Friends, Family, or Freeloaders?

While pulling out of his driveway one morning, Dr. Michael Lasser, a pediatrician in Columbia, Md., noticed the nervous young mother of twins who lived across the street from him. She was frantically flagging him down, one of the babies in her arms.

“She positioned herself in front of my car so there was no way I could drive forward,” he says. “When I rolled down the window, she said one of the babies had a goopy eye and asked if I thought it was pink eye.”

Such curbsiding is an all too familiar scenario. You experience it yourself, don’t you?

FIND OUT MORE
To treat in spite of the patientNegotiating privacy lawsWorking with difficult patients

In the grocery store, at the gym, even while dining with friends. They corner you - friends, family members, even casual acquaintances - sidling up for some seemingly friendly conversation that inevitably turns to their medical concerns. “Hey, my arm hurts when I go like this - think it’s broken?” or “Is this lump on the side of my neck anything I should be worried about?” or “Does this sound like a kidney stone or cancer?”

You certainly do want the best for those close to you. But you need some downtime, too. How do you draw boundaries without damaging your family and friend relationships?

Part of the job or totally rude?

While curbsiding is neither new nor exclusive to physicians (imagine the life of a financial advisor in the fall of 2008 or what celebrities have to put up with every single day), it’s nevertheless bewildering and bothersome. It also happens for a myriad of reasons. For starters, it’s convenient for would-be patients: Here they are, here you are. They know you, you know them. What’s the problem? Also, since getting in to see their own doctor will cost money and take time, it’s more economical (for them) to ask you.

But the issue goes even deeper than convenience and expense. Believe it or not, such line-crossing is also sometimes a misguided way for people to show respect to you and to the medical profession. It also illustrates that people sometimes just don’t know what else to talk about.

David Albenberg, a primary-care physician in Charleston, S.C., shares his view: “On a simplistic level, it’s free and easier than going to your own doctor. But on a deeper level, it’s a way to connect with someone or what I call the ‘dead mouse phenomenon.’ When a cat really loves you, it brings you a dead mouse, right? To [the cat], it’s the most wonderful thing in the world. But to you, it’s still just a dead mouse.”

Similarly, people want to bring you their “dead mice,” almost as a tribute to your respected status as a community physician.

On top of feeling cornered and harassed, doling out medical advice without a proper examination could have serious consequences, too. Once you address a clinical concern - no matter who the patient is or where you are - a patient-physician relationship is established. “Whatever medical advice a doctor gives, they are the doctor of record no matter where they gave the advice,” confirms Michael Schaff, a New Jersey-based malpractice attorney. “Just because you’re not being paid doesn’t mean you’re not liable.”

And as far as prescribing controlled substances, federal law states that a prescriber must have a written record of a patient-physician relationship. Some state laws further require documenting a medical history and a physical exam before prescribing any medication.

Handle with care

Still, treating friends and family members is a murky area. While the AMA Code of Medical Ethics states that “physicians generally should not treat themselves or members of their immediate families because their professional objectivity may be compromised in those situations,” it can be difficult to stand your ground when your sweet Aunt May who doesn’t drive or barely leaves her house calls to complain of what you suspect is a raging urinary tract infection.

So what you do, of course, depends on the circumstances and the people involved. As a general rule, if you are outside a professional setting, the best advice is not to give advice at all. But since we’re talking about dear friends and family members, approach this carefully to avoid offending those you love. Here are some guidelines:

• Basic questions, basic answers - If someone has a medical question that doesn’t exactly pertain to him (and he’s not looking for a diagnosis, suggestion of treatment, or - yikes!-a prescription), just answer the question. It’s about the same as if he looked up the information online, but he’d rather ask you and these are people you like. Think dead mouse.

• Minor problems - Giving an opinion is fine, treating is even OK if it’s a first-aid situation where Good Samaritan laws cover you. But, even if you’re faced with treating a seemingly simple problem for your sister-in-law, secondary problems could potentially arise, so either have her make a formal appointment with you, refer her to her own doctor who has her full history, or offer to help her find a doctor in her area. While this may not be what she wants to hear (after all, no time like the present), it’s in her best interest to pursue medical concerns with a physician who is nearby and, even better, already involved in her care.

Albenberg recalls having to have this very uncomfortable - but very necessary conversation - with his own mother, after she e-mailed him complaining of what seemed to be the precursor to a full-blown sinus infection. While her complaints seemed straightforward, he says, Albenberg stood his ground and didn’t treat her online (what she wanted) and instead responded with “My most loving and caring recommendation as a doctor is that you find a doctor. … It’s true that your problem seems straightforward, but one of the things that I have learned from slowing down, getting to really know my patients, and really focusing on even their routine physical complaints is that there is often more to the picture. I want this for myself and more importantly, I want it for you.” A tough conversation to have with your mother, sure, but Albenberg knows he did the right thing.

“She hasn’t exactly responded yet, but I know this is what’s best for her,” he says, sighing. (Mrs. Albenberg, if you’re reading this, please call your son.)

Still, some people are, um, blessed with dogged determination. If it becomes apparent that your cousin really wants you to treat him, point out that you’re both standing in the middle of a parking lot - hardly an appropriate place for a proper exam. Suggest that he come into the office to see you the next day. One way to sweeten the idea of scheduling an examination is to offer to come in to your office earlier or later than regular office hours so he’ll feel like you are truly going out of your way to help him out (and you are).

“This way they feel like you are taking care of them without putting yourself in an uncomfortable situation,” says Schaff. “It makes them feel special.”

• Bigger problems or emergencies - Good Samaritan laws should cover you in true emergencies. But then there are situations where someone’s condition might be serious, and even if it’s in your specialty, you have no way of knowing without the benefit of performing a proper exam.

Lasser says that on one level he really wouldn’t have minded helping when he was held hostage in his car by his nervous neighbor, but situations like this are more complicated than patients usually realize. “It just put me in a bad situation because an eye infection sometimes goes hand-in-hand with an ear infection and not being in my office with my equipment I couldn’t be sure.”

Even if the person is your patient, be persistent in your efforts to persuade her to make an appointment - soon - either with you or someone else that you feel would be appropriate for her to see. This is in everybody’s best interests. “If you’re going to give advice, make sure your advice is right,” says Schaff. “But don’t go beyond your expertise. Be accommodating, not stupid.”

Laughter as medicine

Knowing what to do is not quite enough, though, is it? You also need to know how to do it with tactful finesse, and both the situation and the involved person can sorely test your diplomacy skills. Keep these factors in mind: your audience, the presented problem, your area of expertise, and your perceived seriousness of the situation.

A sense of humor can really help here. Next time you’re in a social situation and you’re pressed to actually provide treatment or give a more detailed diagnosis, try saying, “I would be happy to help you. Let’s go to a private room so you can get undressed and I can examine you.” Unless you socialize with exhibitionists, that usually shuts people down.

Other times, you’ll have to be very blunt and call a person on his motives. If you feel like you are being cornered by someone who is just trying to avoid seeing his own doctor, or paying a copay, try something like, “Sure I can help you. May I scan your Visa card first?” Again, he’ll usually get the hint and that will end it or defer it to an office visit.

No matter what you decide to do - treat/don’t treat, respond/don’t respond - document everything. OK, maybe not right at a dinner party onto your napkin, but jot down notes as soon as you get home or the next day in your office so you have a record of the encounter.

Keep your game plan in your pocket

Clearly, there are few accepted protocols for handling this tricky matter. A lot depends on specific circumstances, and there’s plenty open to interpretation. But planning out your reactions by rehearsing responses to various situations, and knowing the law will help you to make solid decisions when faced with unwelcome curbsiding. Friends and family who truly respect your position will also respect your ultimate decision, albeit sometimes with gentle reminders of the boundaries.

That said, warns Lasser, people routinely offering you their physical updates will always be part of your life’s work. “I was sitting out on my front porch when this neighbor kid rode by on his bike. It was a nice day and I called out to him ‘Hi, how’s it going?’ He stopped and said ‘Fine. My nose was running the other day, but I seem to be OK now.’”

Kellie Rowden-Racette is a former associate editor for Physicians Practice. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the June 2009 issue of Physicians Practice.