Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, October 16, 2006

Clinical Dilemma

This is a true story; names and some identifying details have been changed to protect privacy, but I'm having a tough time with this one.

A lady (call her Abigail) came to see me a few weeks ago, very upset: her father had just died. Apparently he had known he had cancer for a year and a half but had told no one. Not his children; not his wife; had not seen a doctor. By the time he came to medical attention it was far too late, and he had died the week before.

She described her family as "not very supportive," including a brother and a sister, as well as her husband. In fact she said she had been talking to a lawyer, mainly to prevent her husband from hiding money if she decided to leave. I tried to get a sense of what the issues were, but she was pretty vague. The patient had taken care of the father in his last days and had been with him when he died. She had not gone to the funeral because, as she said, she and her family just didn't agree on certain things. Besides, she said she didn't want to remember him in a box.

I proffered my usual comfort, offered a small prescription of tranquilizers (there was no history of prescription drug abuse; just scrips for half a dozen Xanax for flying once or twice a year) which she accepted, and a gave her a handout from Family Practice Management called "Mourner's Rights", which I've found quite helpful. She thanked me and, at my request, made another appointment in about two weeks to see how she was doing.

Later that week I saw another patient I'll call Bob. He apologized for being late, as he explained that his father had died a week ago. His mother was having a tough time, so he had just taken her out to lunch. He went on to tell me that his father had known he had cancer for a year and a half but hadn't told anyone. By the time they finally got him to the doctor, it was too late.

That was too odd to be coincidence, so I asked him, "Do you have a sister named Abigail?" It turns out he did. Then he said, "Oh yes; I'd forgotten she comes to you too. We're at the end of our rope with her. She does drugs. Cocaine. She stole our father's hospice meds. She didn't even come to the funeral."

This happens more often than you'd expect. No, not skipping a funeral or stealing hospice meds; but a family member telling me about another's drug use, or drinking, or infidelity, or noncompliance with medical care; all kinds of information that, while potentially useful, is also filled with pitfalls. Is the family member telling me the truth, for starters. I've found myself in the middle of all kinds of family conflicts.

"Bob, are you sure?" Having just seen her, I hadn't detected any signs or warning flags that there might be a drug issue.

"100%. I've seen her with drug dealers. This has been going on so long, we're all just fed up. The problem is that my mother is a nervous wreck, and my sister is really doing a number on her."

"Bob; I'm not very good at keeping secrets." I am, but this is how I broach the topic of sharing uninvited information. "Can I tell your sister that you told me about this?"

"Absolutely not. She's mad at the rest of us anyway, and I'm afraid it would just make things worse." I tried to persuade him. No luck. There was nothing I could do but confront her directly with general questions about drug use and hope she admitted it to me.

I saw Abigail again. I noticed her smiling in the waiting room. When I asked how she was doing, she said, "Fine", but still had this wide grin on her face the whole time she was talking. She said she had another bombshell: "We're getting divorced."

I've been divorced. I never smiled like that.

"Tell me more," I said.

"We just decided. It's been coming for a long time. I've been talking to a lawyer." She went on for a while.

Finally I got a chance to ask some more questions. In the guise of updating her history I asked about any surgeries, new allergies or immunizations in the last year. When I got to the social history I asked about smoking (no), exercise (walking) and drug use: "No."


"Not since high school, and that was just some experimentation."

"With what?"


"Cocaine ever?"


She had mentioned she was getting a little cold, so I had a pretext for a brief physical. Nothing abnormal I could detect about her nasal mucosa, pupils or anything else, so I was stuck. There was nothing I could say.

I had the chance to talk with Bob again when I called with his blood tests. He asked if I had seen Abigail and I avoided answering directly. But I said to him, "What can I do if she flat out denies the drug use?" He suggested lying about physical findings, telling her something like "I can tell from your nose you've been doing coke" but those kinds of lies often backfire. I don't do things like that. What if she wasn't snorting it?

I asked again how certain he was.

"Positive. I've seen her with known drug dealers, right up the street from your office." (Oh, great!) "I've seen where the money comes from. I'm certain."

"Have you said anything to her?"

"Like I said; it's been going on so long now, we're all fed up. She won't listen to us."

"Any idea who she would listen to?"

"You, I hope." (Great.)

What if her brother is lying? I don't think so. The balance of credibilty is very much with him (even if I haven't done a very good job in this post of conveying that.)

And that's where it's been left. So what should I do:
  1. Confront the patient with the information, along with the name of the informant (against the informant's wishes?)
  2. Confront the patient with the information but refuse to tell her how I found out? (This often becomes problematic as the visit devolves into a guessing game about the informant's identity.)
  3. Not say anything to the patient unless or until she comes clean on her own? (This becomes more difficult for me as time goes on, as I see things in the context of her drug use but can't address them directly.)
#3 is the obvious ethical default, but it's hard to just stand by and watch when you know someone is doing this to themselves.



At Mon Oct 16, 06:28:00 PM, Blogger Pieces of Mind said...

FWIW, you aren't just standing by and watching; you are making an effort to intervene, even if you feel right now as if it's going nowhere.

Option 4: Continue to subtly prod and let the patient know you will offer help if and when she needs/asks for it. Sometimes, once you've planted the seed, you have to nurture it along and wait for results.

It's tough when you get caught up in family dynamics and the whole "he said-she said" dilemma. In these scenarios, the truth tends to be hard to pin down. Sometimes the truth isn't on one side or the other; it's somewhere in the middle.

At Mon Oct 16, 07:30:00 PM, Anonymous Anonymous said...

I'd go with #4 as well, only don't prescribe the obvious sought after drugs. Remember, things aren't always what they seem . . .

At Mon Oct 16, 08:39:00 PM, Blogger Shodan25 said...

I would vote for #3, with the proviso that you never give her any tranquilizers or pain meds. Families with problems do weird stuff and say strange things to "get back at" their relatives. With the information given, I'm not sure I'd trust the brother. Mind you, I'm not sure I'd distrust the brother either.

Drug use, particularly snorted or injected drugs, shows up pretty quickly to an informed observer, lika a doc. I've never heard about rookie, casual drug users (which she has to be if there are no signs) hanging out with scummy street dealers selling dime bags.

You could always request a urinalysis on a pretense...

At Mon Oct 16, 09:03:00 PM, Anonymous Anonymous said...

1 and 2 are absolutely ethically prohibited, imho. You were given confidential information, it is not your decision whether to disclose it. Even if she is a drug user, she is under no obligation to talk to you about it; it's up to the patient to decide how involved they want the doctor-patient relationship to be.

You might ask both parties if they were interested in having a family conference with you moderating, though. If the sister isn't aware that you treat her brother than I think she should be -- she should have the option of choosing to go to a doctor who isn't treating other family members if she wishes.

Also, I think that "I'm not very good at keeping secrets" is a poor way to broach a topic as a physician. I'd be super concerned if my physician told me that in any context. I would wonder if this means that my confidential health information isn't really confidential.

At Mon Oct 16, 09:16:00 PM, Blogger Big Lebowski Store said...

Tough case.

Go with #3. I'm not sure you have a choice.


At Mon Oct 16, 11:21:00 PM, Blogger Felix Kasza said...

I believe this is less a question of medical ethics and more a question of honourable behaviour in general. You are not Abigail's guardian, nor were you appointed to snoop or, worse yet, meddle.

Option #3, all the way. Should the patient request drugs that are commonly abused, you would then base your decision on the same criteria that you would apply had you never met Bob.

At Mon Oct 16, 11:27:00 PM, Anonymous Anonymous said...

I think you are walking on a very thin line. I would stay out of mediating between family members; if anything goes wrong, they are blood relatives, you are not.

If the family doesn't want to get involved, I have serious doubts you can persuade a drug addict to accept a detox. She'll probably have to hit rock-bottom first.

No good deed goes unpunished. This is one of those situations where one has to watch from the sides, even if there is no happy end in sight. From a HIPAA standpoint, you shouldn't even have disclosed that you found no evidence she was a drug addict.

Option 4 seems the best.

At Mon Oct 16, 11:29:00 PM, Anonymous Anonymous said...

On a second thought: option 3, with option 4 as a backup, in case you cannot resist the urge of doing something.

At Tue Oct 17, 06:08:00 AM, Blogger #1 Dinosaur said...

Last anon: I never actually disclosed to Bob that I hadn't found anything on exam. In fact, I never disclosed to him that I'd even seen her a second time. The whole conversation was phrased in the hypothetical: "What if" she denies it/I don't find anything.

The sister has never displayed anything in the way of "seeking" behavior. Apparently she only does cocaine. The brother is fed up enough that his only concern is the crap the sister is putting his newly widowed mother through. Each is aware the other is a patient of mine. Neither comes in all that often, so it's a very episodic kind of story.

Good input here, so thanks all.

At Tue Oct 17, 06:24:00 PM, Blogger Unknown said...

I want to propose an 8th Law - The reliability of family information is inversely proportional to the family's level of dysfunction.

Not as flip as it sounds - I think this is an ethical quagmire
for which option 3 is the only viable approach.

Regards - Shinga

At Wed Oct 18, 12:16:00 AM, Blogger drncc said...

Heya dinosaur,

In the small town where I practice, I get (unsolicited) an awful lot of third-party "intelligence" about individual patients.

(Including newspaper clippings about arrests of family members and close associates, added to the chart by the staff, which I remove.)

Your dilemma arises frequently.

I don't know what to do either.

For this patient's particular situation, I would look mostly at 3 or 4 as outlined above.

Maybe 5. "toughlove" would help. No drugs that can be diverted (or daily partfills with a drug contract, maybe with random urine testing). If she's legit she'll complain only briefly about these limitations.

Careful cultivation of her confidence. I have one guy who told me about cocaine after his LFTs came back elevated.

If it looks like drug use, be straight with her that this looks like drug use. And about the threat to her health and drug interactions. And about confidentiality.

Leave her brother out of it.

Maybe she'll trust you or be scared enough to come clean.

All we can do is what the patients let us do.


At Wed Oct 18, 12:39:00 PM, Anonymous Anonymous said...

Sir Dino -

I understand your wanting to intervene and protect/help your patient - it is admirable and obviously part of what makes you a great doctor. But consider:

You have no proof of any wrongdoing on the sister's part. NO PROOF WHATSOEVER. All you have is hearsay from a brother who admits he is not happy with her. His proof? He has seen her with people he cannot identify. These are drug dealers? Really? He can tell who is a drug dealer by looking at them? Why doesn't he work for the police?! And why didn't he call the police to report them if he had any other proof as to their occupation?

That is ALL you have to go on. In fact, your own exam came up COMPLETELY NEGATIVE for any concerns. From how I read your post (which may or may not be true), you believed everything this woman told you, with no reason to suspect otherwise. She raised no red flags to you.
So WHY are you choosing to believe a brother whom she states is "not very supportive"? Why not believe the person accused?
I have a brother with whom my entire family does not get along. We have in fact disowned him. If I'm feeling petty about him, I can make someone who doesn't know him well believe all sorts of things about him. Doesn't make them true, or perhaps they're just my suspicions, but they will be believable.
Perhaps option 4 is your best choice. Or may I offer option 5 - trust your inital reading of the patient, and trust your exam findings. If he is more credible and trustworthy than her, choose 4. If she is more than he, choose 5.

At Mon Nov 13, 02:56:00 AM, Blogger adventures in disaster said...

First you need to examine your own motives here.
What purpose are you serving?

Abigail has never asked you for drugs.Abigail has never requested medical intervention for addiction.

Her brother told you that Abigail is giving her mother a bad time.
This is third party information. You have no idea how the mother feels, the mother has not requested your assistance.

Abigail came to you, her doctor in confidence for some support, you provided that. Your duty ends there.

Next time you see the brother you need to CLEARLY tell him Abigail has a right to medical privacy.
What is being indulged here is gossip, plain and simple.
Support both patients with a generic "that is a pity" and move on.

Unless Abigail comes to you and asks for drug treatment you have no right to treat her like a drug addict.
On the word of a brother who admits he has a poor relationship with Abigail you have labelled her a potential drug seeking coke head.

Step away from the gossip, everyone deserves to be treated not guilty until proven.
For all you know the brother is the coke head and he is doing a little end run manipulation because he thinks Abigail said something bad about him to you.

Dn't be so naive as to believe Bob doesn't know you recently saw Abigail.

Disengage from this.
Poor Abigail, if she gets hit by a bus she will get denied pain medication because her chart will announce she is a coke head..according to her disgruntled brother...acck.


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