Family Physician or Physician in the Family?

I was on a 28-hour call shift in the medical ICU (MICU) at Massachusetts General Hospital during a month-long rotation during my second year of medicine residency. That night I felt responsible for 12 people: two first-year residents; nine critically ill MICU patients; and my short-of-breath grandmother, Molly, admitted to a hospital thousands of miles away in California.

The medicine resident treating Molly phoned to give me an evening update. I anxiously stepped into the MICU call room, reminding my interns that I was just on the other side of the door if they needed me.

What no one in the buzzing ICU could see was an attempt to trade my doctor hat for my family-member hat. I calmed my ICU-rattled nerves to not appear pushy or opinionated on the phone.

I could not bear the thought of my grandmother’s care suffering because of anything I said. I did not want to be viewed as a “difficult” family member whose work stress subconsciously pushed her team away from viewing her in the most positive light she deserved.

As her health declined that spring, my grandmother — a truly remarkable, robust 96-year-young matriarch with an unparalleled zest for life — needed different versions of me. I was her inhaler whisperer, reminding her which one was to be used daily. I was also her trusted thought partner, listening as she lamented her failing body. And I was the physician in the family, there to ask her what her team members had not asked: if she even wanted to be hospitalized again.

I have become a better doctor by experiencing the tension between doctor and family member when confronted with end-of-life medical decisions. When balancing these roles, conflicts arise in many facets of medical care, down to the most mundane decisions, like when to weigh in on a parent’s blood pressure medications. Each clinician must decide how to share a difference of opinion with a family member’s physician without breeding mistrust and assuming the role of their doctor.

When wearing the doctor hat, physicians often cope with the weight of their own work by constructing emotional barriers for self-preservation. These barriers facilitate the closest that it is possible to get to objectivity.

Emotional walls don’t mean that doctors are unable to feel, cry, or grieve for their patients. But it does certainly feel different from donning the family member hat, which often entails leading with a more emotional approach.

Some physicians report that they have personal experiences early in training that help them code-switch more readily, or more effectively bear this duality.

Every physician who trained me was also someone’s child, sibling, or parent, pushed concurrently to know what they know about medicine and to be in the role of family member. Although all of these educators were at some stage of striking a balance between family and professional identities, this tension was never discussed in my formal medical training.

Healthcare professionals must discuss these issues and learn strategies to address the tradeoffs.

The need for a clearer understanding of the rulebook is new, as this 2001 study shows. Medical school curricula in the United States would benefit from a formal discussion on the topic. It is time to bring ethicists in to teach the ethical principles at play and proposed frameworks for navigating this duality.

Medical schools and residency programs must create dedicated spaces to support trainees without formed professional identities whose family medical circumstances call on these balancing skills early in their careers. In residency, where habits that span careers are established, dedicating time to review frameworks and best practices in separating family member and doctor roles and identities is essential.

This process must include review of the established ethical code discouraging physicians from directly treating family members. Trainees need space to recognize that objectivity is threatened with emotional entanglement.

Juggling these identities will look different for each healthcare professional. Solutions cannot be monolithic and must incorporate cultural perspectives; not all families embrace deference to children or share beliefs on the role of doctor.

While many doctors have networks of colleagues and friends in medicine to lean on when faced with this juggling act, some don’t. Formalized support structures would bring this issue out of the shadows and ensure that all can access this vital resource.

Spaces such as Balint Groups, whose many positive effects include easing burnout, can foster discussions of the effect of professional identities on families and of family identities on medical practice. They also offer clinicians support in coping with the isolation associated with knowing future side effects, risks, or potential bad outcomes of care recommended to a loved one.

To be sure, I’m not advocating that clinicians bow out completely. Some patients need help from their physician relatives to navigate the complexity of the healthcare system. And research in Sweden shows that people related to doctors have better health outcomes, not because of back-door access to care or personal connections but because of improved preventive care and healthier habits.

Had I known the inevitable tension I’d face between my work and family identities, I might have been better equipped to navigate my grandmother’s decline until her passing in June 2019.

With training on this duality, I would have felt less alone during that call shift in the MICU and more empowered to solicit support from peers and mentors. Most important, I would have known when to take off my doctor hat entirely and grant myself space to be just a granddaughter. We must all work to ensure that the physicians of today and tomorrow openly acknowledge when they are carrying another patient on their list.

Gabrielle Kis Bromberg, MD, is an educator and academic hospitalist in Massachusetts General Hospital’s Department of Medicine. She is a Public Voices Fellow with The OpEd Project.