One of the trickier things to learn as a young doctor is how to navigate boundaries between patient, doctor, family and friends. Medical school teaches us that it is unethical to treat yourself or your close family due to a lack of objectivity that can affect judgement. It is fairly obvious why doing otherwise can create poor medical care due to blind spots created by subjectivity, hope, selective listening, personal agendas, and bias for a certain approach to treatment. Less attention is given, in my experience, to other aspects of doctoring while a loved one is ill. A resident physician is just beginning to understand her field and careens wildly between emerging competence and gross misunderstandings of the “a little knowledge is a dangerous thing” type.
Friends and family often view the emerging physician as easy-access medical advice and free care. This can manifest as the, “Why do you think I keep getting hangnails?” or the friend that shows up on your doorstep at 2 o’clock in the morning saying, “My brain feels like it is loose and shaking around in my head.” Coming up with the “right” answer is a fraught process. What should the resident do? As fellowship director, I routinely tell trainees that to render medical opinion without a thorough history and examination is a dangerous practice, and one to be avoided. We should not “curbside” specialist colleagues because it is asking them to commit a shortcut that can endanger the patient and compromise the physician. The resident additionally should be practicing under appropriate supervision. When your mother-in-law calls for a quick refill of her sleeping medicine, or your sister believes her child just needs an inhaler for his wheezing and shortness of breath while on vacation … what is the resident to do? My suggestion is to resist the shortcut and refer the person back to the primary care physician, the pediatrician, and the expert.
More challenging than deflecting opportunistic requests for medical expertise are the situations in which your family member is ill and expects you to become the treating physician, refuses to engage with her usual physicians, disregards appropriate medical advice, or expects more involvement than is realistic. This can be a very difficult situation. How does the doctor in the family balance the demands of family loyalty and love with the professional code of conduct? Some physicians struggle with control issues surrounding the patient and loved one. And what happens when that loved one’s decisions are catastrophic? The brother that commits suicide despite best efforts to get him to counseling, or the alcoholic spouse that spirals out of control and has a devastating car wreck — how does the physician handle the fact that a medical crisis was not averted in her own home? These issues aren’t limited to residents but are likely first encountered during the transition into a full-fledged physician.
Everyone will have relatives and friends that get sick. A doctor-in-training may have a skewed view of what to expect after a diagnosis, which stems from a training emphasis on inpatient, acute and critical medicine. Housestaff see acute presentations, severe illnesses and end stages of disabilities that can create the impression that these situations are seemingly hopeless. The housestaff experience does not often afford an understanding of a livable natural history for most diseases. The truth that patients may actually recover successfully with time and rehabilitation often becomes evident with longer experience, which comes after training is completed.
Lastly, the emotional burden of caring for a sick loved one is a very real for all of us. Handling the stress and grief of having a sick parent, sibling or close friend can profoundly affect a physician’s ability to be emotionally present for the work necessary to be a good physician. As a personal example, I had a friend who committed suicide when I was a resident. I think I was not unique in asking myself, “How could I have prevented this — what could I have done?” As a new physician this question was fundamental to who I was trying to become. I reasoned, incorrectly, that if I could not see that this person, whom I knew well and saw often, was so depressed and desperate that he committed suicide, how could I be competent to practice medicine for patients about whom I knew very little and saw only for briefly in the office? Many medical students blissfully believe that once enough medicine is learned, the trajectory of illness would become predictable and cure likely. The aftermath of a failure in “saving” your close friend or family is devastating. An overwhelming concern that a remotely competent doctor should have been able to prevent his death was a manifestation of my own naivety as a physician. Accepting the limits of a physician’s ability to control illness and acknowledging that no amount of training or knowledge grants one the ability to save whom you love was a fundamental step to developing humility.
In light of that, I have found that there are some helpful, practical steps that can be taken to mitigate harm to oneself and to your loved ones in similar situations.
- Recognize your inherent inability to be objective towards those you care about. Do not try to be the doctor for those people. Tell them explicitly that you will help to try to find the best and brightest doctors to address the issue, but that doctor is not you. If appropriate for the relationship, attend medical visits as support, but not to debate or challenge the treating doctor. Focus on helping to build trust and communication between the treating physicians and the patient.
- Acknowledge the stress of having a sick loved one. When stress is overwhelming, detach to care for oneself. Take days off work. Find someone to share the caregiving responsibilities. Use FMLA policies, if you need to, to prevent being too distracted or stressed to focus at work.
- Remember humility. You don’t know everything about medicine or surgery or any particular specialty and you never will. You probably don’t know what your relative thinks is the right path forward for him.
- Don’t be the doctor — be the role your relationship requires. If the ill person is your mother, be the daughter. If it is your husband, be the wife. If it is your friend, be a friend. Do not start pulling every article on the diagnosis, checking medication regimens and micromanaging. Instead, listen and support the autonomy of the people you already respect.
- Figure out how to manage your own anxiety and fear stemming from workplace exposure to tragedy. Don’t talk about the train-wrecks, the misdiagnoses or the malpractice you witnessed on a patient with the same issues. This will not be therapeutic to the patient or yourself.
- Remember to breathe and do your best to be supportive.
Practical Wellness: Perspectives from a Program Director
A program director’s perspectives on practical wellness in residency and how graduate medical education leadership can facilitate housestaff resiliency and self-advocacy.
Image source: Curves by Rosmarie Voegti licensed under CC BY 2.0.
Attending Physician Guest Writer
Geisel School of Medicine at Dartmouth
Dr. Ronan is an associate professor of neurology and medicine at the Geisel School of Medicine and is the program director of the Dartmouth-Hitchcock Neurology Residency.
Practical Wellness: Perspectives from a Program Director
A program director's perspectives on practical wellness in residency and how graduate medical education leadership can facilitate housestaff resiliency and self-advocacy.