Dear Hague R Rubin

As a physician greatly interested me answer your question Do doctors provide lower quality care close relatives or friends?

My answer in principle is not Why?

• I am Mexican doctor and my country not prevented legally, ethically or morally meet friends or close relatives.
• I know the codes of ethics and none explicitly prohibit doctors attend to family and friends.
• I have 42 years of practicing medicine in Public and Private Institutions of Health.
• In all these years of practice, I have attended free or with "minimal costs or fees" to friends and my family (children, spouse, siblings, parents, grandparents, uncles, cousins, nephews, brothers, etc.)
• Both in the public health sector and private, medical care of family and friends, you have to be careful, respectful and scientific quality; with support from both updated in the field, and with the use of newer, effective and efficient technology available in the media where I worked, whether community, clinics, hospitals or clinics knowledge.
• It must have the grace not to conduct interrogations or ethically and morally questionable or unnecessary scans. For example: Do not perform gynecological, andrological and rectal explorations friends and relatives of the opposite sex.
• If necessary this type of physical examinations (in relatives and friends of the same sex), having the presence of another family member responsible for the patient (parents, older siblings, spouses) and (a) nurse (o) or auxiliary office or hospital; or refer the family member or friend with another trusted physician for care.
• Psychiatric and psychological problems, normal care and long term, it is advisable to make other medical professional who is trained to such care; because it is difficult or causing mutual frustration (patient and doctor) and ineffective care in the area of emotions and feelings, when psychologically and emotionally, the doctor might be too emotionally involved. The exception might be the urgent attention of a case of self-destructive psychosis or delirium that endanger life, while the patient can be served by other medical professional.
• Of course I know doctors or trained not to feel inhibited to meet family and friends, do not and prefer to seek outside professional help, which I think is very responsible; thus avoiding providing inadequate medical care and poor quality.

regards

Dr. Jose Luis Garcia Vigil

Estimada Haya R Rubin

Como médico me interesa sobremanera contestar su pregunta ¿Los médicos proporcionan una menor calidad de la atención a familiares cercanos o amigos?

Mi respuesta en principio es No ¿Porqué?

• Soy médico mexicano y en mi país no se impide legal, ética ni moralmente atender a los amigos o familiares cercanos.
• Conozco los códigos de ética y en ninguno prohíben en forma explícita que los médicos atiendan a familiares y amigos.
• Tengo 42 años de practicar la medicina en Instituciones de Salud Públicas y Privadas. 
• En todos estos años de práctica profesional, he atendido en forma gratuita o con "costos mínimos u honorarios" a los amigos y a mi familia (hijos, esposa, hermanos, padres, abuelos, tios, primos, sobrinos, cuñados, etc.)
• Tanto en el Sector Salud Público como en el Privado, la atención médica de familiares y amigos, tiene que ser cuidadosa, respetuosa y de calidad científica; con apoyo tanto de conocimientos actualizados en la materia, como con la utilización de tecnología más reciente, eficaz y eficiente, disponible en los medios donde he trabajado, ya sea comunidad, consultorios, clínicas u hospitales.
• Se debe de tener la delicadeza de no realizar interrogatorios o exploraciones ética y moralmente cuestionables o no necesarias. Por ejemplo: No realizar exploraciones ginecológicas, andrológicas y rectales en amistades y familiares del sexo contrario.
• De ser necesarias este tipo de exploraciones físicas (en familiares y amistades del mismo sexo), contar con la presencia de otro familiar responsable del paciente (padres, hermanos mayores, esposos) y un(a) enfermera(o) o auxiliar de consultorio u hospital; o derivar al familiar o amistad con otro médico de confianza para su atención.
• En problemas psiquiátricos y psicológicos, la atención normal y a largo plazo, es conveniente que se realice por otro profesional de la medicina que esté capacitado para dicha atención; debido a que es difícil o causante de mutua frustración (paciente y médico) e ineficaz la atención en el área de las emociones y sentimientos, cuando psicológica y emocionalmente, el médico pudiera estar también emocionalmente involucrado. La excepción pudiera ser la atención urgente de un caso de psicosis o delirio autodestructivo que ponga en peligro la vida, mientras el paciente puede ser atendida por otro profesional de la medicina.
• Por supuesto que conozco médicos que por no sentirse capacitados o inhibidos para atender amigos y familiares, no lo hacen y prefieren buscar ayuda profesional externa, lo cual considero es muy responsable; así se evita proporcionar atención médica insuficiente y de mala calidad.

Saludos

Dr. José Luis García Vigil

I totally agree with the comment of Napoleon Ono Imaah

regards

Jose Luis

Estoy totalmente de acuerdo con el comentario de Napoleón Ono Imaah

Saludos

José Luis

The article published in NEJM "Ethical Challenges in treating Friends and Family" and proposes Reiss Marco, is very interesting and important content in the light of the question we are discussing in this forum, so it is highly recommended reading in order to take a position on it.

Ethical concerns in this article focuses are in providing informal care and undocumented friends and family members, that is, care outside regular medical encounter.

True that there are certain ethical standards of medical associations, which issues recommendations that should abide, preferably in most cases, but are not restrictive at all, for caring; confidentiality, conflicts of interest, skills and aspects potentially economic or legal conflict, so that the medical professional, can contribute to their preparation and special care, the care of relatives and friends, along with the network of medical professionals and other health sciences, to be involved in such care complete and comprehensive manner.

Of course it is important to convey this information to medical students (without our fully exempt physicians with experience and competence), which are the most risk would commit acts of legal involvement and questionable ethics in the care of friends and family.

regards

Jose Luis

El artículo publicado en NEJM "Desafíos éticos en el tratamiento de Amigos y familia " y que propone Marco Reiss, es muy interesante y trascendente su contenido a la luz de la cuestión que estamos discutiendo en este foro, por lo que es muy recomendable su lectura, a fin de tomar una posición al respecto.

Las preocupaciones éticas en las que se centra este artículo, son en la prestación de cuidados informales e indocumentados a los amigos y miembros de la familia, o sea, el cuidado fuera del encuentro médico habitual.

Cierto que existen normas éticas de ciertas asociaciones médicas, que emiten recomendaciones que conviene acatar, de preferencia en la mayoría de los casos, pero que no son limitativas en absoluto, para cuidando; confidencialidad, conflicto de interés, competencias profesionales y aspectos potencialmente de conflicto económico o legal, para que el profesional de la medicina, pueda contribuir con su preparación y atención especial, al cuidado de amigos y familiares, junto con la red de profesionales de la medicina y otras ciencias de la salud, que deban de participar en dicha atención de manera completa e integral.

Por supuesto que es importante transmitir esta información a los estudiantes de medicina (sin que estemos exentos totalmente los médicos con experiencia y competencia), que son los que más riesgo tendrían de cometer actos de implicación legal y ética cuestionables, en la atención de amigos y familiares.

Saludos

José Luis

I have read the NEJM article (I would not classify it as a study, just an opinion piece) and it cites no actual studies of quality of cae. I have heard these ethical cautions for years and find them a bit overbearing and tiresome in the absence of any evidence.  

Everyone always cites the potential bad things, and ethical probems, but in my opinion they completely ignore the possible reasons why care might be better fo friends and family members, which are equally compelling in my vview:

1. Most obviously, it is human nature to care more about the outcomes of care for friends and family.  While that might interfere with our objectivity, it can also motivate us more to be carefult so we avoid a bad outcome. This is a broad and far ranging positive bias.  Increased motivation to do a good job can affect every single domain of quality of care in dramatic ways. When relatives and friends ask me for recommendations, I feel very motivated to do an excellent job researching the options and alternatives and feel quite energized about helping. This can create a boost in performance and quality.

2. We understand the context of our friends' and relatives' lives much better. This improved knowledge of family and social history may often help us avoid errors in care and understand certain interactions.  For example, we may be more likely to be able to judge ccorrectly whether our friends or relatives will adhere to recommendations based on their past track record or opinons they have expressed to us about "Western medicine" vs. alternative therapeutic modalities.. .

3.  We understand our friends' and relatives'' +++values better.  Therefore it is conceivvable that we are more likely to be able to tailor our recommendations to the outccomes they value the most.

4. Our friends and relatives, if they have consulted us, probably trust us.  Therefore they may be more likely to follow our advice and adhere to our recommendations, which, if we are good practitioners, will make us more effective doctors for them. 

5. We may be more likely to understand our friends and relatives questions and histories since we are llikely to be more culturally similar to them, to be part of the same cohort, or to have had years to learn to understand how they speak.  We are more likely to share language, idiom, metaphor and to understand their usage of words or the meaning behind something they say. 

6.  We are likely to be more culturally competent with our friends and relatives, since we are more likely to share culture and social norms with them.

I have only begun to speculate, and I am sure I have missed several things.

This is definitely a subject that would benefit fom study.  

I am a doctor,

Doctors will not necessarily provide lower quality of care to relatives and friends. Rather there is an inner desire to to the best for your friends. this could lead to using a higher than required medication. Secondly emotions due really play a role especially in handling family members.

Just imagine yourself attending to your child who is convulsing! It will take special strength to remain with the guidelines. 

Again doctors can also exhibit denial state like any other person. It might be difficult diagnosing your spouse of having cancer , not because you cannot diagnose cancer but because of the state of denial.

in conclusion doctors will not deliver lower quality of care to close friends but emotions can interfere clinical reasoning and judgement. simple truth is in any case where you will be emotionally involved seek a second opinion.

hope this helps.

Disappointing that after al this time, no one has come up with any actual studies of this question. Many people have opinions on the topic, even to the point of publications in NEJM without citing any actual study of the subject,

Again, if anyone wants to study this (unlikely because no profit in it) I would be happy to mentor or collaborate.