Should physicians treat loved ones? It’s complicated, DOs say
When Thomas E. McWilliams, DO, worked in the Alaska bush near False Pass, he took care of his whole family along with the area’s natives and seamen.
“The nearest physician services were 500 miles away,” he says. “We were 750 miles from the nearest road that was connected to anything.”
Dr. McWilliams, who spent two years in Alaska’s backcountry, sutured a laceration for one of his sons. He took care of another son’s corneal abrasion. But when his wife had a suspicious skin legion, he referred her to a dermatologist.
“She had to travel 750 miles,” he says. “It took her three days to get in and have a consult and then another day or so to get back home. It was a big deal.”
“There’s no reason a physician wouldn’t use OMT on his own family if it was used in the proper aspect.”
But now that he doesn’t practice in a remote area, he avoids treating family members, says Dr. McWilliams, who is the associate dean for graduate medical education at the A.T. Still University-School of Osteopathic Medicine in Arizona in Mesa.
“I’m rather hesitant to provide any sort of a ‘curbside’ consult for fear of providing less than optimum care for either family members or neighbors,” he says. “There’s a hazard in trying to work outside your normal environment where the full range of lab, X-ray, assistance and sterile materials are available.”
A complex issue
Dr. McWilliams’ varied experiences caring for family and friends reflect the complexity of the issue. While the AOA doesn’t address physician treatment of family and friends in its code of ethics, it does support the tenets of the American Medical Association’s policy on the matter. The AMA recommends that physicians generally avoid caring for themselves or family, as doing so may compromise professional objectivity and the care the patient receives. The policy also lists exceptions—emergencies, isolated settings and routine care for short-term problems.
The American College of Osteopathic Family Physicians (ACOFP) also doesn’t have a policy on treating family and friends. It would be hard to develop because medical care runs across such a wide spectrum, says Michael K. Murphy, DO, the chairman of the ACOFP’s ethics committee.
“It comes in degrees,” says Dr. Murphy, who is an AOA trustee. “That’s the difficulty we face both at the AOA and the ACOFP. We have discussed this on multiple occasions.” Defining the parameters of routine care and when exactly it would be OK for a physician to treat family is tricky, he says.
Like many other physicians, Dr. Murphy has had to reckon with this distinction in deciding whether to care for family members.
“I treated my own children rather than take them to the ER at 3 in the morning when they had ear infections,” he says, noting that he documented the encounters. “But when my daughter broke her arm, I didn’t set it at home and wrap it up in a newspaper. I took her to an orthopedic surgeon who reduced the fracture.”
Francisco A. Ward, DO, has a similar philosophy when it comes to caring for friends and relatives, in that he’s treated his family and friends for minor issues but not major ones. He once diagnosed lung cancer in a friend, but he then referred his friend to a specialist.
What about OMT?
But Dr. Ward, who specializes in physical medicine, rehabilitation and pain medicine in Baltimore, says he doesn’t always document the osteopathic manipulative treatment he performs on his relatives.
“When I treat my 14-year-old who says, ‘My back has been hurting for two days,’ I’m not producing a record, and the medicolegal risk there is extremely low,” he says. “I don’t think we live in a police state—I don’t think I need to produce a record to treat my daughter or my brother or my mother—but you run some risk when doing that. If I treat my mother, and she says I hurt her and she wants to sue me, then I’m at risk.”
Dr. Ward’s comments raise the question of whether guidelines on caring for family would also apply to OMT. Other DOs have mixed opinions. Dr. Murphy agrees with Dr. Ward.
“OMT is completely different,” he says. “It’s not invasive. It’s physical medicine; it’s not quite the same. There’s no reason a physician wouldn’t use OMT on his own family if it was used in the proper aspect.”
Kenneth J. Veit, DO, the dean of the Philadelphia College of Osteopathic Medicine (PCOM), takes the opposite view.
“OMT is a medical treatment and should be treated like any other medical treatment,” he says.
Physicians giving free OMT as a favor to friends and relatives should be aware of state laws and take care to follow proper medical protocol, such as documenting the encounter and recommending follow-up care if necessary, says Humayun Chaudhry, DO, the CEO of the Federation of State Medical Boards (FSMB).
“Most students understand treating family and friends may be unethical. However, students often struggle to identify exactly why it’s unethical and when it’s unethical.”
“If it’s going to be done for specific medical reasons, then documentation should be kept,” he says. “All types of treatments are best applied in a patient-physician relationship context.”
What the laws say
Some state medical boards have statutes covering physician self-treatment or treatment of relatives, but many do not. The FSMB doesn’t have a record of which state boards do and do not address the matter.
A random sampling of state osteopathic medical boards revealed that New Mexico does not have specific statutes on physician treatment of relatives; osteopathic physicians in West Virginia are not to prescribe a controlled substance to a family member for more than a 72-hour time period; Vermont DOs cannot prescribe controlled substances for themselves or immediate family members; and in California, osteopathic physicians are discouraged from writing any prescriptions for family members, though it’s not in the statutes.
What happens to physicians who break the rules? Punishment varies by state, but in California, physicians receive a warning first.
“If we’re notified that they’re writing prescriptions for family members, we send a very friendly reminder that they should not be doing that because it can cause problems,” says Angie Burton, an enforcement analyst for the Osteopathic Medical Board of California. When controlled substances are involved, the board will open an investigation, she notes.
The West Virginia Osteopathic Medical Board has seen five cases in which physicians prescribed controlled substances to relatives for more than 72 hours in the past five years, administrative assistant Chelsea Slack wrote in an email. Although one case is still pending, each infraction is penalized with a consent order and a fine, which varies but was $500 in one case, according to Slack.
But even if treating family isn’t codified in a medical board’s statutes, a physician could still be disciplined for doing so, says Dr. Chaudhry.
“Many states don’t address the issue through regulation,” he says. “But they do talk about the consequences of violating acceptable standards of care. And sometimes when you take care of family members yourself, there are areas where you can get in trouble.”
For instance, when a state pharmacy board prohibits the prescription of controlled substances to family members, the state medical board could discipline a physician for violating the pharmacy board’s statutes.
“A state medical board, even though it may not have the specific statute in the medical practice act, could prosecute the offending physician under language in their own regulations that prohibits prescribing in violation of any state statute,” Dr. Chaudhry says. “It’s a nuance that the average physician wouldn’t be aware of.”
Laws aside, the medical community largely agrees that physicians shouldn’t treat themselves or family members for many reasons, Dr. Chaudhry says. In addition to the loss of objectivity mentioned in the AMA policy, physicians may demur from asking sensitive questions, and relatives may be unwilling to share embarrassing but pertinent information. Also, family members may feel obligated to follow a physician’s advice instead of questioning it or seeking a second opinion.
How students learn
Most physicians learn about the ethics of treating family members in medical school or residency. The topic falls under the umbrella of professionalism and is typically covered at every school of osteopathic medicine, according to Tyler C. Cymet, DO, the associate vice president for medical education at the American Association of Colleges of Osteopathic Medicine.
Treatment of family members is not covered in ATSU-SOMA’s formal curriculum, Dr. McWilliams says, adding that students nonetheless do encounter the issue when working under a preceptor.
PCOM covers the topic in its physician-patient relationship course, says Dr. Veit.
“We do stress that it’s inadvisable for many reasons to treat family members, both morally and ethically,” he says.
Students at the West Virginia School of Osteopathic Medicine (WVSOM) in Lewisburg also discuss the ethics of treating family in professionalism and ethics courses, says Lorenzo L. Pence, DO, the school’s dean. WVSOM faculty also advise students on dealing with requests for treatment and advice from relatives, he says. Sometimes students are the first in the family to attend medical school, and then the questions start rolling in.
“You always have to guide those students to remind them that they’re not doctors, they’re in training, and they have to have some sense of how they may respond when those questions come up,” he says.
“All types of treatments are best applied in a patient-physician relationship context.”
Nosheen Jawaid, OMS III, agrees. She was getting questions from family and friends when she was in her first year at the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine in Stratford.
“I felt very comfortable saying no because I lacked the clinical experience and the knowledge, but perhaps I may not feel comfortable saying no as I progress through my training,” she says. “So it’s important to start talking about this in medical school.”
Discussing specific cases in her professionalism courses was helpful, Jawaid says, particularly those that aren’t so clear-cut. For instance, what should a physician or medical student do if a friend needs nonemergency medical care but doesn’t have health insurance and can’t afford treatment?
“Most students understand treating family and friends may be unethical,” Jawaid says. “However, students often struggle to identify exactly why it’s unethical and when it’s unethical. It’s not so black and white all the time.”
Another example: Although professors advised Jawaid and her classmates not to treat family, they also encouraged students to practice OMT on their friends, family and each other, she says.
“OMT is definitely another gray area,” she says. “Whereas it’s clear we shouldn’t be prescribing things, it’s not so clear with OMT.”