“You're starting medical school, right? I have a question for you….” Weeks prior to college graduation, an acquaintance called me in search of medical advice.
Rob,* an enlisted sailor in the U.S. Navy, related a multi-year history of anabolic steroid use, culminating in the development of a warm, erythematous, “orange-sized” mass at an injection site in his left deltoid. Fearful of disclosing his steroid use to military physicians, he sought advice from a mutual friend, who referred him to me—a twenty-two-year-old biochemistry major, sparsely credentialed with a medical school acceptance letter, a nearly expired EMT certification, and a Boy Scout First Aid Merit Badge.
I told him to go to the doctor.
During my first year of medical school, similar encounters occurred; friends and family solicited curbside, tableside and poolside “consults.” “Should I have this mole examined by a dermatologist?” “Do I need the pneumonia vaccine?” “What could be causing this cough?” And in one instance, a friend happened upon a woman seizing on the sidewalk—he first dialed 911, and then me, looking for instructions on first aid.
Their confidence was flattering, but unfounded. In most cases, my response was reflexive: I redirected my friends and relatives to a qualified health care provider. However, one event changed my perspective.
Moved to intervene
In January of my first year of medical school, a relative underwent a supraclavicular lymph node biopsy to characterize a suspected malignancy. Five weeks later, she had not yet received the pathology report. Her anxiety—and her cancer—grew daily, as she began to question whether her file had been lost or neglected. With some reservation, I approached a trusted oncology professor who validated this concern and kindly offered to make a professional inquiry on my relative's behalf. As it turned out, the report arrived before he could intervene, a total of six weeks after the biopsy, bearing evidence of a diffuse large B-cell lymphoma.
I debated whether my actions had been appropriate. Though I refrained from providing actual medical advice, I employed professional resources to address a personal problem. However, I intervened not as a health care provider, but as a health care advocate. In retrospect, I've grown comfortable with my decision, but the experience shifted my concerns to the future, when my clinical experience will be greater, my connections broader, and my family sicker. How will I respond to family illness as a seasoned physician?
As the year progressed, I realized that many of my classmates shared similar experiences. This observation prompted my online survey of the 200-member Harvard Medical and Dental School Class of 2011: 92% of the 96 respondents reported that they had been approached by friends or family seeking medical advice by May of their first year. Future physicians confront this challenge early in training–even prior to residency, or in my case, medical school orientation.
More surprising was the number of first-year students who acceded to their friends' or relatives' requests: 81% reported dispensing some form of medical advice. This percentage approaches that of practicing physicians; one survey of clinicians revealed that 95% of respondents “almost always” or “sometimes” provide advice when questioned by relatives (La Puma et al. N Engl J Med. 1991;325:1290-1294).
Ethical guidelines lacking
Traditional medical wisdom and professional guidelines suggest that “physicians generally should not treat themselves or members of their immediate families” (American Medical Association, Health and Ethics Policies, 1993). Exceptions include care in emergency or isolated settings, when no other provider is available, and some “situations in which routine care is acceptable for short-term, minor problems.” The policy has sound justification, given the hazards of treating immediate relatives. Professional objectivity and judgment may be impaired, intimate areas of the history or examination may be neglected, the physician may overstep his or her field of expertise, the relationship may undermine patient autonomy and discourage adequate informed consent, and the physician may feel obligated to provide care in spite of personal reservations, the policy notes.
Ethical guidelines, however, sidestep the difference between “treatment” and “advice.” Rarely are medical students invited to treat a relative's illness. It's almost certain, however, that they will be invited to offer their medical opinion. Physicians, meanwhile, are petitioned for both. Under certain circumstances, some forms of advice may be practically and ethically equivalent to treatment. Hasty clinical recommendations predicated solely on the patient's own account may steer the patient towards an imprudent or inappropriate medical decision.
My colleagues in medical school appear to recognize such risks. My survey findings indicate that students are uncomfortable advising friends and family. They cited lack of knowledge, fear of providing inaccurate advice, impaired objectivity, and lack of a medical license as the principal sources of their concern. Excluding the last of those objections, many experienced physicians offer similar explanations for their unease. However, one in five acknowledged that they have complied with a relative's medical request in spite of their own reservations, according to La Puma's study.
The role of role strain
Why do we continue to advise and treat relatives even though our personal instincts are to refrain? The failure to disengage from loved ones' care is predictable, and perhaps normal—a likely product of role strain, the term proposed by sociologist William J. Goode to describe the difficulty of fulfilling multiple, competing social demands. When confronted with a loved one's illness, the physician must reconcile his or her responsibilities as a health care provider with those of a concerned friend or relative—two roles that may be impossible to disconnect. This “contradictory performance” is often termed role conflict.
Goode concluded, “For even when ‘the norms of society’ are fully accepted by the individual, they are not adequate guides for individual action.” Acceptance need not translate into practice; abstract ethical standards offer little practical guidance to physicians faced with the concerns of an ill family member or close friend. Current policy fails to characterize the spectrum of appropriate conduct, and grossly underestimates the power of blood loyalty. Even veteran physicians admit that separation of professional and familial demands is easier to achieve in theory than in practice.
This dilemma extracts a considerable, often silent, toll on the physician. Considering that nearly every physician will confront this issue during his or her career, how might the medical community lend support? The scarcity of published data on this topic underscores the need to better characterize this problem before we can definitively propose practical, informed solutions.
The early onset of the problem—during medical school—may afford an opportunity for educational intervention. Discussion at all levels of training is needed to better clarify the physician's role within the family. Perhaps it is permissible to serve as a relative's health care advocate. Careful guidance by an advocating medical professional may thwart administrative or clinical errors, facilitate navigation through administrative entanglements, or direct the patient to appropriate clinical resources.
Ultimately, a more practical and nuanced ethical code is needed. At present, physicians and physicians-in-training lie pinned between competing allegiances. Preliminary evidence, both anecdotal and quantitative, suggests that we will continue to advise relatives in a manner often inconsistent with traditional medical guidance. We owe ourselves—and our families—further clarification of our conflicting familial and professional roles.
In the meantime, I'm going to tell my friends and family to eat their vegetables.