Ethical responses needed for inappropriate requests

Substandard care is biggest issue

When a friend or acquaintance asks for informal medical advice, Steven Brown, MD, a clinical associate professor at Texas Tech University in Lubbock, gives this standard reply: "I would be doing you a great disservice by pretending that I could give you good medical advice outside the context of a thorough review of your full medical history and an appropriate physical examination."

The risk of giving substandard care is the biggest ethical issue when an individual asks for medical advice inappropriately, according to Brown.

The format of a medical visit results in good medical care, he sa ys, beginning with the chief complaint, moving on to the history of present illness, then reviewing the past medical history and other symptoms, performing an adequate physical examination, and finally coming up with a plan based on a full consideration of potential diagnoses, testing, and treatments.

"This was developed in the 20th century as a way of ensuring that issues were not overlooked," he says. "This type of evaluation will not happen standing in line at the supermarket."

Incomplete information

"Having incomplete information is almost always a problem outside the formality of an office consultation," says Brown.

When Brown was a medical student, one of his professors told him about a medical intern whose toddler son was having lower abdominal pain. She took him to the emergency room, bringing him not through registration and the throngs of people in the waiting area, but directly to the emergency room doctor.

"The emergency room doctor, thinking he was doing his young colleague a favor, was happy to take a quick look at him, give him a diagnosis of a stomach bug, and let him go home," says Brown.

Several hours later, when the child became more ill, the intern returned with her son, and the doctor now removed his diaper and examined him properly.

As it turned out, the child had testicular torsion, a condition where the testicle becomes twisted, losing its blood supply. The child had to have the testicle removed, a surgery that would not have been necessary if he had been examined properly, as he would have been if he had been treated the same as everyone else, says Brown.

"The lesson to us as medical students was clear: Treat everyone the same way every time, and you won't miss important facts," he says. "You are not doing anyone a favor by taking shortcuts."

Family members

Brown says that appropriate thoroughness is the biggest ethical issue when advice is given outside the context of a full, proper evaluation, and another ethical issue is objectivity. "'The doctor who treats himself has a fool for a patient' refers to the problem of not being objective," he says. "This problem is so profound that the [American Medical Association] Code of Ethics forbids treatment of a family member."

The Texas Medical Board recognizes that there are mitigating factors that sometimes occur, and that emergent or urgent treatment and brief treatment of clearly benign problems does not rise to the level of being unethical, even though it is not ideal, notes Brown.

"The Board also decided that it would be legal to treat family and friends, as long as there are adequate medical records," says Brown. "This requirement ensures that the care is thorough, and follows the proper format of a medical evaluation."

Brown says that another ethical issue is that, if physicians have a family member who is ill, their primary role should be as a comforting son, daughter, father, or mother, not as the doctor. "Who wants their doctor daughter badgering her to lose weight as her physician?" he asks. "It is annoying enough when she does it as her daughter." (See related story, below, on ethical considerations when physician colleagues are the ones asking for advice.)

Source

Steven Brown, MD, PHD, Clinical Associate Professor, Texas Tech University, Lubbock. E-mail: info@drstevenbrown.org.

Consider ethics of "curbside consults"

Sometimes an emergency room doctor will ask Steven Brown, MD, a cardiologist, "What should I do with this patient?"

"My answer is always the same: 'I can't tell you what to do with the patient,'" says Brown, a clinical associate professor at Texas Tech University in Lubbock. "I can tell them that a hypothetical patient with a problem exactly as they have described to me, with no other issues, can be treated in this way or that."

Brown says that if he were to see the actual patient, however, he might very well learn things that would change his opinion.

"The 'What should I do with the patient?'" question is very common with physician assistants and nurse practitioners, adds Brown, and if this occurs, he asks to speak with their supervising physician.

"The doctor seeing the patient is the one responsible for making that call," he explains. "I am happy to see the patient in the emergency room or, if they feel it is safe, see the patient in the office the next day. But to direct their care would be foolish."

When a physician asks a colleague about a situation with a patient, the physician asking the question assumes professional responsibility for making the final decision, and should be well aware of the limits of such a consultation, says Brown.

It is generally recognized that when advice is offered to the treating physician in this context, there is no physician-patient relationship between the patient and the advising doctor, adds Brown.

"This legal principle underlines the limits of the value of informal advice. It is worth what was paid for it, which is nothing," he says.