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January 9th, 2012
09:55 AM ET
Why doctors shouldn't treat family membersAnthony Youn, M.D., is a plastic surgeon in Detroit. He is the author of “In Stitches,” a humorous memoir about growing up Asian American and becoming a doctor.
The injuries are so severe that he needs a physician to operate on him immediately. Even though a qualified surgeon is ready, willing and able to perform his surgery, do you ask that surgeon to step aside and operate on your grandson yourself? This was a dilemma that a colleague of mine encountered several years ago. At this moment of crisis, he faced the choice that physicians face all the time: Do you give medical care to your family members or leave it up to other doctors? Not wanting to put Joey’s life into another surgeon’s hands, Dr. Sanders decided to operate on his grandson himself. A 1991 study published in the New England Journal of Medicine found that 99% of the 465 physicians surveyed received requests from family members for medical advice, diagnosis and treatment. Eighty-three percent prescribed medications for a family member, 80% diagnosed medical illnesses, 72% performed physical examinations, 15% acted as a family member’s primary doctor, and 9% performed surgery on a family member. Bottom line: physicians often treat family members. But does that make it right? Not according to most physicians and physician associations. The American Medical Association’s Code of Medical Ethics: Opinion 8.19 states that “physicians generally should not treat themselves or members of their immediate families.” The American College of Physicians Ethics Manual states that “physicians should avoid treating themselves, close friends, or members of their own family.” William Beaumont Hospital, where I operate and act as associate professor of surgery, forbids surgeons from operating on family members. As physicians, we are taught to hold the doctor–patient relationship sacred and to keep a proper professional boundary between us and our patients. In this way, we can prevent emotions from clouding medical judgment. Obviously, emotions play a role when it comes to family. I react very differently when one of my children gets hurt than I do when I see an injured patient in my office. I can easily fall into my nervous “Daddy” mode and step out of my confident “Doctor” mode. In an extreme case such as Dr. Sanders and his grandson, any less-than-acceptable medical outcome can do more than strain the doctor-patient relationship. It can tear a family apart. Yet, so many physicians - including plastic surgeons - insist on treating family members. I know of many male plastic surgeons who have performed breast augmentations, tummy tucks, and facelifts on their wives. I suspect there are several reasons for this. First, as surgeons, we are supremely confident in our training and skills and worry that another surgeon might not do as good a job as we would. Second, performing the surgery ourselves can save a lot of money. Third, and most disturbing, some plastic surgeons use their spouses as living billboards for their work. To them, there is no better advertisement than showing off their fifty-year-old spouse who now kind of resembles Pam Anderson. Yuck. Full disclosure: Other than removing a mole or two, I’ve never operated on my wife and I never will. I consider myself a highly skilled surgeon, I’ve been known to be a teeny bit frugal, and I’ve purchased advertising for my practice in the past. However, the potential risk of a devastating situation like Dr. Sanders’ is reason enough for me to avoid performing surgery on my wife. Well, this and one other major factor - I have no desire to see her insides. I’ll leave that to another doctor.
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Imagine you are a highly skilled surgeon. Then imagine that your grandson gets into a terrible car accident and suffers serious internal injuries. 
Probably the most important reason not to treat your spouse: you really need the insight about how much it really cost to be a patient. Most doctors have almost no sense of the cost of their treatment. Only when they are the receiving end of the bills do they begin to understand what their patients have to pay after treatment. Doctors are the most part totally isolated from the cost of their services. Patients have to have medical insurance and sign a contract to pay the bills regardless of what their insurance does or does not cover.
Actually, one of the main reasons their prices are so high is because they have to be able to afford medical malpractice insurance. It costs a lot of money, and doctors have to ensure that they aren't going to be sued for millions of dollars because of an ignorant patient.
At the same time, physicians do not receive very much of what patients pay. It's absolutely correct that physicians aren't aware of their patients' bills because the financial personnel handle billing and sort out all the costs from what's left over to make payroll.
Not true. Studies have shown that insurance and legal costs only add about 5 – 6% to the overall cost of medical care. We need to look at the whole system and figure why it costs so much even in comparison to other Western countries that have as good or better patient outcomes.
Insurance and Administrative costs run to 30% of the cost. Insurance companies pay at most 60% of charges. Medicaid and Medicare only pay 30% of charges. Malpractice insurance boosts costs even higher. Doctors don't collect anywhere near their gross charges are.
In most countries in Europe issues around treatments are decided on the basis of whether they are medically necessary. Money doesn't come into it. That's because we are decent and civilised people. Deciding whether to treat someone on the basis of cost is shocking and one of the many reasons why we think of Americans as immoral . Gun laws are another example.
A nice reasoned set of arguments that overlook a couple of issues.
You are talking about surgery in many cases or other serious conditions. I do routine exams. There many interesting and complex issues that can arise, but usually don't. All my family members have pretty healthy eyes, so the exams are routine. If a surgery or complex consult is required, I would refer out.
Second, you are in a high density population area. What about a rural doctor, say in the far reaches of Montana or Alaska. Similarly, not all doctors are in the US. If you are living in Somalia and your wife develops appendicitis at your rural charity clinic, you may have different criteria. Nice article none the less.
I have to disagree with your comment. In this day and age of cutbacks in every aspect of healthcare, most doctors are very aware of the cost to patients. I speak from personal experience as a physician. We know the cost of the procedure, the anesthetic, the prep, etc because it is in our best interests to know. The days of blindly doing things and letting insurance figure it out are over.
As a patient, I agree with this comment. Even though I have insurance, every visit with my doctor has a "how much does this cost" discussion, and I don't approve the procedure until I have a firm cost.
And I generally turn down treatment because I can't afford it, even though I have been diagnosed with "likely MS" – I can't afford the tests to confirm. And this is even though I have insurance. Only in America do we pay three times, first in over-priced insurance, then in taxes, and finally out-of-pocket.
Only in America can you go in for a 2-day hospital stay, WITH insurance, and walk out with a $30,000 bill.
I respectively disagree. My son went to a doctor and was told that a procedure would cost X dollars. When he received the bill, it was much more. So my son had to pay the higher amount. He complained to the doctor but was told to pay the bill. I am sure that this a very common experience. If you are a doctor, the next time you see a patient ask the patient if the cost was higher than expected. I understand that doctors should be concerned with treatment but handling the payment of the service also affects a patient's health. Over 2/3 of bankruptcies in this country is because of the cost of medical treatment. In this issue of CNN is an article about a couple who fell from the middle class partly due to medical crisis. Their names are Alan and Andono Bryant and she had a $47,000 medical crisis. Our medical system has a severe medical problem and only doctors have the power to fix it. Patients have to accept what happens to them.
Some doctors have no idea how much things cost even in their own business. Our system is totally messed up.
"Apart from removing a mole or two" – excuse me, that IS treating your wife as your family. I suspect this was done for the sake of convenience – why send her to someone who will see her for a get-to-know-you appointment so she can then come back and have the thing removed and possibly have to come back for a little check up on it – when you can just remove it yourself? Save time and hassle, money and paperwork. No harm, no foul. How about giving other people the same treatment – no you say? Other people have to set aside three different days for appointments?
Hahahaha! So true....
So he should treat everyone for free?
I am pretty sure my mechanic takes care of his own car on the weekend, why doesn't he take care of mine on Sunday morning, for free? And the lady who prepares my taxes, why can't she do mine for free like she does hers, after hours? And the teacher who mentors his own kids for free? Or the babysitter who takes care of her own kids for free?
If you want free treatment, become or marry a physician. If you want free car maintenance, become or marry a car mechanic. We all get free stuff from family, that is what family is for. We all pay for everything else.
But you drive your child to school, don't you? And there could be an accident and something bad could happen. I am not so sure there is a logical, non-sentimental rationale to this argument
For superficial bruises, aches and pains, maybe even setting a broken limb. For minor surgery probably yes. For major invasive or ER work no. But then again if your dad is the world's top brain surgeon, why settle for number 2?
Portland Tony, well put!
The ethical conundrums about treating your relatives are new. Decades ago, unless you were a psychiatrist you wouldn't give it a second thought. The ideal was to be close to your patient, not to develop so much distance. Even today, retired physicians often keep a limited medical license to treat their family members.
The idea that a physician should have distance from his patients is a mistake. And you know it every time a patient asks you, "what would you do if I were your mother?" Please, treat your family. And then try to treat your other patients that way too.
I disagree. A great deal of illness is caused by poor behavioral choices. Patients need someone with enough distance (immune to emotional blackmailing of doctor by patient) to tell the patient how it is, why it's that way and what they need to do to fix it. If the patient chooses not to comply, the doctor won't take it personally. Doctors can't force patients to listen or comply so they should maintain the emotional distance to not be upset when patients do stupid things. Patients frequently do stupid things including pressuring doctors for opiates when they are just addicted. Family members fall for that, doctors shouldn't.
I think doctors have a pretty good ability to keep an emotional distance. If they can deal with drug-seekers and other manipulators, they can deal with well-meaning but confused family members.
hi
There was a bill passed in Congress, believe it or not, that doctors could not charge more than what the insurance would pay if they accepted the co-pay from you. It is illegal for them to charge additional charges. It the doctor says they will not treat you unless you agree to pay the additional expenses be sure that you write on the agreement that you are signing under duress and threat of refusal to treat. A doctor can not refuse to treat because you can not pay the bill it is illegal.
HA.....See you in bankruptcy court!
Unless a person is dying, physicians can absolutely refuse to treat. Insurance companies are in business to make money so they low-ball practices to reimburse for as little money as possible and therefore insurance companies make as much as possible. When the profit margin (read: ability to pay building rent, payroll and benefits for staff) is reduced to next to nothing, practices simply go out of business and now the community has fewer physicians to treat the citizens. Cheryl, your money is being sucked up by insurance companies in the form of "medical insurance" for you and "malpractice insurance" all physicians have to pay because people treat their doctor like a lottery ticket. Don't fight your doctor, fight the insurance paradigm of health care that's bleeding our nation out. Pay your provider, not an insurance company.
Cheryl,
I understand things differently. A doctor is not allowed to bill a self-pay patient less than an insured patient would be billed. Bililng has to be consistent from patient to patient, so one price is set, but the price is set knowing that various insurance companies will only pay a small percentage (different for each insurance company, mind you, so the law as you described doesn't make sense). The effect is that we know more money is being paid to the physician from self-pay patients than insured patients (and it's often collected up front as many practices can't consistently afford self pay IOUs). The law was written in favor of insurance companies. They are worried doctors will try billing a patient with "different insurance" less, giving others preferential treatment.
If there is recent legislation, I'm unaware. Please inform.
That is NOT the law. There are situations where you must be notified (via an Advance Beneficiary Notice, aka ABN) if a service is not covered and you will be fully liable for the cost. You can't balance bill Medicare patients for more than the Medicare rate. There are restrictions that you may agree to as a condition to becoming a participant in a plan, e.g., BC/BS participants typically agree not to balance bill beyond the BC/BS fee schedule. There is certainly no federal law that does what you describe.
I don't make patients pay more than what insurance pays. I don't have them sign a contract. I really have no say in what I charge, as I am an employed physician (I work for a large group of academic physicians) and some administrator in our group negotiates the rates for different services with each insurance company usually as a factor of medicare payment. Ie, 1.3 times medicare, or 1.5 times medicare etc. Medicare typically pays only 20-30 cents per dollar billed.
Remember, most of the costs to the patient for an inpatient hospital stay are the Hospital bills, which have nothing to do with the physician. I might perform a long complex brain surgery fixing your aneurysm that takes me 8 hours. I bill based on a pre-set value for that type of surgery based on RVUs (Relative Value Units) that every procedure has. So in this case, the RVU's might be 100, where a typical office visit might be 1-3 RVUs. That might be $3800 (about $38.00 per RVU). Now, this payment is divided into three parts... one is the work RVU (wRVU) which is to reflect payment for the doctor's time and difficulty of the task. The other two parts are supposed to cover the doctor's overhead (office space, payroll of his employees, etc ,as well as the malpractice insurance). As a result, the wRVUs for that procedure might be around 50. At $38.00 per RVU from medicare, I would collect about $1900 for that procedure that would theoretically go towards my salary. Now for that same patient, their total hospital bill including costs for all doctors and services might be along the lines of $50,000-$75,000. I'd only be getting $1900 of that. Are you starting to see that the doctors are not really the problem when it comes to the high cost of medical care? My practice would be getting about between 5%-7.5% of the total cost of the hospital stay, and I'd personally (theoretically) be getting about 2.5%-3.8% of the total amount owed for the procedure and hospital stay.
Also, RVUs don't necessarily reflect time spent. I could spend 8 hours in clinic seeing 30 patients and bill only about 30 RVUs if they were all short visits with limited problems. Or I could spend 8 hours operating on an aneurysm and bill 100 RVUs for that time. The RVU's go up not only based on the time it takes to do the task, but also based on the perceived difficulty/effort involved as well including risk etc. Additionally, that one time operative fee also includes ALL of the inpatient follow-up with the doctor, as well as all of the office visits for the next 3 months. If you come in for a post-op check to the office 1 month after surgery, the doctor cannot bill for that visit.
And, time for my original reason for replying.
Yes, a doctor can refuse to treat you. As long as you are not suffering from an emergency, a doctor can refuse to treat you if you do not provide payment. Now, he may have made a deal with your insurance company, that he will treat all of X insurance company's patients and collect only what they provide regardless of what he bills. Then he would not be able to refuse you because you wouldn't pay the extra amount he charged on top of the negotiated rate with X insurance company. He could refuse to treat you for other reasons (difficult patient-doctor relationship, patient is drug seeking, personality conflict etc). But he would have to provide you with information of another doctor who would be able to handle your problem, so that you could schedule yourself an appointment with that other doctor. A doctor is not allowed to "abandon" a patient. But he can replace himself with another doctor. If it is a non-emergent situation, he can expect you to do the legwork and make the phone calls to have that happen if he provides a list of names and numbers etc. If it is an emergent situation, the doctor would be obligated to find someone else to treat you immediately if there was some reason he could not or would not provide the treatment.
It is true that they cannot "balance bill" a patient. This is because doctors sign a contract with each insurance company agreeing to what the member of that insurance company will pay for various services. If they agree that the member will pay $100 for a particular type of exam, they are probably "billing" more than that. So they may bill $200, but at most, they have legally agreed to collect $100. So maybe the insurance company pays $80 and the member pays $20. But they cannot then turn around and demand the additional difference from what they billed. Physicians know well in advance what rates they have agreed to pay versus what they plan to bill.
So right about out of control health care. My husband wrecked his motorcycle. He was really just scraped up not seriously hurt but was hospitalized over night. With Blue Cross Blue Shield insurance and our auto insurance, we are still making monthly payments a year later – after having already done $4000. out of pocket. YES I SAID WITH INSURANCE – 2 KINDS
healthcare is out of comtrol. Really hope nothing serious ever happens or we're screwed.
Most people have NO IDEA that a typical one-night stay in a hospital ranges $1500 – $9000, depending on the intensity of the care and the contract the hospital negotiated with the insurance company. And the hospital probably bills twice that much, but the insurance company has negotiated a better rate for their members. And this is just for a regular night's stay. Now imagine if you have some type of surgery in which the hospital "specializes." You may be paying $50,000 for a cardiac surgery with a two day stay....yikes!
It is also well known in the legal field.....he who represents himself, had a fool for a lawyer....lol
If your doctor wouldn't want to treat his own relative, find out what doctor he would suggest instead... and go to her!
All treatments are not the same. As a physician, yes I treat my family for minor illnesses or injuries. But something that has long term effects, it is unethical to treat without objectivity-whether it be a family member, friend, or colleague. Reimbursement issues are not what the article was about.
I agree. I don't think it's a big deal for a doctor to diagnose their child with the flu and prescribe a cough syrup, rather than pay to go a clinic. That seems a bit silly. But I would consider it unethical for them to perform a major surgery. Totally different.
I can understand not treating major issues, but my wife and I are so busy running a clinic neither one of us can afford to take the three hours off that it takes to get in and out of a Dr's. office. I dont prescribe controlled substances to family but have no problem with orher minor things. The issue is having good judgment. Only 20 percent of american physicians belong to the AMA. It became a political creature a long time ago that no longer represents us. We no longer accept anything the AMA says including their policy to ban handguns and boxing.
The main reason why physicians should not treat our familyis that our judgement is very poor when trying to our family. Even worse when trying to treat oneself. A physician who treats himself, has a fool as a patient.
Yea, but what about when a physician's wife is being treated by another doc and then dies because of mistakes this other doc made and you know you could have done better? It's quite a dilemma as in rural areas there are not enough MD's and finding qualified highly skilled ones in these areas is tough and your a doc who is highly skills> what do you do? Let someone you don't think is that good take care of your wife when you are better qualified? Not an easy decision either way and there are possible negative consequences with both decisions.
I found this article because I am a future medical student and I would love to sit in on my father's surgery but I am thinking I should sit it out.
I trust the surgeon immensely and she has taught me so much but I just worry about my father. Plus, the procedure itself is interesting and the perfect educational opportunity. I worry emotions might cloud my ability to focus on the procedure and view my father as any other patient I would encounter.
Thanks for writing this post!
'I know an aged person. He has so many physical problems but he is not a rich man. Some times it is very difficult for him to arrange money for treatment. He has a nephew who is a dentist. Now I understand why he doesn't go to his nephew for treatment.'
'I know an aged person. He has so many physical problems but he is not a rich man. Some times it is very difficult for him to arrange money for treatment. He has a nephew who is a dentist. Now I understand why he doesn't go to his nephew for treatment.
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I respect your views. I particularly treat every patient as my family member, with the care, love, compassion, I would give to my immediate family member, my own parent, my own brother or sister or child. There have been times as an anesthesiologist, I have fought with the surgeon who is clearly doing some ethical behavior to protect my patient.
I have learnt over years withy regular meditation practice to control my emotions. My wife has put it in her advance directives and living will that I be her anesthesiologist for all her surgeries as needed.
I know she trusts me and I trust myself.. I don't see what's wrong with that..
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My second cousin is a PA, but I don't think family members of any stripe should treat other family members. She'd probably have the necessary boundary between her and my mother because they're not blood and don't know each other that well, but since she's my favorite cousin, it's better to leave off.
wt is the process of not treating our family members called....
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I think for major surgery, it is better to have a non-related doctor perform it, especially if it is their field of expertise. As the author pointed out, the most fundamental reason is the consequences if the procedure goes wrong and it is directly the doctor's responsibility. I can't imagine the potential level of guilt and grief the doctor may feel. Even more, what kind of strain and adverse effects would that place on their other familial relationships? I particularly like the idea, of "who do you go to, if you didn't treat yourself?" It's kind of like where would a restaurateur go for lunch, if they didn't want to eat at their own place.
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