The limits of treating loved ones

It was a busy day for the cardiologist. Between juggling patients, he received a phone call from his mother. She said she had heartburn and complained that none of the usual over-the-counter medications had helped.

So the cardiologist quickly called in a prescription for her for an acid blocker and went back to seeing patients. Later that afternoon, his mother called again -- this time from an emergency department. The doctors there said she had a heart attack.

It's a story that Humayun Chaudhry, DO, president of the Federation of State Medical Boards, told medical students during his teaching days. The cardiologist, a former colleague of Dr. Chaudhry's who was well-respected in the field, couldn't believe he had missed the diagnosis in his own mother.

"There was a disconnect because it was his mother calling," Dr. Chaudhry said. "That objectivity was just never there."

Professional ethics policies have long warned about the perils of physicians treating themselves or family members. Many state medical boards have rules restricting the practice, particularly as it relates to prescribing controlled substances. Medicare and private health insurers often refuse to pay for the care.

Such rules warn that physicians who treat themselves or relatives risk providing inferior care that could harm those they love. Yet medical board officials say such rules are commonly violated by well-meaning physicians, either knowingly or unknowingly.

A 2011 survey of more than 1,000 physicians in North Carolina found that nearly half had treated themselves and that 85% had treated an immediate family member, significant other or close friend.

"We've dealt with this extensively for years," said Scott Kirby, MD, medical director of the North Carolina Medical Board.

"It is frequently an issue that comes to the attention of the board, because physicians provide care to family members and themselves that is generally below standards. They cut corners. They don't do things they would normally do in treating a patient."

"A fool for a patient"

Doctors often have a blind spot about treating themselves or relatives, said Glen Stream, MD, president of the American Academy of Family Physicians. "We as physicians could unknowingly set ourselves up to compromise the care of those most close to us," he said.

Dr. William Osler, a physician and professor who helped found Johns Hopkins Hospital in 1889, put it more bluntly: "A physician who treats himself has a fool for a patient."

Whether physicians are treating themselves or relatives, many of the dangers cited are the same. They center around the risks of loss of objectivity.

"It really is a matter of patient protection," Dr. Kirby said. "The patient is receiving substandard care."

Physicians often jump to conclusions or make assumptions about themselves or loved ones that they wouldn't with a typical patient. They are less likely to take a thorough medical history or keep any records, said Lois Snyder, director of the American College of Physician's Center for Ethics & Professionalism.

The ACP's recently revised ethics policy states that physicians shouldn't treat themselves, except in emergencies when no other options are available. "A physician cannot adequately interview, examine or counsel herself; without which, ordering diagnostic tests, medications or other treatments is ill-advised," the policy says.

American Medical Association policy issued in 1993 warns that one's personal feelings can interfere with sound medical judgment. Physicians treating themselves or loved ones may be inclined to treat problems that are beyond their expertise or training.

Informed consent also is a concern in treating family members, because a spouse, child, sibling or parent may be reluctant to refuse care from a relative, AMA policy says. Doctors may fail to ask sensitive questions or perform intimate parts of a physical exam, or a patient may feel uncomfortable giving sensitive information to a relative.

"In particular, minor children will generally not feel free to refuse care from their parents," the AMA policy states. "Likewise, physicians may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care."

It is inappropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members, except in emergencies, AMA policy says.

Contentious policies

Regulations governing self-treatment and the treatment of relatives vary from state to state. In California, for example, there is no specific law prohibiting physicians from treating themselves or family members, but the practice is discouraged, said Dan Wood, spokesman for the Medical Board of California.

State law does prohibit doctors from prescribing controlled substances to themselves or relatives.

"When treating family members, a doctor must follow the same protocol as for any other patient," Wood said. "There must be an appropriate prior examination and medical indication and a medical record for the patient."

The Texas Medical Board prohibits physicians from prescribing medications to themselves, relatives or others in which there is a close personal relationship without taking an adequate history, doing a physical examination and maintaining proper records. Controlled substances can be prescribed only in cases of immediate need, which is defined as no longer than 72 hours, said Mari Robinson, the board's executive director.

In North Carolina, policy prohibits physicians from treating themselves, close relatives or other loved ones except in minor, acute illnesses or emergency situations. The North Carolina Medical Board is re-examining the rule and plans to develop a new law addressing the prescribing of controlled substances, Dr. Kirby said.

Some physicians complain that rules governing self-treatment and treatment of family members are vague, confusing or overly intrusive. They may feel that they know their loved ones better than anyone else and are therefore best suited to care for them, Dr. Kirby said. In other cases, physicians say they aren't aware of such policies.

"There is no question that this is the most contentious physician statement that we have," he said.

The Federation of State Medical Boards does not track how many medical boards have policies regarding self-treatment or the treatment of relatives, Dr. Chaudhry said. But even states that don't have specific policies on the subject have broader standards for professionalism and quality of care that would apply. For example, throughout the U.S., physicians are required to document patient care, but medical records often don't exist when a physician treats himself or a family member, he said.

In many cases, health insurance companies will not pay for self-care or care provided to a family member. Many plans use the AMA policy and Medicare as a guide, said Robert Zirkelbach, spokesman for America's Health Insurance Plans.

Cigna does not cover self-treatment or treatment of relatives, and WellPoint's affiliated health plans "generally prohibit health plan members from receiving treatment from an immediate family member," representatives for those insurers said.

Aetna doesn't prohibit such treatment, but state laws and industry standards would apply in consideration of specific claims, said spokeswoman Cynthia Michener.

Gray areas

There are some exceptions to rules governing self-treatment and treatment of relatives. For example, AMA policy says that such treatment may be justified in emergencies, in isolated settings where no other qualified physician is available, or in "situations in which routine care is acceptable for short-term, minor problems."

For physicians working in isolated rural areas, keeping a record of all care is crucial, said Dr. Stream, of the AAFP.

Small-town doctors need to be aware that their objectivity could be compromised and do everything they can to prevent that from interfering with care.

Dr. Stream explained how he cared for the children of the nurse he has worked with for 17 years. To prevent her role as the parent from influencing their care, the pair agreed early on that she wouldn't be present at any of the children's examinations, he said.

"I do think that we need to understand that there is a need for flexibility, that these aren't hard and fast rules," Dr. Stream said.

It's up to physicians to explain the ethical issues involved to family members requesting care. Many aren't aware that they're asking for something inappropriate, he said.

The consequences for violating rules related to self-treatment or care of relatives vary depending on the case, Dr. Kirby said. The board may send a warning letter to a physician who has prescribed a noncontrolled substance to a spouse, or suspend the license in a more egregious case where a physician has prescribed controlled substances to a relative for many months.

"We have seen physicians who are prescribing narcotics and other medications to family members who clearly have an addiction problem, and they are facilitating that," Dr. Kirby said.

Many times doctors start out writing a prescription for one family member and it quickly spirals out of control. Before long, they are treating several relatives, said Robinson, of the Texas Medical Board. Having policies makes it easier for physicians to say no.

"We're happy to be the excuse for the physician," she said.