On the virtue of being friendly, 

but not friends

I used to take care of one of my best friends, someone I’ve been close to for decades. Then one day we had a minor falling out over personal stuff and he didn’t return my phone calls for a while. That’s when I realized I would rather discharge him from my practice than from my life.

Why? Because our spat, as brief as it turned out to be, could have put his health at risk. During the time I couldn’t get through to him for personal reasons, I also would not have been able to reach him with medical information if I’d needed to. When your doctor calls with medical information, you have to make that call a priority and not let personal things get in the way.

This is called clinical distance, and in our opinion it is essential to the best medical care. Without it, there is a small but vital level of objectivity that melts away in the warmth of personal friendship and that, believe it or not, can be the difference between life and death.

Here’s another example that reinforced the importance of clinical distance. I had a new patient, a man in his 40s, who told me he was about to get married. When he came in for his annual physical, I did a rectal examination. I didn’t really get a good feel of his prostate gland, but since this was his first such exam, I didn’t want to make him uncomfortable. While he was getting dressed after the exam, I went back to my office and thought about it. I realized that the right thing to do for him medically was to march back into the room, explain that my exam was incomplete, ask for his understanding, and then do a more detailed — and less comfortable — examination.

He concurred, and I immediately had a second dilemma — but this was the kind of dilemma I’d trained for. His prostate did in fact harbor a worrisome nodule. Of course it went through my head that the nodule might be nothing, and I didn’t want to be the joy-killer who diagnosed prostate cancer in a relatively young patient who was about to get married and go on his honeymoon. However, I had to. So I went back into the room and explained what I found and what I recommended: a biopsy.

Unhappily, my suspicion of malignancy was correct. Happily, he went on to be treated — and almost certainly cured — as well as to be married. And I learned a lesson about the utter necessity of objectivity.

With this lesson still in mind, I declined when a patient whom I’m very fond of invited me to a low-key social event. It pained me to have to awkwardly explain that while I would’ve loved to spend time with him as a friend, that was not my role. He thought about it, looked at me, and said, “You’re right. I’ve got lots of friends. I don’t need more. I need a doctor.”

Also for reasons of clinical distance, I’m a little leery when someone tells me they asked their friendly neighbor who happens to be a physician for advice. I know that almost all the time, this is perfectly fine. But I also know that in the small percentage of times when it isn’t, it can really cause problems. So I suggest to people that they not seek medical advice outside of an actual medical setting. At work, we physicians are 100% physicians, but at home we’re not.

So if you’re a neighbor who wants to borrow my power washer, I’ll seriously consider your request. If you want me to look at the thing you just discovered on your forehead, I’d rather you find a doctor who can be 100% your doctor.



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