You can't be the right doctor for your family

Why wouldn't the surgeon operate on his own daughter? Theauthor couldn't understand—until he became a physician himself.

By William T. Sheahan, MD
Family Physician / Winter Park , FL

The author (below) woudln't treat 5-year-old Tommy for a serious illness. But a fast boat ride is a treat for both father and son.

I love you," my mother says, as we're concluding a phone call. I'mready to reply, "I love you, too." But she interrupts: "Oh,by the way. My right leg has been painful, red, and swollen. Should I beworried?"

Several days later, my older brother asks for a favor. He has a physicalexam form that he needs completed. Would I mind doing it?

My other brother calls because his cat just scratched him, leaving anasty laceration. Should he be concerned? What treatment would I recommend?

You, too, have no doubt been called upon many times to offer informaladvice to friends and family. And perhaps you've found, as I have, thatfriends usually understand a mutually respected boundary, and seldom crossit except in certain situations.

With family members, though, the dynamic becomes much more complex. Notonly are you dealing with the emotional upset of a loved one's being ill,but there is a stronger desire to diagnose and treat, as well. Boundariesaren't as clear for those involved.

I learned first-hand about this issue many years ago. My mother's fatherwas a general surgeon. For years, he was a chief of surgery, in additionto serving a term as president of the Medical Society of New Jersey. I remembermy grandfather working long hours and being admired by patients and colleagues.

In the spring of 1979, when I was in college, my mother was diagnosedwith breast cancer. During her surgery, I was confused to see my grandfathersitting in the postoperative waiting room along with the rest of us-notperforming the operation himself, or even assisting. I thought he had letmy mother down. Here he was, a surgeon who'd treated hundreds of women withbreast cancer, sitting in the waiting room when his own daughter neededcare. Surely, if my grandfather had operated, my mother's lymph nodes wouldn'thave been positive and she wouldn't have needed chemotherapy.

I was even more disappointed when my mother subsequently developed adeep venous thrombosis in her right leg. How could my grandfather have alsoallowed this to happen? It made no sense to me then.

It does now. I realize the terrible sense of helplessness he must havefelt. Although he possessed the professional skills to treat my mother,he understood the even greater importance of being, first and foremost,her father. He knew instinctively that it was best to leave her care tothose who could proceed more objectively, and probably more effectively.He was her father, not her physician.

I am now in a similar situation. Roughly three decades ago, when he wasin his mid-40s, my dad was diagnosed with Parkinson's disease. Today, hehas little use of his arms, has swallow dysfunction, and is incontinent.His speech is nearly unintelligible. He is delusional and has some dementia.

I have tried to be helpful to my parents over the years. However, mymother has always insisted on doing the bulk of the caregiving, and forthat, although I am almost ashamed, I've been very thankful. I've oftentalked with my father's physicians and tried to help explain to my familythe issues related to his care. Because I'm boarded in both family practiceand geriatrics, I have the professional knowledge and skill to care forhim myself. However, when we are together, I am his son, not his physician.

The time will come when I will have to help my family decide about initiatingenteral nutritional supplementation and make other difficult end-of-lifechoices. When I'm counseling my patients and their families in such matters,I present all the options. I let them know that by withholding artificialnutrition, they are not actively causing the demise of their loved one.I assure them that the inability to eat sufficient calories to sustain lifein the end stage of an illness is a natural way to die.

I don't want my father to die. But I also don't want him to suffer. Therefore,as his son, I'll need to address the many difficult choices my family inevitablywill face. I'll do my best to enable us to feel comfortable with our decisions.

The question, then: What boundaries are important for a physician whendealing with health-related concerns of a family member? You wouldn't treatoutside your expertise, of course, but beyond that the lines begin to blurand the desire to diagnose and treat remains strong. Still, there seem tobe several situations in which a family member's care is better left toanother doctor. Among the boundaries I try not to cross are these:

• When the situation is too personal. Luckily for me, my brother declined to have me complete his physical exam form when I told him I would need to do a history and physical, including a sexual history and genital-rectal exam. If he hadn't withdrawn his request, I would have told him I wasn't comfortable performing the exam. Similarly, if my mother had a gynecologic problem, I certainly wouldn't feel comfortable as her examining physician.
• When it's too emotional. You also wouldn't want to be a family member's physician if you thought that your emotional involvement might render you less effective. Emotions might cause you to overreact and make less-than-optimal decisions. There's also the risk that you might not take the situation seriously enough.
• When you know too much to be objective. Background knowledge is helpful in treating patients, but it can hinder managing the care of a family member. For instance, if I'm treating a nursing home patient, I'll carefully consider the staff's insights and input. After all, they see the patient a great deal more than I do.

But if I'm treating a family member, background knowledge might renderme less objective. For example, I can appreciate how it might make me lessresponsive in treating my own children, simply because I know they havea certain pain threshold or emotional makeup.

It's important for a physician to recognize the emotions involved whentreating family members. It's also important to be comfortable with developingboundaries appropriate for your family. There's no definitive word on when-andto what degree-to provide care for family members. As with so many otherfacets of medicine, we're forced simply to use our best judgment. Most ofthe time we know instinctively when our loved ones will be best served bydeferring to a colleague.

William Sheahan. You can't be the right doctor for your family. Medical Economics 1999;23:97.