When Relatives and Friends Ask Physicians for Medical Advice: Ethical, Legal, and Practical Consider

Physicians often are asked for advice about medical matters by relatives and friends. This ranges from simply acting as interpreter or facilitator to offering medical advice to providing medical care. This discussion is about the more ambiguous portion of the range of requests from relatives and friends in which physicians are asked to act as informal medical consultants, a topic that has received little attention in the published literature. It is not about issues related to the medical care of family and friends, including prescribing medications, which have been covered well in the literature1–4. Although physicians handle most such requests well, occasionally the requests provoke misunderstandings and conflicts that could be mitigated or prevented by attention to the dynamics of the transactions and adherence to some practical guidelines.



THE CONTEXT
Requests for medical advice begin for many of us as early as medical school when we return home for holiday vacations and our brother or high school friend wants to know what a pain or a rash means. Later, when we become fully trained physicians, family members and friends ask us to help navigate the complexities of the health care system; to interpret symptoms, physical signs, laboratory tests, and other medical information; to recommend a generalist or a specialist; to explain a diagnosis; and in other ways to act as a knowledgeable, sympathetic intermediary and medical resource. The relationship between the relative or friend and us may be close or distant, but the common thread is this: the requester is relying on us as professionals who have medical knowledge and familiarity with the medical system.

The requests usually seem uncomplicated—a simple need for factual information or a “good doctor” to see. Sometimes we are asked to use our judgment or offer advice. For purposes of conceptualizing and discussing this issue, the following describes a range of requests for medical advice that physicians may receive from relatives and friends. The categories progress generally from requests for simple information to requests for medical judgment and more substantial involvement by the physician. The categories are not cleanly separable, requests may fall into more than one category, and relatives and friends may ask something that is not covered by any category below.

• Request for factual medical information (e.g., What are the signs and symptoms of diabetes? How does prostate cancer develop?)
  
  
• Request for recommendation about which physician to see (e.g., Do you know a good cardiologist?)
  
  
• Request for medical information plus some judgment (e.g., What does a PSA of 7.5 mean? How would I know if I had prostate cancer?)
  
  
• Request to speak with the requester’s physician(s) (e.g., I don’t understand what is going on. Could you please talk with my doctor?)
  
  
• Request to facilitate a person’s care (e.g., Can you intervene on my behalf?)
  
  
• Request to encourage a third party to access medical care (e.g., Would you please call Rosemary and get her to see Dr. Jones?)
  
  
• Request for medical judgment about a medical event (e.g., What would you do, given these symptoms, results, or events?)
  
  
• Request for a medical opinion about the appropriateness of medical recommendations or the course of treatment (e.g., Do you think my doctor is doing the right thing?)
  

MOTIVATIONS AND EXPECTATIONS OF THE REQUESTER AND THE PHYSICIAN
The family member or friend is motivated by one or more interests. These include mere curiosity, need for guidance in an uncomfortable or unfamiliar environment, concern about oneself or a loved one, a desire for “free” advice, and frustration or anger with another physician, the health care system, or events. The requester also may be searching, hoping, for a different answer in a threatening medical situation. Lack of access to medical care may stimulate the request. Sometimes such requests reflect poor communication between the requester and his/her usual physician.

Physicians generally are motivated to respond by love, friendship, duty, and the desire to help. They, too, simply may be curious. Sometimes physicians feel they need to control the medical situation of their friend or relative because they think they possess the appropriate expertise or do not trust other physicians or the system to do the right thing.

The expectations of the requester and the physician usually align and there is a mutual understanding of the role of the physician as provider of information, interpreter, and advisor and that the request is limited to the information that is sought.

Sometimes the expectations and understandings of the requester and the physician do not align. For example, the requester may not distinguish among physicians with regard to their medical expertise and view all MDs as capable of addressing most medical matters or the requester may expect the physician to continue to be involved in the situation when the physician feels his or her involvement is limited to the initial interaction.

ETHICAL CONSIDERATIONS
In interacting with relatives and friends, physicians bring traditional ethical principles of the medical profession to bear. These are a mixture of the desire to do good and alleviate suffering (beneficence), an intent to minimize harm (nonmaleficence), and the duty to provide care. Generally, the physician respects the requester’s autonomy and confidentiality, although these may be diminished or modified in a close relationship.

We sometimes assume, often erroneously, because of the familiarity of a relationship, that medical information may be shared with others in the close circle of family or friends. Also, if the requester is speaking for another person in need of medical advice, the ethical prerogatives of that person as deserving confidentiality and as an autonomous individual need to be respected. It is difficult to establish rigid rules of procedure for this, but physicians should be mindful of the need to preserve autonomy and confidentiality. Further, because of the ambiguity between confidentiality and openness in certain relationships, the physician may wonder, when a relative or friend is telling a personal medical story, whether this is something they should be talking about.

LEGAL CONSIDERATIONS
Friends and relatives are not immune from suing physicians whom they consult informally5. What Olick and Bergus say regarding informal consultations between physicians about patients seems pertinent to informal consultations by relatives and friends with physicians: “…the existence of a physician-patient relationship is a prerequisite to any malpractice claim… The physician-patient relationship is consensual in nature and is based on the idea of contract, whether express or implied. Typically, the scope and nature of the relationship are not explicitly agreed on at the outset. Rather, the relationship evolves and is inferred from the communications and conduct of the physician and patient… Personally examining the patient or expecting payment for services—features typical of formal consults—would almost certainly establish a legal relationship with the patient.”6

Johnson advises physicians to approach relatives and friends who seek clinical advice with the same professional expertise and judgment as any other patient, to document the encounter, to ask the person to come to the office if an examination is necessary or records need to be reviewed, and to be mindful of HIPAA (Health Insurance Portability and Accountability Act of 1996) rules5. Under HIPAA, the patient needs to give permission for the physician to review previous records.

What constitutes a physical examination would seem to be a matter of context and interpretation. To physicians, a physical examination ordinarily means a structured, albeit often limited, hands-on examination of the patient that usually occurs in a health care setting. However, an examination in the context of a social or family situation may be a focused appraisal of something that is readily evident, such as detecting jaundice, or easy to do, such as limited palpation or assessing joint mobility. In such instances, a physician probably would not consider charging a fee.

PRACTICAL CONSIDERATIONS
Requests for medical advice from relatives and friends generally come in the context of existing family ties or friendship and a history of trust and shared experiences. These create an environment in which the requester feels that he or she has permission to approach the physician for medical advice and to which most physicians respond favorably. Usually the relative or friend is happy to receive the advice, and the physician is pleased to be of service. After all, that is what physicians are supposed to do!

These generally salutary influences may be mitigated by concerns that the requester or the physician may have. The requester may worry about imposing on the physician or be embarrassed by the medical situation and thus limit the information that is given to the physician, restricting the physician’s ability to respond appropriately. Conversely, the requester may not be concerned about imposing on the physician, which may engender resentment by the physician. Some physicians develop “safe zones” in their lives, such as family, church, and vacation, in which they feel relatively free from the responsibilities of medical practice. Physicians differ in respect to this, but some may resent what they interpret as a violation of a safe zone or otherwise feel burdened by requests for medical advice from relatives and friends.

Tensions may develop when the parties do not have a mutual implicit or explicit understanding of the expectations and limits of the transaction; the physician fears an awkward situation or the possibility of discord within the family or friendship; the requester seeks medical advice beyond the capability or comfort level of the physician; the physician gives advice that is misinterpreted, misused, not followed, or incorrect; the requester regards the physician as one of the responsible physicians in the case; the physician feels conflicted in multiple roles, e.g., as physician and sibling; or the physician becomes fearful of the possibility of malpractice litigation. Further, prior experiences with the requester may raise caution, animosity, or otherwise condition the current request.

SOME RESPONSES TO REQUESTS FOR MEDICAL ADVICE
“Yes, of course, I would be happy to help.”

“Let me make sure that I understand what you are asking.”

“I would be happy to continue to be involved.”

“I am happy to help but please understand that [I have not examined you], [I am not a cardiologist], [I am not your doctor].”

“I am not your doctor, but in situations like this I believe X is recommended.”

“I am sorry, but I don’t think I can do this because…”

“Under these circumstances, you should not rely on me for medical advice.”

“I would feel better if you asked your doctor about this.”

“I am your friend (or cousin, etc.) who happens to be a physician, but I think you can appreciate that that is different from being your physician.”



The last response could apply to several of the situations implied in the preceding responses and combined with them. Thus, one might say, “I would be happy to continue to be involved. But remember, I am your friend who happens to be a physician, and I think you can appreciate that that is different from being your physician.” Or “I would feel better if you asked your doctor about this. I am your cousin who happens to be a physician, but I think you can appreciate that that is different from being your physician.”


RECOMMENDATIONS FOR RESPONDING TO REQUESTS FOR MEDICAL ADVICE AND HELP FROM RELATIVES AND FRIENDS

1. Be clear about the expectations of the requester and yourself, including whether you are being asked for simple factual information, for your medical judgment, or to be more substantially involved. If for some reason you cannot respond to the request or have concerns, make that clear. In close relationships, such as with a spouse, a parent, a child, or sibling, it is a matter of judgment whether you explicitly express the extent of your initial and ongoing involvement and commitment.
   
   
2. Treat your interactions with relatives or friends with the same professional expertise and judgment as you would any patient, even though those interactions may be informal. Document the encounter with a brief note for your personal files, which can be useful if you have continuing interactions with your relative or friend.
   
   
3. Be aware that a structured physical examination and especially charging a fee strengthen the establishment of a legal relationship with the requester as your patient. Most requests for medical advice do not require a structured physical examination, but if you choose to examine the patient, you will need to decide whether the examination should take place in your office.
   
   
4. Respect the requester’s autonomy and confidentiality and conform to HIPAA requirements where applicable. Be sure the requester approves the sharing of information, even in close relationships. Obtain the patient’s permission if you review medical records or other information. If the requester is speaking for another person, respect that person’s autonomy and confidentiality.
   
   
5. Be aware of the potential conflict between your roles as a relative or friend and as a physician. Your professional judgment may be in conflict with your emotional judgment. Further, all physicians play a number of different roles (e.g., doctor, spouse, parent, friend, community leader) which can reinforce or conflict with one another, and we all may benefit by reflecting on this and discussing such matters with colleagues to try to understand better how to avoid conflict and optimize synergy among our various roles.
   

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