Don't Treat a Relative? I'm Glad I Did

Article excerpt

Defying conventional wisdom, this doctor reluctantly acceded to his family's wishes.

"What happens if I make a mistake-and your father dies? Could you ever forgive me?"

My wife, Laurel, looked at me in bewilderment. She had long accepted on faith both my infallibility as an oncologist and her father's immortality "That won't happen," she replied. "You'll treat his cancer, and he'll be cured, and that's that."

Then, more plaintively, she asked, "Daddy's not going to die, is he?"

"Probably not," I told her, trying to make my tone sound more positive than my words. Who could be certain? Although the best results for stage I large cell lymphoma-a 75 percent cure rate-were far better than for most cancers, a cure was hardly a sure thing. Besides, Dad was over 80 years old. He looked relatively youthful, but I knew that under the impact of aggressive multi-agent chemotherapy, patients tend to age very fast.

The conventional wisdom is that physicians should not treat family members. Accepting that dictum, I had begun my involvement in my father-in-law's health care with the careful decision not to be his doctor. One day when I was hopelessly behind schedule-my waiting room overflowing with sick patients-my nurse knocked on an exam room door to call me to the phone. The fear in my wife's voice persuaded me not to complain about the interruption. Her father had been seated at our kitchen table chatting with her when he suddenly slumped and seemed "out of it" for a few seconds, she said. Then he was perfectly normal.

"Take him to the emergency room," I said. "Maybe it's something, maybe it's nothing, but he needs a doctor to evaluate him-not a sonin-law analyzing a second-hand report of symptoms."

Dad left the hospital several days later, sporting a dull red incision on his chest where a pacemaker had been implanted. I was pleased: He had received fast and proper medical care and hadn't suffered another episode of syncope-or worse. And I had given him good, nontechnical advice without becoming his doctor.

Or so I thought. A few weeks later, I saw my father-in-law's name on my list of patients for the day. I later learned that since the pacemaker surgery, he had been complaining of pain in the chest, near the incision site. More from stoicism than from stubbornness, he had refused to call his doctor. "It's not that bad;' he had told my wife. "I dori t want to bother him for a little thing like this."

Worried about his inaction, Laurel had simply called my office to arrange an appointment. Neither Dad nor I was happy about that, but we had no choice. Sometimes my wife, like Hilda Rumpole of the British mystery series, is simply "She Who Must Be Obeyed."

I assumed that my examination would reveal a tender pacemaker generator pocket, an ordinary problem that could be handled with a simple NSAID. But that's not what I found.

Dad had a lump in his axilla.

I explained the range of possibilities that the lump represented, including cancer. Ordinarily, I would have handled that type of problem without any consultation. But I was still trying to avoid becoming his doctor. I had Dad evaluated that day by the cardiologist who had implanted the device. He agreed with me that the axillary lymph node felt soft, like a reactive lymphadenitis. He ordered a chest CT scan, which showed no subpectoral abscess beneath the generator site.

We agreed to treat the findings as a post-op infection, but neither of us was completely satisfied with the diagnosis. If the lump was reactive lymphadenitis, what was it reactive to?

"Here," I told my father-in-law, "take these pills for 10 days. On the 11th day, I want to see you back here. If the lump hasn't gone away, you'll need a biopsy." Too often, I'd seen cancer patients whose primary care doctors had dithered for months, losing valuable time as they treated lymph node malignancies as infections. …