- 02:52 The tension, the push and pull
- 05:45 Prevalence
- 06:33 Stances of societies/professional organizations
- 08:20 Concerns
- 10:31 How to respond
- 17:53 Favors for physician/trainee colleagues, self-doctoring
- 22:27 Formal vs informal, documentation
- 23:57 Long-term care
- The tension, the push and pull
- Stances of societies/professional organizations
- Reframing the whole discussion: Goal is to ensure best care for this person
- May get in the way of them having a dedicated physician
- Loss of objectivity
- Not full information: medications, delicate parts of the history
- How to respond
- Finding “the line”
- Determining risk level
- Clear times to decline
- Consider that there are limited times where it makes sense
- Make sure they are getting healthcare
- Finding confidence through being their advocate
- Other considerations
- Favors for physician/trainee colleagues, self-doctoring
- Formal vs informal, documentation
- Long-term care
Tamar: Welcome back to At the Bedside. In today’s episode, we’re hoping to explore a set of scenarios nearly every clinician, and many healthcare trainees, have experienced: We want to talk about the challenges that come up when friends and family ask for medical care or even just medical advice. I’m Tamar.
Margot: I’m Margot
Jafar: And this is Jafar
Tamar: We’re lucky to have with us today Dr. Erik Fromme, a palliative care physician at the Dana Farber Cancer Institute. He is also faculty at the Serious Care Illness Program at Ariadne Labs a joint center for health systems innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. Dr. Fromme’s research and publications on this helped us think about real practical approaches to these scenarios. And we asked him how he became interested in the topic.
Fromme: This was at the society of general internal medicine.. I was talking with some colleagues about our experiences, um, uh, as family members getting healthcare… we all found, uh, that we’d had experiences like this in healthcare. And we thought, you know, there’s really not any good guidance around this. So we decided to kind of put our heads together and combine our experiences. And, you know, my experience was very, uh, negative. I felt like I really failed my wife.
Tamar: Dr. Fromme was especially gracious in allowing us to share his personal experience discussed in a 2008 paper in Annals of Internal Medicine. He writes of a particularly difficult and tiring day attending on the medicine wards, when he received a call from his pregnant wife saying she was spotting. They both thought was another miscarriage. When she had abdominal pain that night, he examined her and told her it was probably cramping, though she said the pain was different. She went to see an obstetrician the next morning, and was diagnosed with a tubal pregnancy requiring surgery.
Fromme: I couldn’t, I sort of couldn’t really get myself to, uh, gosh, I was, I, I was that doctor who was impaired and didn’t know it and made some bad decisions that fortunately my wife was bright enough to not make, and she managed to get herself good care, but it was, you know, it was a near miss event that left me kind of shaken and realizing that I needed to learn more about this in order to not compromise my family’s healthcare in the future.
Tamar: While not all scenarios of being involved in a loved one’s care are like Dr. Fromme’s, we want to discuss the wide spectrum of interactions that fall into this bucket, and how they each bring their own dilemmas. As we explore this topic, we’ll review just how prevalent it is among clinicians, and the guidance we have from professional societies. Then, with Dr. Fromme’s help, we’ll spend most of the episode unpacking how we can actually approach these situations.
The tension, the push and pull
Jafar: Ok, before we begin, let’s start off by defining the issue–we want to help the people in our lives when they come to us with medical questions and requests, but we know there should be probably some limits. And right off the bat I’m going to start with an admission–when I was in medical school, I really liked the idea of playing doctor to my friends and family. I thought, wow, I’m gonna have all this critical knowledge at my fingertips, I could be a really great resource for them. And it wasn’t until I got a little more maturity and humility that I started to really appreciate the responsibility I was taking on in trying to do that.
Fromme: In an effort to help you can make things worse, whether or not you have a medical degree. I think when you have a medical degree because of the status and access and privileges that go with that, the risks are higher because you have more power in the healthcare system.
Jafar: Still, it’s really hard to just put away that doctor part of me. Like, when someone in my life asks for a favor or some advice, do I just throw up hands and say I can’t get involved?
Fromme: There’s some potential disadvantages of trying to pretend that you’re not a doctor too. One is that we have status within the healthcare system, and we can use that, and you could say, well, that’s not fair or equitable, but it’s status that we spent like decades earning. And so trying to help a family member find the best doctor for them sort of navigate their way through the healthcare system. I think just saying, well, I don’t want to be involved in your healthcare in that way is not necessarily the best solution.
Jafar: Look, the bottom line is that I just never want to turn down a request for help. And yes, I know taking on the doctor role to my friends and family may be less than ideal, but if we’re being honest here, nothing in our current system is ideal. Sometimes I want to take ownership of my loved one’s care because I’m not sure I can trust that someone else will be as attentive to them and follow through on what they need.
Fromme: We work in a broken healthcare system and when our family members are sick, it doesn’t benefit us to pretend that that’s not the case. If we could be confident our family members would get consistently high quality of care in a health system that recognizes them both as sort of unique individuals with values and goals, and as well as part of a family and part of a community that was free of racism or gender bias and where significant errors were really rare, then I think asking us to keep our noses out of their healthcare would be perfectly reasonable, but of course it’s not, that’s not the case. And so, we do need to be involved and try to be helpful where we can.
Jafar: Ultimately, we can’t ignore our immense potential to help those around us in their medical needs. The real question is where and how we apply our expertise.
Tamar: First of all, we wanted to normalize this. Studies have shown that the overwhelming majority of clinicians have received requests from family members for treatment or prescriptions, or even just advice on care or diagnosis. And this has been the case for a long time. In fact, about 30 years ago, La Puma and colleagues published a survey of physicians in a large community teaching hospital in the New England Journal of Medicine. They reported that among the over 450 physicians that responded, 99% had received such requests. 83% had provided a family member with a prescription and 80% had provided a diagnosis. So if you’ve been in this situation, and maybe even felt you were unsure of what to do, know that you’re far from alone.
Stances of societies/professional organizations
Margot: Several professional societies have issued guidelines on this topic – let’s talk about the guidelines put out by the American Medical Association and American College of Physicians. The American Medical Association generally recommends against treating friends and family. The first problem they point out is that physicians might feel too awkward to ask personal questions or perform sensitive exams. Second, physicians might feel obligated to help out with medical questions outside their area of expertise. And on the other side of the equation, the patient might not feel comfortable getting a sensitive exam, or disclosing sensitive information. The AMA does say it could be appropriate to treat a loved one in an emergency or for minor, short-term problems, but it encourages physicians to document the care they provide. The American College of Physicians also cautions that it’s tough to stay objective when treating a loved one, and they warn that it can lead to overtesting, inappropriate prescribing, and incomplete medical records. They recommend acting as an ally, accompanying the patient to appointments, helping them understand the nuances of the choices in front of them, and advocating for the patient.
Reframing the whole discussion: Goal is to ensure best care for this person
Fromme: The key question is, you know, how does your family member get the best care? And does that happen with you playing the role of physician or a family member? The other considerations are, you know, what is the impact on your relationship with your family member and what is the impact on the relationship between your family member and their healthcare team?
Margot: We’re going to spend the rest of the episode talking about how to approach these conversations, but Dr. Fromme’s advice was always built on this key question: how does your loved one get the best care?
Tamar: So when does getting involved help your loved one get the best medical care? And when does it get in the way? There are a few concerns that Dr. Fromme raised other than the ones in the professional guidelines Margot just reviewed.
Fromme: Think about this as the spectrum, and you could respond more from your role as a physician or more as your role, um, as a, uh, as a family member. So if you respond, um, from your physician role, the, the concern is that you may be interfering with your family members need or even ability to establish strong relationships with their own health care professionals. Like if they can get what they need from you, then they don’t have to go somewhere else.
Loss of objectivity
Tamar: And there is a very real chance we’re not able to provide the same type or level of care to our loved ones that we would to another patient, simply because our relationship with them outside the typical clinician-patient relationship makes us less objective.
Fromme: How do you avoid the pitfalls of lost objectivity when if you’ve lost it, you’re already impaired. And I think, um, you know, one of my colleagues who was a coauthor on the paper, Neil suggested the question could I do this if I didn’t have a medical license? And I think that’s a decent question to ask whenever you’re meddling, because the, the potential risk, I think, goes up the more you do things that normal family members don’t or can’t do.
Not full information: medications, delicate parts of the history
Tamar: And then, of course, there is just the plain fact that if we provide care or advice outside the normal framework, we may not be working with all the information. Gold and co-authors discussed some of what we could be missing in a 2014 New England Journal of Medicine paper. When trying to help our family or friends, we may not be aware of their full medical or social history, or a full list of medications. And that’s a situation that would make us pretty uncomfortable with any other patient. The nature of the relationship may also actually make us less likely to give our loved ones the same opportunity for real informed consent or shared decision making that we would give to someone we see in a clinic appointment.
How to respond
Jafar: Ok, so to sum it up, if I’m trying to work around conventional care to treat my friends and family, there’s so many ways for it to go wrong, even with the best intentions. It’s still hard, though, to know how to respond in these situations, so we wanted to take some time here to explore how to do that successfully.
Finding “the line”
Fromme: You know, friends and family members will throughout your career, come to you for help. And how do you respond? What we learned was that you can respond, um, anywhere on a continuum of sort of being a physician versus being a friend or a family member. And the most helpful response can come sometimes from anywhere along that continuum. I think what we discovered was that there was a line we just ended up calling it the line and we knew it was there. We weren’t exactly sure where it was or should be.
Determining risk level
Margot: While it’s often clear where to draw the line, realistically most of these situations will exist in kind of a gray area. One way to figure out how to navigate the situation is to think about how much risk is involved.
Fromme: That’s where we sort of came up with this question of the line and like, where’s the line and where do you draw it? I think it was hard for us to give a straightforward answer to that question. And the tack that we took instead was to try to identify what was a, a higher versus a lower risk, sort of crossing of the line. And for example, we figured it was a much higher risk to tell somebody who was having symptoms, Oh, you don’t need to worry about that. It was a lower risk to recommend that they see a health professional about their problem. It was a lower risk to give them sort of self-care advice like, well, this is how you take care of a sprain, you know, rest ice compression elevation, or something like that. It was higher risk to say, Oh, well, maybe you should try this medication that works really well.
Margot: Dr Fromme and his co-authors have developed a table that splits different activities into low, medium, and high risk categories, which we’ll include in the show notes
Clear times to decline
Jafar: It can be easy to argue back and forth on how much one can justify, so it might be easier to start from the kind of requests you should definitely NOT get involved with.
Fromme: If they’re looking for a controlled substance or a new medication that’s outside the scope of your practice, I think it’s easy to say that’s a hard, no, and that’s a boundary that you shouldn’t compromise, really probably for any reason. What I tend to say is, I’m not allowed to prescribe that for you, which sort of combines both the legal and professional boundaries that exist.
Consider that there are limited times where it makes sense
Jafar: Even when it’s much lower risk, we really have to be clear about the cost/benefit ratio in the care we try to provide to friends and family. Many times, if we’re being honest, the main benefit is just convenience, but there are many hidden costs in doing that.
Fromme: I would say in general, if the issue is simply one of convenience, then it’s, it’s really not. It’s not a good time to pull out the prescription pad because at a minimum you are preventing them from sort of establishing care with their personal physician or with their healthcare system. It’s so hard to find and establish a relationship with a personal physician, which is what we think everybody should have. I think it’s okay for us to set a boundary like that. And some families will need to have that boundary set and explained to them and I think that’s okay that your intention is that they get the best care possible.
Jafar: But there are occasionally some circumstances that can justify acting as a doctor with our friends and family–typically when the cost of access is really high. This can include emergencies and providing first aid, and situations involving care in rural areas – where severe shortages of clinicians inevitably bring us into healthcare relationships with people we know personally. This can also include situations where again healthcare access is difficult, and the risk of intervention is very low:
Fromme: So uh, for example, I had a, uh, my wife asked me to refill a prescription for one of her friends who was visiting from overseas, who got stuck here because of the coronavirus there travel back to Asia was delayed by three weeks and he was going to run out of his blood pressure medication. He was doing fine. He wasn’t having any medical problems. He’d been on this medication for a long time, and I didn’t see a lot of downside to, uh, giving him a prescription for his amlodipine. Although it was a matter of convenience the level of risk was very I went ahead and I did that. So, I guess that, you know, the tricky thing is how should one respond is not such a straightforward question.
Make sure they are getting healthcare
Margot: Whether you end up in the role of a friend, family member, or physician, remember that the care you’re providing isn’t quite what they’d get from a standard medical encounter. Healthcare involves a lot more than just a patient and a clinician.
Fromme: If someone wants, you know, medical advice, I would recommend telling them, I’m happy to help you think through this, but I really want you to see a real doctor, if they haven’t yet. If they’re already, seeing a doctor, then I just would emphasize I can help you think through this, but afterwards you should be going back to your doctor for care, because what we’re providing is not healthcare. You know, we’re just a person with some medical experience and knowledge. Healthcare entails a whole group of professionals labs, diagnostic studies, a thorough history and physical exam, a medical record, as well as billing and all that stuff.
Margot: Ultimately, your loved one is probably going to get the best care if they have an established relationship with a doctor. Here’s a question to ask yourself when you’re asked to get involved: is the care that I provide going to get in the way of the healthcare they should be getting?
Finding confidence in responding as their advocate (instead of their doctor)
Jafar: Ok, so even when we determine that we want our friends and family to have full healthcare, and we know where the line is that we don’t want to cross, how do we go about talking to them about holding that boundary? It helps me to know that even if I’m not their doctor, I can still be their advocate–you know, my response to them is still: “yes, let me help you with this problem.”
Fromme: Remember that you can feel confident responding as a well-informed family member. You are their friend or their family member, and you should feel unencumbered about doing things that friends and family members do for each other. And you can add the benefit that you have some medical knowledge that may or may not be, I mean, now that we’re so specialized, it may or may not be relevant. I think the real value of what we can bring is we can help them think through their problems and interpret what they’re hearing, uh, so that they have a better understanding of their own situation and can deal with it better.
Favors for physician/trainee colleagues, self-doctoring
Margot: There’s another topic that didn’t quite fall under our title of treating friends and family, but it’s a situation that comes up so often that we wanted to make sure to talk about it. Physicians often treat each other off the books – a prescription here, a few stitches there, or maybe a second opinion sometimes. We asked Dr. Fromme about his thoughts: what should doctors do when their colleagues ask them for medical help?
Fromme: What it reflects is that they don’t have a relationship with a personal doctor that they can go to. And because I think that’s such an important part of getting good care over the lifespan. I would want them to have a personal doctor and this is a great opportunity for them to, to meet somebody and see if that person’s the right person for them. So it’s hard to justify this along the lines of how did they get the best care, it’s just convenient. Uh, and I get that we’re all busy and especially if you’re in training and you have to move a lot, it’s really hard to establish care with a new person. I think it’s important enough that we shouldn’t have a workaround for that, so I think if you really, if you really care about them, this is one of those things where like the right thing to do is also the more difficult thing to do.
Margot: Residents in particular often feel like they’re too busy to go to the doctor, and there were plenty of times where colleagues asked me to write them a one-time prescription. It’s hard to say no when you know just how busy they are, but sometimes no is the right answer.
Fromme: Like the easiest thing to do would be to just say yes, and just do it. You know, this is one of those things where, what you owe to that person actually is to say, you need to have a personal physician.
Margot: I just finished residency and I’ll admit that I was one of the many trainees who didn’t have a PCP. A lot of my co-residents were in the same boat. It didn’t seem like a big deal to refill a colleague’s birth control prescription when she was stuck in the hospital 80 hours a week, but now that I’m a few months out from my training I’ve been spending a lot of time wondering about my priorities. A birth control script is one thing, but it’s certainly not the only problem trainees encounter.
Fromme: In particular for residents, like what’s the biggest health risk for a resident or a fellow it’s gotta be depression or anxiety. By refilling their birth control pills, you’re basically allowing them to not have a relationship where they could feel safe in bringing up those issues. Remember Tait Shanafelt did a study where they learned that like half of the people in their residency class were on SSRIs. They were essentially prescribing their own or prescribing them for each other. So I think that was a big wake up for U.S. residency programs because they recognize gosh, we’re probably in the same boat. That’s probably the, um, the vulnerability of residents and fellows is they haven’t yet learned to take as good a care of themselves as they take care of other people, but this is an opportunity for them to learn to do that. And if you, if you can tell them in a compassionate firm way that they need to take as good care of themselves as they take of everybody else, then I think you’re doing them a bigger favor than you are by refilling their oral contraceptive.
Margot: I think we’d all kind of known that we were toe-ing a line when we wrote each other prescriptions. But I didn’t really give it much thought, didn’t really think about why that line was there in the first place.
Fromme: I think it’s if you view it as just like a boundary then that does make it hard to justify. What you want to focus on though, is why is the boundary there? What is the boundary in service of, and what do you owe this person in front of you? If what you owe them is to actually breach the boundary and you have a good justification for that, fine. But the reality is that this is about them getting good care. And not just now, but in the future. I think particularly for people in training who are generally otherwise healthy, that’s having access to someone that they can talk to about mental health concerns. And so you want to make that as easy as possible for them. It’s helpful to think of it less in terms of a rule or a boundary and more of what do you really owe this person? If you really want the best for them, what do you owe them?
Formal vs informal, documentation
Tamar: One last point that came up in some of the guidelines on this was that if you are going to provide some care, you should document it like you would for any other patient. But we weren’t so sure about whether that actually makes sense and we asked Dr. Fromme about it.
Fromme: I think if you’re trying to figure out how you can make an entry into a family member’s electronic medical record to document care that you’re providing. That should be a note to yourself that maybe I’ve crossed a line here because you’re about to cross a big line, right? And a trackable line. There’s conflation there between our roles and responsibilities as a family member and a friend versus a physician. And there’s a ton of really helpful things that we can do for people to improve their health care that don’t require us to go into their electronic medical record and leave a note.
Tamar: And the answer was pretty similar when considering if we should establish a long term clinician-patient relationship with a loved one.
Fromme: I wouldn’t suggest that anybody engage in a longitudinal patient physician relationship with their family member. I would hope from the rest of our conversation, it would be clear that we believe that people get the best healthcare when they’re able to establish and have their own personal doctor. And we don’t want to do anything that inhibits them from finding and building that relationship.
Tamar: In wrapping up this episode, we hope to highlight the big takeaways for when you consider providing care, treatment, or advice to a friend or loved one. Again, we’re so thankful to Dr. Fromme for his insights on practical considerations and approaches in these situations.
Remember that this is an extremely common position to find yourself in and that you can still be very helpful to the friend or family member asking for medical help. Maybe you shouldn’t put yourself in the position to be their doctor, but don’t pretend you’re not a doctor.
Fromme: It really helps to have somebody who is, uh, sort of used to speaking that language, hearing that language and thinking, you know, sort of the way that, uh, that healthcare professionals think so that they can serve as a translator and a guide through this sort of land of the sick. My message though, is that I think that most of that benefit can be accrued without putting yourself in a situation where you actually have to use your medical license to impact their care. And that most of the things that you are doing, you are doing as just a very, well-informed a friend or family member, not as a treating physician.
Tamar: As clinicians, we have the privilege of having a very high health literacy, and we can bring that together with how well we know our loved one.
Fromme: I think you can be very comfortable involving yourself in a loved one’s care in your role as their friend or their family member who has sort of extra knowledge and some extra privileges… And I think we should be trying to land more on the side of being a really useful family member than being their doctor.
Jafar: Thanks for tuning in! We know these topics can stir up more questions than answers, and we look forward to hearing more about your experiences caring for friends and family. Please continue the conversation with us online at our facebook page, on twitter, or email us directly. Find show notes and contact information for us on our website: www.coreimpodcast.com
If you enjoyed listening to our show, and you’d like to give us a medical assessment as one of your friends, please give us a review on itunes or whichever podcast app you use; it helps other people find us. We work really hard on these podcasts so we’d love to hear from you. Let us know what we are doing right and how we can improve. And as always opinions expressed in this podcast are our own and do not represent the opinions of any affiliated institutions. Finally, special thanks to all our collaborators on this episode, our wonderful audio editor Solon Kelleher, our illustrator Michael Shen, endless technical support from Harit Shah, moral and executive support from Shreya Triveda, and most importantly thanks to you, our listeners!
- Fromme, E. K., Farber, N. J., Babbott, S. F., Pickett, M. E., & Beasley, B. W. (2008). What do you do when your loved one is ill? The line between physician and family member.
- Gold, K. J., Goldman, E. B., Kamil, L. H., Walton, S., Burdette, T. G., & Moseley, K. L. (2014). No appointment necessary? Ethical challenges in treating friends and family. N Engl J Med, 371(13), 1254-1258.
- La Puma, J., Stocking, C. B., LaVoie, D., & Darling, C. A. (1991). When physicians treat members of their own families. New England Journal of Medicine, 325(18), 1290-1294.
- Aboff, B. M., Collier, V. U., Farber, N. J., & Ehrenthal, D. B. (2002). Residents’ prescription writing for nonpatients. JAMA, 288(3), 381-385.
Tags: advice, advocate, At the Bedside, healthcare, humanities, Medical Humanities, patient care