The Exception to a Rule | to pdf >
By Renate G. Justin, MD

"The natural anxiety, the solitude which the physician experiences at the sickness of a wife, a child, or any one who by ties of consanguinity is rendered peculiarly dear to him, tend to obscure his judgment, and produce timidity and irresolution in his practice."¹

"You'll assist, won't you?" the surgeon, with whom I had worked for years, asked me. Well...yes..., I assisted with all my patients who needed surgery, but this time? In my own practice, I had witnessed the tragic consequences of physicians treating members of their family. The wife of an orthopedist came to see me with extensive hair loss, looking like a blimp. She had every other known side effect of prolonged use of high-dose cortisone, which had been supplied to her from her husband's sample closet to treat her severe asthma.

A young colleague of mine prescribed narcotics for his wife's migraines and caused her to become an addict. Another doctor, who could not resist his need for control, treated his children, leaving them with unnecessary, ugly scars.

I knew the risks, I was familiar with the literature: "The physician who is family lacks the gyroscope of clinical poise, an axis of objectivity in the reeling emotions of family illness.''² And again: "The physician does not have a valid physician-patient relationship with his or her own family."³ Knowing all this, what should I do?

My hands shook, and I perspired as I scrubbed the morning of the surgery. Once we started to work, I was able to concentrate on what we were doing and the shaking stopped. When we saw the size and extent of the tumor, there was no question of resectability. A tear ran down my cheek into my mask, but all who were working around the table were too busy to notice.

After we had closed Eva's chest, I went into the locker room to change. I surprised myself when I started to swear under my breath, very uncharacteristic for me. I was really angry and hurled my gown into the hamper rather than tossing it as I usually did. I slammed the locker door shut before I got a-hold of myself and remembered that anger is one of the prominent reactions to grief and loss. I was no different, as a physician, than any one else who found out that a family member had widely metastasized lung cancer; I was angry. I asked myself, why her? Why at her age? Why my sister?

When I visited Eva in the intensive care unit, she asked me whether we had been able to do anything. I mutely shook my head.

After getting her affairs in order, my sister moved in with my family, and I became her caretaker and physician. We had asked an internist to be her doctor and write her prescriptions, but she ignored his advice. Hypnosis, along with pain pills, controlled her distress. When she developed superior vena cava, obstruction we switched to demerol and morphine. It was hard to be her sister and doctor. She would complain that the shots hurt and that I should return to medical school to learn how to do what I was doing, and the next minute we would be hugging each other and crying. Once her face started to swell, she did not want to see any other family members, including her two children, because she did not want to be remembered puffy and distorted.

My sister and patient was insistent to the end to be in charge of her surroundings and her life. She would not sleep in a hospital bed with rails, because it felt too confining–"like a jail." She had fallen out of her regular bed several times, and she was too heavy for me to pick up. We compromised and both of us slept on the floor, which she found acceptable. She decided how much, and at what time interval, she would take which medication. She smoked until the end. She decided who should visit her and when, she was in charge of arranging her flowers, and ordering her menu. She became incontinent when she was near death but adamantly refused a catheter; she could not even accept that she had lost control of her bladder function. She gave her body to the medical school. She was angry at dying young, before she could make enough money to help her children finish their education.

Should I have done things differently, not assisted at her surgery, not cared for her but admitted her to a nursing home? I think not. Because of Eva's overwhelming need for control and independence, she would have been unable to fit into the compliant, passive role expected of a patient.

A stranger would have found it very difficult to extend to her the understanding and compassionate care which she sought as her life came to an end. My rule not to care for relatives, as all rules, has exceptions. Caring for Eva was an exception.

References
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: 1810-2.
2. Miles SH. A piece of my mind. Midnight Visiting Hour. JAMA. 1989; 262:2008.
3. Boiko PE, Schuman SH, physicians treating their own spouses: relationship of physicians to their own family's health care. J Fam Pract. 1984;18:891-6.