Thursday, March 27, 2008

Cutting It Close

Shortly after I set up practice, my mom mentioned a little skin growth she wanted removed. Since she was part of paying for my college and med school (yes, I was one of the lucky ones!) I figured it was the least I could do. The lesion was a simple non-worrisome thing; removal was strictly cosmetic. But its orientation was such that I had to choose between a smaller excision, not in proper skin lines, versus a bigger one that might be less visible. For some reason, which I still can't understand thirty years later, I made the former choice, and it wasn't a very respectable scar. It did, however, lead me to pay much more attention to orientation; and to the realization that it had been under-emphasized in training. Little things like that are little things like that, when you are trying to learn how to remove half a liver.

But that's not my point. A recent post of mine, and comments thereon, led to thinking about operating on people to whom one is close. It's a close call. On several occasions I've operated on partners, or their family. I've operated on friends (it helps that I have few really close friends), and on people who came to me on the recommendation of friends. In-laws have been under my knife, if a small one. It's an interesting subject, a complicated one. To some extent, it depends on one's ability to compartmentalize. Or, more properly, to focus.

I've not considered it a matter of ethics; to me, it's about judgment. One of my commenters said she was taught in med school that caring for family is considered unethical; perhaps it's a semantic disagreement that we have. To me, "unethical" means submitting false charges, operating with no indications to collect the fee, taking kickbacks for using particular products (a matter of current investigation, evidently.) Were I to operate on someone close, the question is whether I could rise above emotion and make care decisions exactly in the way I would for a "normal" patient.

There's a strange implication here, when you think about it. I like getting to know my patients. Not only, as I've written, do I believe in the importance of establishing trust and confidence and a positive attitude, I just enjoy the relationship for its own sake. It could be said -- it is said, in fact -- that it's a mistake to have anything but a cold and distant relationship with one's patients. But if it's okay to reject that, if it's acceptable -- laudable, even, according to various patient advocates -- for doctors to establish and to have a connected relationship with their patients, then doesn't it follow that the idea of "professional distance" is a flawed one? Doesn't it imply I'd make better decisions when caring for a patient I don't like than for one I do? If not, then at best the idea of caring for a relative or close friend differs from caring for "regulars" only in degree; and a smaller degree, at that, than convention would suggest. Ethics, per se, are not the issue. Attitude is.

Perhaps I'm missing something, but I sort of reject the idea that I care less about my unrelated patients than I would about friends or family. Maybe I'm deluding myself in believing it, but when I enter the operating room I get into a zone of intensity and focus on the problem at hand that nearly obliterates everything else. Totally concerned about addressing the requirements of what I find, while I operate the personhood of my patient is no more and no less than that of the last one, or the next: I'm obliged to do my best. Period.

Of course, I'm not unaware of the temptation to think wishfully, to opt for a path less discomforting for a loved one; it's a possibility, to be sure, especially, perhaps, in after-care. Included in my "memorable patient" series is the story of operating, with only a couple of years of practice under my belt, on my partner. When I had to re-operate on him -- a decision which was harder in many ways than one to delay -- I deliberately chose as an assistant a surgeon out of my clinic, and told him ahead of time I wanted him to speak his mind. Not only was he among those that had suggested waiting, he also made a recommendation during the operation that I ended up rejecting. Later, he commended both of my decisions, and said he'd been wrong, twice. I was able, I'd argue, to think clearly about the needs of my patient irrespective of who he was.

It's not my aim to suggest that doctors ought to start caring for their loved ones; nor am I implying (I don't think so!) that I have mystical powers of concentration absent in others. But it wouldn't be the first time conventional wisdom was found wanting; at the least, it's not crazy-stupid to wonder about it. It's not impossible to focus. Like the paranoid who actually does have enemies, some doctors who think they could provide better care than their colleagues, even to loved ones, might actually be right in some instances. When he was a baby, it looked like my son might have had a hernia. I really liked the way I fixed pedi-hernias; no one in the area did it as simply or with as tiny an incision, sez me. (Most of the pediatricians I knew sent all of their hernia patients to me, because they thought so, too.) Had my son turned up with one -- he didn't -- I'd have been sorely tempted to do it myself, believing it would be in his best interest. My wife told me several times that if she had breast cancer, she'd want me to do the surgery. And having seen my work and that of others, I'd have considered it; probably I wouldn't have done it, but I'm not sure. Happily, I never needed to make the decision. Nor am I unaware of the egotistical implications of the pre-penultimate sentence of this paragraph.

Greater than the risk of providing improper care, as I see it, would be the burden to bear if something went wrong. In that, there would be a difference. It's hard enough to forgive oneself for error or poor outcome under any circumstances. It might be more than I could take, in someone close. Which, of course, argues strongly against taking it on, if for reasons somewhat different that those generally offered.

Maybe there's a happy medium. Plastic surgeon and rabid blogger Ramona Bates responded to my original post with one of her own, and she gave examples of what a surgeon can do to help in meaningful ways, while avoiding the potential pitfalls. When my dad needed surgery of the sort that I did, I had him come to town and hooked him up with a hand-picked team. I stuck my head in the room a couple of times and transmitted the information to my wife and mom. Same when my son had an orthopedic procedure. I was unobtrusive in the OR, helpful to my family, and felt useful in a surgical sort of way. Dayenu. As they say.


Anonymous said...

Interesting and thought-provoking post.

You cut it close, so to speak about the ability to maintain a professional objectivity. But can we ever know our own objectivity? I think we are inherently biased in that respect.

The other side of the coin is the ability of your relative/friend/colleague/staff/patient to express concerns, complaints, fears, etc. Those people know you outside your surgeon role. Would they feel free to express a disagreement with your recommendations? How do you manage noncompliance? What happens if there are undisclosed "secrets" which affect the treatment or outcome?

I think that having a relationship other than the professional one does affect the meta relationship, treatment and outcomes. It's terrific that your experiences have all been positive ones, but I also think that it's important to disclose these other factors with people who you know outside that relationship.

I'm not sure about legal ramifications, but what would happen if such a patient had a bad outcome and decided to pursue legal remedies? Would you have other or added risks?


Sid Schwab said...

annie: a really excellent comment!! As I said, I'm not advocating it; and when my dad needed an operation I intervened only to the extent of choosing the team. Of course, then my partner was operating on the father of his partner. Interestingly my father did not like the surgeon at all (even though things went fine) and let me know quite clearly...

I think the questions you raise from the patient perspective are very good ones. Thank you.

Mainly, I wrote this just because I'd been sparked to think about it. It's particularly easy, now that I'm only looking back...

rlbates said...

Dr. Sid, I think that "rabid" was a compliment? (smile)

Nice post and love Annie's comment. There are some procedures I would feel comfortable doing for family members/close friends and some I would not. Also, there are some family members I would do almost anything to avoid taking care of as their doctor/surgeon. Blood kin may mean I "love them" but I don't always "like them". Does that muddy things even more? I think judgement more than ethics is the key. Some relatives (like some patients) you know you aren't a "good match" for--are realistic, won't follow postop recommendations, etc.

rlbates said...

are UNrealistic

Sid Schwab said...

ramona: I most definitely meant to be complimentary. Maybe I should have said "avid." Or "really, really, really devoted." Or "blogger who takes amazing care to provide depth and detail in every post."

Rabid, in other words.

rlbates said...

Well, Dr Sid, they nicknamed me "mad dog Bates" on the pulmonary service in medical school. I always tracked down those x-rays. So rabid works.

Now, back on topic--good post.

Anonymous said...

Thanks, Dr. Schwab!

You surely provide rich food for thought!

I hadn't thought about this for awhile, but as a nurse, I pretty much tried not to divulge that when family members were hospitalized. But....My mother underwent a AAA repair by a surgeon unfamiliar to me and in a hospital where I had never visited or known staff. When I visited her on POD 2, she was still on an MSO4 PCA, hadn't ambulated, was shallowly breathing with the incentive spirometer gathering dust, and she looked really out of it. A 1PPD x 50+ years smoker and obese, her color was that craptastic grey. I couldn't fully awaken her, and yet, there she was, pushing the PCA button I asked her if she was in pain. Her response: "I'm calling the nurse." I went to find her nurse to get the scoop, and no one would speak to me. I finally got out of the nurse that they were assessing her pain level solely by the PCA pump use - no one had actually asked her about her pain, so no one knew that she had confused the PCA button for the call light. I asked for her PCA pump to be D/Ced and to ambulate her. The next thing I know, the nurse pops into her room and tells me to follow her to the nursing station, where she hands me a phone without telling me who is on the other end.

Yep - the attending's son, who is his partner and is covering. I try to be very polite and dance around the situation, and the guy starts giving ME telephone orders (I hadn't identified myself as a nurse, either). What a way to lose all confidence in everyone.

I wrote out all of the normal post-op progress and standards for my father so that he could monitor her progress and call me if there were questions, ambulated my mother, listened to her breath sounds myself (lousy and diminished, as expected), checked her wound, changed her dressing, and left only after her Foley had been d/c'ed and she had voided.

I left feeling very frightened for her safety. I wasn't able to get back to see her again until a couple of weeks after her discharge. Turns out she was on morphine so long that she had no post op recollection - including pain, and she successfully stopped smoking since she went through acute withdrawal while still sedated.

Happy ending, but scary ride for me. I wouldn't allow her to go back to that surgeon or that hospital. For the nursing staff to have such issues that they wouldn't call him about pain meds and post op order progression said to me that there were serious, serious problems that usually aren't all due to one party.

#1 Dinosaur said...

Great post. I'd like to point out, though, that the whole "doctor-patient relationship" thing has very different implications in surgery than, say, in psychiatry -- and by extension, to many facets of what I do in primary care.

Surgery = problem to be fixed; fix it; done. Without denigrating your contention that your positivity and relationship with your patients enhanced their surgical experience and perhaps their healing, the fact remains that it is quite possible to have a completely successful surgical procedure performed by someone you can't stand. Not optimal, perhaps, but in a way, the relationship is optional.

Contrast that to diagnosing and treating things like depression, STDs and substance abuse. It's all about the relationship (given the disclosures that must occur) and in those cases there is *no way* a physician could appropriately diagnose and treat close family members. Frankly, those are the kinds of cases that define the lines between friend and patient; a distinction that needs to be made on a case by case basis.

Just wanted to point out that much of your discussion is pretty specific to surgery and other acute care conditions; can't really generalize to "all docs."

Anonymous said...

Thank you for addressing this! A lot of it does go back to semantics. Clearly, there's a wide gulf between "unethical" in the sense of truly wrong and "unethical" in the sense of not-the-best-plan-in-the-world. I was using unethical in the latter sense.

The discussion at my school was really geared more toward the ethics of treating family members in primary care. For instance, I would not be the best choice for my father's primary care physician. I'm likely to assume he's faithful to my mother and skip the sexual history, and I'm likely to skip genital and rectal exams. Perhaps the specialty has an effect on the degree to which it is a good/bad idea to treat family?

I would also concur with Annie that it can be hard to tell if one is being objective. Not to open this can of worms, but as an example, some people will argue that accepting any gift from a pharmaceutical company will subconsciously make you feel indebted and impart a need to repay the debt. This is well-supported by social psychology research, and well-exploited by organizations who send you address labels and ask for a donation. Of course, no one thinks they are donating to Cause X just because they got a sheet of stickers (except for over-educated people like myself who can't stop obsessing about cognitive dissonance ;-)).

Thank you again for the thought-provoking post!

Sid Schwab said...

dino: I agree. And my prior post which led to these thoughts was quite specific to surgery as well.

It's a strange thing, this d-p relationship. I know people who stick with docs they don't like. In some cases, ironically, it's because they don't want to hurt their feelings; or because of a professional connection of some sort. I know docs whose patients just love them, despite receiving (unbeknownst) decidedly inferior care.

FWIW, I did have very long-standing and on-going relations with many patients, particularly those with cancer.

SeaSpray said...

I enjoyed the post and comments.

I have a slightly different twist for you.

You said you have operated on partners. Would it be equally as easy for you to operate on your office staff? Receptionists,MAs other clerical that you had an office relationship with but now would become your patient with whatever that entails?

Would the fact that their paycheck and benefits, time out on disability etc. affect how you might handle the case because of a possible conflict of interest? Or would you be concerned that either the work/patient relationship/friendship could be compromised?

Sid Schwab said...

I have operated on office staff. It wasn't a problem. I suppose there could be some scenario in which complications and/or delayed return to work could be tricky. On the other hand, I think they have a right to request whom they want, and it's one of the (smaller) perks of working there...

therapydoc said...

Very interesting stuff. It's different being a therapist, but similar in some ways. You can't really ever stop seeing the way you see. Just like you can't miss a mole, I can't miss a diagnosis and the potential strategies that would work. Friends, patients, makes no difference.

And they see you that way, too, as a professional, so you really can't just say what you feel. Almost everything's got to be salubrious. Gimme a knife any day.

Ian Furst said...

I hate to say it but as a criteria I want to be able to detach myself from the situation. If something bad happens during surgery (desat, bad bleed, whatever) I want to be concentrating on the problem not their kids. So I will do certain procedures on friends or family but not other procedures. I think, if you can maintain objectivity during the diagnosis, procedure and any complications then it's ok - otherwise it's best to refer them to someone you trust.

DDx:dx said...

I have to jump in. I think the line drawn by Dino (and you) around surgery different from psych is too grey and too comforting to be real. The hardest part about surgery is the deciding/ recommending surgery, not the cutting. And the psychic issues in this process CAN be (not always) huge. And for that reason, I think the "closeness" to the patient can be a benefit, but as Annie said, a pitfall. It takes a lot of awareness and maturity to have these discussions. Patients often want to capitulate their adult responsibility to the authority of physician. Physicians have been known to take advantage of this relationship.
I personnaly have seen surgeons operate on family members and it was inappropriate. Their care was compromised. I doubt the surgeon could tell, the emotions are strong.
My story about a failed ditzelectomy on my wife is not the basis for my belief, just a supporting anecdote.

webhill said...

Nice post.

I wonder if you would feel differently about caring for family or friends if you were, oh I don't know - an intensivist, or infectious disease specialist - where the plan wasn't necessarily so clear going in to it?

Gosh I hope you don't take that the wrong way. I'm not saying surgeons do not have to think about what to do or ANYTHING like that, and in fact I have a LOT of respect for you as a profession and you in particular, so please, don't be offended.

I am just thinking out loud here, because I know that I haven't really had any major problems with doing surgical procedures on my own animals - but I can't bring myself to be in charge of their anesthesia (which ordinarily I would be!), for example. Also when I have had very ill animals, like when my one cat turned out ultimately to have a rare myelodysplastic syndrome - well, as soon as I noticed that he was anemic, I lost all ability to work it up with a clear head - I took him to a friend and said "figure this out please," because my initial workup was pointing toward something very complicated and I was far too upset to be able to focus and think clearly about how best to proceed. Whereas, in surgery, once you start - I agree, there is a focus, you are handling a situation, not necessarily an individual any more. I find with the medical side of things I am much less inclined to have that disconnect.

Do you know what I mean?

Anonymous said...

Professional objectivity and bias aside, my former employer's partner did a knee replacement on his own mother. I thought it was creepy and COMPLETELY arrogant that he thought he was the only person fit enough to do her surgery. And it's not like she lived in the area and it was convenient. No, he flew her in to CA from OH for her operation.

Removing skin lesions or doing minor procedures is one thing. The line should be drawn somewhere, though, and I thought this surgeon crossed the line...

Fortunately, the surgery was completely successful.

Sid Schwab said...

webhill: yes, I do. A couple of comments north, I agreed with a similar comment. And this whole post was more of a rumination than a policy statement.


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