Practice of Medicine

Article

Treating Employees, Family and Yourself

December 21, 2016

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. He is seen quickly by the FP and given 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 the following should be considered:

  1. Confidentiality—Office records of employees that can be perused by their co-workers are a risk. Give consideration to having records of this nature in the equivalent of a secure area, whether electronically 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 completely secure records. Audit trails of the 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 is more than just medical record breach risks—providers, staff, and employee patients should have the same benefit of confidential and professional care that all of your patients receive.
  2. 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?
  3. 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.
  4. Expectations— A brief visit with an employee’s spouse might be a “no charge” on your part, but did you suggest a referral? Did you document the encounter? There is often a strong tendency for either the patient or the provider to just do a curbside consult in order 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.
  5. 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.
  6. 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.”

 

Conclusion

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 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.

[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.

 

Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners.

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.