Guidelines for Treating Employees and Family

Medical treatment of their employees and loved ones by physicians can raise significant concerns about confidentiality, appropriateness, documentation, expectations and errors due to biases. If care to an employee or loved one is necessary, physicians should treat them as they would any other patient, including complete documentation of treatment maintained in a secure medical record.

Recommended Actions

• Document all evaluations, treatment recommendations and sample products provided to employees or family members.
• Store employee medical records in a secure area, whether electronically or in physical form for confidentiality purposes.
• Avoid treating people with whom you have significant emotional attachments unless other options aren’t available.
• Avoid prescribing opioids, sedative hypnotics or anything mind-altering or potentially addictive except in a formal doctor-patient relationship and within the typical prescribing patterns.

Case Study

Late one afternoon, the office manager of a rural medical practice brings her 15-year-old son to see her boss, a family practitioner (FP). The son has upper respiratory infection symptoms with fever, myalgia and a stiff neck. The physician sees him quickly and gives him a Zithromax pack from the sample closet.

The next day, the son wakes up and is confused. The mother calls the FP, who speaks with her between appointments. He attributes the confusion to the patient’s fever and suggests more vigorous antipyretics and fluids. Twenty-four hours later, the patient becomes lethargic, febrile and cannot be prompted to take oral fluids or food.

The mother then takes her son to the local ER, where he is diagnosed with bacterial meningitis and admitted. He has a difficult hospital course and never recovers fully. A rift develops in the office between a group of staff members supportive of the mother and other staff who are supportive of the FP’s care. The mother quits, and one year later, she files a malpractice lawsuit against the FP for failure to timely diagnose meningitis.

Case Analysis

In this case, there is no medical record for the son at the FP’s practice. The whole incident was a curbside visit and no vital signs were documented. The FP was rushed in his evaluation and tired at the end of a long day. If this had been a regular office visit, or an office visit prompted by the phone call after that visit, he might have made the same diagnosis and prescribed the same treatment, but the lack of documentation makes this a very difficult case to defend.

Treating Employee Patients

Treating employees and their families brings up significant concerns about confidentiality, appropriateness, documentation, expectations and errors arising from biases. We do not advocate an absolute “no employee treated in the office” policy, as that may be unworkable and may also, for geographic, specialty or trust reasons, be the worst solution for patient care. Rather, we believe physicians should consider the following.

Confidentiality

Office records of employees that co-workers can access are a risk. Consider moving such records to a secure area, whether electronic or in physical form. Recognize that “limited access” or “lock/unlock by an administrator” features for sealing or securing the record are unique to your EHR. The HIPAA implications are obvious and the inadvertent sharing of medical information carries a significant risk. When you are treating employees, your confidentiality policy needs to stress that the medical records can only be viewed for legitimate purposes such as treatment, coordination of care, scheduling and payment issues.

Even with such efforts, it is difficult to  secure records. Audit trails of access to employee and other privacy risk patients may reveal breaches. Your policy and its enforcement should be clear and consistent. Everyone in the office should understand the risk of inadvertent disclosure. Finally, realize that there are more than just medical record breach risks — providers, staff and employee patients should have the same benefit of confidential and professional care that all your patients receive.

Embarrassing diseases

Employees might present with STDs, injuries from abuse or an illness that might affect their employment. How about areas such as HIV status? Would you have concerns in dealing with this? And will you be able to perform the complete physical exam necessary with an employee who works with you every day? More importantly, will you ask the necessary questions to properly diagnose and treat your employee, their family or others close to you?

Documentation

All employee patients should have the complete formal history and examination pertinent to their needs as your other patients expect and receive. This includes elements such as complete vital signs in an acute illness. The visit should take place in your office as it normally would. Document the visit and any tests or referrals given.

Whether or not you charge the employee, the care needs to be similar to the care you give all of your patients. The natural tendency to curbside treat and either not or insufficiently document can result in serious diagnostic oversights, medication and prescription errors borne out of informal and quick assessments and a minimization of serious illness that could possibly lead to preventable harm. As this case demonstrates, improper documentation will decrease the likelihood of a successful defense if accused of negligence.

Expectations

A brief visit with an employee’s spouse might be done at no charge, but did you suggest a referral? Did you document the encounter? There is often a strong tendency for either the patient or the provider do a curbside consult to minimize the time or difficulty, and the issues of incomplete evaluations and cognitive errors become even more evident.

We often care deeply about our employees and this will set us up for conflicts. Is the evaluation in an area of your expertise? Are you being asked to evaluate the child of your manager when you are an internist who cares for adults? Is the visit being done on the employee’s own time or is he/she clocked in and working in the office?

Finally, if things go poorly with the employee and you fire him/her for another reason, any missed medical diagnoses may be more likely to lead to litigation. We have seen cases that revolved around angry ex-employees, curbside visits and poor documentation.

Cognitive errors

Diagnostic reasoning is often faulty when you evaluate those you care about. Professional relationships with your patients are fiduciary in nature. Employee relationships might involve someone you deeply care about and family relationships are based on love. This results in errors in either direction of a decision. One might feel lymph nodes and order a biopsy or a scan when watchful waiting is in order. Our normal clinician acumen may not kick in, and we may want to exclude the possibility of all diseases. You might examine the abdomen and suggest waiting when appendicitis is really the diagnosis. This is described in cognitive literature as an “affection bias” and refers to when you can’t imagine a loved one having a serious illness.

Medication samples

Dispensing samples of prescription medicine requires prescriptive authority. Employees should only receive samples on the authority of the physician or an allied health professional who has such authority. Distribution of samples should be documented in the medical record. This should be discussed with staff and there should be a no tolerance policy in terms of dispensing sample medications without the proper authority.

Treating Your Loved Ones

Several national groups have policies suggesting that physicians should avoid providing medical care for people with whom they have significant emotional attachments. This would include treating yourself, your family and your close friends. A classic study in the New England Journal of Medicine^[1] found that 99 percent of physicians had requests from family members for advice, diagnosis or treatment; 83 percent prescribed medicine for a family member; and 22 percent stated that they felt uncomfortable fulfilling such requests. Given this study, it is likely that most physicians have been involved in the medical care of loved ones.

Most physicians are not aware that ethical guidelines on the treatment of non-patients do exist. The American Medical Association (AMA) suggests limiting your care to the emergency treatment of minor problems in your area of expertise. Opinion 8.19 of the AMA Code of Medical Ethics^[2] states that “physicians generally should not treat themselves or members of their immediate families” because their professional objectivity may be compromised in those situations. Exceptions are allowed for “short-term, minor problems” or “in emergency or isolated settings.” While this is good advice, the definition of “minor” is still vague. This might mean that checking your five-year-old’s ear while on vacation is okay, but perhaps it’s not okay to perform elective surgery on your spouse.

The American College of Physicians (ACP) suggests that the amount of “emotional” closeness should be a determining factor. It recommends using your expertise to give advice and for a skilled physician to provide your loved ones with direct patient care. The ACP Ethics Manual^[3] similarly asserts that “physicians should avoid treating themselves, close friends or members of their own families.” It goes on to comment that “physicians should be very cautious about assuming the care of closely associated employees.”

As physicians, we are conflicted when it comes to taking care of friends, family and ourselves. The same may hold true for employees and their families. If possible, especially when other caregivers are available, consider suggesting that employees seek the care of other physicians. If you need to provide care, then it should be done in a confidential office setting and you should treat the employee as you would treat other patients, with complete documentation in a secure medical record.

Lessons Learned

• Consider implementing protocols in your healthcare organization for storing and restricting access to employee medical records to avoid the risk of any HIPAA violations.
• Provide every patient — including staff, employee and other physician patients — with the same level of confidentiality and care.
• Consider suggesting to your employees and loved ones that they seek care by another physician or offer them recommended providers.

Potential Damages

Improper storage of employee medical records can lead to HIPAA violations and subsequent fines. Additionally, providing biased or inappropriate care to employees or loved ones can lead to severe patient harm and costly negligence claims. While claims against physicians who provide care to employees or loved ones are relatively infrequent, defending against such claims, especially with limited documentation of treatment, can be time-consuming and costly.

[1] N Engl J Med. 1991 Oct 31;325(18):1290-4.

[2]www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medicalethics/opinion819.page

[3]American College of Physicians Ethics Manual. 4th edition. Ann Intern Med. 1998;128:576-594.