On this week’s episode, Physician’s Weekly board member Dr. Alex McDonald speaks with Dr. Shannon Udovic-Constant about what physicians should keep in mind when treating colleagues or their children.

Dr. McDonald: Welcome everyone to this week’s Physician’s Weekly podcast, wherever you may be tuning in or listening. Thanks for joining us. Today is a great conversation. We are talking about caring for your colleagues and caring for your colleagues’ children. With us is my good friend and pediatrician, Dr. Shannon Udovic-Constant. Tell us who you are and what you do.

Dr. Udovic-Constant: Thanks so much for having me. I’m excited to join you in conversation. I am a pediatrician with Permanente Medical Group in San Francisco, where I’ve been in practice in outpatient pediatrics since 2001—so, 23 years. Time flies when we’re having fun.

Dr. McDonald: Excellent. Tell us a little bit about your experience caring for colleagues and, in this situation, colleagues’ children. I assume you don’t actually care for your colleagues. I’d be worried if pediatricians did, unless they’re Doogie Howser or something, and they’re a pediatrician while also being a physician. But that’s pretty rare, I imagine.

Dr. Udovic-Constant: Yes, that has been rare. I consider it the highest praise to be selected as a pediatrician for my colleagues. It’s your most prized possession and you’re taking somebody’s advice. I think, especially for us pediatricians, it can be hard to figure out whom you trust and whom you’re going to not doubt in those moments when you are most worried and vulnerable. It’s been really amazing to be able to do that over the years.

And I’ll tell you, I had an excellent experience that highlights some of the challenges that has happened with this. I wasn’t always so great at this. When I was only two years out of training and in my general pediatric practice, I walked into a room with a newborn baby, and the physician colleague who was there with this baby was someone who interviewed me for medical school. I was completely intimidated. I was still getting my bearings on how to do this doctoring on my own outside of training, and I just got nervous. It was the most awkward visit I think I’ve ever had.

It was because I got in my head about a way that I should or shouldn’t be, rather than trusting myself. I left the room, and I just shook my head and went, “Oh my goodness, what was that?” I came home and talked to my husband and said, “I had the most awkward visit with one of our colleagues today. Likely, I’m going to need to circle back and have a conversation about this.”

She had obviously felt the same thing and switched to someone else, I thought, excellent. Now, I don’t have to worry about this.

Dr. McDonald: Problem solved.

Dr. Udovic-Constant: Problem solved. Then I ran into her in the halls about a year later. I just approached her and said, “I’m so sorry for how awkward that visit was, and thank you for recognizing that it didn’t go well and for switching over.”

It was this reminder to be who you are, even if it’s with somebody with whom, for whatever reason, there’s some type of imbalance in the relationship, because it won’t go well if you aren’t. Approach those situations in the same way you would with everybody else, with a few caveats that we can get to.

Dr. McDonald: Sure. I think that story is telling and powerful. We’ve all had experiences like that, whether it’s with a colleague or just an uncomfortable patient interaction that leaves us feeling bad, and we can’t bring ourselves to work. For me, as a family medicine physician practicing sports medicine, the thing that I love best is connecting with my patients and colleagues. Sometimes, with colleagues or patients, it just doesn’t always fit.

Now, with a little more experience under your belt, what do you do when you are approached with a colleague who wants to have their childcare from you? What kind of boundaries do you set? How do you set expectations and move forward?

Dr. Udovic-Constant: If they just end up on my schedule, it’s a different conversation. I’ll do the visit as I usually would. I do explain at the beginning that I am going to recognize that you understand some medical terminology and you have a little bit more information on this. I’m going to approach decision-making with you in the same way that I usually would, recognizing we can get there a little faster because of your knowledge.  I think people appreciate that. I just call out that I’m not going to treat you differently. I’m going to explain things and do this decision-making in the same way.

If someone approaches me in advance and asks me if I’ll take them on in my practice, I will have a bit more of a conversation about ground rules that I think are important to establish upfront. This typically includes things like: I want you to use me for orders and prescribing. I will provide some courtesy to you in that access to me that is going to be a little easier, and you can bypass some of the harder ways to get to me. I’m also not going to deviate from standard of care. If it’s best for us to do something in person or it’s outside of my comfort, I am going to say no. As long as you’re comfortable with those parameters, then I’d love to care for your child.

Dr. McDonald:

I always like to joke that, practicing sports medicine, there is not a dinner party, a kid’s birthday party, or an event that goes past where somebody is not like, “Hey, my shoulder hurts” or “My knee hurts.” I doubt OBGYNs have this problem. And I’m sure pediatricians are the same way. “Hey, can you look at my kid’s rash?” or “Little Johnny’s been snotting, I think he has sinusitis.”

Being in one of those specialties that maybe feels a little bit more approachable in public—I’ll speak for myself, I tend to get cornered a little bit more, and those encounters are often with colleagues. I struggle with that a little bit. I want to be cordial. I want to be friendly. The system is just so convoluted. Let’s be honest, the whole healthcare system in this country is broken in general, so you want to help those that you can, especially your colleagues.

I really like how you set up those expectations and that framework ahead of time. I’ve cared for some of my colleagues, and it’s felt a bit rushed, and we jump to whatever they want rather than going through the process. It’s not as high quality or up to my regular standards. You feel like you’re doing them a favor, you’re squeezing them in. Does that ever happen to you as well, or have you been able to set up these guidelines ahead of time so that you don’t fall into that trap?

Dr. Udovic-Constant: Well, I think you have to approach each situation in a way that’s going to help you to sleep at night. I don’t have any hard and fast rules. I will run into somebody at a lunchtime meeting and they’ll say, “Oh my gosh, I’ve been meaning to share this picture with you. What do you think of this rash?” If it’s incredibly straightforward, I’m happy to provide information.

If I need some more context and we don’t have the time right now, I’ll ask my staff to reach out and we’ll get some time on the schedule for a phone call, at least. Send me those pictures so that I have them available and can use my thinking brain to properly do this. I think people appreciate that and recognize they don’t want to cut corners. Maybe that’s easier because it’s their kid versus themselves. That typically hasn’t gotten me into any trouble. I can just say, “Look, I really want to do this right and do good by you and your child,” and that tends to go well.

Dr. McDonald: That certainly makes a lot of sense. I want to go back to something that you said prior about it being an honor for one of your colleagues to trust you, especially with your children. I actually had a call recently from a former faculty member of mine who’s now retired. He said, “Hey, my knee’s really hurting. Can you get me in?” And I was a bit intimidated. This is somebody who trained me in many respects, and I’m deeply honored to have them even consider reaching out to me.

How do you approach that relationship? Does that change the relationship at all? Does that change the dynamic with you as colleagues, or is it one of those things that fills you up and provides you with professional fulfillment and satisfaction?

Dr. Udovic-Constant: It definitely fills me up now. I’m not as nervous because I am very solidly mid-career and very comfortable in my doctoring now compared with that awkward visit only two years in. It feels better now. I think what I would tell my earlier self is: you got this. Do what you would do with everyone else without getting in your head about the hierarchy.

The other piece is—and I think this is true for every specialty—your colleague may be an excellent anesthesiologist, but they don’t really know anything about pediatrics.

Dr. McDonald: Exactly.

Dr. Udovic-Constant: I’m married to a surgeon, and he jokes all the time with his family. He says, “You don’t want to ask me. You’ve got to ask her. She’s the one who knows that way better than I do.” So, even if somebody is an exceptional doctor, it doesn’t mean that they’re exceptional in pediatrics, child health, or child development. Also, they’re emotionally entangled in a way that sometimes makes it hard even to lean into the medical knowledge.

I often tell my doctor parents that I want them to call me on a weekend or an evening—within parameters; I’m not going to answer the phone after 10 at night and generally not before 6:30 in the morning. But if you’re on the fence about needing to go to the ER, for instance, I give you permission to call me.

I have an example: an extremely exceptional doctor whose child had peanut allergy. It was the middle of a Saturday, and she texted me saying, “My child just accidentally ingested peanuts and is having some symptoms. Which ER should I go to?” I called her and asked her to tell me what the symptoms were.

Her child was in anaphylaxis. I told her to hang up the phone and call 911. Do not drive your child to the ER.

This reminded me that our colleagues are worried that if they go to the ER, they’re going to be judged by their colleagues if it was an inappropriate use of an ER visit. So, sometimes they will not escalate the level of care as fast as they need to.

I’ve had that happen with a number of doctors. An ER doc had a child at home who was having an asthma flare with respiratory distress. He said, “Yeah, he’s still talking. He is alright.” No, no, this is respiratory distress, and your child needed a higher level of care in that moment. You need to call me, and we can go through this.

It’s interesting because the opposite happens sometimes with doctor families. They’ll either pretend it’s not as serious as it is or go to this deep, dark, scary place, thinking it’s the worst thing ever. And then they’re at home worrying about something. I like them to use me in those two scenarios. Let’s level set and get into the right place.

Dr. McDonald: I have a theory, and this is totally anecdotal, but there are two types of physician parents—those that say, “Oh, rub some dirt on it, you’ll be fine,” while the kid is actively in anaphylaxis or respiratory stress; and those that freak out about every little cut and scrape and bruise, because we’re so emotionally invested that it’s hard to find that middle ground. We tend to be one of the two extremes. (Full disclosure, I’m the one that tells my kids to rub dirt in it, and they’ll be fine.)

But I do think that that point of being emotionally invested and not objective makes it very, very hard to follow evidence-based guidelines and see things objectively, which is the same reason why you don’t treat your own family members, regardless of what age they are. So that’s a really important piece that you pointed out.

Thanks for listening. Stay tuned for next week’s episode. To hear more, follow PeerPOV: The Pulse on Medicine on Apple Podcasts, Spotify, or Amazon Music.

This transcript has been edited for readability.