We have all been approached by our colleagues, both formally and informally, regarding orthopaedic problems. We are usually honored when a fellow physician chooses us to be his or her treating doctor. However, caring for physicians as patients can be a difficult assignment, fraught with ethical dilemmas. This article explores several of the potential pitfalls in treating physician-patients and contains some basic guidelines.
The above scenario illustrates an often encountered problem—namely, the curbside consult1. We are likely to be more familiar with this situation as one that occurs with friends, relatives, and acquaintances at social gatherings, and most of us have become quite adept at handling such circumstances. However, when a physician-colleague is asking about himself or herself, most physicians tend to be more tolerant of the questions. None of us wants to offend the asking physician, despite the fact that we know we are not practicing good medicine. These encounters can frequently lead to misinformation, incorrect diagnoses, and a delay in obtaining appropriate treatment.
As all of us are well aware, most physicians do not wish to spend the time that it may take to have their ailments correctly diagnosed and treated. Physicians will frequently downplay the extent or seriousness of their own illnesses. They often believe that they are indispensable to their practices and immune to their own medical problems, and they rarely, if ever, take sick leave from work, even when they are seriously ill. These characteristics have been termed the disease of being a doctor2.
Interestingly, many physician-patients will choose their treating doctor not on the basis of professional expertise but rather because of personal or social relationships3. These prior collegial relationships can further compound the development of a working doctor-patient relationship. The patient may be reluctant to divulge pertinent medical or social information, and the treating physician may be hesitant to ask. Very often a cursory history or physical examination is performed in an attempt to spare the patient embarrassment or discomfort, and diagnostic testing may be deferred to avoid further bother.
Additionally, many physicians have little personal experience at being patients. They may have a great deal of difficulty in navigating the current medical system as patients. Difficulties in obtaining appointments, delays in test scheduling, restrictive insurance preapprovals, and even considerable medical costs may all be unfamiliar territory for the physician-patient4.
If the treating physician has previously been in a subordinate position, such as medical student, resident, or junior attending physician, then the situation may be further compounded. The senior physician may have difficulty relinquishing his or her prior authority and assuming the role of patient. This can often lead to the physician-patient attempting to control the workup and treatment plan of the younger physician. It is important that the treating physician maintain control of the medical management of the patient. If he or she is unable to do so, then terminating the doctor-patient relationship is appropriate. The physician must not be intimidated into acting in a manner that he or she believes is not in the best interest of the patient.
There are also several issues on the treating physician's side of the relationship that must be considered. Many physicians will assume that the patient, as a colleague, will be well versed with regard to the particular ailment. This is often not true. Most nonorthopaedic physicians will have relatively little knowledge regarding orthopaedic diseases or injuries and even less knowledge about the specifics of treatment protocols. Orthopaedic surgery is a highly technical field, and few nonorthopaedic physicians are familiar with the nuances of our field.
It is imperative that the treating physician presuppose that his or her colleague knows little about the specific injury or disease and proposed treatment, especially if surgical intervention is required. The physician must take the time to carefully explain, as he or she would with any other patient, the details of the diagnosis, the prognosis, and the risks, benefits, and alternatives of the proposed treatment. He or she should not assume that the physician-patient possesses the same medical knowledge that the treating physician does.
It is also important to keep in mind that office visits with the physician-patient may, paradoxically, take longer than the typical office consultation. The questions and discussions may be more in depth and time-consuming. In addition, no matter how much of an effort is made to try to limit them, social, hospital, and practice issues will often insinuate themselves into the conversation. It is often good practice to allow extra time for these visits or to schedule them at times when they will not interfere with other appointments, such as early in the morning, over lunchtime, or late in the afternoon.
Although honored to be asked to participate in a colleague's care, the treating physician will likely have a great deal of anxiety regarding the care of a crony5. This can be especially true if surgery is anticipated or planned. We all want to "get it right" and make sure that our colleague is receiving the best possible care. Unfortunately, in our effort to be extra vigilant, we may begin to doubt our usual protocols. There is a tendency to want to change our routine, whether it is with regard to our diagnostic evaluations or, worse, our surgical techniques. It is important that the treating physician continue to practice his or her expertise in a manner that is customary and comfortable, doing what he or she would do for any patient with a similar problem without beginning to doubt what has worked well for all previous patients.
A final issue regarding care of the physician-patient is one of confidentiality. The treating physician must be especially vigilant in guarding the patient's confidentiality and must be cautious to share medical information only with those directly involved in the patient's care. There may be a strong temptation to discuss the patient's condition or treatment with colleagues or other staff members5,6. I have often found it helpful to discuss early on with the physician-patient the way in which he or she would like queries from well-meaning colleagues, staff, and administrators to be handled.
The ethical issues raised when treating the physician-patient are similar to those encountered when caring for family members7-9. Several authors have proposed guidelines that the treating physician should consider prior to treating relatives or colleagues5,6,10. We might even stop and consider these same questions when we become the patient seeking medical advice. Below are some questions to be considered:1. Can I remain objective in maintaining the doctor-patient relationship or is an inappropriate collegial rapport likely to ensue?2. Do I have an excessive amount of anxiety that may jeopardize my ability to care for a colleague or friend?3. Am I treating this patient in the same manner that I treat all of my other patients (e.g., with regard to history and physical examination, diagnostic testing, and treatment considerations)?4. Have I carefully explained to this patient the diagnosis, treatment plan options, surgical procedure, postoperative care, risks, goals, and alternatives in the same detail that I would for a nonphysician patient?5. Have I clarified the boundaries of this relationship and made it comfortable for the patient to ask questions, to express his or her feelings, and to continue or terminate the relationship without sentiments of guilt or anxiety?6. Can I maintain this patient's confidentiality?7. Can I always act for the good of this patient even if it means making decisions that may jeopardize the friendship?
1. Can I remain objective in maintaining the doctor-patient relationship or is an inappropriate collegial rapport likely to ensue?
2. Do I have an excessive amount of anxiety that may jeopardize my ability to care for a colleague or friend?
3. Am I treating this patient in the same manner that I treat all of my other patients (e.g., with regard to history and physical examination, diagnostic testing, and treatment considerations)?
4. Have I carefully explained to this patient the diagnosis, treatment plan options, surgical procedure, postoperative care, risks, goals, and alternatives in the same detail that I would for a nonphysician patient?
5. Have I clarified the boundaries of this relationship and made it comfortable for the patient to ask questions, to express his or her feelings, and to continue or terminate the relationship without sentiments of guilt or anxiety?
6. Can I maintain this patient's confidentiality?
7. Can I always act for the good of this patient even if it means making decisions that may jeopardize the friendship?
We are all aware that treating colleagues, friends, and relatives can be difficult. Despite careful introspection, awareness, and being on guard, we all tend to change our behavior, even slightly, when treating people with whom we are familiar. Those alterations in behavior are most likely inevitable. What is important, however, is to avoid the serious pitfalls discussed above. The curbside consult should be firmly avoided. It takes only a few seconds to explain to a colleague the appreciable risks of a misdiagnosis and the importance of differentiating between seemingly benign and more dangerous conditions. In the above scenario, M.G., as the physician, discovered the truth in Clare Boothe Luce's observation that "no good deed goes unpunished." The patient-colleague remains angry even to this day because the wrong "diagnosis" was made, even though no official diagnosis had ever been rendered. We should take the time to treat colleagues and friends as we would any other patient. In the long run, careful evaluation, correct diagnosis, and appropriate treatment will be appreciated by all parties involved.