Some doctors come from grand medical dynasties. Most of us do not. Many of us were the first people in our family or social circle to embark on this journey. Whether you consider being a junior doctor to be some higher calling, a reputable vocation or just a job like any other (all valid viewpoints), having a doctor in the family is no doubt a point of pride for your parents and relatives.
Like any other person with a particular set of skills, you will inevitably be asked to provide some free advice to those closest to you. While the guidelines are clear regarding treating our loved ones, the nuances of giving advice are not as clearly addressed.
The line between giving general advice and treating someone can be very blurry, and a series of innocuous questions and hypotheticals can quickly snowball into a full-on consultation. Here’s some advice on how to navigate these conundrums.
“Can you look at this for me?”
I would be lying if I said being asked for my medical opinion isn’t a huge ego boost. The feeling of being needed, of being recognised as an accomplished and competent professional by friends and family is incredibly rewarding. Simple things like translating medical terminology on reports or explaining the rationale behind investigations is high value advice for your non-medical peers and being the “go to” person for any and all queries is very satisfying. In short, it feels nice to be needed.
Your advice-giving capabilities extends beyond the hypothetical. The insight you have into the inner workings of the health system allows you to guide your family members through the complex gauntlet of accessing healthcare. When a cousin of mine was expecting her first child I was hammered with questions about the process of giving birth in the hospital. Among a basic play-by-play of how things would run and explaining the medical marvel that is an epidural, I made sure to impart a crucial piece of advice: If you are even considering an epidural, ask for it as soon as possible, ideally during business hours when the anaesthetist is actually at the hospital. If you wait, it will be too late. She enjoyed an epidural-assisted 12 hour labour thanks to this advice, an outcome she was very happy with.
Your training has also made you useful in a crisis. Any kitchen mishap or scraped knee is no match for your wound-care skills. You may even one day get your “hero moment” in front of all your friends. Mine came a few months ago, on a hike in the mountains with my school friends. Two hours into a six hour hike, one guy developed sudden palpitations (a recurring issue for him), with his Fitbit reading a heart rate of 170. I figured it was probably SVT, so after a pep talk I convinced him to let me try some vagal manoeuvres. I was able to successfully revert him by dunking his head into the freezing cold water of a nearby stream. The palpitations resolved, and the hike was saved.
Never a bad time
The sheen of being “the family doctor” can wear off very quickly. While I’m happy to provide the odd pearl of wisdom, being asked to weigh in on every detail of Aunt Erma’s recent GP consultation about her blood pressure management gets very tiring. In a profession where it can be hard to switch off and compartmentalise work vs home, constantly being asked for advice in your personal life can cause unwanted bleed over of work stress. Sometimes I want to enjoy a catch up with old friends without being asked to look at a suspect mole.
Being asked to give advice that is way above your pay-grade is incredibly awkward and fraught with danger. The layperson’s understanding of medical hierarchy and training is sketchy at best, “no grandma, I’m not a specialist yet. I only graduated a few years ago,” and while a junior can provide general explanations and context, being asked to give a “second-opinion” on a management plan formulated by a specialist puts you in a very tense position. Your family respects and values your opinion, but they may not understand that the scope of your experience and expertise is limited.
This issue was never more evident than in 2020, where junior doctors all over the country (myself included) became, in the eyes of their non-medical friends and family, the premier authority on all things related to Covid-19. Almost daily I found myself fielding unsolicited questions about the nature of the disease, being asked to provide judgements on the efficacy of social distancing on limiting spread of the disease, and being asked to justify the particulars of the government’s testing guidelines and lockdown strategy. Even 12 months on I am still being asked by distant relations to explain the virtues of the different Covid-19 vaccines and justify the government’s vaccination rollout plan. Despite being a simple foot soldier in the fight against Covid-19, my family mistakenly believed me to be a spokesperson for the entire country’s response to this global pandemic.
The fundamental disconnect between medical and non-medical people is the appreciation of uncertainty. TV and film portray medicine as cut-and-dry, completely and infallibly certain. In reality, medicine is full of uncertainty, and in many situations we are flying by the seat of our pants, settling on “most likely based on available evidence.” To your family who view you as an accomplished professional, “I don’t know” or “that’s not my area” may not be easy to accept. You’re a doctor after all, weren’t you trained for this?
The Medical Board of Australia’s Code of Conduct is clear in its position on treating friends and family: “Whenever possible, avoid providing medical care to anyone with whom you have a close personal relationship” citing “lack of objectivity, discontinuity of care and risks to the doctor and patient” as the rationale behind this.
Our own biases are magnified when it comes to those close to us – depending on your sensibilities you may overtreat out of worry of missing something dire, or undertreat due to outcome bias of hoping there is “nothing to worry about.” We may also be prone to making unethical choices due to our personal stakes, using contacts to jump queues or circumvent due process.
While the guidelines are clear regarding treating our loved ones, the nuances of giving advice are not as clearly addressed.
The line between giving general advice and treating someone can be very blurry, and a series of innocuous questions and hypotheticals can quickly snowball into a full-on consultation. We all want the best for our family and friends, and the desire to help them in a time of need can cause us to overstep professional boundaries. It’s a two-way street, and a pushy family member can breach these boundaries with an unreasonable request, unaware of the ethical complexity involved.
As “the family doctor,” you are responsible for maintaining these boundaries to protect yourself and your loved ones. While this can be a complex minefield full of nuance, it is in your best interest to learn to navigate it.
Things that are appropriate:
Providing care in an emergency
My escapade with my friend’s SVT is a good example of this. In the middle of nowhere, my treatment was appropriate as the only available option at the time.
Know the limitations of your scope of practice in emergency situations. If your loved one needs a higher level of care, you need to facilitate this (call an ambulance, go to ED). Once an alternative care provider is available, yield care of your loved one to them. In my case, had my friend’s palpitations persisted, seeking urgent medical care would be the next course of action.
- Giving general advice – things like sleep hygiene, dietary and lifestyle advice, recommending over the counter medications, whether someone should present for a Covid-19 test are all OK.
- Explaining things – acronyms, medical terminology, reasons for investigations, the structure of the medical admissions and referral process in the hospital (good luck with this one)
Things that are NOT appropriate
Prescribing medications to friends or family (except in emergencies)
Being the primary care provider for a loved one
Providing advice on things outside of your area of expertise
Giving advice contradictory to a loved one’s treating physician’s plan (unless there are serious concerns/potential dangers – e.g. prescribed a medication they are allergic to)
Maintaining These Boundaries
It can be a real challenge maintaining these professional boundaries with particularly pushy family members. The medical culture of ethics and professionalism have been taught to you, and you are immersed in it every day of your working life. While you understand your boundaries and their importance, your family may not.
Maintaining the sanctity of these boundaries against someone who does not understand how they are overstepping them can be incredibly difficult, and doing so in a way that does not offend your family members requires a deft touch.
Graded-assertiveness is a vital skill in conflict resolution that you will encounter time and time again in the medical field. This framework is particularly useful in establishing and maintaining professional boundaries when they are being overstepped. There are a multitude of acronyms that describe different approaches to graded assertiveness, but they all involve a gradual escalation in the intensity of communication until the message is received.
The “Ready, Set, NO” approach is a framework I have used to deal with unwanted requests from patients and occasionally family members
READY - Preemptively determine your boundaries
Let your scope of practice be known before anything is asked of you. It can be a bit clunky to state the AMA’s position every time someone asks you about a sore toe. Something simple like “I can give you some basic advice, but this is NOT the same as a doctor visit” is my go-to.
Doing this early is very important as it disrupts “pushy-relative inertia” - where you get pinned down and overcome by questions that rapidly escalate and cross the line.
You may feel guilty saying no to a request that has unknowingly overstepped your boundaries. By establishing the rules of engagement beforehand you can prevent relatives naively violating your boundaries.
SET - System, Experience, Talk to your doctor
These are essentially a set of excuses - reasons why you can’t do what someone is asking that are not a flat-out “I won’t do it”. This is an initial gentle approach which allows you to avoid unnecessary personal conflict.
System: Blame the system:
While refusing to treat family members is important in maintaining ethical practice, your family may see it as a personal affront to them - that you have the ability to help them but are choosing not to. Your family members may not see the distinction between your personal and professional lives, and be angry with you personally.
Blaming the system can be a useful way to redirect this frustration.
A request for a script can be quickly deflected by blaming hospital bureaucracy: “As a junior doctor my prescriber number is only valid if the prescription is from the hospital”.
If they continue to push, blame the AMA guidelines: “I can’t write you a script/order a test/look up your results. There are rules about not treating friends or family”
I tend to leave out the “unless in an emergency” part - “but this is an emergency” comes up way too often over innocuous things.
Experience: Embrace your own lack of expertise:
As a junior doctor, your level of knowledge and expertise is limited. If you get asked about something you cannot weigh in on, “I don’t know” can diffuse the situation. This can be a useful strategy to knock back unwanted questions if your family won’t take no for an answer. As you enter registrar training, this framework can be applied to any question that is not in your specialty area.
“Talk to your doctor”
Encouraging family members to engage with their primary care provider is very important. Reiterate the limitations of giving advice in a non-clinical scenario: “I don’t have access to your results/medical history/specialist letters. I can’t make any decisions without this information. Your GP/specialist will have a better idea of what is going on and will be able to help you”
Offer to support them in engaging with these services - if it is a close family member or a big issue it may be appropriate to join them at their appointment. It’s important not to give the sense that you are washing your hands of the situation. You are still helping them resolve their problem without inappropriately assuming responsibility for their care.
If a request is being made of you that is inappropriate, ultimately the answer is no. No you can’t, no you won’t. By this point you will have exhausted all of your excuses and face-saving work-arounds. Now is the time to be clear - a request has been made, and the answer is no. Modulating your tone, posture and non-verbal communication is important in showing that you mean what you are saying. Your family may never have seen you in “work mode” and may be surprised to see you exercising your graded assertiveness skills. You are well past the stage of negotiation or challenging. This is a command - No. Even among renowned envelope-pushers, a clear and uncompromising no will be enough for most people.
Remember - No means No
Occasionally you will encounter someone who will not take no for an answer - a family member or friend who is relentless, has no respect for the boundaries you have set, and who is demanding something inappropriate (a specialist referral or a script are the usual culprits). Refer back to Exhibit A - the boundaries you set out before the discussion began. Remind them their request is violating the professional boundaries you have told them about, as well as the guidelines of your regulatory body - and could result in serious legal/professional ramifications for you.
Conflicts of this nature with patients and colleagues always have the option of terminating the interaction. Family conflict has the added dimension of needing to maintain or mend the relationship after the resolution. While compromise is an important part of conflict resolution, your professional ethics are non-negotiable. NO is the only correct answer - If the person is not willing to accept it, despite all the above strategies, it is clear that they do not respect you or the ethical responsibilities you have as part of your profession. This may create tension or fractures in your relationships - and unfortunately these may be unavoidable.
While this example is extreme, it is not impossible. If you are seriously being asked to violate your professional ethics by a friend or family member, then you need to decide whether this relationship is worth maintaining. People who truly care about us should not expect us to do things we are uncomfortable with, let alone things which violate our moral or ethical code, or could result in serious personal or professional consequences. Not accepting a no is incredibly disrespectful, and continuing to push despite being told no crosses the line into abuse. I hope you never find yourself in this situation, but it is important to stand your ground and not yield to this kind of abuse.
Take Home Messages
Most inappropriate requests come from a place of ignorance. Your friends and family are likely not aware of the ethical issues preventing you from treating them, or at what point innocuous advice becomes treatment. In the vast majority of cases, they will not be seeking to exploit your position as a doctor for personal gain or for nefarious reasons. Knowing your professional boundaries and communicating these to your family and friends is the most important thing you can do when being asked for advice or assistance. Your friends and family care about you, and they will, in most cases, respect the boundaries you establish. As often happens in medicine, it is important to prepare for the worst. Know how to diffuse uncomfortable situations where people push too far, and know when and how to stand your ground. You may never find yourself in a situation like I have detailed above, but knowing how to prevent such situations arising, and how to deal with them should they occur is important. No is the most important word in your vocabulary, do not be afraid to say it.
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