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Malpractice Rx


Should you prescribe medications for family and friends?

Vol. 10, No. 06 / June 2011

Dear Dr. Mossman:
On a recent golf outing, my buddy Mike told me about his trouble staying “focused” while studying for his grad school exams. He asked me to write him a prescription for methylphenidate, which he had taken in high school and college. I want to help Mike, but I’m worried about my liability if something goes wrong. What should I do?—Submitted by “Dr. C”

Doctors learn early in their careers that family, friends, or coworkers often seek informal medical advice and ask for prescriptions. Also, doctors commonly diagnose and medicate themselves rather than seek care from other professionals.1,2

In this article, we use the phrase “casual prescribing” to describe activities related to prescribing drugs for individuals such as Mike, a friend who has sought medication outside Dr. C’s customary practice setting. Despite having good intentions, you’re probably increasing your malpractice liability whenever you casually prescribe medication. Even more serious, if you casually prescribe controlled substances (eg, stimulants), you risk investigation and potential sanction by your state medical licensing agency.

DO YOU HAVE A QUESTION ABOUT POSSIBLE LIABILITY?

  • Submit your malpractice-related questions to Dr. Mossman at douglas.mossman@qhc.com.
  • Include your name, address, and practice location. If your question is chosen for publication, your name can be withheld by request.

To decide whether, how, and when you may prescribe drugs for yourself, family members, colleagues, or friends, you need to:

  • anticipate being asked to casually prescribe
  • understand the emotions and forces that drive casual prescribing
  • know your state medical board’s rules and regulations
  • be prepared with an appropriate response.

After we explore these points, we’ll consider what Dr. C might do.

A common request

People often seek medical advice outside doctors’ offices. Playing a sport together, sitting on an airplane, or sharing other social activities strips away the veneer of formality, lets people relax, makes doctors seem more approachable, and allows medical concerns to come forth more easily.3

Access to medical care is a problem for lay people and doctors alike. In many locales, simply getting an appointment with a primary care physician or psychiatrist is difficult.4,5 Navigating health insurance rules and referral lists is frustrating. When people find a provider, they may feel guilty about taking a slot from someone else. Job expectations or a tough economy can make employees reluctant to take time off work6,7 or concerned that they’ll miss productivity goals because of illness.1

Doctors often self-prescribe to avoid facing the stigma of being ill. Although doctors should know better, many of us don’t want to experience the vulnerability that comes with being sick and needing health care. Some doctors fear colleagues’ scrutiny if their serious mental illness (eg, depression) becomes known, or they would rather treat themselves than seek professional help.1 The most formidable obstacle physicians face is time—or lack of it. Many doctors work >60 hours per week, and their dedication and altruism causes them to neglect their own health until illness interferes with their professional lives.8

Emotional factors

Doctors pride themselves on knowing how to help people, and when loved ones or colleagues ask for our help, it’s gratifying and flattering.3 Such feelings may help explain why the largest numbers of prescriptions written for non-patients are for family members and friends, followed by prescriptions written by residents for fellow house officers.9

The circumstances surrounding casual prescribing usually make it difficult to maintain objectivity, avoid substandard care, uphold ethical principles, and handle discomfort. Your professional objectivity and clinical judgment likely are compromised when a close friend, an immediate family member, or you yourself are the patient.10 Treating loved ones and close friends can make it awkward to ask about sensitive matters (eg, “How much alcohol do you drink?”) or to perform intimate parts of a physical examination. Physicians who want to “go the extra mile” for family members or friends may try to treat problems that are beyond their expertise or training—a setup for failing to meet your legal and medical obligations to conform to the prevailing standard of care.11

State medical board rules

The American Medical Association, British Medical Association, and Canadian Medical Association all discourage physicians from prescribing for themselves or family members.2 Table 110,12-16 gives examples of states’ comments and guidelines relevant to casual prescribing. Overwhelmingly, state medical boards tell you that casual prescribing is ill-advised. However, in emergencies or in isolated settings where no other qualified physician is readily available, you should provide needed treatment for yourself, family, friends, or colleagues until another physician can assume care. Physicians should not be the primary or regular care providers for their immediate family members, but giving routine care for short-term, minor problems may be acceptable.14 Although state medical boards use differing language, all agree that casual prescribing requires assessment and documentation similar to what you do for patients seen in your regular practice setting. Table 2 summarizes appropriate casual prescribing practices, but you should also know the boards’ rules in the locales where you work.

Restrictions and rules for prescribing controlled substances are stricter, despite many doctors’ sometime-lax attitudes. State medical boards tell doctors not to prescribe controlled substances for friends, family, or themselves except in emergencies. Yet studies have found that house officers often write prescriptions for psychoactive drugs (including narcotics) for family members, friends, and colleagues9 and that residents are willing to prescribe codeine for a hypothetical colleague with pain from a fractured finger.17

Table 1

Selected state medical board rules and comments on casual prescribing

State

Rules

California12

‘[E]valuating, diagnosing, treating, or prescribing to family members, co-workers, or friends…is discouraged’ and requires ‘the same practice/protocol for any patient in which medications are prescribed,’ including a ‘good faith exam’ and documentation that justifies the prescription

Montana13

Although prescribing for one’s family or oneself is not prohibited, doing so ‘arguably…does not meet the general accepted standards of practice, and is therefore unprofessional conduct [that] may subject the physician to license discipline’

New Hampshire14

‘Physicians generally should not treat themselves or members of their immediate families.…Except in emergencies, it is not appropriate for physicians to write prescriptions for controlled substances for themselves or immediate family members’

Ohio15

‘[I]t is almost always a bad idea to treat a family member’s chronic condition, serious illness, or psychiatric/emotional problems’

South Carolina10

Treating immediate family members may produce less than optimal care. ‘[P]rescribing controlled substances for family members is outside the scope of good medical practice except for a bona fide emergency situation’

Virginia16

Prescriptions ‘must be based on a bona fide practitioner-patient relationship. Practitioners should obtain a medical or drug history, provide information about risks, benefits, and side effects, perform an exam, and initiate follow-up care. Practitioners should not prescribe controlled substances for themselves or family members except in emergencies, isolated settings, or for a single episode of an acute illness’

Table 2

Cautions and recommendations for casual prescribing

Avoid doing it in non-emergencies

Obtain a medical and drug history

Perform an appropriate, good-faith exam

Create a medical record that documents the need for a prescription

Prescribe controlled substances only in emergencies or isolated settings

Inform your patient about risks, benefits, and side effects

Initiate needed additional interventions and follow-up care

Maintain confidentiality and respect HIPAA rules

Ask yourself, ‘Can I avoid this—is there another option?’ If the answer is ‘yes,’ don’t do it

HIPAA: Health Insurance Portability and Accountability Act

Liability risk

Most residents are unaware of federal or state regulations addressing the appropriateness of prescription writing for non-patients.18 A survey of U.S. internal medicine and family practice residents at a teaching hospital found that less than a quarter believed that ethical guidelines on prescription writing existed.17 Such deficits can make malpractice liability more likely if something “goes wrong” with your casually prescribed treatment. Friends and relatives do sue doctors whom they have consulted informally,18 and casual prescribing can be hard to defend in court because it usually looks suspicious and is not well documented.

Revisiting Mike’s case

Understandably, Dr. C wants to help Mike and may even think he has a condition (eg, adult attention-deficit/hyperactivity disorder) for which a stimulant would be appropriate. But respect for Mike’s humanity—the paramount value in medical practice19—suggests that his treatment should occur after and because of a careful medical assessment rather than a golf game. Moreover, prescribing a controlled substance in a non-emergency likely would violate standards of practice promulgated by Dr. C’s medical board. Dr. C should tell Mike that his problem deserves thoughtful evaluation and suggest that Mike see his primary physician. Dr. C also could recommend psychiatrists whom Mike might consult.

Related Resource

  • Aboff B, Collier V, Farber N. Residents’ prescription writing for nonpatients. JAMA. 2002;288:381-385.

Drug Brand Names

  • Codeine • Tylenol with Codeine, others
  • Methylphenidate • Ritalin

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Bottom Line

Be prepared to be asked for advice and prescriptions in casual settings. When this happens, it’s fine to provide general medical information, but it’s best not to give specific advice or engage in “casual prescribing.” You can maintain social connections, be caring, and avoid boundary violations by responding with tact, referral information, and good judgment.19,20

References

1. Balon R. Psychiatrist attitudes toward self-treatment of their own depression. Psychother Psychosom. 2007;76:306-310.

2. Walter JK, Lang CW, Ross LF. When physicians forego the doctor-patient relationship should they elect to self-prescribe or curbside? An empirical and ethical analysis. J Med Ethics. 2010;36:19-23.

3. Reynolds H. Medical ear in the early morning tennis group—when to advise and what to say. Pharos Alpha Omega Alpha Honor Med Soc. 2010;73:14-15 discussion 16.

4. Sataline S, Wang SS. Medical schools can’t keep up: as ranks of insured expand nation faces shortage of 150,000 doctors in 15 years. Available at: http://online.wsj.com/article/SB10001424052702304506904575180331528424238.html. Accessed March 21, 2011.

5. Steinberg S. Of medical specialties demand for psychiatrists growing fastest. USA Today. July 1, 2010:6D.

6. Leonhardt D. A labor market punishing to mothers. New York Times. August 4 2010:B1.

7. Madden K. Reluctant to go on vacation? Available at: http://www.cnn.com/2010/LIVING/08/04/cb.reluctant.to.take.vacation/index.html. Accessed March 20 2011.

8. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286:3007-3014.

9. Clark A, Kau J. Patterns of psychoactive drug prescriptions by house officers for nonpatients. J Med Educ. 1988;63:44-50.

10. State Medical Board of South Carolina. Prescribing for family members. Available at: http://www.llr.state.sc.us/pol/medical/index.asp?file=Policies/MEPRESCRIBEFAM.HTM. Accessed March 20 2011.

11. Dietz LH, Jacobs A, Leming TL, et al. Physicians, surgeons, and other healers, §§130, 216-218. In: American jurisprudence. vol 61. 2nd ed. New York, NY: Thomson Reuters; 2010.

12. Medical Board of California. General office practices/protocols-frequently asked questions. Available at: http://www.medbd.ca.gov/consumer/complaint_info_questions_practice.html#13. Accessed March 20 2011.

13. Montana Board of Medical Examiners. Statement of physician prescribing for self or members of the physician’s immediate family. Available at: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/prescribing_self.pdf. Accessed March 20 2011.

14. New Hampshire Medical Board. Guidelines for self-prescribing and prescribing for family members. Available at: http://www.nh.gov/medicine/aboutus/self_presc.htm. Accessed March 21 2011.

15. State Medical Board of Ohio. Frequently asked questions. Available at: http://www.med.ohio.gov/professional_guidelines.htm. Accessed March 20 2011.

16. Virginia Board of Medicine. Can I prescribe for my family and myself? Available at: http://www.dhp.virginia.gov/Medicine/medicine_faq.htm#Prescribe. Accessed March 20 2011.

17. Aboff B, Collier V, Farber N. Residents’ prescription writing for nonpatients. JAMA. 2002;288:381-385.

18. Johnson LJ. Malpractice consult. Should you give informal medical advice? Med Econ. 2007;84:36.-

19. Nisselle P. Danger zone: when boundaries are crossed in the doctor-patient relationship. Aust Family Physician. 2000;29:541-544.

20. Eastwood GL. When relatives and friends ask physicians for medical advice: ethical legal, and practical considerations. J Gen Intern Med. 2009;24:1333-1335.

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