AMA Journal of Ethics^®

Case

Dr. Manning had been Mr. Hayden’s primary care physician for two decades. Previously in general good health, at 51 Mr. Hayden experienced severe chest pain and shortness of breath. His wife drove him to the local emergency room. After receiving a work-up for his symptoms, Mr. Hayden was diagnosed with an arrhythmia and transferred to the cardiology unit. He received a pacemaker and was prescribed medication to help manage his condition. He was also advised to take things easy and cautioned that, even after his recovery, he could not return to his job as a metalworker in a machine fabrication shop.

Some months after the pacemaker surgery, Mr. Hayden visited Dr. Manning for follow-up. He told Dr. Manning that, because he could not return to his job, he would lose his employer-sponsored insurance at the end of the month when he had exhausted his sick time and vacation. He said he had been unsuccessful in finding less strenuous work that fit his skills and knowledge. Even with the provisions provided by the Affordable Care Act, maintaining basic payments and covering his necessary medications would be difficult.

The following day, a friend of Dr. Manning who owned a small business told him that she was hiring for a position that seemed to fit Mr. Hayden’s education and skills and would not, it seemed to Dr. Manning, jeopardize Mr. Hayden’s health. The position came with benefits, including health insurance coverage. Dr. Manning wondered whether he should tell Mr. Haydon about the position.

Commentary

In Dr. Manning’s position, I would without any hesitation help this patient by speaking to my friend. I realize that some doctors, who have firm barriers between their professional relationships and the lives of their patients, would not do so. They may be truly empathetic but do not cross certain lines in the patient-doctor relationship. They seem to never take off their white coats. They are armored against being too involved with their patients and therefore stick to the medical aspect of the relationship at all times.

Others, who follow a strict interpretation of the Health Insurance Portability and Accountability Act (HIPAA), never share who their patients are with anyone. This approach certainly follows the letter of the law, if not the spirit of it. I think this strict interpretation is slowly changing but is still the generally accepted view.

In primary care, however, the physician’s areas of concern are broader than they might be in subspecialty care, and there is more latitude in defining the borders of the patient-doctor relationship. Primary care doctors deal with “dis-ease,” which can be defined as a problem, whether it is medical or psychosocial, that is causing dysfunction in the patient’s life.

I have always thought that a more compassionate, open style was the better approach to patient care. It allows me to use my “helping personality.” The opportunity to truly help a patient, medically or otherwise, during a difficult time, is personally rewarding to me. Obviously, there has to be a certain professional distance or boundary between the doctor and the patient. The doctor certainly should maintain patient confidentiality, but his or her humanistic, helping self should be present. In fact, I learned a long time ago that an emotional relationship with patients is a critical tool in helping them get well.

The question always is where to draw the line in helping? There are a number of issues I hear my students struggle with all the time:

What should patients call me? Are first names ever appropriate?

Should I wear a white coat or dress like my patients dress?

Should I give out my home phone number, especially when I can do more than the on-call doctor?

Should I accept gifts?

Should I go to dinner at a patient’s house when invited?

Should I go to a patient’s funeral?

And—the important question raised in this case—should I help a patient cope with life’s obstacles or limit my help to purely medical issues?

When I was a student, one of my professors said to me: “John, when you practice, friends will become patients and patients will become friends. You have to learn to handle the situation ethically and morally.”

Some basic rules are important. Do not use the patient for your own advantage. You are there to help your patients. As the old saying goes, “If I give you a fish, you eat for one day, but if I teach you how to fish, you’ll eat for your whole life.” So our helping should not foster dependence but, instead, aid someone in starting something positive in his or her own life.

With that in mind, it seems clear that you certainly may network with a friend to help your patient get a new job. It would be a good idea to talk with your patient first and get his or her permission to discuss the situation with your friend. Assure the patient that there will be no divulging of medical information and then inform the friend that the patient might be in contact. It should be noted that there may be taking some risk—if your patient is hired and doesn’t work out, there might be some discord between you and your friend. But by facilitating this communication, perhaps you can provide some life-changing good for your long-time patient.