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Emergentology: Don't Treat Your Friends and Family (or Sometimes, Maybe, Perhaps?)

Walker, Graham MD

doi: 10.1097/01.EEM.0000524792.89926.81
Emergentology

Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

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I always loved brain teasers as a kid. One of the first I encountered involved a father and son in a car crash. The boy is transported to the ED; the trauma surgeon enters the room and exclaims, “I can't operate on this patient; he's my son!” (The answer, of course, is that the surgeon is his mother, you sexist.)

I remember not really getting the point, and asked my parents, both in medicine, “Why can't she operate on him if she's related to him?” They explained the issues, but most of it was lost on me. I just accepted it because my parents said so, like why you don't do drugs or that apologies don't count if they sound insincere.

I generally decline (refuse?) to provide medical care to my friends, family, and co-workers. (As you well know, this does not prevent them from asking.) I don't feel it's right to give advice without the full story, or make recommendations without knowing the medical history, medications, and most awkwardly, sexual history. (It would be nice at least to eyeball people, especially when they consult via text.) The inevitable advice they seek puts you in a quandary: It's hard to recommend that someone seek treatment when they may later “blame” you for racking up a big medical bill; conversely, they'll definitely fault you if they have something wrong and you falsely reassured them. Damned if you do, damned if you don't.

To less awkwardly escape from these situations when people can't take a hint, I give very generic advice, and blame the profession and the job. Some of my classic one-liners include, “Oh, gosh, sorry, but I can't write prescriptions outside of the ED,” “No physician is ever going to tell you not to seek medical attention if you're concerned,” and “Definitely sounds like it'd be worth talking with your doctor.” Have I refilled an albuterol inhaler? Have I recommended people try some ibuprofen? Of course. I try to be ethical and aware of these hazards, but I'm also more pragmatic than straight-laced.

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Biased, Plain and Simple

As it happened, my boyfriend David woke up the day before our trip to the Canadian Rockies with a painful toe. He had been complaining about his toenail for a few days, so when he said it was much worse, I knew without even looking that the paronychia had blossomed. Examining the toe, yellow-white under the cuticle and exquisitely tender to the touch, I recalled my parents' lesson: You're not supposed to treat people you know. You'll be biased; you'll do too little because you don't want to hurt them or too much because you don't want to miss anything.

After a little shared decision-making, offering to take him to an urgent care center, and explaining my worries (but also my competence) in managing this, he chose the Dr. Walker option. An attempt to numb his toe with ice failed, so I digitally blocked his toe and got that satisfying drop of pus from the paronychia. I thought, “OK, that wasn't so bad. I did it, I didn't make the wrong diagnosis, and I helped him. Take that, medical ethics!”

But then I thought about the hiking and walking we were going to be doing over the next five days, and looked at the cuticle again. The purulence was still present, though less so, and was actively draining. Admittedly, I sometimes will stop there in the ED with smaller paronychias and encourage warm soaks, elevation, and close follow-up. But I wanted to do more for David. Part of me wanted to do the best job I could for him, but part of me also selfishly wanted not to ruin our trip with his inability to walk for extended periods of time. So back I went, lifting a little more cuticle, and even separating a bit of the nail to look for an ingrown fold. The rest of the story? Uneventful. David healed up (thanks to my nagging to soak his toe and change his socks), and our trip was wonderful.

This left me with mixed feelings. I'd broken my own rule. Not only had I given medical advice, I'd performed a medical procedure on someone I care about. Part of me rationalized this away—it's a simple procedure with rare complications and a common minor disease without significant alternative diagnoses. But part of me also wondered, was being more aggressive the right thing to do? And if it was, did I do it because I thought it would help David or because it would help me (and our trip)? Should I be more aggressive more often because it worked in David's case? Less often? Should I not change at all even if I felt like I did a better job for him than my average patient?

This is the irony of providing medical care to our loved ones: It's impossible in practice to find the right answer or know if what you did was better or worse. You're biased, plain and simple. I routinely tell patients, “If you were my mother, I'd want you to have this medicine or procedure.” Obviously, I'm implying that these are the recommendations I'd give my own family. But after this experience, would I? We always say we want to provide care like the care we would expect for our family, but who even knows what that looks like?

I for one am only more stumped than ever. Please let me know if you solve that brain teaser.

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