Friends do each other favors. And if your friend is a physician, that favor might be lending you medical expertise or a prescription pad. This type of informal health care happens all the time, and while it may be off the record, it doesn’t mean the physician is off the hook. The question we must ask is whether it is ethical.
Jon Zirn, a dermatologist in Danbury, CT, says he is consulted by friends and family on a regular basis. For example, he commonly hears from friends with a dermatologic emergency the night before they have a big meeting or presentation.
“People call me up at 10 o’clock at night, ‘Oh my god, I have a giant zit. Can I come over and get an injection?’ And they’ll come over, I’ll sit em down and then give them an injection of Kenalog right there in the house.”
A risky business
While Zirn’s living room couch frequently serves as an examination table, he knows that treating friends and family is not without its downsides.
Zirn once agreed to have his colleague’s brother, who was visiting from Russia, come to his home for an examination, as a courtesy. The man had been suffering for months with a debilitatingly itchy rash and had seen multiple doctors in his country with no relief.
He arrived late in the evening, and the bulb in the entryway had gone out. “It was almost pitch black at the front door,” Zirn said.
He shook his hand and then led him to the kitchen where he could see the rash in the light. “Within one second of looking at him in the light I knew what it was,” he said.
It was scabies, a highly contagious infection that classically infects the skin of the hands. Zirn was relieved to diagnose an easily treatable condition, but he wasn’t so happy to have shaken the man’s infected hand in his unlit doorway.
Sure enough, he and his daughter started getting itchy a week later, and he had to treat his entire family for scabies.
But, like many physicians, he still is not deterred from doing a friend or family member a favor.
“You know, lots of times it’s just friends or something that just wants me to look at something,” Zirn said. “So I’m only too happy to say, ‘Yeah, just come over.'”
The ethical guidelines
The medical ethics community, however, strongly discourages this practice.
“The American Medical Association has addressed this issue since they put out early guidelines in 1847, and they have maintained that physicians should generally not treat themselves or members of their immediate family,” says Katherine Gold, assistant professor of Family Medicine and OB-GYN at the University of Michigan, who does research on the topic.
“I have not come across any associations that have publicly disagreed with this.”
Gold says the guidelines are in place for good reason. One concern is that a physician may have inappropriate emotional investment in the care of a friend or family member.
“It may cloud your ability to make a good judgment, so you might treat them differently than you would treat a patient in your office,” Gold says. “For example you might order extra tests for the family member that you wouldn’t order for someone else.”
Physicians may also avoid broaching uncomfortable topics with someone they know personally.
“Sometimes we’re talking about sensitive issues,” says Gold. “If someone has a sexually transmitted disease, it’s very awkward with a family member to go into a lot of detail with them… even though with a patient you would have those discussions.”
This is particularly true when it comes to mental health. For example, physicians are commonly asked to prescribe antidepressant medications for their colleagues, and many find it challenging to ask the necessary follow-up questions.
“You might or might not ask a physician who was asking for antidepressant off the books if they were feeling suicidal,” Gold explains. “That might feel like you were kind of overstepping your bounds.”
There are also potential conflicts of interest that may influence a provider’s judgment.
“There in some situations might be certain benefits to the doctor,” says Gold. “If your friend asks you to prescribe something to them and you do, it makes them happy.”
Other benefits may be more concrete. “In some cases you help out a colleague… and then maybe that colleague provides referrals back to you.”
Informal health care is also fraught with potential legal ramifications.
“If there’s something bad that happens, you have no documentation of what occurred, no informed consent… [and] no legal grounds should something go wrong,” Gold said.
Many have suffered the consequences. Jon Zirn, the Connecticut dermatologist, told the story of a physician who prescribed an antibiotic for his friend with a sore throat. “The guy ended up developing a pharyngeal abscess from strep throat and ended up dying,” Zirn said.
“Not that the guy himself would ever sue his friend, the family who was completely unaware of what had transpired, went ahead and sued the guy’s friend who had written the prescription, as a favor to him, and I think the guy must have lost his license or something, I can’t remember exactly, but it was not good. You gotta be careful.”
A common practice
Despite the myriad of legal risks and ethical considerations, the practice is far from infrequent. A 1991 study found that 83 percent of over 400 surveyed physicians had prescribed a medication to a family member. A 2002 study surveyed 80 internal medicine and family medicine residents and found that 85 percent had prescribed a medication to a non-patient and that 95 percent would write a prescription for a nonpatient in at least one of the given hypothetical situations.
Gold admits that even she has asked a colleague for informal care. Back when she was a resident, a colleague agreed to prescribe her an antibiotic for a skin infection.
“There was no physical exam, nothing went onto the books formally,” she said. “It seemed at the time like a perfectly fine thing to do… and I hadn’t really thought through all the potential ethical complications.”
Lack of standardization in education
The same survey that found that 85 percent of residents had written prescriptions for nonpatients also found that only 13 percent of residents were aware of any ethical guidelines regarding prescription writing for nonpatients.
Awareness is lacking, as physicians in training do not universally learn about the subject. The accrediting bodies for medical schools and residency programs do not require that it be addressed. The ethical topics that are covered in medical school and residency are determined by each individual program.
Medical students at the University of Pennsylvania, for example, are taught about the ethics of informal care as part of the required fourth year Bioethics class. The course director, Paul Lanken, said that it was his own decision to include this topic in the curriculum.
“I thought it was important for [medical students in their fourth year] to discuss before they became residents with their own medical licenses,” Lanken said. “Plus the problem of physician addictions continues and those patterns may start with self-prescribing.”
One barrier to stricter rules or more regulated education may be that physicians are not all in agreement. Gold says that while researching and giving presentations on the topic, she heard quite a mix of opinions from her colleagues.
“The reactions were all over the board,” she said.
Many of her colleagues defended the practice. “There were physicians who said, ‘Look, I’m a doctor, I paid the dues, and I should be able to write these prescriptions or take care of minor things.’ There were physicians who said, ‘I am the best doctor for my family… I know the most about them, I have their values at heart, I should take care of them.'”
At the University of Michigan, Gold has worked with a committee to create internal rules for treatment of friends and family, and even her fellow committee members recognized the nuances.
“Virtually all of the physicians in the room at some point had written a prescription for someone or done something informally, and we all recognize that and acknowledge that.”
She adds that context is important. For example, it may be acceptable to refill a chronic medication for a family member, as long as the primary care physician is quickly notified.
“I try not to be absolute in coming down in sort of black and white because I think it’s such a nuanced issue.”
Jon Zirn, the dermatologist who frequently provides informal care for his friends and family, agrees that it is a complicated issue. “You know it’s an imperfect world, so when we have to do that kind of thing, you know, we do it, but it’s not optimal.”
Gold says that physicians can help their loved ones without direct involvement in their treatment by guiding them through health care decisions and advocating for them.