Originally appeared in the CAS Weekly Newsletter
Dear Legal Mailbag,
I’m reaching out with a situation involving a high school student’s absences and the role of the student’s parent, who is also a licensed doctor. The parent has been submitting notes excusing her child’s absences, but here’s the catch: the parent is writing the notes as the child’s primary care physician. Doctors’ notes are typically exempt from the limit of parent-excused absences.
Here’s the issue: our school has a policy limiting the number of parent notes a student can submit before absences begin to affect their course credit. This parent has been submitting multiple notes excusing absences, and since the parent is also a doctor, we’re unsure how to handle this situation.
Can we refuse to accept these notes based on the policy, or is there any exception given the parent’s medical background? How can we approach this without inadvertently violating any policies or laws, especially considering the parent’s dual role as both a parent and a physician?
We want to ensure we’re consistent with school policy, but we’re also wary of overstepping. Looking forward to your guidance!
Excuse Me?
Dear Excuse:
Legal Mailbag has not reviewed your district’s attendance policy for course credit, but looks to the Definitions of Excused and Unexcused Absences Adopted June 27, 2012 by the State Board of Education for guidance. For purposes of Conn. Gen. Stat. § 10-198a (the student truancy statute), this document defines when an absence will be excused, and those definitions invite the same question — is an excuse written by a dual-status parent (parent who is also a physician) a parent excuse or a doctor’s note? That distinction is relevant because under the Definitions, parents can excuse up to nine absences unilaterally, but there are specific requirements for excusing the tenth and subsequent absences.
The first option for excusing absences in excess of nine is listed as follows:
1. student illness (Note: all student illness absences must be verified by an appropriately licensed medical professional to be deemed excused, regardless of the length of absence).
The question is thus posed — is an excuse for the tenth absence written by a dual-status parent written by “an appropriately licensed medical professional” or is it a parent excuse that, standing alone, is not effective for the tenth and following absence?
Under Connecticut law, medical doctors are not prohibited from treating family members, though Conn. Gen. Stat. § 21a-252(j) prohibits a physician from prescribing controlled substances. However, as a matter of medical ethics, physicians are strongly discouraged from being the treating physician for a family member.
For example, Opinion 8.19 – Self-Treatment or Treatment of Immediate Family Members (June 1993) of the American Medical Association describes the general principle (subject to limited exceptions in cases of emergency):
Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physician’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered. . . . This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients. When treating themselves or immediate family members, physicians may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a physician’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the physician.
Similarly, the Federation of State Medical Boards has issued a Position Statement: Treatment of Self, Family Members and Close Relations, and it also recommends that physicians not treat family members except in emergencies:
Physicians may be tempted for reasons of convenience, cost, or accessibility to provide medical treatment to themselves or to their family members. They may also receive requests from social or professional acquaintances for informal medical advice and even for treatment or prescriptions. Physicians may even receive pressure from family members for treatment and advice and feel compelled to provide it, perhaps even beyond their skill or expertise.1 However, engaging in a treating relationship with someone with whom another pre-existing familial or social relationship exists presents several challenges and ethical concerns.
1American Medical Association Code of Medical Ethics Opinion 1.2.1.
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Dual Relationships:
The physician-patient relationship is characterized by an inherent imbalance of power because of the specialized knowledge held by the physician, the significant access the physician has to intimate knowledge of the patient and their personal information, and the high degree of trust the patient typically places in the physician. . . . Circumstances where different relationships involving competing responsibilities exist between the same individuals are sometimes labeled as “dual relationships.” Examples include a physician who is also the parent, spouse/partner, sibling or child of the patient, a physician who is treating themselves, and a physician who prescribes to an employee, colleague, or friend. Dual relationships may result in confusion for the patient and the physician, especially when it is unclear which role is being, or should be, played. . . . It is recommended as a best practice that physicians strive to avoid any treatment or prescribing that would put the physician in a dual relationship.
In short, serious practical and ethical concerns arise when a parent purports to be a treating physician for a child.
What you wish to do with this information as it relates to your question is up to you. Given that you are interpreting a board policy (rather than the state statute on truancy), you can simply continue to accept the parent/physician notes to excuse the absences. However, another possibility would be to communicate to the parent/physician (1) that your district relies on the state standards for excusing absences described above, (2) that medical excuses beyond the first nine must come from a medical professional treating the child, and (3) citing the guidance quoted above you presume that this parent is not acting as the treating physician for her own child because there are no emergency circumstances, and, accordingly, (4) the district will not accept further excuses from the parent after the first nine.
Legal Mailbag cannot predict the response of the parent, should you take the initiative and follow this course of action. As with many things, you will simply have to take things a step at a time and see how much energy you have. At the end of the day, however, Legal Mailbag believes that you can enforce the standards for excusing absences described above, and the burden would be on the parent/physician to show why she would purport to be the treating physician for her own child.
In providing this response, Legal Mailbag acknowledges the assistance of Dr. Christopher Hammel of West Hartford, a psychiatrist and wonderful son-in-law.