Should We Treat Friends and Family?

Author: Dr. Julian Watson
Editors: Dr. Smruti Desai, Dr. Robby Allen

Why would we?

Posing this question to an emergency physician is like asking a plumber why he would fix their friend’s sink. The answer too, is the same – because they can. They do it all the time. It’s almost harder to resist than not. Especially if it is an easy problem, why would a plumber have a friend spend money to hire someone else for a job he could practically do in his sleep? Unless the issue is more complex and requires resources that the plumber cannot provide in real time, the idea of a plumber providing basic plumbing service to a friend is far from unreasonable.

Is the analogy that simple? Yes, almost. We would treat our friend’s back pain, diarrhea, headache, cold, or heartburn, because we can – we do it every day. Our job is to sniff out and handle medical emergencies, but in doing so, we also master the art of identifying and treating non-emergencies. Our friends and family know what we do, and expect us to be there for them when they need help. In a 2013 Psychology Report on this very question, researchers combed through various surveys to get an idea of the answer. The results were relatively consistent[1]:

• – 95% of 691 Illinois physicians surveyed in 1991 admitted to treating friends/family.
• – 74% of 701 Iowa physicians surveyed in 1993 admitted to treating friends/family.
• – Over 1300 Oregon physicians surveyed in 1994 admitted to treating friends/family.
• – 95% of 92 Delaware physicians surveyed in 2002 admitted to treating friends/family.

In the same report, common reasons stated by physicians for treating friends/family were a desire to:

• – Honor a request
• – Show reciprocity for emotional or financial support
• – Maintain a good relationship
• – Provide convenience and financial savings for relatives

Not all of the physicians in these studies were emergency physicians, but the reasons why any physician would treat friends or family are relatively simple – we are human beings and (ideally) empathetic human beings at that. To see our friends and family in need of a service that we so frequently provide elicits an innate sense of duty that is difficult to ignore.

Should we?

Now, this is an entirely different question and one with both ethical and legal consequences. It is a battle primarily between a physician’s desire for both beneficence (to help the patient) and non-maleficence (to not harm the patient). This question seeks to identify the natural consequences of physicians treating friends and family, which may or may not be easy to predict. A 2019 review by the American Journal of Emergency Medicine cites some of the most prevalent risks regarding this practice[2]:

• – Limitations on history/physical due to privacy concerns
• – Patients withholding vital information out of embarrassment
• – Physicians and/or patients experiencing guilt or blame following negative interactions or outcomes, even if an outcome is a known side effect of treatment or the natural course of the disease
• – Patients feeling obligated to follow recommendations despite having reservations that would have been voiced in the absence of a personal relationship with the physician
• – Physicians making recommendations out of fear of errors, consequences, and/or deleterious effects on the personal relationship, rather than following standard practice
• – Pressure on the physician to provide services outside their scope of practice

This list is not an exhaustive one. It is easy to be shortsighted when a loved one requests medical advice or assistance since most people just want to help those whom they care about. The issue, however, is that the full ramifications of treating friends and family are rarely understood until the treatment is begun or complete. The takeaway is that there are often consequences and that in general, the greater the emotional/social investment in the relationship, the higher the risk.

Can we?

Prominent medical societies and organizations have tried to provide physicians with guidelines and recommendations on this question; understandably, a definitive consensus has not been reached. The short answer seems to be yes, but only in specific situations. Here are some of these recommendations:

American College of Emergency Medicine, 2020[3]:

Refrain from providing medical treatment for family members, close friends, professional colleagues, and themselves, except in several limited and specific circumstances, including:

• – Emergency conditions or isolated geographic settings, when no other qualified physician is available
• – Short-term treatment of minor illnesses or injuries
• – Specific request by a healthcare colleague, provided treatment is within the physician’s skillset

The New England Journal of Medicine, 2014[4]:

Physicians who provide treatment are advised to notify the patient’s primary care physician as soon as possible to allow for proper documentation.

American College of Surgeons, 2011[5]:

These questions can serve as a guide in determining to what extent treatment is an option and when one should refer a patient for further care from another physician:

• – “Am I trained to meet my relative’s needs?”
• – “Am I too close to probe my relative’s intimate history and physical being to cope with bearing bad news if need be?”
• – “Can I be objective enough to not give too much, too little, or inappropriate care?”
• – “Is medical involvement likely to provoke or intensify intrafamilial conflicts?”
• – “Will I allow the physician to whom I refer my relative to attend him or her?”
• – “Am I willing to be accountable to my peers and to the public for this care?”

International Journal of Gynecology and Obstetrics, 2016[6]:

Obstetrician/gynecologists may advise family members and friends, but undertake to treat them only within ordinary domestic (“band-aid”) limits, except in cases of emergency or when there is an immediate need and no other appropriate healthcare provider is available.

The primary care physicians of recipients of such care should promptly be informed of any treatment or prescription given or refilled, and of any indicated follow-up care that may be required.

American Journal of Emergency Medicine, 2019[2]:

• – In true emergency situations provide care until another competent healthcare provider is available.
• – It is generally acceptable to treat minor, episodic conditions if the consequences of failure are small.
• – Know the legal and regulatory limits placed on this behavior by various professional bodies (e.g., state laws, state medical boards, professional organization ethical codes, hospital bylaws).

Shall we?

Ultimately, this is going to be an ongoing dilemma that providers will have to grapple with for the duration of their careers. For some, this may be an indiscriminate “no” or “yes”, and for others, it may not be so cut and dry. In conclusion, be clear in your mind as to why you want to treat your loved one, consider why you should or shouldn’t, and educate yourself on existing guidelines that apply if and when a loved one requests your care.

References

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