Clinical Scenario
You as the provider:
In conjunction with a recent upgrade of your electronic health record (EHR) software, you added a patient portal to help your patients more easily access your services and staff, as well as their medical records, tests, appointments, and information updates. The portal has become important to providing more efficient care, especially through the appointment and messaging features.
You’re just leaving the office for the New Year’s holiday when one of the medical assistants catches you—a patient of yours who’s also a physician has placed an “urgent” message on the patient portal, and she felt you should be aware of it.
You recall that this physician–patient is someone for whom you have cared over the years, treating seasonal allergies and laryngopharyngeal reflux, both of which are under good medical control. The physician–patient is requesting urgent prescriptions for valacyclovir and gabapentin to be sent to an out-of-state pharmacy for the acute onset of “trigeminal neuralgia,” which is becoming very painful for him. As you scan his medical information in the EHR, you note a distant history of trigeminal neuralgia, with the last attack happening over 10 years ago. He has never identified that disorder to you as an active problem, and you have no clinic notes from any neurologist, nor imaging study results from the past pertinent to trigeminal neuralgia. The message from the physician further identifies that he’s currently traveling and won’t be available until he arrives at his cabin in the mountains, where phone coverage is spotty.
You’re also leaving soon, taking a well-deserved holiday vacation with your family. You attempt to reach the physician–patient by mobile phone, but, after no response, you leave a message for a return call, explaining your reluctance to prescribe these medications without personal contact with him to rule out other potentially serious conditions. You’re also concerned with potential issues associated with prescribing these medications, which you haven’t previously prescribed for this physician–patient.
You as the patient:
You awoke this morning with vague symptoms of a unilateral sore throat, a right-sided throbbing headache, and hypersensitivity of the ipsilateral facial skin in the trigeminal distribution. Within three hours, the pain has become lancinating, and by the time you’re ready to board the aircraft with your family, you realize this is the classic recurrence of your trigeminal neuralgia.
A quick call to your otolaryngologist’s office is shunted to an answering service for the holiday, with the operator indicating that the office just closed, and the on-call otolaryngologist is “so busy I don’t know when they will be able to call you. Perhaps you should go to an emergency room.”
Out of desperation, you go online to the patient portal and place a medication request message for the two medications that have been successful in the past for controlling the neuralgia. You believe that surely a fellow physician will trust your judgment and experience with trigeminal neuralgia and contact the receiving pharmacy at your destination. Otherwise, the neuralgia will worsen, and you’ll become nearly incapacitated and miserable. Your options are currently very limited.
How would you ethically handle this situation? Read below for the discussion.
Discussion
Being asked to care for fellow physicians and other healthcare providers can be quite rewarding and a distinct honor. We appreciate being selected to care for their otolaryngologic concerns, and pledge to care for them at the highest level possible.
Yet, caring for a colleague in medicine carries additional responsibilities, including properly navigating potential challenges to your care in the context of autonomy, beneficence, nonmaleficence, and social justice. To be aware of these challenges is to be prepared to face them appropriately. Most literature on the topic of caring for physician–patients reflects the patient’s perspective, and little has been published on the nuances from the treating physician’s perspective.
Recognizing the honor of caring for a colleague cannot overshadow the importance of treating them in accordance with established protocols, standards of care, evidence-based diagnoses, and acceptable treatment options, all in the context of professional compassion and empathy. Their selection of us to provide specialty care cannot be allowed to inflate our egos or to change the patient–physician relational dynamics to any substantive degree.
Maintaining Professional Boundaries
Maintaining professional boundaries and setting appropriate expectations for the patient–physician relationship are fundamental to caring for physician–patients. It’s important to remain within the envelope of acceptable standards of care with fellow physicians, just as we do with nonphysician patients.
Adhering to evidence-based practice standards and specialty-specific clinical guidelines are foundational precepts that should be explained to your physician–patient in the initial discussion. Some physician–patients may be concerned that, because they’re colleagues, you might take some shortcuts, different from your usual practice parameters, that might lead to some laxity in care. Conversely, other physician–patients might feel they deserve “special” treatment that could engender inappropriate care.
Explaining your intent to treat the physician–patient to the best of your knowledge and abilities, but without compromise, can positively influence the subsequent relationship. It’s commonly held that physicians should be treated just like any other patient, which is true on its face, but we must also recognize that physician–patients present unique challenges not necessarily encountered with other patient groups.
While otolaryngologists don’t provide holistic care in the traditional sense of primary care, there’s certainly a need to obtain a complete history and review of systems from the physician–patient. This requirement obligates us to maintain strict nondisclosure of stigmatizing or personal information that the physician–patient may be wary of sharing. Therefore, it would be appropriate to remind the physician–patient that all shared information will be held in the strictest confidence under HIPAA regulations. The office staff should be reminded of the rules for privileged personal health information to reduce the risk of an information breach. If a physician–patient requests that certain information not be placed in the medical record, this should be considered a concerning sign and openly discussed with them.
It’s particularly important to maintain professional control of the clinical encounter. Not necessarily intentionally, physician–patients may begin to treat their own clinical encounter with the same manner of control that they use in the care of their own patients. Patience and understanding by the physician are required here to allow the physician–patient to present their thoughts and considerations while the physician keeps the encounter on an appropriate, controlled track.
Properly navigating this ebb and flow often requires experience and may be difficult when there’s a perceived relational differential between the physician and physician–patient. Take, for example, a young otolaryngologist, recently in practice, who’s seeing an established, respected older colleague for a health issue. It may be difficult to avoid taking that differential into account—but the encounter must be kept in proper clinical perspective. Conversely, when a faculty physician is asked to care for a resident physician in the department, that inequality of academic roles may influence the clinical encounter balance. The treating physician must be aware of these differentials, discussing them in general terms at the start of the encounter to properly develop the therapeutic relationship and subsequent shared decision-making for diagnosis and treatment.
Caring for physician–patients may also raise the question of how detailed language should be when discussing diagnoses and recommended therapies. Some physician–patients may prefer medical explanations to be delivered in the same manner as they would be for any patient, while others may wish to have a discussion with more scientific detail. Inquiring about how familiar the physician–patient is with a particular disorder or treatment can give direction to how the discussion might best proceed.
Recognizing the honor of caring for a colleague cannot overshadow the importance of treating them in accordance with established protocols, standards of care, evidence-based diagnoses, and acceptable treatment options.
Some physician–patients may expect to have special accommodations for scheduling and appointments, which may well fall under “professional courtesy.” But there may be a limit to what can be accommodated under such courtesies, and it’s wise to set limitations early in the clinical encounter. Owing to busy schedules, the use of texts and emails may be appropriate if limited and conducted with proper information safeguards, as personal health information must be carefully protected. Phone calls work well when not excessive, and virtual visits may be quite helpful with dual busy practices.
Shared decision making can be challenging in some physician–patient/physician relationships. We’re all used to being in charge of diagnostic and treatment discussions with patients, but it’s never wrong to listen carefully to the physician–patient in shared decision making and to take a little extra time to explain any options and why you recommend them in the face of physician–patient attempts to control the encounter—shared decision making should be a bilateral conversation.
The final choice is always the physician–patient’s prerogative, and one must accept that. However, the physician must feel confident that they’ve adequately presented all the pertinent information for the physician–patient to consider. This doesn’t mean that the physician is obligated to acquiesce to a decision by the patient that’s not in the physician–patient’s best interests, however, or not in keeping with established standards of care.
Thoughtful consideration should be undertaken when the physician is asked to care for a close physician friend in the presence of a serious disease, such as head and neck cancer, when a poor outcome or complications could negatively affect the relationship. Strong consideration should be given to referring the physician–patient/friend to a competent otolaryngologist–head and neck surgeon who does not have the same personal relationship with the patient. Remaining objective in caring for physician–patients is an ethical obligation.
Resolving the Clinical Scenario
In the scenario presented earlier, an effort was made to present both the physician and physician–patient perspectives. The physician has a duty to provide evidence-based medical care to patients, following practice guidelines and appropriate standards of care. Yet, the physician–patient is hoping that their colleague will trust that what is requested is, indeed, appropriate, and consistent with the health needs of the physician–patient.
For physicians who have treated patients with trigeminal neuralgia, there’s an appreciation for the extent of the unrelenting pain associated with an attack. An appropriate resolution could involve the treating physician contacting the physician–patient as soon as possible (not letting four or five days go by), discussing the situation over the phone, and performing a “virtual encounter” to rule out other diagnoses as thoroughly as possible. It’s likely that whatever encounter is possible would result in a satisfactory conclusion—the successful and timely prescribing of the appropriate medications and ensuring future follow-up with the physician–patient.
We all have been, or will be, patients ourselves, and our ability to empathize with our patients through these experiences must also be applied when our patients are physicians or other healthcare professionals. Stated differently, we must be able to appreciate their own perspectives on their illness, empathize with them, and act professionally while caring for their best interests. Indeed, it is an honor and privilege to care for colleagues in the medical profession, but we must appreciate that the common rules of professionalism and duties still apply to these unique relationships.
Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.