To determine the involvement ofmedical practitionersworking in a tropical setting in the treatment of their relatives. Cross-sectional. Medical practitioners of all cadresworking in theUniversity of Calabar TeachingHospital, Calabar, Nigeria.Alarge teaching hospital inCalabar,Nigeria.Areferral centre for two states.Extent, type and effect of involvement in the practice.Majority (90.9%) of medical practitioners in our centre were found to have been involved in the treatment of their relatives. Services rendered included consultation, in which all respondents (100%) have partaken. Cardiopulmonary resuscitation (16.9%) and emergency surgery were performed by only a few (3.1%). Though fees were not charged for services provided by most; a few (13.1%) did so. Outcome of involvement was unfavourable in some instances: 9.4% lost relatives they were involved in treating.Majority of the respondents 51.7% believed it is unethical to treat relatives and advocated for only limited involvement.This is because the pressure fromrelatives for care cannot be entirely ignored.It is difficult in our environment not to accede to request to treat familymembers.We recommend that practitioners may offer only consultation, and in some cases treat minor ailments while referring more serious ones to appropriate colleagues. Keywords: Treatment of relatives; doctors; Calabar  Nigerian Journal of Clinical Practice Vol. 11 (1) 2008: pp 41-4

Anah, MU

Ansa, VO

Udonwa, NE

English

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41Nigerian Journal of Clinical PracticeMarch 2008 Vol.11(1) 41-44TREATMENT OF RELATIVES BY DOCTORS: EXPERIENCE FROMCALABAR, NIGERIA.*M.U.Anah **V.O.Ansa. ***N.E.Udonwa.SUMMARYObjective:Design:Subjects:Setting:Main Outcome Measures:Results:Conclusion:Key words:Departments. of *Paediatrics, **Medicine and, ***Family Practice,University of Calabar ,Calabar, Nigeria(Accepted 9 March 2007To determine the involvement of medical practitioners working in a tropical setting in the treatmentof their relatives.Cross-sectional.Medical practitioners of all cadres working in the University of Calabar Teaching Hospital, Calabar,Nigeria.Alarge teaching hospital in Calabar, Nigeria.Areferral centre for two states.Extent, type and effect of involvement in the practice.Majority (90.9%) of medical practitioners in our centre were found to have been involved in thetreatment of their relatives. Services rendered included consultation, in which all respondents (100%) havepartaken. Cardiopulmonary resuscitation (16.9%) and emergency surgery were performed by only a few(3.1%). Though fees were not charged for services provided by most; a few (13.1%) did so. Outcome ofinvolvement was unfavourable in some instances: 9.4% lost relatives they were involved in treating. Majorityof the respondents 51.7% believed it is unethical to treat relatives and advocated for only limited involvement.This is because the pressure from relatives for care cannot be entirely ignored.It is difficult in our environment not to accede to request to treat family members. We recommendthat practitioners may offer only consultation, and in some cases treat minor ailments while referring moreserious ones to appropriate colleagues.Treatment of relatives, doctors, Calabar )INTRODUCTIONIt is a common knowledge worldwide thatphysicians treat their family members andsignificant others. Some provide care to friends,employees and even themselves. Family memberscommonly request care from doctors who are relatedto them for various reasons. Good reasonsprobably motivate or encourage these age-longpractices. The family is believed to be the mostfrequent source of decision-making about healthmatters and personal care of its members . Familydynamics expect the physician-member of thefamily to be fully involved, not only for care ofminor illness but also in acute illness at home, pre-hospital and post hospital care, long term illness anddisability of the family members . The dearth ofM.U.AnahEmail :1,234Correspondence: Drmaxejen@yahoo.commedical practitioners in developing countries makestreatment of relations almost unavoidable. In Nigeria,the World Health Organization (WHO) estimatesabout 18 doctors per 100,000 populations, so it maybe difficult if not impossible for family members notto be treated by their own relatives who arephysicians.Ethical questions have arisen about the right ofphysicians to treat members of their own families.For example, the American College of PhysiciansEthics Manual strongly discourages but does notprohibit physicians from treating family members,limiting such situations to those of necessity andcautioning that the patient be transferred to the careof another physician as soon as practical. The 1901code of ethics of the American Medical Association(AMA) noted that a family member's illness tendsto obscure (the physician's) judgment and producetimidity and irresolution in his practice. Recently5678The AMA, stated that there are situations in whichfamily members can provide routine care for short-term “minor” problems. The AMA specifies thatdoctors should write prescriptions for controlledsubstances for themselves or immediate familymembers only in emergencies. The CanadianMedical Association agrees with this position. Itstates that treatment of family members should belimited to minor or emergency care or instanceswhen another physician is unavailable. TheMedical and Dental Council of Nigeria (MDCN)also agrees with this position but advises that severeailments be referred to another doctor who wouldtreat without distracting emotions .The family setup in developed countries are different from ours. InNigeria, extended family members are integratedinto the nuclear family. The MDCN however, did notdifferentiate between nuclear and extended families.These differences in family set ups not withstanding,several problems can arise when physicians care fortheir relatives. The informal nature of the situationmay result in compromised care at different steps inthe clinical encounter: history taking, physicalexamination, diagnosis, treatment and follow-up.McSherry found incomplete physical examination,medical records and immunizations to beundesirable consequences of physicians treatingtheir first degree relatives such as their children.To our knowledge, the involvement of practitionersin this practice has not been studied in our region.This cross-sectional study was therefore conductedto ascertain the extent of involvement in this practiceamong doctors working in our centre.Calabar, the capital city of Cross River State, islocated in the southeastern coastal region of Nigeria.It has one of the oldest hospitals in Nigeriaestablished in 1897 (that now metamorphosed to ateaching hospital) and the oldest psychiatric hospital(1903) in Nigeria. The University of CalabarTeaching Hospital (UCTH) provides tertiary healthcare for the inhabitants and outsiders alike.This study was carried out between March 1 and 30August 2003. Pretested self administered semi-structured questionnaires were distributed torespondents selected by systematic randomsampling. All the doctors were grouped according totheir cadres and using the nominal roll of each cadrewith the aid of table of random numbers, doctorswere selected from each cadre in the proportion of4:6:3 for interns, resident doctors and consultantsrespectively. Two hundred doctors were chosen andgiven questionnaires. After 6 weeks, a secondquestionnaire was sent to the physicians who had not991010116612st thSUBJECTSAND METHODSresponded, and after 6 more weeks a thirdquestionnaire was sent. One hundred and seventy sixreturned the questionnaires.The questions included age of respondent, length ofpractice, specialization, whether any request had beenmade by family member before, type of requests madeby family members, the degree of relationship withthe member and type of treatment given. Otherquestions asked included any payment of medical bill,requests that were not met, any mortality followingtreatment, whether it is unethical to treat them andsuggestions on what should be done when request ismade. The data were analysed using Microsoft Excel.One hundred and seventy-six physicians completedthe questionnaires giving a response rate of 88%. Theage range was 25-66 years with a mean of 34.7 ± 7.5years. The male to female ratio was 13.1:1. Theaverage number of years of practice was 8.3 ± 6.5years with a range of 1-38 years. One hundred andtwelve (63.6%) were married.Only 16 (9.1%) respondents reported that they hadnever been requested to give medical treatment to afamily member. Most of them (13) were found to beworking far away from their relatives. One hundredand sixty (90.9%) however, had requests from familymembers. Analysis of the requests showed that allnuclear and extended family members consultedthem, namely: spouses (58%), children (63%), fathers(31%), mothers (46%), brothers (67%), sisters (71%)and others (66%). “Others” include cousins, nephews,nieces, in-laws and other extended family members.Out of the 160 respondents to whom requests weremade, 83 (51.9%) of them agreed that requests werefrequent, 9 (5.6%), very frequent; 56 (35%) rarely and12 (7.5%) very rarely. Services given to familymembers by all 160 respondents are shown in Table 1.Twenty-one (13.1%) charge for services provided butnot consistently.Some respondents, 60 (32.5%) out of 160 haverefused requests for treatment by relatives. Thisincluded treatment involving termination ofpregnancy (15), intravenous drugs administration(10), delivery (10), surgery (10), vaginal examination(5), and others (10).Forty three (26.9%) had requeststhat made them uncomfortable also ranging fromtermination of pregnancy to issuing of fake medicalcertificate of fitness to surgery.Fifteen (9.4%) had lost relations they participated inR E S U LTRequests by family membersFrequency of requestsPayment for servicesRefusal to treat/Uncomfortable requestOutcome of treatment42Nigerian Journal of Clinical Practice March. 2008, Vol.11(1) Treatment of Relatives By Doctors Anah et al43Treating.Ninety-one (51.7%) out of all the respondents (176)agreed that it is unethical to treat relations withoutdistinction. They cited emotional attachments (37),poor judgments/bias (35), improper examination(15) and other reasons (4), as the reasons theyadduced.On what should be done when faced with requests,73 (41.5%) recommended referral, 46 (26.1%)recommended treating minor and emergency cases,28 (15.9%) recommended listening and referral toappropriate colleagues, 19 (10.8%) recommendedtreatment after consultation, while 10 (5.7%) wouldcommence treatment and refer later.Ethical considerations in the treatment ofrelativesTable 1:Consultation 160 100Treatment 145 90Physical examination 113 70.6Cardio pulmonary 27 16.9ResuscitationElective surgery 13 3.1Delivery 9 5.6Emergency surgery 5 3.1*More than one could be provided at same timeThis cross-sectional survey has shown that in ourlocality physicians do treat members of theirfamilies. The frequency of involvement is 90.9%.This is very high even though the response rate wasnot one hundred percent but there was adequaterepresentation of all categories of practitioners. Thishigh frequency may be due to the dearth of medicalpractitioners in the country making easy access toqualified physicians difficult. Those physicians whohad not been consulted by their own family memberswere those that stayed and worked far away fromtheir relatives. Probably, when they relocate, thestory may be different. Family members frequentlymake all kinds of requests to practitioners in thiscentre. This may not be surprising bearing in mindthe high cost of medical services in Nigeria resultingfrom the current economic situation. These requestswould continue to be high as long as the situationremains the same. Services provided to familymembers range from consultation to emergencysurgery. It is noted that even elective surgeries hadbeen performed on family members.Agood numberProfile of Services RenderedService* No %DISCUSSIONalso performed cardiopulmonary resuscitation (CPR)a necessary life saving procedure in emergencies. TheAmerican Medical Association (AMA) and indeedother medical associations readily subscribe toperformance of CPR. This in most instances wouldbe basic life support needed urgently to rescue apatient, be it a relation or a non relation. Surprisingly,a small number of doctors charge for servicesrendered to relatives. They were mostly extendedfamily members. The motive for this could not beascertained. A study would be needed to assess thereasons why our doctors charge relations. Usually,profit is not the motive for treating relatives. Standardmedical practice will require that fellow doctors treattheir colleagues and immediate family memberswithout professional charge but only cost recoverycharges.Some respondents had to turn down requests rangingfrom termination of pregnancies to surgery. It is notsurprising that termination of pregnancies wererefused because abortion has not been legalized inNigeria, even if it is legalized it will however, still notbe ethically right to do so. In addition, some of ourreligious beliefs do not support abortion.Some requests also impacted negatively on thepsyche of the physicians making themuncomfortable, particularly, requests for fakemedical certificate of fitness and termination ofpregnancies. They contributed to refusal of requests,which sometimes may strain family relationships.Some physicians (9.4%) have lost relations theyparticipated in treating and this could be a verytraumatic experience. Poor judgments as well asundue emotional attachment may contribute to this.Regarding the general opinion on this issue, majority(51.7%) of the respondents think that it is unethical totreat relatives. They cited emotional attachments,poor judgments/bias and improper examination asmajor reasons. This study assessed the treatment ofdiseases based on prescription only. The facts that onecould be biased coupled with poor judgement makeeven the use of non-prescription drugs questionableand make us reluctant to encourage it. It is alwaysbetter to seek the opinion of a colleague. TheHippocratic Oath and its modification did notmention anything about the treatment of relatives,the same with the Code of Ethics of the NorwegianMedical Association . Overall, 46 (26.1%) ofrespondents recommended treating only minorailments and emergencies. This is in agreement withthe AMA and MDCN. Many respondents (41.5%)however; recommended referral to colleagues. It isthe opinion of the authors that before referral, onehowever, needs to listen to the complaints first, whichis consultation. This is a prerequisite for proper9, 1013148 11Nigerian Journal of Clinical Practice March. 2008, Vol.11(1) Treatment of Relatives By Doctors Anah et al44referral and subsequent treatment. Our study shows a100% response rate for consultation and should beencouraged. It is difficult in our locality not to accedeto requests made by family members as it can drivethem away to quacks.Physicians in our community also treat their relationsand this corroborates with the findings in otherplaces. Majority believed it is unethical to treatrelations no matter the degree of relationship, andopined that this should be discontinued. Caring forfamily members is not a personal issue, but one ourprofession should acknowledge and manage.We would recommend listening to complaints(consultations), treating minor illnesses andreferring more serious ones to colleagues if they arefirst-degree relatives or others with significantemotional attachment. We also recommend that thereshould be improvement in ethics among doctors onthe treatment of relations and colleagues and first-degree relatives of colleagues.We acknowledge colleagues who responded to ourquestionnaires. Special thanks to Mrs. Juliet E. E.Ekanem for typing the manuscript.1.When physicians treat members of theirown families. Practices in a CommunityHospital. N Engl J. Med. 1991 1290-4.2.Who provides health care to the children ofphysicians?Amer J Dis Chil.1991; :391-2.Conceptual andcontextual paradigm of the family as a unit ofcare. Nig Med Pract, 2004; 45(1&2) 9-13.4. (Eds). The family asa unit of care in community. In: CommunityHealth Nursing Practice. W.B. SaundersPublishers, 1981; 87-92.C O N C LU S I O NACKNOWLEDGEMENTR E FE R E N C E SLa Puma J, Stocking CB, La Vote D, DarlingCA.; 325:Dusdieker L, Murp J, Dungy C, Murp W.1453 Inem AV, Ayankogbe OO, Obazee M,Udonwa NE, Kofo K.Freeman RB, Henrich J.5 World Health Organization: WHO statistics,estimates of health personnel: 1998.Geneva.6. American College of Physicians. In: Ethics casestudy. Should doctors treat their relatives?ACP-ASIM Observer, 1999; 17 American College of Physicians Ethics Manual'Fourth Ed.Ann Intern Med, 1998; 128:76-94.8 American Medical Association, Code of Ethicsof the American Medical Association, Chicago.1901:159 American Medical Association. Code ofMedical Ethics: current opinions, 1996-97.Chicago.1997.10 Canadian Medical Association Code of Ethics.Can Med.Ass J., 1996; 155: 1176A-1176B.11 Medical and Dental Council of Nigeria. Rules ofprofessional conduct for medical & dentalpractitioners in Nigeria. MDCN/PetravamiCoy Ltd. Lagos, 1998.12 Long distance meddling: do MDsreally know what's best for their children? CanMedAssoc J. 1988; 139: 420-2.13. The Hippocratic Oath today.Academic Publications. The School ofMedicine at Tufts University, Boston, UnitedStates. 1964.14 The Norwegian MedicalAssociation In: Code ofEthics for Doctors. Den norske Laegeforening2000.Mcsherry J.La Sazou L.Nigerian Journal of Clinical Practice March. 2008, Vol.11(1) Treatment of Relatives By Doctors Anah et al

Treatment of relatives by doctors: experience from Calabar, Nigeria

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Treatment of relatives by doctors: experience from Calabar, Nigeria

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