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There are many professional privileges associated with working as a physician in the United States. These physician related privileges and courtesies include perks like professional discounts and the ability to see other doctors or receive care without a wait, but one thing that should never be allowed is for any physician to medically treat their own family. The “AMA Principles of Medical Ethics” states that, “In general, physicians should not treat themselves or members of their own families”, with the exception of emergency situations or for short-term, minor problems. The details of section ‘1.2.1 Treating Self or Family’ include the many reasons why this should be avoided. But physicians are not legally bound to these principles, and this is a problem. A big problem. Because physicians routinely treat their own family members in this country, often to the detriment of the long term health of the family member.
The dangers of treating family members include not just the harmful results of potentially inappropriate treatment when working outside of one’s specialty, but the great likelihood of the family member not having the benefit of a second opinion and of the home treatment not being included in their medical record, resulting in conflicting or overlapping treatment.
So how big problem is this, despite the AMA’s position that this practice is unethical? According to the New England Journal of Medicine, in their 1991 survey of 465 physicians, the problem is massive:
“ Eighty-three percent prescribed medications for a family member, 80% diagnosed medical illnesses, 72% performed physical examinations, 15% acted as a family member’s primary doctor, and 9% performed surgery on a family member”
http://thechart.blogs.cnn.com/2012/01/09/why-doctors-shouldnt-treat-family-members/
A 2001 abstract detailing confidential interviews with eight chairs of family medicine departments further highlights the commonality of this abuse of medical privilege:
“In a profession that emphasizes detached objectivity and scientific inquiry, the illness of a family member engenders an emotional involvement that can cloud critical thinking and sound judgment…in one survey, a third of physicians reported observing another physician “inappropriately involved” in a family member's care.”
https://iths.pure.elsevier.com/en/publications/role-conflicts-of-physicians-and-their-family-members-rules-but-no rulebook
As astounding as these numbers are, what is more astounding are the reasons citied for this unethical behavior; arrogance, cost and convenience. Dr. Youn, a plastic surgeon writing for CNN, explains the following:
“…as surgeons, we are supremely confident in our training and skills and worry that another surgeon might not do as good a job as we would. Second, performing the surgery ourselves can save a lot of money. Third, and most disturbing, some plastic surgeons use their spouses as living billboards for their work.”
http://thechart.blogs.cnn.com/2012/01/09/why-doctors-shouldnt-treat-family-members/
In accord, Edward J. Krall, in his 2008 essay ‘Doctors Who Doctor Self, Family, and Colleagues’ printed in the Wisconsin Journal of Medicine, writes that:
“Convenience is most often citied as the reason for physicians to address a problem themselves, with confidence in their own diagnostic and treatment skills … and cost also factoring into the decision.”
Continuing on, Mr. Krall reports that the detrimental effects are evident in the available data on families of physicians which reveals the following:
“(family members) were seen less often for acute illness, had incomplete exams, incomplete or absent medical records, and incomplete documentation of immunizations.”
The lax attitude regarding these dangerous facts must be addressed. Family members of physicians are a particularly vulnerable subset of the public. They are the most likely to be improperly treated due to their level of trust in the physician, the physicians’ unfettered accessibility to that individual in the home and their de facto control of the situation related to physical isolation.
In Ontario, Canada, governmental prohibitions have been wisely instituted to specifically address the treatment of physicians’ sexual partners, including spouses. Physicians can, and sometimes do, act with malevolence. Their occupation does not set them apart from other human beings. The potential for abuse of sexual partners (spouses or others) in Canada has been addressed thusly:
“Physicians must not provide treatment to a spouse, partner, or anyone else with whom they are sexually or romantically involved, beyond the circumstances of a minor condition or emergency, and where no other qualified health care professional is readily available… providing treatment that exceeds the circumstances set out in this policy ….may give rise to a physician-patient relationship, and, as a result, the sexual abuse provisions of the Regulated Health Professions Act, 1991 would apply.”
The RHPA is governmental legislation created under the ‘Medicine Act, 1991’ in Ontario. Common sense principles in this document point out that;
“Sexual activity and ‘romantic interactions’ ….obscure the physician’s objective judgment concerning the patient’s health care”,
and that;
“Patients must be protected from sexual abuse by physicians.”
http://www.cpso.on.ca/uploadedFiles/downloads/cpsodocuments/policies/policies/sexual_abuse_boundaries.pdf
Therefore, in Ontario, a physician may neither provide treatment nor administer drugs or prescribe medications to a spouse. Patients need to be protected from potential abuse. Family members should never be patients, and this applies especially to children. Children are unaware of the detrimental effects any substandard care will have on their long term health and are inhibited or unable to object to parental authority. This is the default position of the American Medical Association, which warns against treating one’s own child, “…who may not feel free to refuse care from a parent. “ (AMA Principles of Medical Ethics: I.2.1)
As John Henning Schumann, M.D. writes in ‘What could go wrong when doctors treat their own kids?’:
“It’s a dark corner of medicine. Nobody I know talks about it much. Still, nearly all medical parents treat their kids. There are many reasons, though it's usually for the convenience of not having to put up with what regular folks do: sitting on the phone, making appointments, dealing with copays and deductibles, waiting and missing work or school..One doctor told me about sewing up his young son's heel after it had been cut on some glass. …."Why did I do it myself?" he asked "I could. It would save time and money…He prescribed an antibiotic for both children to treat (a) bacterial infection, but he didn't test them for pertussis first. His curiosity got the better of him, so he tested the older kid, figuring if one had it, they both did. It came back positive. Oops.”
As a former spouse of a surgeon and privy to the familial habits of the local medical community for 14 years, I can tell you that if a particular physician isn’t prescribing medication for his/her own family, that doctor certainly knows dozens who are. The practice is rampant. And everyone looks the other way. I complained for years about my ex-husband and his over-medication of our son, and while the pediatrician listened, and later school health officials listened, no one ever tried to stop it. His immune system has been compromised, he gets sick much too frequently and takes longer and longer to get well. This is directly related to the pediatrician prescribing one thing, and then his father (an orthopedic surgeon) prescribing additional medications, unneeded medication or inappropriate mediation, and even doling out his own left over medication on a regular basis for over 15 years. I have been written off as overly emotional on the subject. I am not. This is not just for the sake of my child and the children of other physicians, but for all children. Here’s why:
“Unfortunately, antibiotics are excessively prescribed, especially to children. The Center for Disease Control estimates that of the 235 million doses of antibiotics given each year, between 20 and 50 percent are unnecessary. Tragically, this overuse of antibiotics can cause devastating health consequences to children. Antibiotics do not just go after the pathogenic or “bad” bacteria. They also indiscriminately destroy the beneficial bacteria necessary and vital to good health… (that) help protect the body against infection. Depleting these organisms can disrupt the balance of the body, suppress immunity, and lead to increased susceptibility to infections by fungi, bacteria, viruses and parasites…
When your child is continually treated with antibiotics, the bacteria in his or her body may eventually be able to survive the drugs, making it much harder to cure an infection.
Antibiotic resistance can affect the whole family and everyone around the child with a history of frequent antibiotic use. If the child develops resistant bacteria, he or she can pass them along to others [this can include playmates and friends] through coughing, sneezing, and kissing…
A truly disturbing practice is the prescribing of antibiotics by some doctors to treat colds, coughs, runny noses or flu. Most upper respiratory infections are viral. Treating them with antibiotics is clear and blatant misuse, since the drugs kill only bacteria and are of no value at all in treating viral infections.”
Healthy child.com, Jane Sheppard, October 15, 2008
That this practice continues unabated is shocking in light of the CDC’s stance on antibiotic resistance:
“Antibiotic resistance is one of the most serious public health problems in the United States and threatens to return us to the time when simple infections were often fatal.(1)… At least 80 million antibiotic prescriptions each year are unnecessary, which makes improving antibiotic prescribing and use a national priority.”(2)
How can we even begin to make progress when physicians themselves are a core part of the problem? The CDC promotes the notion of antibiotic stewardship as a potential answer:
“Stopping even some of the inappropriate and unnecessary use of antibiotics in people and animals would help greatly in slowing down the spread of resistant bacteria. This commitment to always use antibiotics appropriately and safely - only when they are needed to treat disease, and to choose the right antibiotics and to administer them in the right way in every case - is know as antibiotic stewardship”
www.cdc.gov/drugresistance/about.html
The CDC’s notion of stewardship assumes doctors are automatically onboard as a matter of ethical course. Yet the physicians interviewed admit to skirting ethical standards on a regular basis sheerly for convenience and cost. This is with full knowledge of the adverse affects of this practice on the publics’ health and well-being as antibiotic resistance spreads. It’s almost as if the CDC is afraid to firmly address the issue with physicians themselves. In their community campaign targeting antibiotic resistance they inform the public that:
“The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. Approximately half of outpatient antibiotic prescribing in humans might be inappropriate, including antibiotic selection, dosing, or duration, in addition to unnecessary antibiotic prescribing”.
This campaign recommends that members of the public;
“Require explicit written justification in the medical record for non-recommended antibiotic prescribing.”
It is the CDC’s belief that;
“This technique has reduced inappropriate prescribing by holding physicians accountable in the medical record for their decisions.”
Should the public bear so much responsibility for the actions of the many physicians who clearly can not be entrusted as proper stewards of the antibiotic resistance awareness campaign? I think not. Empowering the public by setting forth the proper information is a wonderful thing. But the outpatient community will not change the behavior of these doctors any more than the spouse of such an individual can change their behavior. They do what they want, for convenience, for cost, and in their arrogance.
It is of utmost urgency that going forward medical practitioners be mandated to comply with government standards of prescribing as outlined by the CDC. Unfortunately the CDC is not a regulating body. Medical boards regulate, but do not mandate. In order to enforce compliance, oversight must be handled by a regulatory body that advocates for patients’ rights and not the rights of physicians. The Medical Board of Massachusetts comes closest to advocating for patient protections over physicians’ rights by curtailing irresponsible prescribing in their ‘Prescribing Practices, Policy and Guidelines’:
“Part I, Section 1: Basic Requirements of Acceptable Medical Practice:
To be valid, a prescription must be issued in the usual course of the physician’s professional practice, and within a physician-patient relationship that is for the purpose of maintaining the patient’s well-being. In addition, the physician must conform to certain minimum standards of patient care, such as taking an adequate medical history, doing a physical and/or mental status examination and documenting the findings. This rule applies to any prescription, issued by any means, including the Internet or other electronic process. Prescribing that does not meet these requirements is unlawful.”
While this is definitely a step in the right direction, it will take too long to lobby for changes state by state. Establishing clear legal codes at the federal level now that define what is unacceptable is the only way to truly hold physicians responsible for their behavior and to safeguard the publics’ health. Doctors are just people like the rest of us. Their occupation doesn’t make them statistically better human beings. By allowing them to continually breach the boundaries of ethical practice with vulnerable family members, and through their excessive prescribing which can affect entire townships and municipalities, we have enabled arrogant, permissive attitudes to take hold of the medical community and thrive, to the detriment of the public good.
