Rationally irrational: Physicians taking care of family

Dr. Afshar is Resident Physician, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.

“We need an additional large bore IV in the other arm, run the fluids wide open, draw a STAT CBC, coags and cross-match, and call for blood,” I calmly told the postpartum nurse as I looked at a pale woman who became acutely hypotensive to 60/30 and tachy to the 140s as soon as she heard a “pop” in her abdomen along with a bout of emesis, several hours after her cesarean delivery. I STAT paged the OR while getting the ultrasound to bedside. During the modified FAST scan I saw a significant amount of blood in the paracolic gutters, and I collectedly explained to the patient and her partner that we would need to go back to the OR for an exploratory laparotomy and evacuation of hemoperitoneum. We did a quick pelvic exam and placed the Foley catheter in anticipation of moving back to the OR. I explained the possibility of a hysterectomy and that we may/may not ever find the source of bleeding, but that we needed to go back. En route to wheeling her to the OR, the patient’s hemoglobin was reported to have dropped 5 units and we had already started a massive transfusion on her. The woman’s postoperative course was uncomplicated and she did great.

Residency has trained me to respond and approach any acute decompensation without skipping a beat. Calling for the next step is starting to come naturally and I feel confident in knowing when to ask for help. Every time we are urgently called to the PACU or the ER, by way of a brief one-liner about the patient, we use the time we walk/run over to consider the worst-case scenario and to anticipate and rationalize what is going on. Most of us have no trouble doing this at work. We rationalize the differential and go through the algorithms.

See another of Dr. Afshar's blog posts: Physicians and 'natural birth': The two can co-exist

I live for intensity and high-acuity patients, but I’ve realized that I want that part of my life to stay at work. Not because I wish any illness on another soul, but because I understand why physicians are proscribed from being intimately involved in taking care of their friends and family.

I am haunted by memories of being in the hospital when my younger brother spent days in the ICU after a near-fatal car accident, comatose, intubated, and on pressors with multiple casted extremities.

Honestly, it is natural for physicians to feel compelled to become involved in the care of family members in a health care system that is incredibly complex, error-prone and difficult to navigate. My personal experience has been incredibly morally informative and I strongly support the stance that physicians should be discouraged from providing medical care for their own family members (obviously, outside of an emergency setting). This recommendation was original published by Percival in 1803 in Medical Ethics, arguing for the separation of professional and personal identities in the care of family members.¹

My brother’s accident was years ago, but I remember pounding irrational anxiety watching his heart rate, fever spikes, and pressor requirement as the days went on. There was nothing orderly about my worries and mental processing. I watched the contents of his Foley turn to dark brown and obsessively told the night nurse that he should talk to the team about concern for rhabdomyolysis and that at 3 am, he should make sure to tell the neurosurgeon that my previously comatose brother was now reacting to a voice (my nagging presence at his bedside). My parents continually reminded me that my role at his bedside was to be his big sister, and not his medical team. I am beyond thankful for this reminder because I never fully recovered from that tragedy and that guttural sense of uselessness.

Today if anybody saw my brother, they would never know that he spent weeks in the ICU and months on the floor and in rehab after his accident. The only proof he has are some gnarly scars. Perhaps what I could have done better during that time was to support my parents and my other brother, who were worried that they might lose a sibling and brother, instead of obsessing about a lab value that I had no place reacting to or perhaps even knowing what to do with. But, that was how I dealt with the tragedy and how I came to realize that we never really should take care of our own. The American Medical Association has published an opinion about this: “Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.” I lived this.

For now, I will go no further than talking to friends and families about birth control (birth control is primary prevention!) and answering their questions about ovulation, recommending a gynecologist and preconception counseling, and suggesting where they should go to follow up with their diagnosis. I am happy to provide them endless resources, recommend wonderful physicians, and pave the way for them to get excellent care. However, I’ve realized first hand that it is better to draw a line so that emotional attachments do not creep into medical care for family and friends. Do not get me wrong, I have had the privilege of delivering a handful of friends, but I always had another physician with me calling the shots. I’m happy to assist, mentally support and physically be there, but this is one of the few times that I do not want to be making the calls.

Reference

1. La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA 1992;267: 1810-1812.