Should family physicians treat members of the same family?

In this debate, I will not defend the radical position that a family doctor should never follow members of a single family. Instead, I will question the proposition that a family doctor should ideally follow all members of a family, and that families that are not fortunate enough to share the same doctor are somehow being short-changed.

Curiously, this ideal is nowhere explicit in the 4 principles of family medicine, perhaps because it “goes without saying.” Or maybe it is absent because we recognize that a family doctor can provide excellent care ignoring this unwritten rule.

Unlike a cardiologist who does not treat heart problems, or a pediatrician who cares for no children, it is possible to conceive of a family doctor who follows no families. Despite the name, there is no logical or practical contradiction in this. The “family” in family medicine refers neither to the population nor to the organ that is the focus of the discipline.

Maybe this is why I have never been comfortable with this title. I follow patients at a clinic where I also supervise trainees. I do walk-in clinics and shifts in an emergency department. I have done hospitalist and palliative care. I treat all kinds of patients in different settings: but I treat patients—individuals—not families.

Confidentiality and conflict of interest

The most obvious problem with following families is confidentiality and conflict of interest. While I concede that true medicolegal or ethical dilemmas are rare, the stress is real and common, and can substantially colour the doctor-patient relationship. Treating members of a family can provide a more complex picture of family dynamics, but this complexity often distracts from the account the patient chooses to share.

The act of patients presenting their view of reality is fundamental to the medical history. It is the basis of good medicine. But patients lie to their doctors for all sorts of reasons. Even without lying, editing and colouring are necessary parts of any narrative. We must accept that patients have a right to present their versions and not be preoccupied with trying to reconcile conflicting accounts. We are, after all, doctors, not private investigators or lawyers.

Of course, knowing about a patient’s family is important; but it does not follow that treating his family is the only or even the best way to gain this insight. The patient can and must tell the doctor what he judges is important, how and when he chooses.

Many things are shared in a family: a home, possessions, and responsibilities. But in most successful families, each member keeps some things separate from the family unit—a private space. A patient-doctor relationship might be one such space. A patient, aware that he has been portrayed to “the family doctor” as a good, loving father and happy husband, might be more reluctant to share his symptoms of depression, frustration, substance abuse, or infidelity. He might be better served by having his “own” doctor.

Overestimation of benefits

Convenience is a commonly cited advantage of having one doctor for an entire family. True, it might save time, but usually it penalizes someone. We have all been confronted with couples where one partner talks incessantly and the supposed patient has difficulty getting a word in. What about the mother who doesn’t have her Pap test done (again) because the kids came for their vaccines at the same time?

For better or for worse, few family doctors are equally comfortable with all types of patients. If the principle that family doctors should follow all members of a family is perceived as an obligation, doctors will feel compelled to take on patients they are not comfortable following. Furthermore, if accepting a new patient implies taking on the entire family, this creates a preferential dilemma. Should a doctor accept Mr Smith, thus completing his Smith Family, rather than Mr Jones? Should a family doctor pride himself on the number of whole families he follows?

Family medicine is already perceived by many as a challenging discipline with greater responsibilities and fewer rewards than other specialties. Adding another unrealistic expectation—the whole-family obligation—could prove a further disincentive to the choice of family medicine.

All patients are equal

In our modern multicultural society, the very notion of family must be flexible and loosely defined to avoid offending someone. Many people’s significant relationships do not fit neatly into any clear definition of family. Who decides? Or to put it more provocatively, who cares? For all the close-knit happy families, there are many unhappy ones. But I am a doctor, not a family therapist. I need to know about sources of stress and conflict for my patients. This might well be their families. But this does not mean I have to take them on as patients, any more than I need to meet my patient’s boss (let alone take her on as a patient).

Of course, I do follow families, and I enjoy doing so for many reasons. But I do not believe that I offer them superior care compared to my “orphan” patients. I try not to neglect the role of family or any other important issue in the life of any patient, simply because other family members are not on my patient list.

Doctors treat patients—individuals—not families. To do our job well, we must try to understand the context of the patient’s illness and wellness from many perspectives: biological, psychological, spiritual, and social, including family. But I can do this by listening to my patient. Treating all members of a family does not necessarily add much to the fundamental relationship in medicine, which is the relationship between doctor and patient.

CLOSING ARGUMENTS

• Caring for patients from the same family represents a conflict of interest and confidentiality. It can provide a more complex picture of family dynamics, but such complexity often distracts from the account the patient chooses to share. Primacy should be given to the patient’s version.

• Even close families require private space, and the doctor-patient relationship should be such a space to ensure patients are comfortable disclosing problems.

• The obligation to treat whole families is an unrealistic expectation that can be a disincentive to new doctors pursuing family medicine. It can also lead to unfair prioritization of new patients.