Gift or Grief?

In its Opinions on Practice Matters, the AMA Code of Medical Ethics warns that "professional objectivity may be compromised" and that "the physician's personal feelings may influence his or her professional judgment" when treating family members. The same seems true when treating the "office family" and close friends.

As with a family member, the employee's relationship with the physician has behavioral boundaries that become mutually known and comfortable. An employee who becomes a patient steps over that boundary, as does the physician-employer. Each is apt to be uncomfortable about disclosing and hearing sensitive information or doing or undergoing an intimate physical exam. Subtle encroachments on patient autonomy and patient consent also arise.

In emergency or isolated settings physicians should not hesitate to institute treatment, but they should ask themselves a few questions before moving to a long-term dual-relationship. In a classic article in JAMA, April 1, 1992, Drs. John La Puma and E. Rush Priest suggest the following questions, in order of importance:

1. Am I trained to meet the medical need?
   
2. Am I too close to take an intimate history?
   
3. Am I too close to bear bad news, if need be?
   
4. Am I objective enough to avoid too much, too little or inappropriate care?
   
5. Is my care likely to provoke or intensify intrafamilial (intra-office) conflict?
   
6. Will compliance be better if care comes from an outside physician?
   
7. Will I let the physician to whom I refer tend to the patient without me?
   
8. Am I willing to be accountable to my peers and the public for the care I give?
   

When physicians feel uncomfortable with any of their answers, they should halt the medical process, offer a prompt and supportive explanation and referral, and retreat to the more comfortable employee-employer relationship.

edrudin@aol.com