Advice to the Profession: Physician Treatment of Self, Family Members, or Others Close to Them

Physicians may find themselves in circumstances where they must decide whether it would be appropriate to provide treatment for themselves, family members, or others close to them. While physicians may have the best of intentions and a genuine desire to deliver the best possible care when providing treatment for themselves, family members, or others close to them, the literature suggests that a physician’s ability to maintain the necessary amount of emotional and clinical objectivity may be compromised.  Physicians may then have difficulty meeting the standard of care. Consequently, the individual may not receive the best quality treatment, despite the physician’s best intentions.

This document is intended to help physicians interpret the expectations as set out in the Physician Treatment of Self, Family Members or Others Close to Them policy and provide guidance around how these obligations may be effectively discharged.

How can objectivity and professional judgment be compromised when providing treatment for oneself, family members or others close to you?

A physician’s ability to maintain the necessary amount of emotional and clinical objectivity required for professional judgment can be compromised when treating themselves, family members, or those close to them. The physician may unconsciously hold preconceived notions about the individual’s health and behaviour, or make assumptions about the individual’s medical history or personal circumstances. Similarly, the physician may assume that they are privy to all the relevant information about the individual and therefore taking a full history or conducting a medically indicated examination is unnecessary. For example, a physician providing treatment for their child may assume the child has not engaged in sexual activity or high-risk behaviour, and therefore may not consider all of the possible clinical indications for treatment.

How can compromised objectivity and/or professional judgement impact quality of care?

The literature¹ suggests that physicians who provide treatment for individuals when their emotional and clinical objectivity is compromised may have difficulty meeting the standard of care.  This can occur in a number of ways, including, but not limited to:

• Physician discomfort in discussing sensitive issues or taking medical histories.
• Discomfort amongst family members and others close to the physician in discussing sensitive issues with the physician. This can be especially true with children receiving treatment, and particularly with respect to sexual health and behaviour, drug use, mental health issues, or issues of abuse or neglect.
• Physicians may feel obligated or pressure to treat problems that are beyond the physician’s expertise or training, or to prescribe drugs that are addicting/habituating, including narcotics or controlled substances, for family members or those close to them.
• Difficulty for the physician to recognize the need to obtain informed consent in this context and to respect the individual’s decision-making autonomy.
• Difficulty for the physician to recognize that the duty of confidentiality applies in this context, just as it would for a patient. The physician may also experience difficulty in appreciating that the individual’s information must be kept confidential, even if other family members or others close to the physician insist on knowing ‘what is going on’ in relation to the individual’s health.
• Physician reluctance to make a mandatory report (e.g. an impairment affecting the individual’s ability to drive, or a suspicion of child abuse).

When the standard of care has been adversely impacted, this can result in poorer quality health care for the individual receiving the treatment.

The Canadian Medical Association (CMA) advises physicians to “limit treatment of yourself or members of your immediate family to minor or emergency services, and only when another physician is not readily available; there should be no fee for such treatment.”²

Which family members can I treat within the scope of this policy?

Many of us have family members with whom we are very close, and others with whom we may not maintain as close a relationship, or have no relationship at all. The risks associated with physicians providing treatment to family members arise where the nature of the relationship is personal or close enough that the physician’s feelings toward that individual (positive or negative) could reasonably affect their emotional and clinical objectivity and impair their professional judgment.

Which members of a physician’s family this will include will vary with every physician. They may include members of the physician’s immediate or extended family, in-laws, or members of a non-traditional family unit. Some examples include, but are not limited to: the physician’s spouse or partner; ex-spouse or ex-partner; parent; step-parent; child; step-child; adopted or foster child; sibling or half-sibling; step-sibling; grandparent or grandchild; aunt; uncle; niece or nephew; or those of the physician’s spouse or partner.

What types of non-familial relationships may impact objectivity?

Personal or close relationships with other individuals, who are not family members, could also compromise the physician’s emotional and clinical objectivity in the same way. These individuals can include friends, colleagues, and staff, among others. Not every relationship the physician has would necessarily impair the physician’s objectivity. However, when a physician’s relationship with an individual is of such a nature that the physician’s professional judgment could reasonably be affected, that individual would fall under the scope of the policy as defined by the term ‘others close to them’.

How can I effectively evaluate the nature of the relationship?

When evaluating the nature of a relationship with an individual, if you can answer “yes” to any of the questions below, the individual probably falls within the scope of having a personal or close relationship with you, and your objectivity may be reasonably affected in providing treatment to that individual.

1. Would I be uncomfortable asking the questions necessary to take a full history, performing a medically indicated examination, or making a proper diagnosis, particularly on sensitive topics?
   Relationships with family members or others close to the physician can give rise to the physician unconsciously holding preconceived notions about the individual’s health and behaviour, or making assumptions about the individual’s medical history or personal circumstances. Consequently, the physician may not ask questions or seek information that could inform the diagnosis or subsequent care. Similarly, physicians may feel uncomfortable taking a comprehensive medical history, or assume that they are privy to all the relevant information about the individual and that therefore taking a full history or conducting a medically indicated examination is unnecessary.  This in turn compromises the physician’s ability to meet the standard of care.

2. Would this individual be uncomfortable discussing sensitive topics or disclosing high risk behaviours with me?
   Family members and others close to the physician may feel uncomfortable discussing these issues with a physician with whom they have a personal or close relationship. They may also fear judgment or other consequences in the relationship. This can be particularly true with respect to the individual’s sexual health and behaviour, drug use, mental health issues, or issues of abuse or neglect; especially if the individual is a child. Consequently, the individual may withhold information which is vital to a diagnosis or the management of a condition.

3. Would I have difficulty allowing this individual to make a decision about his/her own care with which I disagree?
   Respect for an individual’s autonomy is central to the provision of ethically sound health care. Individuals must be able to make free and informed decisions about their health care, as well as question or refuse treatment options. Family members and others close to the physician, particularly children, may be unduly influenced by the physician’s opinions, or feel unable to refuse treatment or seek alternative opinions. For more information please see the College’s Consent to Treatment policy. 

4. Could the personal or close relationship with this individual make it more difficult for me to maintain confidentiality or make a mandatory report?
   Confidentiality may be harder to maintain and may be at greater risk of being breached, such as when other family members or others close to the physician insist on knowing ‘what is going on’ in relation to the individual’s health. Conversely, a physician may be more reluctant to make a mandatory report (e.g. an impairment affecting the individual’s ability to drive, or a suspicion of child abuse) where a personal or close relationship exists.

If I treat someone with whom I am sexually or romantically involved, is a physician-patient relationship established?

Providing care to an individual with whom you are sexually or romantically involved may lead to the establishment of a physician-patient relationship and, as a result, the sexual abuse provisions of the Regulated Health Professions Act, 1991 (RHPA) would then apply.

As prescribed in regulation, an individual is not a physician’s patient if all the following conditions are met:

• There is a sexual relationship between the individual and the physician at the time the health care service is provided to the individual;
• The health care service provided by the physician to the individual was done in an emergency circumstance or the service was minor in nature; and,
• The physician has taken reasonable steps to transfer the individual’s care, or there is no reasonable opportunity to transfer care.

However, if these above criteria are not met and any of the following criteria are met then a physician-patient relationship would be established:

• The physician has charged or received payment from the person (or a third party on behalf of the person) for a health care service provided by the physician,
• The physician has contributed to a health record or file for the person,
• The person has consented to the health care service recommended by the physician, or
• The physician prescribed the person a drug for which a prescription is needed.

Providing care to a romantic/sexual partner with any of the four criteria present would trigger the application of the sexual abuse provisions in the RHPA.

For more information, please consult the Boundary Violations policy.

Why does the policy set out expectations for communicating the care provided to other health-care providers involved in the individual’s care? 

Documentation of medical treatment is essential to safe, quality health care. Complete and accurate medical records facilitate and enhance communication in collaborative care models, are essential to continuity of care, and identify problems or patterns that may help determine the course of health care.

When physicians provide treatment for themselves, family members, or others close to them, there is a risk that the individual receiving the care will not have a complete and accurate medical record. Communicating the treatment provided to the individual’s primary care provider helps to ensure that the individual has a complete and accurate medical record.

Does this policy apply in rural or isolated communities?

Yes, the expectations set out in this policy apply in rural and isolated³ communities. While the College recognizes that physicians in these communities often have relationships with many or all of the individuals seeking treatment, the risks associated with compromised objectivity and professional judgment apply in rural and isolated settings just as they do in other settings.

In keeping with the policy, the care that the physician can provide to an individual will be dependent on the nature of the personal relationship between the physician and the individual. Where the nature of the relationship with that family member or other individual close to the physician could reasonably affect the physician’s professional judgment, then the physician is limited to providing treatment only within the context of a minor condition or emergency, and where no other qualified health-care professional is readily available, as set out in this policy.

If the personal relationship between the physician and the individual is not close, and therefore does not fit either the definition of “family member” or “others close to them”, the physician will be able to act as that individual’s treating physician.

Can I refill a prescription for myself, my family members or others close to me?

Regardless of whether physicians are prescribing a drug for the first time or whether they are refilling an existing prescription, physicians are still prescribing. Consequently, when providing treatment for a minor condition or emergency necessitates a refill for a drug, physicians are expected to comply with the College’s Prescribing Drugs policy. Physicians are reminded that they are prohibited from prescribing for themselves, family members, or others close to them, any of the following: narcotics; controlled drugs or substances; monitored drugs; cannabis for medical purposes; or any drugs or substances that have the potential to be addicting or habituating, regardless of whether the prescription is a new prescription or a refill.

Does this policy apply to referrals?

Yes, referrals for yourself, family members, or others close to you would be captured by this policy.

Making a referral requires the referring physician to assess the individual, which may include taking a history, conducting an appropriate examination and/or arranging investigations, to identify a clinical indication for a referral. The steps involved would exceed the scope of care that the policy permits physicians to undertake in relation to themselves, family members or others close to them.

For the purposes of this policy, referrals are considered to be distinct from making informal recommendations to family members or others close to you about a specific physician they might consider seeing, and from facilitating contact between the individual and that physician. To ensure continuity of care, physicians must advise the individual to discuss any recommendations with his/her primary health-care professional.

Endnotes

^1. See for example:

• Katherine J. Gold, et al. “No Appointment Necessary? Ethical Challenges in Treating Friends and Family” (2014) N Engl J Med 2014; 371:1254-1258.
• Carolyne Krupa, “The limits of treating loved ones” Amednews.com (6 February, 2012), online: Amednews.com.
• Chen et al., “Role conflicts of physicians and their family members: rules but no rulebook” (2001) 75(4) West. J. Med. 236–239.
• American Academy of Pediatrics Committee on Bioethics, “Pediatrician-Family-Patient-Relationships: Managing the Boundaries” (2009) Pediatrics Vol. 124 No. 6, 1685 -1688.
• Kathy Oxtoby, “Doctors’ Self Prescribing” BMJ Careers (10 January 2012), online: BMJ Careers.
• Ruth Chambers & John Belcher, “Self-reported health care over the past 10 years: a survey of general practitioners” (1992) 42 British J. Gen. Practice 153-156.
• Richard C. Wasserman et al., “Health Care of Physicians’ Children” (1989) 83 Pediatrics
• Edward J. Krall, “Doctors Who Doctor Self, Family, and Colleagues” (2008) 107 Wisconsin Med. J., No. 6, 279-284.

^2. Canadian Medical Association (CMA), Code of Ethics and Professionalism, Section C. 7.

^3. Isolation could be based on geography, culture, language, etc.