Gary:
I agree with all you said. It is very hard to not be involved - especially if it is your child (I could not imagine). I never resent peoples' involvement, and there is no benefit from stubbornness on my part. My goal is to come to a good answer regardless if the idea came from me, the patient, or a family member.

My only beef in this case was the fact that I was not allowed to show that I was willing to listen and assumed that I was doing a bad job by someone who did not have all the info. I did comply with this doctor's requests, but I was put on the defensive immediately. I care for lots of docs and their families, so there are plenty of chances to get second-guessed, and I accept it just fine. I actually think this is one of my strong-suits - I don't get my ego bruised. I just felt angry at it being assumed that I was an idiot.

Distractible, and Ed;

I have been through all these phases of family care. I think the approach evolves as one ages. By the time you are my age, only brothers, sisters, nephews and your own children are left.....early on even before I was out of med school i would question our family doc. I remember one quote to my mom...."your family has so many doctors, why are you seeing me?" Not surprising.
I think having a serious illness in one's own family gives perspective on this issue, so let me share them with you all. To summarize I think the most important thing a physician can do is to improve access and help patients obtain the best care, whether it is local or at some 'center"....
It's hard to suppress your protective nature toward close family. Early on my brother was diagosed with ulcerative colitis just as I began medical school. I had a frantic call from Belle, my mother who sounds a lot like Moo-mumps, Sid's mother.
Although she never attended college, she was valedictorian of her high school and very intelligent. When mom called, I answered. I as a first year med student was sure I knew as much or more than his own physician who was a mere "college physician" (Air Force Academy). For the next ten years I was the "second" or third opinion regarding his care. Eventually he developed a megacolon and septic shock during which he had an emergency colectomy. I was there by the bedside with mother Belle and his wife. All I would offer was my support and reassurance. No second guessing on my part, but I also knew he was in very good hands, having referred him to the best colon surgeon I knew, who if my brother wanted to construct a Koch's pouch (not bad for an ophthalmologist). ( I was also a GP and ER doc) for about four years prior to my folding up and becoming an ophthalmologist.
My brother survived and is still alive (he decided not to get the pouch) and has lived very nicely with a colostomy.

As life went on my Dad sucumbed to serious heart disease, ruptured aorta, Ma Belle had three open heart surgeries, several carotid endarterectomies, several uncles and aunts sucumbed to the usual aging processes, one cousin died from thyroid cancer, a father in law from Alzheimer's disease,, another father-in-law (married twice..different father-in-law)from an unusual skin cancer, and a mother-in-law that died from metastatic cancer. Which brings me this point.

Family members and patients will tell their family one story or part of the story and the rest of it to their physician. Case in point. My wife's mother who was a heavy smoker and was being treated for COPD became acutely ill. She told us it was due to shortness of breath....she was hospitalized and treated for her acute illness, but required oxygen. At the time she toldl us there was a little 'spot' on her lungs. (i knew better, there never is a "litte spot" on one's lungs. About a month later she slashed her wrists and laid down on her bed to die. At the last minute she panicked and called 911. Sutured up she survived and went home eventually to an assisted living facility. About a month later she called my wiffe and asked her to come over.
She was in acute distress from abdominal pain with ascites that was visible from across the room. She did not want us to call 911......however I thinkt the combination of hypoxia and abdominal pain were too much for her. I intervened and told my wife to call 911. She lasted 48 hours.....her MD who had superb judgment ordered some basic lab work (this was not the original physician who treated her earlier in the year.) My mind went through the usual D/DX llll Scans, CT,,Abdominal taps, etc etc. I kept my mouth SHUT!! My wife ( a retired oncology nurse, bless her also did the same. Several other relatives showed up, highly anxioius demanding all sorts of tests the evening prior to her expiration. We prayed the end would come swiftly. It did, when we came back the next morning a nurse (thank God) intercepted us coming down the hall to tell us "Jean' had expired. I had no regrets about my not intercepting her "spot", never questoned if a CT scan was done.....I don't think it would have made any difference and would have created much more anxiety for the family had I done anything.

I think it makes a great deal of difference in how old the relative is. For instance we have a son with cystic fibrosis. My spouse and I are "all over" his physicians.
I am sure his MDs dread our visits. I am guilty of doing all the 'wrong things' I send them recent articles about CF, notes from the CF Foundation, I even have a NCBI monthly update from PUBMED which I receive monthly forwarded to them.
I felt guiltly about all of this until recently when my son began to do poorly with weight loss, where he dropped off the growth curve to less than 1%. Perhaps this was due to my critical appraisal of his care. Maybe those doctors resented my interest and failed to notice a critical error on their part. They had failed to increase his enzymes from age 13 on. It stunted his growth and created other issues for him in his social upbringing and ability to attend school. My wife actually discovered this error.....serious illnesses require more heads than one. At no time did they offer us a second opinion, in fact his GI doctor had not seen him for several years (even though this is a CF center.)

I think a dispassionate approach is important and without guilt or anger, to inquiries or criticism from families
My response to family members is

"Thank you for bringing this to my attention, I'll review my findings and get back to you" This gives you time to cool off

"You are annoyed" ... my condolences on the loss of your mother. That must truly have been a horrible experience. I can't imagine what you went through.

I sincerely do hope, however, that once your grief is no longer so sharp, you'll be able to see that not all doctors deserve to be accused of being negligent. That one person in a profession makes a mistake doesn't mean that all individuals in that profession are guilty.

It won't help you to go through life accusing each physician in your heart and mind. They're there to help you, and the vast majority of them are empathetic and conscientious.

I hope you feel better soon.

In >2 decades of practice, I have discharged 4 or 5 patients at most, declining to provide further care. One of them was a perfectly reasonable person, but he had a toxic daughter who did not accompany him to visits, but called the next day to challenge or refuse to allow him to get the tests I ordered. I felt bad for him, but this is an example of the adage that 90% of your problems come from 10% of your customers. Life is too short for this kind of trouble.

I am not sure I can fix things. I thought this mother seemed to not trust me in the past - not accepting tests I was offering, etc. I suspect she goes home and talks to her daughter.

I tell patients that if you lose trust in your doctor, you should find another - even if it is me. Probably the best outcome here would be for me to somehow have a heart-to-heart with the daughter and diffuse some of those issues. I doubt that will happen, but I will continue to try to do my best for her mother.

Sounds like the perfect storm of doctor-family-patient collisions…

My personal (less than satisfying) experience is that, even with time, I can only partially placate the unhappy family member. What they interpret as aggressive advocacy, I interpret as hostility. Too often, it seems that there is a hidden agenda that is only known to the family members and they aren’t sharing.

So, asking Dr. Rob…How do you get to the bottom of the patient’s and the daughter’s real underlying issues here? Do you think that there is opportunity for a satisfactory final outcome?

These are great posts on an excellent essay. We’ve all been the doctor-relative along on a visit or getting in touch with a loved-one’s doctors, and my experience has been varied. Some doctors are IMMEDIATELY defensive when they are questioned (in a manner I would consider diplomatic and collegial). Others have been very respectful about it

I’m with Val Jones–maybe this daughter feels guilty for not being more involved i.e., along for the visits of her Mom to you? If she wants to provide input that’s what she needs to do. We’ve all experienced the different agendas of elder parents versus their baby-boomer kids, and it’s something I think about alot because I’m one of those kids too. I might consider talking with the patient about this phone conversation, and what the patient wants you to do w/respect to her doctor daughter.

If this mother is anything like my mother … she complains insessently to me and my sister …then gets into the doctor’s office and either doesn’t tell the doctor what is going on …or if I’m there … downplays what I tell the doctor she’s been complaining about …

or worse! says that it’s not been an issue ..making me look like an absolute idiot.

Because, at this point, I don’t have medical power of attorney, the doctor is obligated to listen to her.

Because, the doctor doesn’t see, nor have a right to see …her fowled up check book (and mom denies that it’s fowled up ..although …she’s made more than $1200 worth of errors in the last 15 months) and she tells her finances are fine.

Because she tells her that she doesn’t loose things … even though my husband and I have made 9 trips to get her into her locked car with the keys inside …and my sister has been to her house to help her find her car keys more times than we can count …

Because my mom’s history of things is different than reality …

what the doctor knows, is FAR different than reality …

and thanks to HIPPA …not the doctor

there is only so much she can do.

I do not blame the doctor …

I blame the frivolous law suits that have tied the hands of good doctors

and stupid Hippa (however that idiotic acronymn goes)

in the meantime … mom won’t agree to get more testing for alzheimers …

Usually when people are hostile towards others it’s some sort of “projection issue.” This daughter may have seen some pretty bad physician decision-making in the past, and is now assuming the worst of others (especially those she doesn’t know). Her approach is irksome and primitive, but I suppose she could also be disarmed by saying something like, “I can tell that you’re frustrated with your mom’s situation - I know that you love her, and are being a good daughter by trying to do what’s best for her. I also really care for your mom and want to tell you what I’ve noticed so far, and why I’ve recommended certain tests…” Hard to respond this way when you feel attacked… but it might help.

That is precisely my point, PJ. I have absolutely no problem with this doctor calling me up. It actually happens a lot. But the problem was that there was no “teamwork” approach, just criticism of me that came more from ignorance than anything else.

When my mother was referred to Killem and Chillem Memorial Hospital for an angiogram, I was freaked out and furious.

My own experience with KCMH was so dreadful, I still get the shakes whenever I think about it.

I did not want my mother going to this hospital, but I *kept my mouth shut* because I felt the last thing she needed was to have me undermine her confidence in the plan of care.

It is bad enough when something goes wrong and your trust in the system is justifiably shredded. Patients don’t need to have all kinds of doubts sown about the care they’re getting or have their trust damaged for no good reason.

Having said that… sometimes questions do need to be raised. And sometimes patients and family members have to be persistent in order to make their concerns heard. But I would hope this could be done in a way that allows us to be a team rather than adversaries.

I was not annoyed because she was right. Why should I be against getting help? My annoyance was because she assumed I was not thinking. I will step in if I think my parents are endangered or are getting bad care. But I will do so in a way that does not assume my parents’ doctors are not thinking right. This doctor made some very inaccurate statements to me, which showed she was reacting with emotion and not rationally thinking like a physician should do.

I suspected, last Labor day, that my mother had a slow brain bleed causing abnormal behavior. She did in fact die of this, and I had the luxury of guilt as well as discovering her body, because I did not aggressively second-guess the ER doc, when I knew he was hanging his ER diagnosis on an inadequate test and not listening to a history that should have tipped him off.

Hey there Dr. Rob,

Oh hell. It always smarts to have anyone whining about one’s perceived “incompetencies”. Goodness, that happens to me daily (and worse). Not an MD (so I don’t fall from so high, not so hard? hmmmm?). But, shoot, you do what you can with whatever the client tells you. Then some third party comes charging in with all sorts of info you were never privy too…

Freakin’ annoying.
go on and be pissed. No point in making excuses or “forgiving” this fellow MD for being a loving daughter. Hell, she is The Devil. So, go on and hate her and hate her behavior. And then go on and get over it and love that old mom if she comes on back to you. (See, if you see mama again, that is a SUPER vote of confidence! ) If you never see that mom again, well just forget about her… she will have forgotten you even sooner.

Big ol’ Moofish HUG for YOU.

Luv,
tl

I actually have had fairly good luck working with other doctors. I have the compliment of being the “doctor’s doctor.” Some of them do a ton of self-medicating, and some don’t. I usually read them the riot act when it comes to family members, however. I don’t treat my own kids, so the orthopedist shouldn’t treat theirs. I don’t treat them differently. I give them the same talks I give other patients. I certainly don’t give “fancy” prostate checks (that sounds gruesome).

This doc wasn’t hostile, she just didn’t give any thought to the fact that I was a reasonable doctor. She assumed her mother was a perfect patient and told me everything in a way that was understandable. This is just not the case!

I do find that if you can use the expertise of the doctor in the family, then you can do well. I give them my cell phone number and say they can use it (I know they won’t abuse it), but I do that for certain regular patients as well.

These days we can get these situations from anybody, given the large number of internet experts out there.

Everyone deserves to have questions answered, but they don’t have a right to grilling the doctor like it’s an investigation of some sort.

Sometimes I have had to interrupt some sort of early tirade by saying something like, “Look, in order for this situation to work, a doctor and a patient, there HAS to be some level of trust in my abilities to analyze a situation and give the best advice I can. If that trust isn’t there, then we’re wasting each other’s time.”

Pretty much without exception, this leads to a backing down and more civil, intelligent behavior.

Though this was clearly poorly handled by your patient’s daughter, I think Dr. Schwab’s comment about being a doc in some ways being an impediment is accurate. It’s kind of a Schroedinger’s cat situation; as much as you try not to let the fact that your patient (or family member) is a doctor (or a lawyer) impact decisions, to some degree it’s unavoidable.

My partner today experienced what he described as a 30 minute prostate exam by our local urologist; my guess is that the urologist wanted to be extra thorough. My partner would have greatly preferred standard treatment.

Having been through the deterioation and death of my dad not long ago, and the ongoing saga of my mom’s Alzheimer’s, and playing the (not-sought) role of the doctor liason for the rest of my family, I know it’s difficult. I try hard as hell not to play doctor when talking to theirs; only to understand what’s going on and to pass it on. In a way, it’s the flip-side of operating on medical folks. As much as I can, I try to deal with them exactly as I would a non-medical patient (maybe with the exception of a fellow surgeon who, I assume, at least knows the meaning of the words.) Being a doc helps in navigating the system; but in relating to the docs of family, it’s actually an impediment in many ways, as you have shown.

Courtesy is something we should all practice with each other, patients, family. I agree with you and Vijay.

“I remember as a resident having contempt for "LMD's" (local MD's) and their care for patients. This is hubris, and nothing else.”

That, I think, is a universal axiom of post-graduate medical residency. I’ve been guilty. Well said, Rob.