• Treatment of Self, Family, Friends, and Employees

    The unique dynamics of a close interpersonal relationship can often complicate the patient-physician relationship. Below is information to assist physicians to remain in compliance with the rules and ethical guidelines for treating oneself, family members, friends, or employees.


    Texas Medical Board Rules

    From Texas Medical Board rules Chapter 190.8(1)(M) - Violation Guidelines

    The following acts, practices, and conduct are considered to be violations of the Act:

    Inappropriate prescription of dangerous drugs or controlled substances to oneself, family members, or others in which there is a close personal relationship that would include the following:

    (i) prescribing or administering dangerous drugs or controlled substances without taking an adequate history, performing a proper physical examination, and creating and maintaining adequate records; and

    (ii) prescribing controlled substances in the absence of immediate need. "Immediate need" shall be considered no more than 72 hours.


    American Medical Association (AMA) Ethical Guidelines

    AMA Code of Medical Ethics provides guidance Patient-Physician Relationships Opinion 1.2.1 Treating Self or Family.


    Texas Medical Association (TMA) Ethical Guidelines

    TMA Board of Councilors Opinion: Treatment of Family Members and Friends 
    One of the physician's primary duties is to alleviate suffering. Thus, it is ethical to treat family and friends. As with all patients, in the course of treating friends and family, a medical record should be maintained; however, in urgent or episodic situations generating a medical record may not be practical or possible.

    However, please note that the legal requirements for treating family members and friends and for keeping medical records exceed the above ethics opinion. See Texas Medical Board rule 190.08(1)(M) above. Please consult your own retained counsel for legal advice on this issue.


    Treating Your Own, It's Legal But It Can Be Risky 
    An article from Texas Medicine, issue October 2011, that discusses some of the concerns and ethical considerations.

    While treating a family member or friend is not against the law, it raises ethical concerns such as:
    – Loss of professional objectivity. The physician may make assumptions and fail to ask key, sensitive questions routinely asked of any other patient.
    – Risk of going beyond expertise level. The physician may feel an obligation to seek out every possible solution or take measures that normally would be referred to someone else.
    – Reluctance of patient to communicate openly. The patient may feel uncomfortable revealing info that is embarrassing or contrary to a family belief system.
    – Loss of patient autonomy. The patient may feel uncomfortable questioning the physician's judgment or obtaining a second opinion.

    A poor outcome could affect the family or friendship as well as alert the Texas Medical Board to a possible violation of the law. This is especially true if the physician makes a mistake or error in judgment.

    If you decide to treat friends or family members, stay on the good side of the law by treating them the same as any other patient. For example:
    – Do not treat a friend or family member outside of your normal practice setting.
    – Do not treat a friend or family member outside of your field of practice.
    – Have the patient complete a new patient information form upon initial treatment.
    – Keep complete medical records.  


    Texas Medical Liability Insurance (TMLT) Guidance

    TMLT provides guidance and risk management considerations for a variety of situations Proceed with caution: treating family, friends, and staff from The Reporter 2011 Volume 3, beginning on page 6.


    Treating Employees

    Risks of Treating Employees
    From TMLT publication, Trends MD-Connecting Physicians, issue May 23, 2012, by Wendy Kaliszewski

    Treating employees can seem like an added benefit for employees and physicians, but the risks may outweigh the benefits.

    Barbara Worsley, VP of risk management at The SCPIE Companies states that, "Many physicians face the same dilemma: Should they personally provide medical care to their employees?"

    Advantages of physicians treating employees include:
    – Saves the employee the time it would take to be seen by their own doctor and
    – Helps the physician since the employee's time away from the office does not have to covered.

    However, the disadvantages can be greater than the advantages due to the high degree of risk:
    – The physician may not be able to safeguard the employee's medical records, and therefore may be less likely to document personal and psychosocial details.
    – The employee may be reluctant to share personal medical info that could be pertinent to his/her care. Not only because the physician is the boss, but also because other employees may have access to the medical records.

    Other disadvantages can be that
    – Employees may seek medical advice in passing and the info would not become part of their medical record.
    – The physician may not be able to be objective when the employee needs time off because of an illness or impairment.

    As far as payment is concerned, keep in mind that physicians offering free or discounted care should be cautious not to violate the terms of their contracts with health plans. The physician may not be allowed to waive copays and deductibles.

    Some physicians may feel that treating employees is just too risky, thereby creating a blanket policy not to do so.

    One of the most important elements in reducing the risk of treating employees is to have clear and concise policies outlining how the practice handles treating office staff.

    Medical Group Management Association profiled three medical practices that have adopted these policies according to their practice's needs, which include:
    – An informal, word-of-mouth policy with discount,
    – An informal policy without discount, and
    – A strict written policy.

    According to Ms. Worsley, "If you do opt to provide medical care to your employees, you need to take measures to minimize the chance of problems arising:
    – Limit your treatment of employees to minor medical problems or emergencies.
    – Clearly communicate to all employees that such treatment is not mandatory and that they're free to obtain medical care elsewhere whenever and wherever they want.
    – Maintain high standards of care. Insist on the same criteria and procedures for evaluating and treating your employees that you use for your regular patients.
    – Document all encounters as to symptoms, findings, treatment plan and progress. Document any provision of medication samples to employees.
    – Avoid prescribing controlled substances. Federal law states that a doctor must have a bona fide patient-physician relationship - including a written record of the relationship - before prescribing controlled substances. Some states require a documented medical history and a physical exam before prescribing any medication.
    – Do not conduct sensitive physical exams on an employee without having a witness in the room.
    – Be consistent. If possible, make sure all physicians in your group follow the same protocol with respect to taking care of employees."