Case Scenario

Larry, a family physician, received a telephone call from his aging father who lived in another state. His father complained of shortness of breath, which Larry thought was probably an exacerbation of chronic bronchitis. Larry told his father to call his physician, who had always been very thorough and conscientious. Larry's father explained that he had been trying to reach his physician for several days, but that his phone calls weren't being returned. Twice when he called he had been told that the nurse was busy, but she didn't call back. The physician had given Larry's father his home telephone number at an earlier visit, saying that “he could call him anytime,” but when his father called he could only reach the answering machine. Wondering whether he himself should try calling the physician, Larry suggested to his father that, in the meantime, he should go to the emergency department at the local hospital. Later, a family friend telephoned Larry to tell him that his father had been hospitalized with new-onset atrial fibrillation.

During the next few days, Larry tried several times to get in touch with his father's cardiologist. When he finally reached him, Larry asked several questions about his father's treatment plan. The cardiologist answered abruptly and did not explain his management choices well. Larry felt uncomfortable because he did not want to sound like he was challenging the cardiologist. Because he didn't know the details of his father's case, he didn't ask any more questions. When Larry's father was released from the hospital several days later, he was doing well.

Commentary

Larry faces a challenging and increasingly common dilemma. As the population ages and extended families are scattered far apart, many of us will have aging parents who become ill while living a long distance away. I recently had an experience similar to Larry's as I cared for my father as he was dying of lung cancer. I struggled with many of the same issues that Larry does here.

Larry is facing at least two problems. First, what is the role of a son or a daughter who is also a physician when a parent (or another family member) becomes ill? Secondly, how does one deal with the special problems that occur when an ill family member lives out of town?

The first issue involves recognizing and using our special expertise as physicians without becoming our parents' personal physicians. How can a physician be a collaborating family member without meddling? Physicians, out of a desire to make sure that family members receive the best care, tend to become overly involved in their parents' medical care. They may compete with the physicians who are treating their parents or they may even assume their parents' care. A 1991 survey published in the New England Journal of Medicine¹ documented how common and extreme this practice has become. Seventy-two percent of the physicians surveyed had performed a physical examination on a family member. Fifteen percent reported acting as the attending physician for a family member in the hospital, and 9 percent had performed surgery on a family member.

Serving as a family member's personal physician can be hazardous.² These hazards include the difficulty (or the impossibility) of remaining objective and separating the parent-child relationship from the physician-patient relationship. It is difficult enough to deal with poor medical outcomes or mistakes, but when your patient is a family member, the difficulties may be insurmountable and lifelong. On the other hand, some physicians may also risk being underinvolved in their parents' medical care out of fear of meddling or “stepping on the physician's toes.”

The key here is for physicians to develop a strong, collaborative relationship early on with the parent's primary care physician and to maintain open lines of communication. Physicians should consider what it is like in their own practices when they are dealing with patients who have physicians as family members. It is inherently threatening to a physician to feel that the medical care he or she is providing is being judged. Therefore, it is useful to establish a good relationship with the parent's physician before serious health problems or complications occur.

In this case, Larry should call his father's physician to discuss the communication breakdown. He should approach the physician in a nonthreatening manner. For example: “Hi, Dr. Z. My father has always been pleased with your care, and you and I have always communicated well, so I was surprised and concerned that my father had such difficulty reaching you when he got sick recently and that you didn't call me about his hospitalization. Can you tell me what happened?” Larry might also ask his father's physician to obtain more information about his father's treatment plan from the cardiologist. In dealing with his father's physician or the cardiologist, it is important for Larry not to come across as challenging or threatening, as this will usually provoke a defensive response or a confrontation. However, it is certainly reasonable for Larry to request more information from the cardiologist, including asking him to fax relevant parts of his father's medical records.

Fortunately, in Larry's case, his father's prognosis was good. In some cases, a physician may not feel that a parent is receiving appropriate medical care or that the parent's physician is doing an adequate job. Before intervening, one should be sure to discuss the care with one's parent and assess the parent's relationship with the physician. Physicians must remember that it is their parent's physician and medical care, not theirs. If, despite a son's or daughter's concerns, a parent is content with the physician and medical care, the son or daughter should not confront the physician because communication may cease altogether.

Dealing with a parent's illness long-distance can cause additional difficulties. Communicating by telephone (versus letter or facsimile) is usually preferable, but when problems arise, it may still be necessary to travel to the parent's home to meet with the physicians involved face-to-face. Physician family members may avoid many misunderstandings and miscommunications by meeting with their parent(s) and the physican involved in the parent's care.

Being a physician-son or physician-daughter is not an easy role, but here are some suggestions: First, start early and work to develop a good relationship with your parent's physician(s) and maintain open lines of communication. Second, if you have concerns about the care that your parent is receiving, speak to his or her physician in an inquiring but nonthreatening manner. Remember what it is like in your practice when you have patients whose sons or daughters are physicians. Third, if you feel your parent is receiving inadequate care, talk to your parent and be sure that you are both in agreement before intervening. Your parent has the ultimate decision about his or her own medical care.

These guidelines should help physicians ensure the best medical care for their parents while, at the same time, remaining supportive and helpful daughters and sons.