After almost 40 years as a physician, with a career as an emergency physician, quality-assurance reviewer, and medicolegal consultant, I have finally retired. Surprisingly, I still spend a fair amount of time searching and reading topics in UpToDate. Like many physicians, I get a lot of requests for medical advice and evaluation of medical care from friends and family. Retirement has not put an end to this. Friends are getting joint replacements, cancer, and other illnesses, and I am now having some of those same ailments as well. Some of the care has been excellent, but unfortunately there have been some distressingly bad outcomes.

As a physician, how should one relate to the medical system when you are not the one providing care? Most of us have been told not to act as our own physician or the physician to our family. There are medical, medicolegal, and interpersonal risks in doing so. The AMA Code of Medical Ethics’ Opinion on Physicians Treating Family Members advises against it.¹ Nevertheless, most physicians do not follow this dictum.² In the real world, it is not so clear-cut, especially at the margins. If you are not going to be the treating physician, how should you interact with the physicians caring for your friends and family members? I could find nothing in the medical literature on this topic. Personally, I was never taught how to navigate these dilemmas, so I have had to learn the hard way. These are the lessons I’ve garnered through experience.

First, Stay in (or Close To) Your Lane

An orthopedist, for example, has little business opining on the care of a family member with an ST-elevation myocardial infarction, unless the care is egregiously inappropriate. Yet they can still become involved in the routine aspects of care as a highly educated layperson. As someone who was board certified in both internal medicine and emergency medicine, my lane has been fairly wide. However, the farther I get from the centerline, the more circumspect I have become. The very last thing you want to do is disrupt good medical care.

Be Judicious About Being Your Own or Your Family’s Doctor

Most laypeople make their own decisions when to seek medical attention for themselves and their family. Until that time, they treat themselves, rightly or wrongly. Physicians do the same thing, just with a lot more medical knowledge. It is convenient and efficient and often effective to handle simple or clear-cut things yourself, but be aware that your medical decision making is often impacted by affective bias, where your feelings about the patient impact your decision making. Often, I have made good decisions, but many times I have not.

For example, I missed my 2-year-old daughter’s post-varicella cerebellar ataxia. Our babysitter told me that she was “walking like she’s drunk,” but I dismissed this as I watched her run right by me that day at the beach. The next morning, unable to walk, she crawled into our bedroom. Fortunately, she recovered in a few weeks and eventually became an athlete.

Then there was the time that my 9-year-old son lacerated his chin when he fell off his bicycle. Judging that I could do a better job closing the laceration than an intern, I had my wife bring him to the community ED where I was working. I have seen a lot of gore, but this was the only time in my entire medical career when I very nearly passed out at the sight of blood–just as I was gloved and had him prepped and draped and ready to begin the procedure. I recovered without fainting and after about 10 sutures, so did he. However, I could have fallen, been injured, and needed laceration repair myself.

On the other hand, being a do-it-yourself physician can come in handy. So far, I have managed all my episodes of renal colic with ibuprofen, a urine dipstick, and a coffee filter.

When I fracture-dislocated my ankle on Mount Rainier, there was no one to do the emergency reduction; so, aided by a rush of endorphins and the lack of swelling, I did it myself. It should go without saying that unless you have no alternative, you have no business handling high-risk situations yourself.

Pay Attention to Everything

Today’s physicians suffer with an overload of information and responsibility. Even the best will occasionally overlook things. No one cares about your health as much as you do. I was recently hospitalized for a fever of unknown origin at a well-respected teaching hospital. My doctors were wonderful. Eventually they made a diagnosis, and I was cured. I continue to go to this hospital for my medical care. Yet there were logistical issues and interservice communication breakdowns that delayed aspects of my care.

With access to my patient portal, I was able to read every physician note, diagnostic report, and laboratory result while I was in the hospital. At times, it was distressing to find out what diagnoses my physicians were considering, but there were a few instances where I uncovered clinically significant incidental findings that were overlooked by my medical team. They had so many other things to focus on and I was only one of their many patients.

This advice to scrutinize one’s own medical records is more appropriate for physicians than laypersons, because as physicians we often know what is important and what is not. An incidental nodule on a CT may be important, but an “abnormally low” serum lipase is not. With this new access to medical information, patients often become unnecessarily anxious about irrelevant or insignificant things that the computer has flagged as statistically abnormal.

A Rube Goldberg situation ensued when I was transferred between hospitals with incompatible electronic medical record systems. The physicians at the receiving institution could not easily access many of my test results from the referring hospital. In contrast, I was receiving real-time notifications from its patient portal, which I would dutifully report to my physicians on their morning rounds.

Medical Errors Don’t Just Happen To Other People

The frequency of medical errors is high enough that you or someone close to you will likely be on the receiving end of one.³ Several years ago, about to undergo arthroscopic shoulder surgery, I told the anesthesiologist that I was not feeling any effects of the brachial plexus block that he had just administered. He responded that the onset would take a few more minutes, but before I could insist that there was a problem, I had been injected with propofol and was unconscious. I emerged from anesthesia with excruciating shoulder pain due to the complete lack of regional anesthesia.

In my own extended family, there has been a metastatic spread of melanoma following a misread skin biopsy, mismanaged care of a tibial-fibular fracture in a teenaged athlete resulting in a malunion, a death from semi-elective surgery, and a misplaced breast biopsy sample that degraded before it was located. Many of these occurred at “world class” institutions. Even the best physicians at the best hospitals can make mistakes.

I even uncovered a more sinister side of medicine. A relative told me that she was newly diagnosed with severe aortic stenosis because on her initial visit with a gastroenterologist, he had listened to her heart and heard a murmur. I took this to be prima facie evidence of primary care negligence and advised her to switch primary care physicians (PCPs). She then confided that her PCP routinely made inappropriate comments about her breast size while ostensibly listening to her heart. Until then she had been too ashamed to tell anyone. She filed a complaint, and the PCP was professionally sanctioned.

Informal “Second Opinions” Can Be a Minefield

Friends and family members frequently ask me for advice or for my opinion of their medical care. This can be very difficult to untangle. Invariably, you are not there, looking at the patient. You don’t have all the information. You probably have affective bias regarding the patient. The patient may have misunderstood what happened or what they were told. Frequently the physician is of a different specialty, and you are rightfully concerned that you are out of your lane. As a physician, you wouldn’t appreciate outside meddling if the shoe was on the other foot. And yet, you may sense that something is not right.

A relative whose alcohol use disorder was an open secret within my family had refused treatment for decades. They presented to their long-term PCP with anxiety, tremors, abdominal pain, and vomiting. Unaware of the alcohol history, he diagnosed “diverticulitis and a UTI” and prescribed oral antibiotics. I found out from the spouse later that day. This was shocking to me.

What history was related? What were the vital signs? Was the patient tremulous? What was the abdominal exam? What did the doctor really say? It made my head want to explode.

This sounded to me like alcohol withdrawal, so ultimately, I told the spouse to bring them to an ED, where they were admitted to the hospital. COVID-19 protocols prohibited visitors, and the spouse had difficulty communicating with the treatment team by phone. As a physician, I had an easier time getting through. I made sure to inform the clinicians of the relevant history, and the proper diagnosis was made. For the first time ever, my relative went into an alcohol treatment program.

Strategies for Interacting with Loved Ones’ Physicians

The easiest scenario that you might encounter is when the patient is getting care within your own medical system. We all know doctors in whose hands we would place our lives and those in whose we would prefer not to do so. This inside information is invaluable.

With doctors you don’t already know, if possible, vet them before the first patient visit. Check out their credentials online and look in the state medical board’s website for complaints or disciplinary action. But this tells you only so much. I don’t usually look at patient review sites, but that probably reflects my bias about such things.

When the physician-patient relationship is already underway, I usually try to talk to the physician by phone. Of course, you need patient permission to do this. On several occasions I have accompanied the patient to the appointment, or if unable to be there, had them telephone me at the beginning of their medical encounter, so that I could listen to the evaluation and hear the doctor’s conclusions. You will learn a lot about their clinical thinking, and you will avoid getting incorrect information via second- or third-hand communication. Usually, the physician is both open and capable and I am reassured, but sometimes the physician will be defensive or dismissive and it becomes difficult to sort out ego from competence. This is a nuance that I am still learning.

When dealing with physicians making potentially questionable medical decisions, the best strategy is to ask them to explain their reasoning. Often, they will hear their own logical errors and will self-correct. I was in the wilderness with only satellite phone access when my wife called to relate that my 3-year-old granddaughter was in the pediatrician’s office for the third time with five days of fever and a diagnosis of influenza despite two negative rapid-flu tests. My wife said she was going to demand “more tests,” but I told her to ask the doctor to do “more thinking.” She asked him, “How many times have you seen a child with influenza who had fever for five days with no respiratory symptoms and two negative flu tests?” He answered, “Never,” promptly concluded that he had ignored some potential important diagnoses, and sent her to the children’s hospital for some focused testing. My granddaughter was admitted and successfully treated for Kawasaki disease.

You Can Always Demur

After all, it may not be your specialty, you may be retired, or have other good reasons not to get involved.

As physicians, we have specialized knowledge and perspective that laypeople lack. Most medical care in the United States is good, but there is significant variation in quality. With the right approach, you can put your expertise to work to help someone close to you navigate the complexities of the medical system and get the best care possible.

Dr. Schwam was previously the director of quality assurance for the emergency department at Sturdy Memorial Hospital in Attleboro, Mass., an attending physician at Rhode Island Hospital in Providence, R.I., and a clinical assistant professor of emergency medicine at the Warren Alpert Medical School of Brown University in Providence, R.I. He is now retired, but still lectures on clinical decision making and medical malpractice.

References

1. American Medical Association. AMA code of medical ethics’ opinion on physicians treating family members. AMA J Ethics. 2012;14(5):396-397.
2. La Puma J, et al. When physicians treat members of their own families. N Engl J Med. 1991;325(8):1290-4.
3. Blendon, RJ, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.