Treating Friends and Family

There is always a temptation for doctors to write prescriptions for family members. Let me share my story of what happened when I gave in to this temptation.

It was my first real vacation as a resident-in-training in psychiatry. I was planning a scuba diving adventure in Florida with my sister, brother, and sister-in-law. I was fresh off a family practice rotation so I felt like a “real doctor.”

We arrived to clear blue ocean, powder-white sand and a promise of spectacular diving. My sister, unfortunately, had a nagging sinus infection that threatened to put her on the sidelines. I wrestled with the idea of writing an antibiotic for her congestion, knowing that there were some vague reasons why I shouldn’t. But, I had written Septra DS so much recently that my pen could write it automatically. We stopped by a pharmacy and picked up the medication with the hopes she might dive the next day - and indeed she was able to join us. Overall, we had a fine trip.

It was weeks later that I would first hear of any consequence.

I got a call from my sister that she’d had some blisters forming and the doctors diagnosed poison ivy. She was sent home from the clinic after a steroid shot. But her condition worsened, and on a later dramatic visit to the ER - with blisters covering her feet so badly that she couldn’t walk - she was diagnosed with Stevens-Johnson Syndrome. Stevens-Johnson is a rare and life-threatening condition that causes the skin to slough off externally and the mucosal linings internally, often triggered by a medication. It is most similar to a severe burn of the skin, but even worse because internal organs also can shut down. Kidneys and lungs, among others, are compromised.

When I arrived at the hospital to see her, I was told she had a 20 percent chance of living. As I walked into her room she appeared like an alien with the soul of my sister. A charred blackness covered her grossly swollen face and body. She was blinded by the swelling. She was very much aware of her surroundings and happy that I was with her. I had never actually seen a case of Stevens-Johnson in medical school or in my residency. I was in shock. I could not believe such a dramatic reaction could occur from a medication.

Doctors in the 1990s were not very familiar with Stevens-Johnson. They also found it hard to determine the exact cause because Stevens-Johnson has an unusual time course. Most allergic-type reactions occur rapidly after the introduction of the offending agent: minutes or hours. With Stevens-Johnson, it takes weeks after the introduction of a substance before any evidence is seen. Then, it is often too late to reverse the damage, and the disease skyrockets.

In my sister’s case there was nothing in her history to predict such a reaction. She had taken very few antibiotics in her lifetime and no previous allergies were seen. Only a small percentage of the population has the genetic predisposition necessary to trigger the disorder. The doctors were suspicious of Septra initially as the cause and over the next several days and weeks grew more confident that it was indeed the cause of her condition.

I was in a panic. I was faced with losing not just my sister, but my best friend. We rode ponies together as kids. We took college classes together, vying for the highest grade. While she was working at a real job, I was in medical school. She planned the fun times we might have traveling during breaks from my program. She always believed in me and helped in every way she could. We were close. My whole family was close. We never left her side during recovery; we were there day and night. We rotated staying by her bed. In the burn unit we wore our masks and booties, which become very itchy after an hour. We wore them all day long.

My sister hated most the baths in hot water. They were agony. She prayed before, during, and after to endure the pain. Overall, she was one of the most gracious patients in the unit and suffered without anger and bitterness. She had many ups and downs during the first month in the burn unit, but she recovered well enough, eventually, that I prepared to return to my residency program. It was a long, emotional seven-hour drive back to South Carolina. As I entered the door, my roommate handed me the phone and said, “It’s your mom.” I dropped my bag. My mother told me that my sister had taken a turn for the worse and was asking for me to come back.

On the even longer drive back to Kentucky, I bargained with God. I asked Him not to take her. I promised Him my life for hers. I queried if I were to drive my car off a bridge could I trade my life for hers? God gave me no such reassurances. I determined that my sister needed me more alive than dead and that my mother could not endure the loss of two daughters at once. I drove on.

When I returned, my sister was battling a fungal infection of the blood. She defeated the infection and ultimately made a miraculous, near-full recovery from Stevens-Johnson. By the time she was discharged a month later she had only severe scarring on her back, eyelashes with a tendency to introvert, and dry eyes; relatively minor reminders of her near death. She was able to forgive me for the unintentional part I played by prescribing this accidental poison. It took me much longer to forgive myself. I’m not sure I have ever fully been able to do so.

Physicians are given the resources to heal and to reduce suffering. So it’s natural to want to use our talent and knowledge to help those we hold most dear. But I have come to the conclusion that there is no good reason other than during an emergency to treat a family member. When I wrote the prescription for my sister, I used what I knew to help her, but I now know that this isn’t the only way. It was only the most direct, most expedient way I could think of.

Studies have shown that up to 100 percent of physicians have prescribed for a family member at one time or another and as many as 84 percent of physicians have self-prescribed. The AMA Code of Medical Ethics frowns on this, noting the difficulty of getting a proper history, documenting properly, examining fully, and obtaining informed consent. All of which are muddled by a personal relationship overlapping a professional one.

For me, the risks now are so clear. Less clear are the benefits. Expediency is not such a high value to me anymore. The most important question for a physician contemplating prescribing for a family member is: What exactly is the benefit? I have yet to hear a benefit described to me that outweighs the risk.

Teresa Ramerth, MD, is a psychiatrist living in Vienna, Va. She and her husband home school their two amazing children. She plans to enter locum tenens practice and travel with her family.

This article originally appeared in the July/August 2010 issue of Physicians Practice.