Monday, December 28, 2009

Treating Family

My father phoned me a few days before Christmas, a little worried. An incidental finding on an abdominal ultrasound showed a 5 cm aneurysm and his FP had referred him to a vascular surgeon who reviewed the aneurysm and decided it was actually 5.5 cm and suggested endovascular repair. My father asked me what I thought. When I told him that it had been 10 (mostly great) years since I had done any vascular surgery, that I was out of touch with that aspect and therefore couldn't really advise him, he sounded a little upset at me. I felt a little guilty, I probably wouldn't have become a doctor without his support.

One of the crosses I have had to bear since becoming a doctor has been having to give advice to relatives.

When I was an intern I worked on the infectious disease ward. One of the children we treated was the son of a doctor who had meningitis. Problem was that for five days his physician-father had treated him for otitis media with Amoxil. While Amoxil was not very effective for killing the meningococci in his brain, it was very effective in prevening anything from growing in culture which meant prolonged treatment with chloramphenicol. This made a powerful impression on me.

This is not to say I haven't glanced at my kids when they were sick and said, "They don't look too bad, and probably don't need to see a doctor". At the same time, I rushed my son into emergency when I thought he had epiglottitis (which of course got better as soon as we hit the cold winter air and turned out to just be croup). I also took the same son's stitches out last night. When my kids obviously broke something, I usually phoned the orthopod rather than deal with the family doc or the ER. I do draw the line at looking in ears, throats and of course other body orifices. My observation is that doctors' children either get very little medical attention (my kids for example) or way too much medical attention.

While I am sure that many doctors are much smarter than me and are able to make an accurate diagnosis and suggest treatment based on the information given over the phone or at the family Christmas party, I usually need to ask some personal, occasionaly intimate questions, lay my hands on and review the medical history. There is also the matter that I am a specialist in anaesthesiology. I was a general practitioner 23 years ago but back then I treated hypertension with Aldomet. Working with surgeons in teaching hospitals has exposed me to much surgical education, how much of it I remember reliably is questionable.

More onerous is the request to phone a relative's doctor. I have been pressured into this a few times and it is usually a tense time for me and for the treating physician. Firstly we are all busy and why should I burden another doctor with a phone call. In addition I have only recently figured out that there are two sides to every story and that usually doctors are not nearly as neglectful as they are made out to be. There is of course the privacy issue; why would a surgeon even discuss my sister-in-law with me. I have in my Pain practice spoken with physician relatives of patients. I usually make sure I have permission from the patient first.

Early on in my career when I was still in general practice, I was visiting my brother. I came home early one day and his wife decided to burden me with her medical history. She laid on a constellation of symptoms to which I replied, "Sounds like you need to see doctor". She said she had and he had found or did nothing. A year or so later she was diagnosed with breast cancer from which she ultimately succumbed. I often wondered whether she knew she had this lump in her breast and was just trying to get somebody to examine her breasts without actually asking.

Shortly after my residency I was visiting my brother in law. His wife asked me if I could see her mother (mother in law of my brother in law) who had swollen legs. I explained that I was no longer a general practitioner, I was a specialist in anaesthesiology, that I was not licensed to practice medicine in that province and that further I felt uncomfortable seeing her. A guilt-trip was laid on me and so I walked over to her house with my wife. It turns out that her family doc had diagnosed venous stasis, suggested bed rest and compression stockings which I would have suggested and which she decided not to comply with. We otherwise had a nice visit and she gave us 2 loaves of bread which she had baked while she was supposed to have been off her feet. I wonder often what would have happened if what was going on was a DVT and she had been found dead the next day.


burnttoast said...

I hate treating family members. I have gradually weaned most of them from the idea that a desired prescription for antibiotics is a phone call (mine) away, but it has taken 25 years. My family has the full gamut from a Mom who announced on Thanksgiving 10 years ago that she had colon cancer, had scheduled surgery (like I maybe can tell who's a good surgeon and who's not wasn't meaningful info?) for Christmas Eve, and no she didn't want any visitors. (Of course we all showed up anyway.) My Dad called me demanding a prescription for a controlled substance for the GIRLFRIEND of a houseguest, neither of whom I knew. Luckily, I could honestly respond that state laws forbade such practice!! How about this one, do you treat coworkers in the hospital? Nurses, OR scrubs, orderlies (called something else now, Job title changes every 5 years, job remains same, underpaid grunt work) all sound us out on who will prescribe antibiotics for UTIs, URIs, kid's otitis media, write MD excuses for their kid's missing school, etc. In the US health care is not easily affordable for anyone, unless you are in prison! I also have weaned out of that job, but it is harder. Is coworker solicitation for care even an issue in Canada?

Bleeding Heart said...

Fortunately I have never written an Rx for a family member if only because my drug plan would not reimburse me for it.

When I went to Mexico and needed Cipro and Loperamide for me and my wife, I wrote an Rx and got the surgeon du jour to sign it.

I have written Rx for nurses occasionally. I wrote a Rx for the Hep A shot for a nurse going to Ecuador and I have a topical NSAID combination I use in the Pain Clinic for which just about every nurse in the hospital has asked for a prescription of.

Years ago a nurse bullied me into writing a sick note for her brother who I had no seen.

I still feel dirty but better for fessing up.

My father has quite bad OA of his knees. I have unsucessfully for five years now tried to get him to get a Rx for topical NSAID or an intraarticular steroid.