Monday, December 6, 2010

Treat them like family?

MY FATHER, a pediatrician, tells a cautionary tale.

A family physician, the story goes, agrees to work at a lakeside summer camp for boys. Several days and many bandaged bumps, bruises and bee stings into this service, the campers catch and fry up some perch. As it turns out, the fish is rather bony, and four kids come to the doctor complaining of bones stuck in their throats. One by one, the doctor examines the boys and removes the small slivers of calcium until he gets to the fourth boy. Here, he loses his nerve. He can't get the child to properly open his mouth, and he can't find the bone. Finally, he gives up. This child, he declares, must see a doctor in town. The problem is that the boy is his own son.

I recount this story in order to scrutinize the oft-encountered circumstance in which physicians and other health-care professionals provide medical assistance to friends or family. Today, I'm not talking about lighthearted, curiosity-inducing discussions, but rather situations in which good health may be at stake.

Situations like this are stressful for everyone involved, and for health-care professionals there can be the added stress of a unique inner conflict. On the one hand, we have knowledge -- not only medical knowledge, but also insight into how the system works. On the other hand, we often take on an added responsibility when we attempt to treat loved ones.

Medical evaluation and treatment requires a tremendous amount of weighing risks and benefits. Unfortunately, for many physicians, the simple fact that they are now giving advice to a family member may change their usual risk/benefit calculation.

In particular, physicians in this situation may have a diminished tolerance for making an error of omission -- that is, failing to take action. For instance, we may be reluctant to reassure a family member that everything is going to be fine if there's a chance that we'll find out later that it's not.

And while the term "taking action" has a positive connotation for many, in medicine there are real risks associated with doing so.

According to a 2007 report from the Institute of Medicine, more than half of medical treatments in this country are unproven. Meanwhile, most physicians, patients and malpractice juries tend to overvalue treatment over potential harm from side effects (for example, in most situations the potential benefit of taking antibiotics for a sore throat is much less significant than the potential harm caused by an adverse reaction to those antibiotics). Mix in concern about committing an error of omission, and you may have doctors making unnecessary and risky recommendations to their family members when in fact the clinical situation calls for a doctor with the courage to do nothing.

Medical science is just starting to explore the implications of certain personality qualities, such as risk tolerance, on clinical decisions. A recent study by Dr. Jesse M. Pines, director of the Center for Health Care Quality at George Washington University Medical Center, found that emergency physicians' scores on a standardized risk-taking scale (sample question: "I try to avoid situations that have uncertain outcomes") were associated with significant differences in the clinical management of patients with chest pain. Interestingly, scores on both fear-of-malpractice and stress-from-uncertainty scales were not associated with differences in decision-making.

While this study also did not attempt to judge whether risk-adverse physicians provided better care than risk-tolerant ones, the clear implication is that how physicians perceive risk can affect their decisions. Thus, it stands to reason that physicians giving advice to family members will have an altered risk-taking score -- they are, after all, taking on a new complex level of risk.

Doubt this conclusion? Then ask yourself these questions: "I try to avoid situations that have an uncertain outcome for my patient" and "I try to avoid situations that have an uncertain outcome for my mother."

During my medical training, I was told to treat patients as if they were family. This "grandmother test" was often invoked when considering a treatment or procedure. "Young Dr. Ballard, would you recommend the procedure to your own grandmother?" The assumption was that such an association would lead to better, more-compassionate decisions. Now, I wonder if that's always true.

Do physicians provide better advice to family and friends than to their patients? On the contrary, I believe that in many circumstances the closeness of the situation may cloud our judgment. A number of physicians I asked about this shared my concern.

For example, one said: "I find myself giving so many 'if/then'-type statements and covering every eventuality it really leads to a breakdown in the decisiveness I have when dealing with a patient. Throw in the often odd family dynamics, and you have some pretty crappy advice."

When I contacted Pines, he agreed that medical advice given to family members is often different but asserted that the quality of this counsel depends on the situation.

"The advice might be better in situations where they are very familiar with the family member's medical history," he says. "But the advice could be worse in cases where the doctor may not feel comfortable asking particular questions (like history of sexual partners) and in certain instances feel less comfortable doing a physical exam."

Valid qualifying points, but nonetheless, I wonder if we should reconsider the maxim, "Treat patients as if they were family"? How about we change it to, "When they are sick, treat your family as if they were patients"? Or, better yet, like the camp doctor of yore, leave the treatment to someone with less emotional investment.