Become friendly with patients? Beware of risks

The scene might look like this: During the treatment of a patient, a casual conversation leads to the realization that you and the patient share a love of tennis and have similar skill levels. Soon you are playing regularly, enjoying both the game and the camaraderie. Before long, you’re more than a doctor-patient. You are friends.

This scene is not that rare, but it presents some dilemmas.

medical landscapein 2022 Friendships between doctors: the joys and the challenges surveyed nearly 1,600 physicians on various aspects of friendships. When asked about doctor-patient friendships, 29% of respondents said they actually befriend their patients.

Mario Tano, MD, pediatric GI at Florida-based KIDZ Medical Services, doesn’t shy away from forming friendships with his patients and their families. “When you’re dealing with kids, you have to be humble and build trust with the parents,” he says. “My goal is to lower anxiety levels and get to know the family.”

Through this enhanced bedside manner, Tano has built lasting friendships with patients and their families. “I give them my cell phone number and consider them friends,” he says. “Many doctors may not be comfortable with this, but for me it’s important to break down barriers with patients and do what’s in their best interests.”

Because her specialty is pediatrics, the friendships Tano forges are usually with parents, but that can change over time. “Once my patients become adults, many of them continue to come to me for advice because we’ve built a foundation of trust,” he says. “They moved on to other doctors at that time, but are still turning to me as well, and I’m okay with that.”

In small, isolated communities, however, doctor-patient friendships sometimes develop out of necessity. Margaret R. McLean, PhD, senior fellow at Santa Clara University’s Markkula Center for Applied Ethics, Santa Clara, Calif., says this is one of the exceptions to the “rules” regarding these allegiances. “If you’re the only cardiovascular surgeon hundreds of miles away, friendships fall into a different context,” she says. “The same applies in an emergency. If your friend is potentially having a heart attack and you can perform CPR, of course you will.

On the official level, there are no laws preventing doctor-patient friendships, but most medical associations frown upon such relationships. The American College of Physicians (ACP), for example, states that physicians should “generally not enter into the dual doctor-family member or doctor-friend relationship.” The American Medical Association (AMA) has ethical guidelines stating that physicians “should not generally treat themselves or members of their immediate family” but refrain from addressing friendships.

Respondents cited concerns about objectivity as one of the main deterrents to such relationships. Yet for those who strike up friendships with patients, the reasons given were varied and seemed valid. “One patient was a new paraplegic who was very depressed,” one said. “I felt he needed something to look forward to that wasn’t related to his paraplegia, and we found out that we were both Marvel fans.”

Another respondent said: “I have been a pediatrician for 35 years and my patients have grown up to be productive adults in our small, rural and isolated area. You can’t help knowing almost everyone.

Yet another said: “I am socially friendly with a few patient mothers who share teachers or teams with my children. But I try to maintain boundaries beyond meeting our children.

Overall, however, McLean sees doctor-patient friendships in more black and white terms. “My thoughts go to professional organizations in that these friendships are really not a good idea,” she explains. “Your first obligation is to do no harm. If you’re friends with a patient, it can lead to unintended injury, and that concerns me.

On a slightly different note, in the same study, 96% of respondents say they give medical advice to their friends, and many have friends who have become patients.

Gregory Hood, MD, a general practitioner in Lexington, Kentucky, says having a long-standing knowledge of patient histories and health can translate into better care. “If you’re a primary care physician and you return to practice in the town where you grew up, it can be a very rewarding experience,” he says. “People know you and are eager to find you to treat them. Knowing about their life experiences and medical history can help you care for them.

Some of Hood’s patients are former classmates, giving her an in-depth perspective on how the past may or may not impact their current health. Patients relax, feel comfortable, and potentially share more information with Hood because of their connection and trust, he says.

Both Hood and Tano keep guardrails in place. Hood emphasizes the importance of drawing strong ethical lines with friends who are patients, as he would with any patient. He is particularly mindful of the potential power disparity in a doctor-patient relationship and how this occurs when the patient is also a friend. “While it’s okay for a patient-friend to talk fully about their moods, stresses, and relationships, a doctor shouldn’t share the same,” he says. “It’s important to have friends outside of your patient group for this.”

Tano says thinking about doctor-patient friendships has evolved over time. “I’ve been practicing for 32 years,” he says, “and I think with younger doctors, relationships are probably more formal.

Hood agrees and points to the corporatization of medicine as one factor in changing attitudes about doctor-patient friendships. “Historically, much of medical practice was personal and not professional,” he explains. “We had longstanding practices in our communities and were more connected to our patients as friends.”

For some physicians, having a doctor-patient relationship with a friend may equate to best practice. This is especially true in cases where the doctor is a familiar presence in the hometown, especially if it is a small rural town without access to a myriad of doctors and institutions.

But it can be a slippery slope. McLean cites lack of objectivity as the main reason for keeping patients at a distance (from friendship). For example, if you’re treating a close friend, you might be hesitant to ask some probing questions. “You have a loyalty to this person through your friendship, and you’re probably not an objective listener or observer, which can cloud your medical judgment,” she says.

The opposite of this equation, a patient who is a friend may be reluctant to share certain medical details. This can lead to both under-processing and over-processing.

Too much familiarity with a patient can also lead to problems in the form of assumptions about a medical condition. Hood witnessed this dynamic as a resident years ago. “A retired doctor brought a close friend to the ER and told the team that his friend had sciatica,” says Hood. “It wasn’t sciatica but an aortic dissection, and by the time the emergency reached the actual diagnosis, it was too late for treatment.”

The best way to help a friend-patient

While many doctors would rather stay away from practicing medicine over friends, there are ways your skills can help them, while staying on the safe side of ethics. One helps interpret medical jargon, McLean says. “Most of us don’t speak that language,” she says. “So act as an interpreter for your friends, help them understand the alphabet soup they are facing.”

Another great way to help out friends is to act as their extra ears. It’s a well-known trope in medicine that the minute patients are, say, diagnosed with cancer, they stop listening. As a doctor, you can accompany friends to appointments, hear what their doctor has to say, and then translate it to the patient after the visit.

Finally, navigating today’s complex medical system is difficult, and helping with that can be another helpful way to help friends. “It’s scary and confusing, and if you have a doctor friend who can stand up for you, the outcome might be better,” McLean says.

However, this is still an area where caution is called for – something the early days of the pandemic brought home when doctors sometimes helped friends get preferential treatment. Using your ties to put your friends before other patients is never acceptable. All patients deserve equal access to treatment.

According to McLean, “In my opinion, we may not recognize our own biases, limitations, and lack of objectivity when it comes to dealing with friends. This is how the guidelines can help us.

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