Conflicts of interest

So up front, I want to say that many names and details have been changed in this story, but sadly, mostly not to protect the innocent. One of the joys of practice when I still did full-service family medicine was to have whole families under my care. I loved seeing parents and children, knowing the grandparents, aunties and uncles. It gave me a very complete and nuanced understanding of people’s lives and their health issues. It is easy to remember the family history when the family are also your patients. There are times, however, when having multiple family members can be a challenge. First, you have to remember who told you what. “Is Kahlua on Rose’s diabetic diet?” for example. You have to remember not to reveal that you have knowledge of things you are not supposed to know, like the father’s will where one patient is favoured. But the absolute worst is when one patient puts you in a conflict of interest with another. One man in my practice put me in the worst position that I can recall. This man was well to do, highly respected and very prominent in the community. While his wife was not as high profile, but she was a highly respected professional in her own circles. Their 14-year-old son was in the throes of early adolescence and wasn't the easiest person in the world; laconic, shy and surly. They's all been my patients for years. One day the man came to see me. Unusually, he was there alone without either his wife or son. After we spent some time discussing his blood pressure and some screening plans, he looked me directly in the eye and said: “Everything I tell you here is confidential, right?” Read: What I learned at my mother's knee before, during and after abortion reform “Well, yes,” I replied. “Unless someone’s life is in danger, I am bound by rules of confidentiality.” He then swore me to secrecy. “My wife and kid are your patients. I absolutely do not want them to know what I am about to tell you.” I should have known what was coming, but I was shocked when he said. “I am having an affair with my assistant and protégée, so I need you to check me for sexually transmitted diseases, but you must promise to never reveal this to my family! I felt caught. We discussed what he would do if the tests came back positive. “They won’t be,” he said. I wished he had gone somewhere else and had anonymous testing instead of making me complicit. I felt he was deliberately manipulating me, enjoying my discomfort, but I did not think I had any options, so I agreed. Soon after this, his wife began having terrible migraines. She had always had occasional migraines in the past, but suddenly they were much more severe, almost constant and debilitating. I did a full work-up, neurology consult, ER visits, imaging, the works. She was on increasingly stronger prophylactic medications but was almost unable to work, spending more and more time in a darkened bedroom. Their son became more withdrawn and spent hours and hours in the World of Warcraft. Read: You used to buzz me on my pager I felt somehow responsible for all this dysfunction. Did my patient’s body know what her brain did not? I carefully asked her about psychological stressors and changes, but she denied any unusual stress or changes in her life. I was bound to secrecy and could only ask, not hint at what I thought was the precipitant for her newly terrible headaches. One day she called in to have an emergency visit. She was red-eyed and crying, her eyes almost closed against the lights in the office, her face a mask of pain. “My head is coming off!” She said. “My husband just told me he is leaving me! I called him yesterday when he was about to come home and told him that I had bought fish for supper, and he said, I can’t do this anymore and I said, what? If you don’t want fish it’s OK, we can have chicken. When he came in the door, he told me that he had been with his assistant for the past two years. He was in love with her and wanted to live with her. How did I not know this was happening?” I did my best to comfort her and gave her some advice. “Get a good divorce lawyer as soon as possible. Call a locksmith and change the locks and make sure that his access to your bank accounts and credit cards are ended.” Read: I'll walk you to your car This advice came from the experience of a friend. Her stay-at-home husband cleaned her out financially while she was away at a conference. She was at a bar, and she couldn't pay for the martini she'd just ordered. My patient, however, did not take kindly to this advice. “That is nonsense,” she said. “My husband is a good man; he will always treat me fairly. After all, we have a child together. “ Even though I had warned her, I was still surprised when my patient told me that she came home from work a few weeks later to find her apartment stripped. The art, the Persian rugs, the expensive cooking pots, even her mother’s pearls were gone. My patient’s income had decreased significantly since her severe migraines started. This limited her ability even to support herself and her son. However, she did recover enough to go back to work and earn a modest living, because funnily enough, her migraines pretty much disappeared when her husband did. Sometimes when couples divorce one of them gets custody of the family doctor. In this case it, she did. When I decided to write this story, I searched for this man on the internet. He is more prominent than ever, with money, power and accolades galore. He is now married to his third wife and has a five-year-old daughter. So, I still need to keep his secrets. Read: Melanie: A portrait of patient progress

Conflicts of interest

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Perle Feldman

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