Feature

How to handle medical advice requests from friends, family

Paul Burcher
Paul Burcher

Friends and family members will ask doctors for medical advice for a variety of reasons: curiosity, needing help in a situation that is unfamiliar, concern about their friends and family, or feeling ‘fed up’ with other physicians and the health care system, research suggests.

However, doctors should think before they speak for a variety of reasons, several sources told Healio Family Medicine.

“Even though I’m an OB-GYN — and OB-GYNs are notorious for thinking first about medical liability — the threat of a lawsuit is not the strongest argument for not giving advice,” Paul Burcher, MD, PhD, associate professor of bioethics and program director, obstetrics and gynecology at York Hospital in Pennsylvania, told Healio Family Medicine. “The strongest argument against giving medical advice to nonpatients is that you are potentially, unknowingly rendering less than ideal care.”

“You may just think you’re just chatting away but they may be thinking it is a real medical consultation and follow whatever you say,” he continued. “We may actually be harming people because the lack of the formality of going through the stepwise process that we do in the office, makes mistakes much more likely and the person may not understand the interaction the same way that you understand it.”

Lawsuits always a possibility

Gregory Eastwood
Gregory L. Eastwood

That’s not to say the potential of a lawsuit should be ignored when the friend or family member looks for medical advice, Gregory L. Eastwood, MD, of the Center for Bioethics and Humanities, State University of New York Upstate Medical University said.

“Friends and relatives are not immune from suing physicians whom they consult informally,” he wrote in a paper published in the Journal of General Internal Medicine.

Robyn Latessa
Robyn Latessa

Legal action may weigh on the mind of some physicians who provide medical advice to nonpatients, according to Robyn Latessa MD, director and assistant dean, University of North Carolina School of Medicine, Asheville campus.

“Malpractice is more common for a physician of record. I’m not aware of that many cases for nonpatients, but that it is a consideration in the back of the mind of some physicians,” she said in an interview. “It’s a factor, but not a large one.”

A recent AMA survey found that 34% of respondents have had a claim filed against them during their career. In addition, a report just published by The Doctors Company found that the rate of claim, or written demand for payment, among full-time family medicine physicians and internal medicine physicians has averaged between 3% and 5% during the last 10 years.

Eastwood said medical professionals should not completely turn away from giving their medical opinions from friends and family, but both sides need to be clear about their expectations from doing so.

He added that doctors should handle the situation just as he or she would if it was not a friend or family member looking for advice; be cognizant of HIPAA requirements, the requester’s autonomy and confidentiality; and being aware that one’s judgment may be a bit skewed and conducting a structured physical exam and/or charging a fee lays the potential groundwork for a legal relationship with the patient.

Eastwood says he wants to inform, not alarm.

“Most of my experience has been very good. Some, not so,” he told Healio Family Medicine in an interview. “I believe that offering factual advice is something that most physicians feel comfortable about and serves a useful function. When the advice begins to rely on the physician’s medical judgment and if it is beyond his/her expertise, that is where the physician must be cautious.”

“I would advise that the physician think about each situation and decide whether offering advice is indicated and how the advice should be conditioned. If the requester is close to the physician, such as a spouse or child, one doesn’t have to think much. Usually you can just give the advice,” Eastwood continued. “If the relationship is more distant or ambiguous, the physician might say that he/she cannot offer advice or must make sure that the requester knows the limitations.”

He offered some possible responses a doctor can give when a friend or family member seeks medical advice:

  • “Yes, of course, I would be happy to help.”
  • “Let me make sure that I understand what you are asking.”
  • “I would be happy to continue to be involved.”
  • “I am happy to help but please understand that [I have not examined you], [I am not a cardiologist], [I am not your doctor].”
  • “I am not your doctor, but in situations like this I believe [X] is recommended.”
  • “I am sorry, but I don’t think I can do this because ...”
  • “Under these circumstances, you should not rely on me for medical advice.”
  • “I would feel better if you asked your doctor about this.”
  • “I am your friend (or cousin, etc.) who happens to be a physician, but I think you can appreciate that that is different from being your physician.”

A report in Family Practice Management coauthored by Latessa suggested that the physician should document everything that happened during the exchange, “even if the treatment was minor.”

AMA stance

AMA’s Code of Ethics also discusses the issue of providing medical advice to family members, stating that in general, physicians should not treat these relatives, except in certain, rare situations, such as emergency settings or isolated settings where there is no other qualified physician available, or for minor, not long-term problems.

Burcher provided examples to cut through the legalese that sometimes comes with official documents.

“Even writing a small prescription for a narcotic, controlled substance or a tranquilizer or things like that for a friend or family member who isn’t your patient and you have not documented an office visit for will get you in trouble,” he said. “If your sister calls and says I have a UTI but also says no one has examined her and no one has checked her urine, that too, could cause problems down the road.”

“Conversely, a pharmacy won’t put up as many red flags if it’s a refill for your aunt’s antihypertension drug, or if a renewal request comes in over the weekend and there is no other way for the patient to get the medication,” Burcher continued.

AMA’s website also states physicians who treat family members have a responsibility to:

  • “Document treatment or care provided and convey relevant information to the patient’s primary care physician.”
  • “Recognize that if tensions develop in the 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.”
  • “Avoid providing sensitive or intimate care especially for a minor patient who is uncomfortable being treated by a family member.”
  • “Recognize that family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician.”

An AMA spokesperson cautioned that some specialty medical societies may have their own guidelines regarding certain situations and thus, specialty physicians should consult their respective group for more information. In addition, the Family Practice Management article noted that some state medical boards may also have their own rules and regulations.

Real-world considerations

Esther Giroldi
Esther Giroldi

Esther Giroldi, PhD, of the department of family medicine at Maastricht University in The Netherlands, and colleagues conducted several focus groups containing 49 physicians that looked at what they considered when handling requests that come from nonpatients. The paper, titled “Family physicians managing medical requests from friends,” was recently published in the Annals of Family Medicine.

Several common themes came up during the sessions:

  • “Who is this person, what is he or she asking of me, and where are we?”
  • “Nature/strength of the relationship with the nonpatient;”
  • “Amount of trust in his/her own knowledge and skills;”
  • “Expected consequences of making mistakes;”
  • “Importance of work-life balance;” and
  • “Risk of disturbing the physician-patient process.”

Researchers also found that physicians who had at least 5 years of working experience in family medicine and supervised a resident in their own practice utilized “more nuanced considerations when deciding whether to respond.” Younger physicians had more problems handling these requests, were less likely to provide answers, and were more worried about disturbing the existing relationship that a person had with their regular physician.

Giroldi told Healio Family Medicine a solution to handling nonfamily requests is not one-size-fits-all.

“Guidelines that state you should not treat family members or friends unless it’s an urgent situation make it seem so simple,” she said in an interview. “Our study showed this is actually a very complex process, and a single guideline doesn’t really fit what actually goes on in an actual clinical setting.”

Latessa agreed, saying the subject matter has a lot of ambiguity.

“Most physicians struggle with the grayer area where if the ethical guideline says minor or emergency or isolated, and how you really define that,” Latessa said. “One physician’s interpretation of what is minor or emergency or isolated might be different than another physician’s interpretation. The guidelines leave a lot open to individualize situations.”

Jochen Cals
Jochen W. L. Cals

The Annals of Family Medicine study also found the personal nature of these relationships sometimes clouded the physicians’ judgment, according to coauthor Jochen W. L. Cals, PhD, MD, also from the department of family medicine at Maastricht University.

“Many recalled examples where they thought their judgement was biased because of emotions. Many also said there were times when they missed the diagnosis with their child or waited too long to consult their own doctor because they didn’t assess the situation correctly because they were trying to act as both the mother or father and a doctor at the time which caused a conflict,” he said in an interview.

Cals suggested that piece of mind may offset the inconvenience family members and friends may experience by scheduling and waiting for an appointment in the nonemergency situation.

“The nonpatient may think talking to you might be easy access to medical care but you can tell them they deserve better, objective treatment and that you don’t want to jeopardize the relationship by giving advice,” he told Healio Family Medicine.

Times have changed
With the average physician aged older than 50 years old, some may not realize how the consequences of giving advice to family and friends has changed.

The recent AMA survey found that 49.2% of physicians aged 55 years and older said they have been sued vs. 8.2% of physicians aged 40 years and younger, suggesting that the likelihood of getting sued increases with age.

Burcher said that age is no excuse for a doctor not changing long-standing procedures on this issue.

“I realize that a lot of physicians have given advice to nonpatients for a long time but I think they should reexamine their practice and habits and recognize that when you’re not speaking to another medical professional, your words are so easily taken out of context and misunderstood and people may be harmed by that and we should be more careful about this,” he said.

Educating the next generation of physicians

A survey in the New England Journal of Medicine stated that 99% of the 465 responding physicians had been approached by a family member for a medical diagnosis, advice or treatment. Also, one-third indicated they had seen another doctor “inappropriately involved” in a family member’s care.

In addition, when it came to physicians’ interactions with family members:

  • 83% had prescribed medication;
  • 80% had diagnosed medical illnesses;
  • 72% had conducted a physical exam;
  • 15% had acted as a family member's primary attending physician in the hospital;
  • 9% had performed an operation on a family member.

Despite such apparent prevalence, Latessa told Healio Family Medicine that teaching the next generation of physicians how to handle medical requests from family and friends is often not part of the required curriculum.

“There is still a lot of room and work to do especially in medical education, both in medical school and at the residency program level. In our program here at the UNC School of Medicine Asheville, we do touch on this topic, but that’s certainly not the case across the board,” she said. “One of the next steps should be training some of the basic bottom lines and then working through some of the grayer areas with sample cases with physicians in training or even with physicians in practice.” – by Janel Miller

References:

AMA. “Treating self or family.” https://www.ama-assn.org/delivering-care/treating-self-or-family. Accessed March 13, 2018.

Eastwood, GL. J Gen Intern Med. 2009;doi:10.1007/s11606-0091127-1.

Giroldi E, et al. Ann Fam Med. 2018. doi:10.1370/afm.2152.

Latessa R, Ray L. Fam Pract Manag. 2005 Mar;12(3):41-4.

La Pluma J, et al. NEJM. 1991;doi10.1056/NEJM199110313251806.

The Physicians Foundation. “America’s physicians practice patterns and perspectives.”

https://physiciansfoundation.org/wp-content/uploads/2017/12/Biennial_Physician_Survey_2016.pdf. Accessed March 13, 2018.

The Doctors Company. “Nurse practitioner closed claims study.” https://www.thedoctors.com/siteassets/pdfs/marketing-order-form-items/nurse-practitioner-closed-claims-study.pdf.” Accessed March 13, 2018.

Disclosure: Burcher, Cals, Eastwood, Giroldi and Latessa all reported not having any relevant financial disclosures.

Paul Burcher
Paul Burcher

Friends and family members will ask doctors for medical advice for a variety of reasons: curiosity, needing help in a situation that is unfamiliar, concern about their friends and family, or feeling ‘fed up’ with other physicians and the health care system, research suggests.

However, doctors should think before they speak for a variety of reasons, several sources told Healio Family Medicine.

“Even though I’m an OB-GYN — and OB-GYNs are notorious for thinking first about medical liability — the threat of a lawsuit is not the strongest argument for not giving advice,” Paul Burcher, MD, PhD, associate professor of bioethics and program director, obstetrics and gynecology at York Hospital in Pennsylvania, told Healio Family Medicine. “The strongest argument against giving medical advice to nonpatients is that you are potentially, unknowingly rendering less than ideal care.”

“You may just think you’re just chatting away but they may be thinking it is a real medical consultation and follow whatever you say,” he continued. “We may actually be harming people because the lack of the formality of going through the stepwise process that we do in the office, makes mistakes much more likely and the person may not understand the interaction the same way that you understand it.”

Lawsuits always a possibility

Gregory Eastwood
Gregory L. Eastwood

That’s not to say the potential of a lawsuit should be ignored when the friend or family member looks for medical advice, Gregory L. Eastwood, MD, of the Center for Bioethics and Humanities, State University of New York Upstate Medical University said.

“Friends and relatives are not immune from suing physicians whom they consult informally,” he wrote in a paper published in the Journal of General Internal Medicine.

Robyn Latessa
Robyn Latessa

Legal action may weigh on the mind of some physicians who provide medical advice to nonpatients, according to Robyn Latessa MD, director and assistant dean, University of North Carolina School of Medicine, Asheville campus.

“Malpractice is more common for a physician of record. I’m not aware of that many cases for nonpatients, but that it is a consideration in the back of the mind of some physicians,” she said in an interview. “It’s a factor, but not a large one.”

A recent AMA survey found that 34% of respondents have had a claim filed against them during their career. In addition, a report just published by The Doctors Company found that the rate of claim, or written demand for payment, among full-time family medicine physicians and internal medicine physicians has averaged between 3% and 5% during the last 10 years.

PAGE BREAK

Eastwood said medical professionals should not completely turn away from giving their medical opinions from friends and family, but both sides need to be clear about their expectations from doing so.

He added that doctors should handle the situation just as he or she would if it was not a friend or family member looking for advice; be cognizant of HIPAA requirements, the requester’s autonomy and confidentiality; and being aware that one’s judgment may be a bit skewed and conducting a structured physical exam and/or charging a fee lays the potential groundwork for a legal relationship with the patient.

Eastwood says he wants to inform, not alarm.

“Most of my experience has been very good. Some, not so,” he told Healio Family Medicine in an interview. “I believe that offering factual advice is something that most physicians feel comfortable about and serves a useful function. When the advice begins to rely on the physician’s medical judgment and if it is beyond his/her expertise, that is where the physician must be cautious.”

“I would advise that the physician think about each situation and decide whether offering advice is indicated and how the advice should be conditioned. If the requester is close to the physician, such as a spouse or child, one doesn’t have to think much. Usually you can just give the advice,” Eastwood continued. “If the relationship is more distant or ambiguous, the physician might say that he/she cannot offer advice or must make sure that the requester knows the limitations.”

He offered some possible responses a doctor can give when a friend or family member seeks medical advice:

  • “Yes, of course, I would be happy to help.”
  • “Let me make sure that I understand what you are asking.”
  • “I would be happy to continue to be involved.”
  • “I am happy to help but please understand that [I have not examined you], [I am not a cardiologist], [I am not your doctor].”
  • “I am not your doctor, but in situations like this I believe [X] is recommended.”
  • “I am sorry, but I don’t think I can do this because ...”
  • “Under these circumstances, you should not rely on me for medical advice.”
  • “I would feel better if you asked your doctor about this.”
  • “I am your friend (or cousin, etc.) who happens to be a physician, but I think you can appreciate that that is different from being your physician.”
PAGE BREAK

A report in Family Practice Management coauthored by Latessa suggested that the physician should document everything that happened during the exchange, “even if the treatment was minor.”

AMA stance

AMA’s Code of Ethics also discusses the issue of providing medical advice to family members, stating that in general, physicians should not treat these relatives, except in certain, rare situations, such as emergency settings or isolated settings where there is no other qualified physician available, or for minor, not long-term problems.

Burcher provided examples to cut through the legalese that sometimes comes with official documents.

“Even writing a small prescription for a narcotic, controlled substance or a tranquilizer or things like that for a friend or family member who isn’t your patient and you have not documented an office visit for will get you in trouble,” he said. “If your sister calls and says I have a UTI but also says no one has examined her and no one has checked her urine, that too, could cause problems down the road.”

“Conversely, a pharmacy won’t put up as many red flags if it’s a refill for your aunt’s antihypertension drug, or if a renewal request comes in over the weekend and there is no other way for the patient to get the medication,” Burcher continued.

AMA’s website also states physicians who treat family members have a responsibility to:

  • “Document treatment or care provided and convey relevant information to the patient’s primary care physician.”
  • “Recognize that if tensions develop in the 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.”
  • “Avoid providing sensitive or intimate care especially for a minor patient who is uncomfortable being treated by a family member.”
  • “Recognize that family members may be reluctant to state their preference for another physician or decline a recommendation for fear of offending the physician.”

An AMA spokesperson cautioned that some specialty medical societies may have their own guidelines regarding certain situations and thus, specialty physicians should consult their respective group for more information. In addition, the Family Practice Management article noted that some state medical boards may also have their own rules and regulations.

Real-world considerations

Esther Giroldi
Esther Giroldi

Esther Giroldi, PhD, of the department of family medicine at Maastricht University in The Netherlands, and colleagues conducted several focus groups containing 49 physicians that looked at what they considered when handling requests that come from nonpatients. The paper, titled “Family physicians managing medical requests from friends,” was recently published in the Annals of Family Medicine.

PAGE BREAK

Several common themes came up during the sessions:

  • “Who is this person, what is he or she asking of me, and where are we?”
  • “Nature/strength of the relationship with the nonpatient;”
  • “Amount of trust in his/her own knowledge and skills;”
  • “Expected consequences of making mistakes;”
  • “Importance of work-life balance;” and
  • “Risk of disturbing the physician-patient process.”

Researchers also found that physicians who had at least 5 years of working experience in family medicine and supervised a resident in their own practice utilized “more nuanced considerations when deciding whether to respond.” Younger physicians had more problems handling these requests, were less likely to provide answers, and were more worried about disturbing the existing relationship that a person had with their regular physician.

Giroldi told Healio Family Medicine a solution to handling nonfamily requests is not one-size-fits-all.

“Guidelines that state you should not treat family members or friends unless it’s an urgent situation make it seem so simple,” she said in an interview. “Our study showed this is actually a very complex process, and a single guideline doesn’t really fit what actually goes on in an actual clinical setting.”

Latessa agreed, saying the subject matter has a lot of ambiguity.

“Most physicians struggle with the grayer area where if the ethical guideline says minor or emergency or isolated, and how you really define that,” Latessa said. “One physician’s interpretation of what is minor or emergency or isolated might be different than another physician’s interpretation. The guidelines leave a lot open to individualize situations.”

Jochen Cals
Jochen W. L. Cals

The Annals of Family Medicine study also found the personal nature of these relationships sometimes clouded the physicians’ judgment, according to coauthor Jochen W. L. Cals, PhD, MD, also from the department of family medicine at Maastricht University.

“Many recalled examples where they thought their judgement was biased because of emotions. Many also said there were times when they missed the diagnosis with their child or waited too long to consult their own doctor because they didn’t assess the situation correctly because they were trying to act as both the mother or father and a doctor at the time which caused a conflict,” he said in an interview.

Cals suggested that piece of mind may offset the inconvenience family members and friends may experience by scheduling and waiting for an appointment in the nonemergency situation.

“The nonpatient may think talking to you might be easy access to medical care but you can tell them they deserve better, objective treatment and that you don’t want to jeopardize the relationship by giving advice,” he told Healio Family Medicine.

PAGE BREAK

Times have changed
With the average physician aged older than 50 years old, some may not realize how the consequences of giving advice to family and friends has changed.

The recent AMA survey found that 49.2% of physicians aged 55 years and older said they have been sued vs. 8.2% of physicians aged 40 years and younger, suggesting that the likelihood of getting sued increases with age.

Burcher said that age is no excuse for a doctor not changing long-standing procedures on this issue.

“I realize that a lot of physicians have given advice to nonpatients for a long time but I think they should reexamine their practice and habits and recognize that when you’re not speaking to another medical professional, your words are so easily taken out of context and misunderstood and people may be harmed by that and we should be more careful about this,” he said.

Educating the next generation of physicians

A survey in the New England Journal of Medicine stated that 99% of the 465 responding physicians had been approached by a family member for a medical diagnosis, advice or treatment. Also, one-third indicated they had seen another doctor “inappropriately involved” in a family member’s care.

In addition, when it came to physicians’ interactions with family members:

  • 83% had prescribed medication;
  • 80% had diagnosed medical illnesses;
  • 72% had conducted a physical exam;
  • 15% had acted as a family member's primary attending physician in the hospital;
  • 9% had performed an operation on a family member.

Despite such apparent prevalence, Latessa told Healio Family Medicine that teaching the next generation of physicians how to handle medical requests from family and friends is often not part of the required curriculum.

“There is still a lot of room and work to do especially in medical education, both in medical school and at the residency program level. In our program here at the UNC School of Medicine Asheville, we do touch on this topic, but that’s certainly not the case across the board,” she said. “One of the next steps should be training some of the basic bottom lines and then working through some of the grayer areas with sample cases with physicians in training or even with physicians in practice.” – by Janel Miller

References:

AMA. “Treating self or family.” https://www.ama-assn.org/delivering-care/treating-self-or-family. Accessed March 13, 2018.

PAGE BREAK

Eastwood, GL. J Gen Intern Med. 2009;doi:10.1007/s11606-0091127-1.

Giroldi E, et al. Ann Fam Med. 2018. doi:10.1370/afm.2152.

Latessa R, Ray L. Fam Pract Manag. 2005 Mar;12(3):41-4.

La Pluma J, et al. NEJM. 1991;doi10.1056/NEJM199110313251806.

The Physicians Foundation. “America’s physicians practice patterns and perspectives.”

https://physiciansfoundation.org/wp-content/uploads/2017/12/Biennial_Physician_Survey_2016.pdf. Accessed March 13, 2018.

The Doctors Company. “Nurse practitioner closed claims study.” https://www.thedoctors.com/siteassets/pdfs/marketing-order-form-items/nurse-practitioner-closed-claims-study.pdf.” Accessed March 13, 2018.

Disclosure: Burcher, Cals, Eastwood, Giroldi and Latessa all reported not having any relevant financial disclosures.