So what happens to these ambitious young men and women after they finish medical school and residency training and finally enter the world of being a doctor? Aside from the few who jump ship to pursue careers that steer them far away from the nearest patient (see McKinsey’s healthcare division), young doctors pride themselves on their newfound skills that allow them to treat the sick. Inside the four walls of the hospital, things work out fine and dandy. Doctors make their rounds in the hospital wards seeing patients in the morning, and then spend the afternoon in their own clinic. But in the hallways and at the home, there is an all too familiar scene that takes place time and time again. The custodian stops you on your way to the office to ask about a pain in his foot. Or your eighty-six year-old neighbor flags you down while you’re walking your dog and shows you a rash in a place you’d rather have her keep covered until you had your morning coffee or at least until there was a curtain to preserve her sanctity (which, notably, she isn’t as concerned about as you are).
The American Medical Association’s (AMA) Code of Ethics recommends that doctors refrain from giving medical advice or treating friends and family unless there is an emergency situation and no one else is around to help. But even then, these situations come up all the time and sometimes make it tough for a doctor to bottle up those altruisms that made them who they are today.
I was once asked to visit a friend who was feeling ill after returning from a bachelor party in Las Vegas. It was influenza season, he was twenty-five, and he’d been having muscle pains, fevers, and fatigue. To add to that, he hadn’t had his “flu” shot yet. He obviously had the flu – the perfect diagnosis that fit everything about his case. So I told him to drink plenty of fluids and to get some rest. Before leaving, I asked him briefly if he had any other medical problems and if there was anything else going on that I should know about. He looked at his girlfriend who was seated next to him, glanced at my wife who had accompanied me to their house, and then quickly answered “No”. I left their house with my wife, thinking to myself that I had done a good deed by reassuring my friend that he probably had the simple “flu” and that he’d get better. I went to bed with a smile on my face that night.
I later found out I was horribly wrong. A few days later, my friend’s girlfriend called me in a panic, asking me to come over to their house because his condition was worsening. I stepped into their living room to find his neck impressively swollen. This time, I opted to talk to him privately. It turns out that about five years ago he was diagnosed with systemic lupus erythematosus (SLE), a condition where the human body generates antibodies that attack its own self. The treatment is to give medicines that suppress the immune system so that the damage can be halted. But because of side effects he developed from the medicines, he decided to stop taking them. In a twenty-five year-old otherwise healthy patient who complains of fevers, fatigue, and muscle aches during influenza season, a diagnosis of the “flu” is probably not a bad guess. But in a patient who has untreated SLE, the common “flu” is just one of the things on a longer list of even more dangerous possibilities – possibilities that could have killed him had he not sought appropriate care in a timely fashion.
There’s a reason that the AMA recommends against physicians treating their friends. Aside from the fact that the usual in-depth history is condensed in casual-speak to a few “yes-no” type questions, there is oftentimes no physical exam to follow. Many times these conversations are had over the phone or at a social event where a proper physical exam is not even feasible (ahem…okay Mr. Anderson, in order for me to fully assess your complaint, why don’t you put down your martini and go into the kitchen and take your shirt off). Additionally, friends aren’t always ready to talk about very personal parts of their medical history, like sexually transmitted diseases, illegal substance use, or even classic medical problems (i.e. SLE). A physician trying to create a differential diagnosis for a patient’s symptoms without the full history is like a construction worker trying to build a house without a hammer.
As much as it may be the job of the physician to maintain boundaries for delivering healthcare advice, the onus of responsibility should also be shared with the patient. Patients should know that unless they are truly forthcoming about their medical history, they should not expect to get the best advice. They should also realize that most medical diagnoses arise from a thorough history AND physical. So if a healthcare professional is making therapeutic or diagnostic recommendations without laying their hands or stethoscope on their body, a major element of how doctors think is missing from the equation.
Then there’s the issue of physicians treating family and loved ones. As any healthcare provider knows, every symptom a patient complains of brings to mind many potential diagnoses, some that are benign and others that are life-threatening. When treating any patient, physicians are expected to think of the entire spectrum of disease and systematically eliminate those conditions that aren’t so likely, while simultaneously evaluating for those that fit the clinical scenario. But things are different when a physician attempts to treat a loved one. It’s only natural to assume that the more life-threatening conditions wouldn’t happen to the ones you love, which makes it tough for physicians to consider certain possibilities. A cough ends up always being because of a cold and never because of lung cancer; chest pain is always because of heartburn and never because of an impending heart attack. Medicine should always be practiced in an impartial and unemotional way so as to allow for the most independent and accurate thought. When emotions cloud clinical judgment, we are performing an injustice.
My friend went to a local emergency room where he underwent a complete history and physical, along with diagnostic testing. His fevers continued to climb, his white blood cells (the cells that fight infections) were non-existent, his neck continued to swell, and he was very anemic. This was clearly not just the “flu”. After performing a biopsy of the enlarged lymph node in his neck, he was diagnosed with a rare syndrome called Kikuchi-Fujimoto disease (a condition where the body’s immune system attacks a lymph node in the neck and can lead to multi-organ failure). With timely administration of intravenous steroids, he immediately began to get better and a week later was ready to return home.
Every physician probably has a story like this that they will never forget. After wanting to do our best for every patient that we see, why do we suddenly find it okay to deliver partial care to the ones who are closest to us? It doesn’t make sense. Helping friends think through some of their medical problems as a reference seems like a harmless thing to do, but the conversation should stop there before a patient feels like they don’t need to see a real doctor.
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