Dr Sophie Haroon reflects on the sometimes complicated doctor-‘doctor-patient’ relationship and ways to manage it.
A while ago, a friend told me this story. Her father, a retired paediatrician, had a nasty infection. He was prescribed ciprofloxacin.
He was checked for allergies but not counselled about side-effects. Within 24 hours of the first dose, he developed Achilles tendinitis and went on to rupture his left Achilles tendon, a known risk he later found out.
As an avid runner, this was not a risk he would have entertained. When he told his doctor what had happened, their response was that it was assumed he would have known about ciprofloxacin’s side- effects because he was a doctor.
In fact, being a paediatrician, he only knew it was not an antibiotic to be used in children because of the risk of juvenile arthropathy, and that it caused problems in weight-bearing joints in lab rats.
Making assumptions
This scenario, of doctors being drawn into their own management and assumptions being made about their medical knowledge, is not uncommon.
And it does not stop there. A former colleague once described how an eminent surgeon had left her to counsel her mother about three surgical options for a gynaecological condition.
As an experienced GP, she knew a lot, but having never undertaken any of the procedures, her counsel of risks and benefits was naturally limited.
A different relationship?
The doctor-patient relationship has evolved from paternalism to one of patient-centredness and a collaborative dynamic. However, throw in a patient who is also a doctor and the relational boundaries become blurred.
Yet, in Good Medical Practice, the GMC is clear: doctors should not treat themselves and should seek independent professional advice rather than relying on their own judgement.
At some point, a doctor is going to have to seek medical attention. In navigating the doctor-‘doctor-patient’ relationship, it is useful to look at both perspectives.
Doctors as ‘doctor-patients’
Studies have shown that despite GMC advice about not seeking medical care from family members or colleagues, doctors do utilise these avenues through formal and informal consultations. The latter tend to be ‘corridor’ consultations.
Again, despite GMC advice, others go on to self-treat, especially if they are GPs compared to specialists. A range of barriers – patient, provider or system-related – can facilitate this behaviour.
Patient elements include embarrassment of exposing oneself to peers, feeling a failure for not coping with illness, being worried about imposing on another busy doctor, shame and stigma especially around mental illness, and loss of control/professional identity as the illness drives a wedge between the healthy doctors and the now sick ‘doctor-patients’.
Provider elements include confidentiality concerns and doctors not being related to as patients in consultations, but instead as doctors.
System elements include lack of time, the culture in the medical profession to be healthy and uncomplaining, self-treatment being perceived as ‘OK’, and presenteeism being an expected phenomenon.
Doctors as treating doctors
Doctors can find managing ‘doctor-patients’ anxiety-provoking. For the treating doctor, there can be awkwardness, intimidation and feeling less able to form independent judgements about the best treatment options.
Over-investigation can prevail in a bid to demonstrate competency of the treating doctor and reduce the likelihood of errors.
Histories may be less interrogated for fear of embarrassing or upsetting the ‘doctor-patient’.
Just as the ‘doctor-patient’ can find it difficult to relinquish authority, the treating doctor may hand over treatment decisions and abdicate their responsibility for fear of scrutiny or because of deference to the ‘doctor-patient’s’ perceived superior medical knowledge.
Boundary issues and role ambiguity are recurrent themes. Some treating doctors may over-identify with ‘doctor-patients’ to improve rapport and empathy.
Others distance themselves to maintain objectivity or because the ‘doctor-patient’ represents a mirrored reflection of their own unconscious fears about illness, the myth of doctor invulnerability being usurped. This can lead to the negative outcome of ‘doctor-patients’ being less supported than non-medical patients.
Unintended consequences
The use of medical terminology can have unintended consequences. While the ‘doctor-patient’ deploys it to exercise greater control in treatment decisions and the treating doctor uses it out of respectfulness of the ‘doctor-patient’s’ knowledge and status, it can result in inadequate information being imparted because of the assumption that the ‘doctor-patient’ has sufficient knowledge.
Furthermore, sometimes medical knowledge may not be consensually understood and the ‘doctor-patient’ may feel unable to question this, so leading to poorly informed consent.
Additionally, the treating doctor can mistakenly accept the ‘doctor-patient’s’ opinion about their illness and management.
Confidentiality can be a huge concern for treating doctors just as it can be for ‘doctor-patients’. Seeking a second opinion is accepted practice, but for the treating doctor, they may be concerned that this questions their competence.
For the ‘doctor-patient’, this may mean more peers know of their illness – for better or worse.
Medical culture and socialisation strongly influence how treating doctors either underestimate or over-manage the ‘doctor-patient’.
TAKE-HOME ADVICE
Taking the factors in this article into account, what can doctors do when consulting with ‘doctor-patients’? Here are some pointers:
- Speak up if a colleague is unwell. They may not be able to see it themselves.
- See the ‘doctor-patient’ as a person. Get to know them beyond their medical identity and their illness.
- Strive for continuity of care rather than the structured disruption of it which simply deforms who ‘doctor-patients’ and doctors can be to, and for, each other.
- Acknowledge medical care’s limitations. Interestingly, doctors tend to choose less intensive treatment than they recommend to their patients.
- Do not be led into ‘corridor’ consultations. ‘Doctor-patients’ should use the proper healthcare channels available to the general population, be they through primary care or emergency medicine and then on to secondary care, with the choice to go private like for anyone else.
- Do not avoid difficult questions. A history is a history. If that involves probing about mental health, alcohol and drug use, the treating doctor only does a disservice to the ‘doctor-patient by omitting this.
- Negotiate the language to be used so the dialogue is based on a shared understanding of terminology.
- Find out what the ‘doctor-patient’ knows about their diagnosis, investigation and management so there is a common platform from which to discuss further and information is not lost or assumed to be already known.
- Investigation, treatment and follow-up should be like that for any patient.
- Determine with the ‘doctor-patient whether they are a patient, a critical analyst studying themselves being a patient, an observant doctor assessing how other doctors work, a researcher processing and analysing the healthcare structures and procedures affecting them as patients, or all four?
Note that the proportions of what a ‘doctor-patient’ is will vary over time – some becoming more passive and dislocating from the doctor role, others engaging further. - Be aware of concerns around confidentiality and access to medical records. Be open and honest when information needs to be shared, seek appropriate consent to disclose and have in place safeguards to protect it.
Only in exceptional cases can any patient’s confidentiality be breached. But disclosure may be needed if the ‘doctor-patient puts others at risk. - Consider out-of-area referrals if there is further concern about a ‘doctor-patient’ being treated by colleagues and this is negatively impacting them.
- Drop the ‘super doctor’ culture. Promoting presenteeism is no good for the doctor, their colleagues or patients.
- Avoid using doctors as proxies for managing patients who are their family.
- If you are concerned about treating a doctor, and have a choice, do not see them but ensure their care is provided by an alternative doctor and they are not negatively impacted.
Dr Sophie Haroon is a medico-legal consultant at Medical Protection
