorities to see where others stand on the issue of treatment of self and family. The Board gathered information on about 25 boards.
Some indicated that they rely on AMA Opinion 8.19 as their guideline. Others have their own formal policies restricting or prohibiting treatment of self and family. Prescribing—especially prescribing of controlled substances—is a particular area of emphasis for most boards that have laws, rules, policies or other guidelines. Even boards that indicated they have no formal laws or other policies reported that they have prosecuted cases involving the treatment of self or family. Clearly, this is an active issue for medical boards.
But we already knew that in North Carolina.
The Board’s staff receives calls about the self treatment position statement on a regular basis. Whenever I give a presentation about the Board, I know prescribing to self and family is the one subject I can count on getting questions on. Some licensees are curious about why the position statement exists. Others have noticed disciplinary actions based on prescribing to self or family and want reassurances that they won’t soon see their own names in the back pages of the Forum. Everyone has an opinion on the subject.
Now, I want to hear yours.
I look forward to hearing your thoughts.
Take our survey! Your opinion will be considered as part of the NCMB's review of its existing position statement on treating self and family.
QUESTIONS TO ASK
Researchers suggest that physicians ask themselves the following questions when they are asked to treat family members in nonemergent, discretionary cases:
- Am I trained to address this medical need?
- Am I too close to obtain intimate history and to cope with bearing bad news if need be?
- Can I be objective enough not to overtreat, undertreat or give inappropriate treatment?
- Is my being medically involved likely to cause or worsen family conflicts?
- Is my relative more likely to comply with an unrelated physician's care plan?
- Will I permit any physician to whom I refer a relative to treat that relative?
- Am I willing to be accountable to my peers and to the public for this care?
Source: American Medical Association; La Puma et al, N Engl J Med. 1991;3251290-1294
The NCMB is currently reviewing the position statement printed below. A task force charged with updating this position expects to propose a revised version for consideration by the Board no later than November.
SELF-TREATMENT AND TREATMENT OF FAMILY MEMBERS AND OTHERS WITH WHOM SIGNIFICANT EMOTIONAL RELATIONSHIPS EXIST
It is the position of the North Carolina Medical Board that, except for minor illnesses and emergencies, physicians should not treat, medically or surgically, or prescribe for themselves, their family members, or others with whom they have significant emotional relationships. The Board strongly believes that such treatment and prescribing practices are inappropriate and may result in less than optimal care being provided. A variety of factors, including personal feelings and attitudes that will inevitably affect judgment, will compromise the objectivity of the physician and make the delivery of sound medical care problematic in such situations, while real patient autonomy and informed consent may be sacrificed.
When a minor illness or emergency requires self-treatment or treatment of a family member or other person with whom the physician has a significant emotional relationship, the physician must prepare and keep a proper written record of that treatment, including but not limited to prescriptions written and the medical indications for them. Record keeping is too frequently neglected when physicians manage such cases.
The Board expects physicians to delegate the medical and surgical care of themselves, their families, and those with whom they have significant emotional relationships to one or more of their colleagues in order to ensure appropriate and objective care is provided and to avoid misunderstandings related to their prescribing practices.
*This position statement was formerly titled, “Treatment of and Prescribing for Family Members”.
Created: May 1, 1991 Amended May 1996, May 2000, March 2002, September 2005
The American Medical Association published an updated opinion on treatment of self and family in 1993, as part of its Code of Medical Ethics. An informal survey conducted by the NCMB found that many medical regulatory boards that lack formal policies of their own use the AMA opinion as a guide.
AMA OPINION 8.19 - SELF-TREATMENT OR TREATMENT OF IMMEDIATE FAMILY MEMBERS
Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Physicians may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the physician is an immediate family member. This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients. When treating themselves or immediate family members, physicians may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.
Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their immediate family. Family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician. In particular, minor children will generally not feel free to refuse care from their parents. Likewise, physicians may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care.
It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems. Except in emergencies, it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members. (I, II, IV)
Comments on this article:
the encouragement of professional courtesy would be a great aid to establish thoughtful consideration of the appropriateness of self care or care of the immediate familyBy John D. Wilkinson M.D. on Jul 22, 2011 at 7:06pm
I agree with the statement but want to posit a caveat. If the condition treated is a chronic one requiring periodic follow-up monitoring, such as TSH tests, and renewal of prescription for T4, why should I (an endocrinologist) not be able to render this care for my wife?By Richard A Dickey, MD on Jul 22, 2011 at 10:36pm
I feel physicians are capable of managing common medical problems. They should have freedom to prescribe simple medications for anyone eg antibiotics, antihypertensives etc. Narcotic meds and uncommon toxic therapies should be excluded however.
Also I feel this will save cost substantially to everyone concerned.By victor williams, MD on Jul 22, 2011 at 10:50pm
other situations of self or family treatment that should be consdered Ok with documentation, of course: refills of medications that are not controlled substances, like blood pressure medicationsm that have recently been prescribed by otherphysicians treatming the patients; medication for topical skin treatments for acute bites and allergies, medications that are about to be released into the public domain as nonprescription items like orlistat and zyrtec.By kim masters on Jul 23, 2011 at 7:45am
Another way to look at this issue is that we are trying to reduct the cost of medcine, and encourage people to treat themselves for monor illnesses. Now we appear to be telling physicians that they are not competent even to do that.
Also we should consider allowing physicians to self prescribe for medications that are freely avaiable to the public in MEXICO LIKE SOME ANTIBIOTICS. May be also to refill veterinary medications for ones pet for acute diarrhea or allergy
No doubt these policies are well intended, but they are extremely vague and based on fears of what could happen, rather than on data about actual events. I have heard this debate for over 45 years, but I have never heard of any actual harm from a physician treating self or family. We should be admonished to be circumspect and most careful, but it is difficult for me to envision a circumstance calling for disciplinary action by the Board. I would not prescribe a controlled substance for family, but sometimes other prescriptions are appropriate. Give us credit for having good judgment, and try not to be overly judgmental or controlling.By Phillip J. Walker, M.D. on Jul 23, 2011 at 2:49pm
I replied to the original editorial.By Robert Spencer Howell on Jul 25, 2011 at 10:05am
I agree the Board Should Have a Policy.
I am a pathologist whose internist, a cardiologist, doesn’t believe in statins. He is a part-time herbalist and spiritualist but we like him and have periodic office visits and I see him nearly every day in the cafeteria. Because of my strong family history of coronary artery disease (associated with smoking in my ancestors)and my abnormal Lp(a) I have been taking statins on my own with my doctor’s knowledge as has my wife who has a metabolic syndrome although she is thin. We also go to the gym and use treadmills 5 days per week. I also read Goodman & Gilman in my spare time and take an ACE inhibitor at possibly homeopathic dose levels to protect my kidney function.
I have no DEA license and never wrote a script for a controlled drug.
I believe no one should do so for themselves as well. I run a forensic toxicology lab and would consider suggesting urinary drug screens on a random basis for everyone.
These uses, and the example you quoted in your illustration should be documented in case things don’t work out so the trail of evidence can be picked up.
Its not too much to ask that notes be kept for whatever self-prescribing is done and finally, there should be a real doctor involved in the process who reviews the activities periodically.
Most physicians see value in addressing minor family or self health issues as beneficial, not an injurious or risky practice. As often as we recommend Benadryl for sleep or probiotics for colon health, we may also recommend an antibiotic for a UTI or drops for a conjunctivits. Most physicians are caring, careful, and also expedient practitioners, and to expect that all family members and MDs go to ERs or wait until their regular doctor is available to address something that one can address simply and expediently is unreasonable. Truly, I would not perform my child’s appendectomy, or write controlled substances, but the cautious recommendations to self and family would be as prudent as that made to our own patients. Making policy that is “enforceable” will lead to very unnecessary restriction of practice, which is not a major safety issue in our healthcare system. Do accountants do their own taxes, and construction workers remodel their own homes? Our practice is our trade, but also our conscientious calling.By Rosa E. Cuenca, MD, FACS on Jul 26, 2011 at 6:26pm