When Doctor Becomes PatientAmy471

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FAMILY MEDICINE VOL.44,NO.7JULY-AUGUST2012 471

ORIGINALARTICLES

Physicians are taught strate-

gies or communicating with

patients throughout the clini-

cal encounter. Special circumstances

arise, however, when the patient is

also a physician. Literature exists re-

porting the perspective o physicians

who have become patients;1-4 howev-

er, little inormation is available in

the extant literature exploring the

experiences o physicians who care

or physician-patients. As with other

patients, primary care providers will

likely provide the rst and ongoing

contact or physician-patients. Strat-

egies or addressing this relationship

and maximizing communication

within it need to be explored so that

primary care clinicians can provideeective care or physician-patients.

The health care physicians receive

or themselves and their amilies

does not always address their unique

needs. Several studies show that

physicians dont pursue adequate

health care.1-5 A survey o general

practitioners sel-reported care-

seeking strategies ound that phy-

sicians tend to treat themselves or

seek an inadequate curbside consul-

tation with a colleague.1 Problems

arise when physicians incomplete-ly describe diagnoses or treatment

and assume their physician-patient

is knowledgeable on his or her con-

dition, become chummy with the

physician-patient, and treat them as

a colleague rather than a patient.4-6

There are ew existing systematic,

empirical investigations o the chal-

lenges physicians ace or strategies

they use when caring or physician-

patients. Rather, relevant articles

addressing caring or physician-

patients tend to be general reviewso physician-patient care-seeking

behaviors or based on the authors

personal experiences o caring or

physician patients.4,6-7 For example,

Krall4 and Stoudemire and Rhoads7

make recommendations o how phy-

sicians might approach caring or

From the University o Iowa.

When Doctor Becomes Patient:Challenges and Strategies in Caring for Physician-PatientsAmy Domeyer-Klenske, MD; Marcy Rosenbaum, PhD

BACKGROUND AND OBJECTIVES: The current study was aimed

at exploring the challenges that arise in the doctor-patient relation-

ship when the patient is also a physician and identifying strategies

physicians use to meet these challenges. No previous research has

systematically investigated primary care physicians perspectiveson caring for physician-patients.

METHODS: Family medicine (n=15) and general internal medicine

(n=14) physicians at a large Midwestern university participated in

semi-structured interviews where they were asked questions about

their experiences with physician-patients and the strategies they

used to meet the unique needs of this patient population. Themat-

ic analysis was used to identify common responses.

RESULTS: Three of the challenges most commonly discussed by

physician participants were: (1) maintaining boundaries between

relationships with colleagues or between roles as physician/col-

league/friend, (2) avoiding assumptions about patient knowledge

and health behaviors, and (3) managing physician-patients access

to informal consultations, personal test results, and opinions from

other colleagues. We were able to identify three main strategies

clinicians use in addressing these perceived challenges: (1) Ignore

the physician-patients background, (2) Acknowledge the physician-

patients background and negotiate care, and (3) Allow care to be

driven primarily by the physician-patient.

CONCLUSIONS: It is important that primary care physicians un-

derstand the challenges inherent in treating physicians and devel-

op a strategy with which they are comfortable addressing them.

Explicitly communicating with the physician-patient to ensure

boundaries are maintained, assumptions about the physician-pa-

tient are avoided, and physician-patient access is properly man-

aged are key to providing quality care to physician-patients.

(Fam Med 2012;44(7):471-7.)


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472 JULY-AUGUST 2012 VOL. 44, NO. 7FAMILY MEDICINE

ORIGINAL ARTICLES

their physician colleagues based on

looking at the literature on physician

care-seeking behaviors. They iden-

tiy the desire or curbside consul-

tations and special access and the

diculty o role reversal as partic-

ular challenges in caring or physi-

cian patients. As another example,Schneck6 provides recommendations

based on personal experiences car-

ing or physicians in his neurology

practice. These recommendations

include such things as physicians

being just as thorough with inorma-

tion gathering through history tak-

ing and physical examination with

their physician-patients as they are

with others and addressing some o

the anxiety and awkwardness o the

encounter directly.6

The objective o this study is toexplore the experiences o a sample

o primary care physicians who care

or physician-patients to delineate

the inherent challenges in this rela-

tionship and the strategies used to

address them.

MethodsIt is standard practice in medi-

cal social science research to use

qualitative methods when investi-

gating domains o knowledge and/

or experience about which little isknown.8,9 To achieve a more compre-

hensive understanding o the actions

o physicians who treat physician-

patients, a qualitative approach

using open-ended interviews and

thematic analysis was used. The In-

stitutional Review Board approved

this project.

Participant RecruitmentStudy participants were physicians

at a large Midwestern university

who provide care to physicians in theUniversity Health Care (UHC) sys-

tem. All primary care physician ac-

ulty members rom the Departments

o Family Medicine (n=25) and Gen-

eral Internal Medicine (n=20) were

invited to participate. All physician

aculty at UHC are given the option

to choose a primary care provider

as part o the employee health plan

and aculty in the two participating

departments make up the majori-

ty o providers within these plans.

Potential participants were intro-

duced to the purpose o the study

via emails and announcements at

department aculty meetings.

Data CollectionData collection involved open-

ended and semi-structured inter-

view questions guided by existing

literature1-7 and the studys content

ocus. All questions were piloted

with three aculty members prior to

data collection to ensure the ques-

tions were useul or understand-

ing the physicians perspective on

medical encounters with physician-

patients. Questions asked physicians

about their experiences caring or

physician-patients and how provid-ing care to physicians diers rom

providing care to nonphysician pa-

tients. Participants were asked about

challenges and strategies they have

developed or eectively caring or

physician-patients. Participants were

also asked to describe both positive

and negative examples o caring or

physician-patients. All interviews

were conducted by the rst author

(AD-K), a second-year medical stu-

dent at the time o the interviews.

AnalysisInterviews were tape recorded, tran-

scribed verbatim, and entered into

a Nvivo 8 database that allowed or

systematic searching, coding, and re-

trieving o qualitative data (Nvivo 8.

Qualitative data analysis sotware.

Doncaster, Victoria, Australia: QSR

International Pty Ltd, 2007). The-

matic analysis, meaning inductive

identication o codes or major topics

arising out o the data rather than

imposed on the data, was applied totranscripts to identiy salient themes

in participants perceptions and ex-

periences o caring or physician-pa-

tients. Using this approach,8-9 each

author read through 10 interview

transcripts that included the range

o physician experiences to identiy

initial themes that occurred in par-

ticipants discussions o caring or

physician-patients. These themes

were then compared, and a prelimi-

nary coding scheme was developed

and applied to coding subsequent

transcripts. Content o each code

was then reviewed to ensure that

all transcript segments refected the

main themes and to identiy salient

subcategories within each theme.The analytic process used and ma-

jor themes are depicted in Figure 1.

Analysis ocused on identiying pat-

terns and challenges in physician re-

lationships with physician-patients

as well as strategies physicians iden-

tied using in treating physician-

patients.

ResultsThirty physicians agreed to partic-

ipate in the study, including 16 o

the 25 amily medicine aculty mem-bers and 14 o the 20 general inter-

nal medicine aculty members. One

junior amily physician was exclud-

ed since he reported caring or no

physician-patients during his career.

Participants represented a range o

experience and reported treating be-

tween an estimated 5 to 100 or more

physician-patients in their career

(See Figure 2). The participants in-

cluded 16 male and 13 emale physi-

cians. Physicians responses included

descriptions o their personal experi-ence treating physicians as well as

their perceptions o the challenges

many physicians ace in these cir-

cumstances. A range o their re-

sponses are included in the Results.

ChallengesThe three challenges consistently

identied by study participants were

(1) maintaining boundaries within

the physician-patient relationship,

(2) avoiding assumptions about pa-

tient knowledge or health behavior,and (3) managing care o physician-

patients in the context o their high

level o access to health care inor-

mation and resources. The myriad

relationships physicians had with

their physician-patients created con-

usion or physicians in determining

what their role was in interacting

with physician-patients both in and

out o the clinic setting and caused


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ORIGINAL ARTICLES

overlap between some o the chal-

lenges.

BoundariesPhysicians described diiculty in

maintaining boundaries between

relationships they had with their

physician-patients. Some o these

relationships included riend, col-

league, co-worker, patient, teacher,

or learner. One physician stated:

There are some boundaries that

have not been acknowledged and

then somebody is asking you

to cross that boundary in some

very personal way I Im not in

that situation where I have those

boundaries up, I simply say to peo-

ple, Im about the dumbest person

youve ever seen when I dont have

my white coat on.

Another physician noted:

I might be taking care o a doc

medically, the next day wed be

in a business meetingand then

the next day we might be sitting

down across the table at a wed-

ding. I think your lie is not abso-

lutely compartmentalized.

Study participants varied in the

extent to which they experienced

diiculty in separating relation-

ships with physician-patients. For

example:

I dont think you can totally sep-

arate them [ie, roles] but I think

you have to try really hard to sep-

arate them becausewhen you

see somebody in the hall you dont

want to hammer at them that

theyre your patient. You want to

just talk to them as a colleague

about other things.

Other physicians did not perceiveas much trouble separating these re-

lationships. One physician said:

The relationship changes quite a

bit when youre in a room talking

to somebody. Its more o a patient-

doctor relationship. Most physi-

cians assume the role o a patient

and deer the role o physician to

me.

Figure 1: Thematic Analysis of Perspectives on Caring for Physician-Patients

eliminarycodes

Challengesincaringfor

physician-patientsStrategiesincaringfor

physician-patients

Step1:Iterative

transcriptreadingto

identifypreliminary

codes

Step2:Grouping

ofcodesintomain

categories

Step3:Group

codesintoprimary

themes

Maintaining

Boundaries

Avoiding

assumptions

Managing

care/access

Ignore

patient

background

Acknowledge

background

&negotiate

care

Physician-

patient

drivescare

Step4:Ensurethatallperspectivesare

capturedwithinthemes


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ORIGINAL ARTICLES

The issue o boundaries became

especially dicult when physicians

perceived an emotional component

to the relationship with their phy-

sician-patient. As one participant

noted:

In my case, they [physician-pa-

tients] have been colleagues so

thats even harder because not

only are you treating a physician,but youre treating a buddyYou

tend to order more tests because

you really care about that person.

Many participants ound it di-

icult to discuss sensitive topics

because o their proessional rela-

tionship with physician-patients:

I Im taking care o a colleague in

my own department that I know

airly well, sometimes its a little

uncomortable to talk about men-

tal health issues or domestic vio-

lence or substance use or sexual

risk actors.

The challenge o discussing sen-

sitive topics was urther complicat-

ed by physician-patients concerns

about the conidentiality o their

medical record. As another physi-

cian said:

I think sometimes theres a reluc-

tance on the part o other physi-

cians to disclose things when they

go to see their health care provid-

er because theyre always worried

about the medical record and whos

going to have access to it.

AssumptionsParticipants described the challenge

o avoiding assumptions about their

physician-patients. Some physicians

assumed that the physician-patient

had knowledge above the average

patient. One participant said:

They know the ramiications o

what might be diagnosed and what

medical terminology means and

these sort o things. It [the patient

encounter] can be more ecient.

Other physicians preerred to avoid

assumptions about physician-

patients knowledge and treat themas any other patient. For example:

In some cases, ones desire to ex-

plain can come o as being con-

descendingI think in a case o

treating physicians, ones to as-

sume neither too much nor too lit-

tle. How do you igure that out?

You talk. You have a genuine di-

alogue.

In many instances, physician-

patients were assumed to monitor

their own symptoms or care, sched-

ule their own ollow-up, and know

whether or not their issue was seri-

ous enough to seek care. One physi-

cian said:

I think [physicians] tend to think

[physician-patients] are going to

notice i something is wrong andtend not to come in unless it is

necessary. There are exceptions to

that, o course, but I once went 6

years without a pap smear because

I just got busy and when I think

about it Im smart enough to

notice symptoms i I see them,

I assume thats how other people

think about it too.

Physicians also described assump-

tions they made about the liestyle

and behavior o their physician-pa-

tients:

I think maybe I assume theyre

making the right choices, which

might not create a super sae en-

vironment.

There was an assumption that a

certain comort level should be a-

orded physician-patients. As one

participant noted:

Figure 2: Range of Experience Treating Physician-Patients

Number of Physician-Patients

Participants


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ORIGINAL ARTICLES

[Physician-patients] sometimes

get worse care because others

that have been involved in their

care tend to make assumptions

about what is unnecessary or nec-

essary related to the evaluation or

management o a given problem

a certain uncomortable part o an

examination should be skipped or

a certain line o questioning should

be skipped because its uncomort-

able and unnecessary.

Physicians discussed how these

assumptions could lead to less or,

in some cases, more care than they

might provide or lay patients. Some

physicians described using ewer

questions with the assumption that

the physician-patient would know

what inormation is important to dis-cuss. For instance:

[The history] is oten less work or

me to do because I can say, Tell me

the story, and theyre more likely

to know what might be more im-

portant aspects o the story. Theres

a trust that theyll eed me the in-

ormation that I want in a more

concise manner.

Other physicians provided a more

thorough history and physical examwith the assumption the physician-

patient had higher expectations or

was evaluating their perormance.

One physician said:

I think [the physical exam] is a lit-

tle bit scarier with a physician, es-

pecially i we have a partialist that

were seeing, an ophthalmologist,

or an ENT doc, or something like

thatwhen youre doing the un-

doscopic exam youre going Eh, I

hope Im doing this OK. Theres al-ways that concern that theyre go-

ing to pick up on something, Oh he

didnt do this or that.

Similar trends or providing more

or less health care than average pa-

tients were described with regard to

diagnostic testing and treatment o

physician-patients.

AccessParticipants discussed the increased

access physician-patients have to

medical inormation and knowl-

edge (their own, research articles,

colleagues, etc), sel-reerrals, and

curbside communication. Curbside

communication was described as aninormal means o contacting their

physician, including email, hallway

discussions, or social gatherings.

Physicians were divided on their

eelings about curbside communica-

tion. Some ound it helpul:

The [health care] process is very

much inluenced by [physician-

patient] access to inormation, their

easy access to curbside consulta-

tion, which I dont think is a bad

thingI think [patient care] actu-

ally moves a bit aster.

Others elt it hindered physician-

patient care:

Theres no evaluation. Theres no

documentation. Theres no ollow-

up. Those aspects are why I say

that I think physicians oten get

poorer health care than traditional

patients, and I will not do [curbside

consultations].

Physician-patients also were per-

ceived as having unique health care

management because o increased

access. They were described as sel-

reerring to specialists, bypassing a

primary care physician who would

otherwise manage and coordinate

their care. A participant said:

[Physician-patients] are saying,

Oh, Im having this problem, Ill

go talk to one o my riends whos

a neurologist or I guess I betterget a mammogram, and schedule

it and just not go through every-

thing that needs to be done. But

wait! Your lipids havent been

checked, and you didnt get your

tetanus shot! Its just more piece-

meal health care.

StrategiesPhysicians adopted a variety o

strategies or addressing the chal-

lenges o caring or their physician-

patients. We identied three main

approaches: (1) ignore the physi-

cian-patients background, (2) ac-

knowledge the physician-patientsbackground and negotiate care, and

(3) allow care to be driven primar-

ily by the physician-patient. These

categories were not mutually exclu-

sive, and some participants noted

using aspects o each o the three

strategies. Additionally, there was

sometimes a dierence between the

strategy participants claimed was

right and the one they used in prac-

tice. Participants also acknowledged

that their strategies have evolved

with experience, or example:

I think the older I get, the more ex-

perienced I get, the more I proba-

bly think that the way I treat them

should not be dierent and is not

dierent.

Ignore the Physician-PatientsBackgroundOne strategy was to ignore the phy-

sician-patients background and treat

them the same as other patients.

One participant said:

You walk through that door, and

you are the doctor. The other per-

son is not a doctor. You have to de-

doctor them. You have to strip

all those proessional assumptions

away. Theyre just another patient.

In general, physicians using this

strategy described setting strict

boundaries to avoid altering the care

they provided or physician-patients.

For instance:

I do give the physician-patients a

little disclaimer. I just say, Hey, Im

going to treat you like every other

patient, some o the things might

be embarrassing or rustrating, but

we just have to get through it.


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ORIGINAL ARTICLES

Acknowledge Physician-PatientsBackground and Negotiate CareAnother strategy was to acknowl-

edge the physician-patients back-

ground and negotiate a care plan

agreeable to patient and provider.

For example:

Theres probably a little bit more

negotiation in some casesI had

to talk with [a physician-patient]

about, What would you preer to

take? and balance that with what

I think was best or her.

Open communication allowed phy-

sician-patients to choose how much

they wanted their own medical

knowledge to aect the care they

received. One physician said:

The range [o physician-patient

preerences] was all over the

placeI think [communication]

was very helpul with opening

the dialogue so [physician-pa-

tients] knewI was open to dis-

cussing their preerences and that

we would include those in uture

shared decision-making issues as

they would arise.

Another physician elt:

Open communication is critical.

and I think it actually helps phy-

sician-patients eel more reassured

theres no assumptions or corner-

cutting going on in their care.

Care Driven Primarilyby the Physician-Patient

A third strategy was to allow the

physician-patient to have the ma-

jority o the control in health care

decision-making. Participants would

go along with requests o physician-patients more than they would with

other patients unless it was contra-

dictory to their philosophy o care.

One participant said:

I [the physician-patient] said,

Why dont you add a asting lipid

prole? and I think to mysel, Be-

cause its not indicated according

to the rules, but i they ask or it,

I might be more willing to do it.

This strategy oten resulted in phy-

sicians providing special avors or

physician-patients or altering their

strategy o care to accommodate the

physician-patient. For example:

I have a physician who is taking

a medicationthat I wish I didnt

have to rell all the time. Im more

likely to go along with that. The

physician sometimes wants rells

without being seen, and I get un-

comortable with that and I think

you should be seen at least once a

year and usually Im trying to in-

sist on that but, you know, its hard

to do with a peer.

This strategy tended to allow phy-

sician-patients greater access to care

outside o the structured medical en-

counter than the participants who

tended to ignore the physician-

patient background.

DiscussionPhysicians ace unique challenges

when treating physician-patients, in-

cluding avoiding assumptions about

physician-patients knowledge and

behaviors, navigating boundariesbetween the many relationships

between physicians and physician-

patients, and understanding phy-

sician-patients increased access

to health care knowledge and re-

sources. These challenges are sim-

ilar to those previously discussed

in the literature (curbside consul-

tations, conidentiality concerns,

and assumptions regarding health

care).1-7 Limited articles exist in

the literature that describe strate-

gies physicians should use in car-ing or physician-patients, and ew

o these are based on direct empiri-

cal investigation o the perspective

o physicians providing this care.6,7

These articles do identiy some simi-

lar strategies to those that were dis-

cussed by participants in this study,

including discussing roles openly and

early, treating a physician-patient as

any other patient, and avoiding as-

sumptions by conducting thorough

history and physicals and discuss-

ing diagnosis and treatment plans.6,7

Thus, this study has empirically in-

vestigated and airmed, rom the

perspective o practicing clinicians,

challenges and strategies or ad-dressing the challenges o caring

or physician-patients. It should be

noted that some o the strategies

or addressing these challenges in

part refect more general models o

what is considered eective clini-

cian-patient communication.11 For

example, strategies such as not mak-

ing assumptions about any patients

knowledge, liestyle, or experience;

engaging in shared decision-making

with patients; and directly address-

ing challenges in the clinician-pa-tient relationships are undamental,

evidence-based approaches identied

in the literature that contribute to

successul clinician-patient relation-

ships.11

One limitation o our study is the

ocus on general practitioners ex-

periences with physician-patients.

Because o the tendency o physi-

cian-patients to sel-reer, general

physicians are sometimes avoided

in treatment o illnesses.10 Additional

studies are necessary to understandthe relationship between specialists

and physician-patients.

The purpose o the study was

to determine the range o respons-

es and strategies utilized by physi-

cians in treating physician-patients.

We were unable, however, to eval-

uate eectiveness o these strate-

gies. Further studies are warranted

to determine which strategies are

most successul in approaching the

challenges presented by physician-

patients. This study ocused on thesubjects experience as the practic-

ing physician caring or physicians.

The ndings rom the current study

provide a useul oundation or sub-

sequent investigations that could

include gathering data rom physi-

cian-patients about their perception

o the prevalence, eectiveness, and

challenges in receiving care rom


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ORIGINAL ARTICLES

physicians who use these dierent

strategies. A nal limitation in the

current study is that the population

or this study was limited to physi-

cians working at one Midwestern

university, and thereore it is uncer-

tain i the same perceptions and ex-

periences exist at other institutions.Primary care physicians need to

understand the challenges inher-

ent in treating physicians and de-

velop a strategy with which they

are comortable or addressing them

to ensure that physician-patients

are receiving appropriately man-

aged care. Some o the strategies

that existed within our study pop-

ulation were: ignoring the physi-

cian-patients medical background,

acknowledging the physician-

patients medical background andnegotiating care, and allowing the

care to be driven primarily by the

physician-patient. The challenges

associated with caring or a phy-

sician-patient tended to get easier

with experience. Explicitly communi-

cating with the physician-patient to

ensure boundaries are maintained,

assumptions about the physician-

patient are avoided, and ensuring

that physician-patient access is prop-

erly managed are key to providing

quality care to physician-patients.

Training could be provided to phy-

sicians to enhance their comort incaring or physician-patients, par-

ticularly those that are colleagues.

ACKNOWLEDGMENTS: Financial support orthis project was provided by a University oIowa Carver College o Medicine student sum-mer research grant. This research was pre-sented at the University o Iowa Medical Stu-dent Research Day, September 11, 2009; theUniversity o Iowa Bioethics Research SeminarFebruary 1, 2010; and the EACH Conerence,

Verona, Italy, September 35, 2010.

CORRESPONDING AUTHOR: Address corre-spondence to Dr Domeyer-Klenske, 21 Everett

Avenue, South Portland, ME 04106. 563-599-5666. Fax: 319-335-8904. [email protected].

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