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Getting Friendly With Patients? Be Wary of Risks

The scene might go like this: Through the course of treating a patient, casual chitchat leads to the realization that you and the patient share a love of tennis and have similar skill levels. Soon you’re playing regularly, enjoying both the game and the camaraderie. Before long, you’re more than doctor-patient. You’re friends.

This scene is not all that uncommon, but it does present dilemmas.

Medscape’s 2022 Physician Friendships: The Joys and Challenges surveyed nearly 1600 doctors on various aspects of friendships. When questioned about doctor-patient friendships, 29% of respondents said that they do indeed make friends with their patients.

Mario Tano, MD, a pediatric GI at Florida-based KIDZ Medical Services, doesn’t think twice about forging friendships with his patients and their families. “When you’re dealing with children, you have to be humble and build trust with the parents,” he says. “My aim is to bring down anxiety levels and get to know the family.”

Through this enhanced bedside manner, Tano has built lasting friendships with patients and their families. “I give them my cellphone number and consider them friends,” he says. “Many doctors might not be comfortable with that, but to me it’s important to lower the barriers with patients and do what’s in their best interests.”

Because his specialty is pediatrics, the friendships Tano forges are usually with the parents, but that can evolve over time. “Once my patients become adults, many of them continue to reach out to me for advice because we’ve built a foundation of trust,” he says. “They’ve moved on to other doctors at that point, but still turn to me as well, and I’m okay with that.” 

In smaller, isolated communities, however, physician-patient friendships sometimes develop out of necessity. Margaret R. McLean, PhD, a senior fellow at the Markkula Center for Applied Ethics at Santa Clara University, Santa Clara, California, says this is one of the exceptions to “rules” regarding these allegiances. “If you’re the only cardiovascular surgeon for hundreds of miles, then friendships fall into a different context,” she says. “The same holds true in an emergency. If your friend is potentially having a heart attack and you can do CPR, then of course you will do that.”

On an official level, there are no laws preventing physician-patient friendships, yet most medical associations frown on such connections. The American College of Physicians (ACP), for instance, states that physicians should “usually not enter into the dual relationship of physician-family member or physician-friend.” The American Medical Association (AMA) has ethical guidelines stating that physicians generally “should not treat themselves or members of their immediate families,” but stops short of addressing friendships.

Respondents cited concerns about objectivity as one of the key deterrents to such relationships. Still, for those who do form friendships with patients, the reasons stated were varied and seemed valid. “A patient was a new paraplegic who was very depressed,” said one. “I felt he needed something to look forward to that wasn’t related to his paraplegia, and we discovered we are both Marvel fans.”

Another respondent had this to say: “I have been a pediatrician for 35 years and my patients have grown up and become productive adults in our small, rural, and isolated area. You can’t help but know almost everyone.”

Still another said this: “I am friendly socially with a couple of patient moms who share teachers or teams with my children. But I try to maintain boundaries beyond our children getting together.”

Overall, however, McLean sees physician-patient friendships in more black-and-white terms. “My thoughts align with the professional organizations in that these friendships are really not a good idea,” she explains. “Your primary obligation is to do no harm. If you’re friends with a patient, it can lead to unintentional harm, and that concerns me.”

On a somewhat different note, in the same study, 96% of respondents say they give medical advice to their friends, and many have friends who became patients.

Gregory Hood, MD, a general practitioner in Lexington, Kentucky, says that having a longstanding knowledge of patient history and health can result in better care. “If you’re a primary care physician and you return to practice in the town where you grew up, it can be a very rewarding experience,” he says. “People know you and look forward to having you back in order to treat them. Knowing their life experiences and health history can inform how you care for them.”

Some of Hood’s patients are former schoolmates, giving him a deep perspective on how the past may or may not impact their current health status. Patients relax, feel comfortable, and potentially share more information with Hood because of their connection and trust, he says.

Both Hood and Tano keep some guardrails in place. Hood emphasizes the importance of drawing strong ethical lines with friends who are patients, just as he would with any patient. He is especially careful of the potential power disparity in a doctor-patient relationship and how that plays out when the patient is also a friend. “While it’s okay for a patient-friend to talk fully about moods, stresses, and relationships, a doctor should not share equally,” he says. “It’s important to have friends outside of your patient pool for that.”

Tano says the thinking on physician-patient friendships has evolved over time. “I’ve been practicing for 32 years,” he says, “and I think that with younger physicians, the relationships are probably more formal.”

Hood agrees, and points to the corporatization of medicine as one of the factors in changing attitudes about doctor-patient friendships. “Historically, so much of medical practice was personal, not corporate,” he explains. “We had longstanding practices in our communities, and we were more connected to our patients as friends.”

For some physicians, having a doctor-patient relationship with a friend can equate to better practice. This holds particularly true in cases where the doctor is a familiar hometown presence, especially if it’s a small rural town without access to myriad doctors and institutions.

But this can be a slippery slope. McLean cites lack of objectivity as a chief reason for keeping patients at (friendship’s) arm’s length. For instance, if you’re treating a close friend, you might be hesitant to ask certain probing questions. “You have a loyalty to that person through your friendship, and you’re likely not an objective listener or observer, which can cloud your medical judgment,” she says.

On the flip side of this equation, a patient who is a friend may shy away from sharing certain medical details. This can lead to both under- and overtreatment.

Over-familiarity with a patient can also lead to trouble in the form of assumptions about a medical condition. Hood witnessed this dynamic as a resident, years ago. “A retired physician brought a close friend into the ER and told the team his friend was suffering from sciatica,” Hood says. “It wasn’t sciatica but an aortic dissection, and by the time the ER reached the actual diagnosis, it was too late for treatment.”

The Best Way to Help a Friend-Patient

While many doctors prefer to stay away from practicing medicine on friends, there are ways your skill set can help them, all while staying on the safe side of ethics. One is helping to interpret medicalese, says McLean. “Most of us don’t talk that language,” she says. “So serve as an interpreter for your friends, helping them understand the alphabet soup they’re facing.”

Another good way to help friends is to serve as an extra set of ears. It’s a well-known trope in medicine that the minute patients receive, say, a cancer diagnosis, they stop listening. As a physician you can accompany friends to appointments, hear what their doctors have to say, then translate that to the patient after the visit.

Finally, navigating today’s complex medical system is difficult, and assisting with that can serve as another useful way to help friends. “It’s scary and confusing, and if you have a doctor friend who can advocate for you, the outcome may be better,” says McLean.

This is still an area where caution is best, however — something the early days of the pandemic drove home when doctors sometimes helped friends get preferential treatment. Using your ties to move friends ahead of other patients is never acceptable. All patients deserve equal access to treatment.

In McLean’s view, “To my mind, we can fail to recognize our own biases, limitations, and lack of objectivity when it comes to treating friends. That’s how guidelines can help us.”

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