“Treat your patient as you would your mother, or your child.”
As clinicians in training, many will recall this adage being passed on to us as words of wisdom from our seniors, write Dr Yash Naidoo, dento-legal consultant and Dr Zarina Sonday, medico-legal consultant, at Medical Protection.
Yet while the concept is powerful and important in the context of patient empathy and care, it should be clear this saying does not seek to encourage us to actually treat our mothers or family as patients.
They write:
At the outset, we must make it clear there is no law or regulation in South Africa saying healthcare practitioners are not allowed to treat friends and family as patients. Technically, any such law or regulation would be unlikely to pass constitutional muster on the one hand, and probably unreasonably encroach on a patient’s right to autonomy on the other.
But quite apart from these legal and ethical technicalities, perhaps the regulator and the lawmakers have deliberately been silent on this issue for another reason, and that is, the reality of South African society.
That reality is one of a resource-constrained, largely poor population, for many of whom access to healthcare is scarce and limited. In some communities, there may only be a single doctor or dentist who is required to serve thousands of patients. Some of those patients may well be friends and family.
So, to say to a practitioner as a blanket rule that you must not or should not treat friends and family, especially where there is no other choice, would simply not be conscionable or practical in South Africa.
Despite there being no rule against it, and despite the nature of the society in which we live, we would nonetheless caution against treating friends and family as patients – and we say this fully conscious of the unique circumstances which prevail in our country. Let us explain why.
When you take on a relative or friend as a patient, even for a simple prescription, you create an additional type of relationship between you and that person. Initially, it was a personal relationship which is not governed by any laws related to your profession, or regulations created by the Health Professions Council of South Africa (HPCSA).
But, when you take on the additional responsibility of providing healthcare to the friend or family member, you create an additional relationship with them: a professional relationship. And with this comes the added obligations and responsibilities imposed on you by the HPCSA and all relevant laws applicable to your profession.
Once that professional relationship is established, you will be expected to adhere to the same standards and rules as would be applicable to any of your patients.
For example, the National Health Act read with the HPCSA’s ethical guidelines would compel you to keep records of your interactions with the patient, and include certain compulsory elements as stipulated by the HPCSA. Those records will need to be kept safely and be accessible to the patient or authorised third parties if necessary in future.
One of the compulsory elements of a patient health record is the full biopsychosocial history of a patient, including allergies and idiosyncrasies. Think about an occasion on which a friend or relative may have sought your clinical care formally rather than in a casual manner – would you have complied with these basic requirements?
The newly established dual relationship brings with it a myriad professional responsibilities and obligations. When you see a friend or relative as a patient, your objectivity may be compromised due to your close personal relationship. You may be driven to go to lengths that you would not ordinarily do.
While you may see this as your acting in the patient’s best interests, you must bear in mind that one of the HPCSA’s rules is that a practitioner may only perform acts for which they are adequately educated, trained and sufficiently experienced, and under proper conditions and in appropriate surroundings.
Going the extra mile for a friend or family member may unwittingly take you beyond those bounds – a contravention of the HPCSA’s rules.
We would all like to believe that we would never be faced with medico-legal challenges as a result of treating family and friends. Yet, when things go wrong those relationships often become insignificant in the face of an adverse clinical outcome.
At Medical Protection we have seen these best intentions come back to haunt practitioners in a number of cases.
In one case, a dentist prescribed a topical cream for a friend suffering with a skin condition which totally unrelated and far removed from that person’s oral or peri-oral area (which falls under the scope of practice of dentistry).
This was done in December, when the friend could not get hold of their dermatologist due to the holiday season. The dentist acted compassionately to help a friend in need.
A few years later, when the friendship broke down, the friend lodged a complaint with the HPCSA against the dentist, alleging that the dentist had prescribed treatment outside the scope of practice of a dentist.
In a separate matter, also involving the prescription of medication by a dentist, the HPCSA was once again called upon to discipline the dentist. In that case, a pharmacist declined to fulfill a script by the dentist for certain chronic medication which the dentist had written for a close relative. The pharmacist’s reason for declining was that the medication prescribed fell outside the scope of a dentist.
The reason why we point out the examples is to illustrate that, no matter how helpful you may think you are being at the time, you open yourself up to several risks despite no doubt wanting to act in what might seem at the time as being in your friend’s or family’s best interests.
Stepping over the line
When asked to treat someone close to you, it is wise to stand back and relate the situation to where on the spectrum the individual’s health issue sits.
There are clearly times where it might be reasonable to prescribe, for example, prescribing a salbutamol inhaler for your asthmatic child on holiday when they have forgotten to bring their regular supply with them. However, it would not be reasonable to manage your child’s respiratory condition on a continuing basis.
One way to avoid such dilemmas is for all doctors to ensure that both they and their families have a family GP.
‘No, not ever’
Then there are times where we are all agreed that doctors must not treat themselves, their families, or those close to them. This would include prescribing or administering controlled drugs and to those with a risk of addiction or misuse; prescribing psychotropic medication; undertaking psychotherapy, or performing invasive procedures. You should also avoid issuing certificates or undertaking medical assessments for third parties.
Some practical steps when considering treating friends or family
1. Be open and honest with the person seeking assistance
Explain the nature of a doctor-patient relationship versus that of a personal relationship. List the benefits and risks of the former to both parties. Be clear on what it is they expect from you and be candid about any potential concerns. Expectation management is critical: outline the limits of your scope and if you cannot reasonably meet their expectations, you should say so and offer to refer to an appropriate clinician.
2. Formalise the doctor-patient relationship
Irrespective of the nature of the underlying connection as either friend or family, when medical advice is sought you are acting in your professional capacity. This must be distinguished and be seperate from a casual, social interaction. A professional interaction assists with maintaining objectivity in assessment, diagnosis, and decision-making. As such, you are now professionally accountable for your actions and in so doing, you are safeguarding both parties.
3. Keep clinical records
Whether the initial request for assistance came at a birthday party on the weekend or via a WhatsApp message, you should keep some form of documentation of the interaction, including the presenting complaint or concern, the advice provided, and prescriptions written. Make it clear from the outset that you will keep records as required by the HPCSA, and that these will be stored securely for future access as needed. This serves to cement the formality of the relationship, and may help ensure the patient understands the need to be open, honest and candid with you at all times, and that you will refer to prior interactions with them as and when necessary.
4. Conduct
When consulting or advising family and friends, your conduct regarding history-taking, examination and consent procedures should be no different from when you are consulting an unrelated patient in your rooms. An important practical first step is to be objective, which requires an enormous amount of self-awareness. As a practitioner, you should be able to recognise your capabilities, know your limitations and understand that certain requests are inappropriate. If the request from a relative or friend makes you feel uncomfortable, then stop. Interrogate the unease.
You should not be providing services or advice to any patient, including family and friends, that fall outside your expertise and scope of practice. Understand that the notion of feeling unwell to being diagnosed with disease is a spectrum, and carefully consider where on that spectrum you would best serve the ‘patient’.
You are accountable
Ultimately, it will be for the practitioner to account for their decisions and actions. It is important that any current guidance is consulted, understood and borne in mind when deciding whether or not to give advice or offer treatment.
Where you do decide to prescribe or treat someone close to you, it is vital that you document what has been done and why, and notify the individual’s GP as soon as reasonably possible. Should the decision be called into question, good record-keeping and communication will greatly assist in justifying your actions.
Further reading: Can I treat an acquaintance?
See more from MedicalBrief archives:
Why it’s important to update personal details with the HPCSA
Understanding why and how to manage patients’ expectations
Clinical report writing – tips and common pitfalls