A few weeks ago one of my friends thought she had strep throat. At first, I was a little skeptical. Adults don’t usually get strep throat and none of her children were sick. Secondly, she was out for a nine mile run with me which would have been an amazing feat with streptococcal pharyngitis.
Like most pediatrician mothers, I have strep swabs in my medicine cabinet. I ran a test in my kitchen to save her a pointless trip to urgent care if negative. Positive results would lead to a potentially sticky situation–to prescribe or not to prescribe. Should physicians prescribe medications for friends, close relatives, or neighbors…basically anyone who is not our patient?
It’s amazing how quickly the requests for medical care come after you walk across the stage and receive your MD. In my first years after graduation, I received phone calls about infected fingers, Lyme disease and even one memorable request for a school excuse for not showing up for a final exam. Sometimes the answer is a simple no. But other times, like in this case with a positive strep test, the answer is more complicated.
There are things explicitly taught in the medical school curriculum and then there are things that get grouped together under the “hidden curriculum.” The hidden curriculum refers to the things that cannot be covered in a textbook or a lecture. They may come up directly in conversation or networking events, but are more often learned through observing another doctor’s actions. Whether to treat loved ones was never discussed in my formal medical education. Luckily in one of my final rotations of residency training, a fabulous attending took the time to sit down and discuss the dangers of prescribing antibiotics and medication for colleagues, family members and friends. Her message was clear: “Just don’t do it.”
When we prescribe medications for someone who we know on a personal level, and more specifically someone who is not our patient, we are at risk of more than just lawsuits. We risk mistakes that could negatively impact the health of those we hold dear. Our objectivity can be skewed by our personal connection. The patient may not fully disclose pertinent medical history. We may not ask sensitive questions or fully examine sensitive areas for fear of making things uncomfortable. More often, the questions we are faced with are outside of our scope of practice and can lead to a slippery scope of overreaching our own comfort level as doctors.
There is an excellent review of the ethical implications by Dr. Katherine Gold et al., in the New England Journal of Medicine called “No Appointment Necessary? Ethical Challenges in Treating Friends and Family.” This is a great reference that delves into some specific circumstances and the legal complications that can arise. Some departments of medicine even have written policies on this subject.
For me, even with established patients, when choosing to treat something outside of a formal office visit, the decision always centers around quality of care. If I choose to treat you in my living room or in my backyard, I may be giving you substandard care. As my loved one or friend, you most certainly deserve access to the same high quality of care as any patient I see in my office. Armed with an incomplete medical history, I could do serious harm by blindly prescribing medication.
I don’t love the idea of Big Brother regulating us, but in this arena, I think some concrete guidance is warranted. According to Dr. Gold, every organization that has released guidelines “recommend against care for self or family other than in exceptional situations.” Five years out in practice, I have dealt with my fair share of exceptional circumstances (What can you do when you are the only pediatrician in the country for your practice and your kid who is a patient is sick?). But, when these circumstances arise, remember this: stay within your scope, documentation is crucial and don’t treat any friend or family member substandard to how you would treat your own patient.
How did I leave it with my friend? I told her to call her primary and explain her history and the positive test. If he did not feel comfortable prescribing, I would get her info, start a note in my chart and document past history and any allergies, then send antibiotics. Luckily, he agreed to send antibiotics in.