Ethicists debate doctors who keep it personal

By Mary Brophy Marcus
http://www.usatoday.com

Have you ever sat frazzled in a doctor’s office, waiting for your or your child’s appointment, only to glance up and see one of those Norman Rockwell paintings of a kindly old doctor gently pressing a stethoscope against the heart of a little girl’s doll?

In this age of managed health care, when personal doctoring is shoved behind the priority of filling out forms and charging co-pays, it’s enough to make you throw a tongue depressor at the image.

But though those Rockwell-esque physicians are infinitely more scarce than they were a century ago, they do still exist. Some are family doctors in small towns, but others include busy emergency-room physicians and specialists who make “Best Doctors” lists and lecture at Ivy League medical schools. They are the doctors who still make house calls because it’s in the best interest of the patient, not their bottom line, who say a prayer with a distraught family, who give their own blood to a sick child.

Yet some medical ethicists warn against practicing medicine too empathetically or becoming too involved in patients’ lives, saying it compromises treatment and the profession as a whole. Others argue personalized care will become extinct if physicians are not able to set aside the business of doctoring and resurrect the art of medicine.

Thomas Graham is a Rockwell painting come to life. A family practitioner for 51 years in Iowa Falls, Iowa, a town of about 5,000 people, he still makes house calls. Graham spent one morning last month visiting three nursing homes in town because wintry weather kept some elderly patients from negotiating the trip to his office.

“They’re old and frail and have trouble getting out in the snow and ice,” says Graham, 77, who had a bout with kidney cancer two years ago and has diabetes. He doesn’t get paid extra to make the out-of-office rounds.

Graham has been the Whitesell family doctor for decades, says Tom Whitesell, who grew up in Iowa Falls with five brothers and now lives in Pacific Palisades, Calif. “When we’ve been back home visiting my parents, he has come to the house and treated my wife and kids when they’ve been sick. He’s very close friends with my parents,” he says.

House calls with a black bag

Whitesell says he’s lucky enough to know another such physician. His good friend, UCLA pediatric plastic surgeon James Bradley, is the other. Neighbors for seven years and friends who vacation together, Whitesell and his wife, Susan, say Bradley is not their family doctor but they call on him for medical help now and then. “Jim is a total throwback to the old-fashioned doctor with the black bag. He even has one,” Whitesell says. “He’s just there if I have questions. Instead of going to the doctor, sometimes I’ll try to diagnose myself and he’ll come and look and tell me I’m totally wrong and write up a prescription if I need it.”

Bradley recently sewed up a beloved doll belonging to Whitesell’s daughter when its legs got pulled off. “He even used black thread. They’re good stitches,” Whitesell says. Bradley is chief of pediatric plastic surgery at Mattel Children’s Hospital UCLA.

Bradley, a father of four boys, doesn’t blink an eye about treating a patient in his home during an emergency. He says sometimes it is easier and less stressful on children and their families than meeting up at the ER. One recent night, an 8-year-old patient came by. “It was unrelated to his facial surgery I had done, but he had cut his lip open. I numbed him up, put SpongeBob on television, and my 11-year-old son held the flashlight while I stitched him up,” he says.

The American Medical Association’s Code of Medical Ethics for doctor-patient relationships advises physicians not to treat friends and family and discourages getting too close with patients, to the extent that it interferes with clinical judgment. Still, medical schools have been making greater efforts over the past decade to help doctors-in-training develop more patient-centered, humane practices. Doctors such as Graham and Bradley say they wouldn’t practice medicine any other way.

Some ethicist see no problem

Medical ethicists have mixed opinions about doctors treating friends and inviting patients to their homes. A physician’s work and private life need to be considered, says medical ethicist Joseph Carrese, a faculty member at Johns Hopkins’ Berman Institute of Bioethics. “It takes additional time and energy. It’s very admirable, but if done to the extreme, it can lead to burnout and compromise a doctor’s personal and family life,” Carrese says.

Says Ross McKinney, director of the Trent Center for Bioethics, Humanities and History of Medicine at Duke University: “I personally don’t have any trouble with a doctor helping patients in his home. There’s a long history of doctors having their offices in their homes.

“It changes the rules a little, but as long as the physician remembers that what he is doing is for the patient and not for him, that is what is important.”

Eve Adalsteinsson, a freelance writer in Kennett Square, Penn., who was diagnosed with breast cancer in 1996 that has since metastasized to her bones, has developed a close friendship with her oncologist. He chose not to participate in this story.

In October, she and her husband traveled with him and his wife to Argentine Patagonia on her dream trip, an unforgettable journey she says she could not have taken without him.

Adalsteinsson says they first got to know each other when he would chat with her during chemotherapy sessions. They had a lot in common, including kids the same age, and the relationship grew into family get-togethers and then occasional dinners and movies together as couples.

“The friendship works because I respect his boundaries,” she says. She rarely brings up her health outside his office.

The trip was their first together. Adalsteinsson’s doctor carried extra prescription medications and developed an emergency plan if a life-threatening medical situation arose. Nothing serious occurred, though he helped her manage some serious pain flare-ups. “Certainly having my doctor with me gave me peace of mind,” Adalsteinsson says.

It can be ethically more complex when certain patients receive a preferential kind of care, says Amy Haddad, director of the Center for Health Policy and Ethics at Creighton University in Omaha. “By treating one patient differently, does that make that patient better than other patients? In a sense, are you discriminating?” Haddad says. “But we’re talking about discrimination in a positive way here, so it makes it complicated.”

Some doctors say the nature of their practice makes it impossible for their professional and social lives not to blur.

Physician Jeff Henderson, director of the Black Hills Center for American Indian Health in Rapid City, S.D., says that as a young doctor he saved the life of a well-loved woman in the tribe, and later her family invited him to their community because the leaders wished to thank him. Henderson says it would have been unthinkable not to accept the invitation, even though the AMA ethics code discourages receiving gifts.

“The family patriarch surprised me by laying star quilts on the ground. They are handmade by the Sioux women and have great currency on the reservation. He had me join them on the quilt for a naming ceremony in which I would receive an Indian name. I had not had an Indian name to that point and I was really overcome.” Henderson, a member of the Cheyenne River Sioux tribe, has since had many similar personal encounters with patients and their families.

Sometimes going beyond the bounds of normal practice standards isn’t a matter of emotional choice but simply about saving a life, says Samuel Weinstein, director of pediatric cardio-thoracic surgery at the Children’s Hospital at Montefiore Medical Center in the Bronx, N.Y.

While performing open-heart surgery on a boy in El Salvador two years ago, the child needed blood but had a rare type not in supply at the hospital. Weinstein, like the child, was B-negative. He says, “I scrubbed out, donated a unit of blood, then scrubbed back in and finished the surgery with my colleague.”

Weinstein says he did not intend to be a hero. “It is just something you have to do,” he says. “You do everything you know how to do to help you put your head on your pillow at night. If he’d had a bad outcome, I would never be able to stop thinking about it.”

Being a good doctor doesn’t always require skills garnered in medical school, says Tiffany Osborn, a critical-care physician at the University of Virginia who often prays with families. “Sometimes they are just looking for connection,” she says.

Says Christine Mitchell, director of the office of ethics at Children’s Hospital Boston: “We all have to find the way we want to practice. It sometimes seems the institutionalized systems we’ve set up make it hard to continue to know patients and also deal directly and efficiently with a patient’s problem.”

Henderson says he balances compassion and professionalism by trying not to impose his value system on patients: “Simply be there and allow yourself to be used in whatever manner the people need you.”

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