Should Doctors Examine, Diagnose and Treat Their Family Members?

In a 1991 study of physicians published in the New England Journal of Medicine:99% of 465 physicians surveyed had requests from family members for medical advice, diagnosis and treatment.

Family members included spouses, children, parents, siblings, nieces, nephews, in-laws, aunts, uncles and cousins. Eighty-three percent of physicians had prescribed medication for a family member, 80% had diagnosed medical illnesses, 72% had performed physical examinations, 15% had acted as a family member's primary doctor, and 9% had performed surgery on a family member.In addition, 152 (33 percent) reported that they had observed another physician "inappropriately involved" in a family member's care, and 103 (22 percent) had acceded to a specific request about which they felt uncomfortable.

The American Medical Association Medical Code of Ethics Opinion 8.91 (1993)"Self-Treatment or Treatment of Immediate Family Members" states the following:

Opinion 8.19 - Self-Treatment or Treatment of Immediate Family Members

Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. Physicians may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the physician is an immediate family member. This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients. When treating themselves or immediate family members, physicians may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.

Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their immediate family. Family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician. In particular, minor children will generally not feel free to refuse care from their parents. Likewise, physicians may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care.

It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems. Except in emergencies, it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members.



All of the above was written from the aspect of the physician but what I would like to know is whether if you are or if you might be the family member of a physician, to what extent, if at all, would you want the "doctor in the family" participating in the diagnosis, advice or treatment of your illness? ..Maurice.

Patient Modesty: Volume 32

We continue on with a multi-faceted discussion regarding patient modesty. Is there any one facet in these previous 31 volumes which hasn't as yet been covered? It seems to me that virtually everything has been discussed except perhaps the role of the government, both state and federal and politics in the distresses expressed here by my visitors. Particularly interesting would be whether anyone who is involved in the United States healthcare reform is considering patient modesty and gender selection issues as part of that reform. Any thoughts on that? ..Maurice.

Graphic: The Donkey and Elephant political cartoon by Thomas Nast (1840-1902) American editorial cartoonist with text applied by me using Picasa3.


NOTICE: AS OF TODAY MARCH 24, 2010 "PATIENT MODESTY: VOLUME 32" WILL BE CLOSED FOR FURTHER COMMENTS. YOU CAN CONTINUE POSTING COMMENTS ON VOLUME 33

Teaching the Painting the Human Body: The Use of Cadavers

Should students who are learning to create paintings of the human body be allowed to have the opportunity to look at and then paint human cadavers? Shouldn't art students have the same opportunity to inspect and draw the human body from the dead as medical students have such an opportunity to learn human anatomy? Should such use be publicized and people asked to donate themselves after death to be a model for an art student? Should unclaimed cadavers be used for this purpose? What is the difference between the use by an art student and that use by a medical student? Is there an ethical difference? Are there certain limits which should be set for the use of the dead by others? If so, what should they be? Many questions..can anyone write an answer? ..Maurice.

Doctors

"Doctors" by Rudyard Kipling (1865-1936)



Man dies too soon, beside his works half-planned.
His days are counted and reprieve is vain:
Who shall entreat with Death to stay his hand;
Or cloke the shameful nakedness of pain?

Send here the bold, the seekers of the way--
The passionless, the unshakeable of soul,
Who serve the inmost mysteries of man's clay,
And ask no more than leave to make them whole.

I am a physician! And as a physician, I feel emotionally strengthened by reading this classic poem by this famous poet from India. I feel encouraged and proud that I am in the right profession and doing the right thing. Shouldn't I? ..Maurice.

Patient Autonomy: Where Should It Begin and End?

I have published threads here in the past for discussion of the ethical conflict between physician paternalism versus patient autonomy in medical decision-making.

Here is a brief vignette extracted from a book review article “Veatch Hates Hippocrates” by ethicist John D. Lantos in the January-February 2010 issue of the Hastings Center Report that sets the conflict rather clearly. Read it and then give us your view of the “good” and “bad” of this communication between a patient and her doctor. ..Maurice.

Doctor: “I notice that you are coughing, that you are using your intercostal muscles when you breathe and that you are breathing sixty times a minute. I don’t want to impose my values upon you. How do you value that state of being?”


Patient (gasping for air): “…can’t….breathe…”


Doctor: “Can’t breathe? Well for me that would be unpleasant, but I happen to value oxygenation. I wouldn’t want to impose those values on you. I could give you a little oxygen. Or I could give you morphine. Or I could give you a nebulizer treatment. Which would you prefer?”


Patient: “I just…want something that will make me feel …better…”


Doctor: “I want to help. Tell me… what does ‘better’ mean to you?”

Ghostwriting Scientific Medical Articles and the Role of Academic Medical Institutions

If you think that college students turning in their term papers, the text of which was actually written by others and sold on the internet is unethical, consider “respected” physicians associated with well known academic institutions getting paid by pharmaceutical companies to have their name attached to medical research articles which were written by ghostwriters working for the company. I started this topic of ghostwriters on Halloween last year and I would like to continue the topic here stimulated by an open-access article in PLOS Medicine published today titled "Ghostwriting at Elite Academic Medical Centers in the United States" by Jeffrey R. Lacasse and Jonathan Leo.

I am reproducing the Background and the Conclusion (without including references) here but I advise my visitors to read the survey study at the above link, which will include the references. Then return and present your views of the issue and its consequences. ..Maurice.

BACKGROUND-
Medical ghostwriting, the practice of pharmaceutical companies secretly authoring journal articles published under the byline of academic researchers, is a troubling phenomenon because it is dangerous to public health . For example, ghostwritten articles on rofecoxib probably contributed to “…lasting injury and even deaths as a result of prescribers and patients being misinformed about risks”. Study 329, a randomized controlled trial of paroxetine in adolescents, was ghostwritten to claim that paroxetine is “generally well tolerated and effective for major depression in adolescents” although data made available through legal proceedings show that “Study 329 was negative for efficacy on all 8 protocol specified outcomes and positive for harm” . Even beyond frank misrepresentation of data, commercially driven ghostwritten articles shape the medical literature in subtler but important ways, affecting how health conditions and treatments are perceived by clinicians. The ability of industry to exercise clandestine influence over the peer-reviewed medical literature is thus a serious threat to public health In 2009, the Institute of Medicine recommended that US-based academic medical centers enact policies that prohibit ghostwriting by their faculties . However, to date, there has been no systematic assessment of ghostwriting policies at academic medical centers. Since US-based academic medical centers generate biomedical research for a worldwide audience, we chose to conduct the first such investigation on elite US-based academic medical centers. … We sought to describe the current policy situation at US-based academic centers and then to propose an ideal ghostwriting policy.

CONCLUSION-
Medical ghostwriting is a threat to public health which currently takes place only due to the cooperation of researchers employed at academic medical centers. Although there is growing awareness of the danger posed by medical ghostwriting, we find that few academic medical centers have public policies which prohibit this behavior, and many of the existing policies are ambiguous or ill-defined. We have proposed an unambiguous policy which defines participating in medical ghostwriting as academic misconduct akin to plagiarism or falsifying data. By adopting and enforcing this policy, academic medical centers would adhere to the norms of science followed across the rest of the University, and would no longer facilitate clandestine industry influence over the peer-reviewed scientific literature. By prohibiting medical ghostwriting, academic medical centers have a rare opportunity- to significantly reduce a major threat to public health with the stroke of a pen.