June, No.6 - Rhode Island Medical Society

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178Dangers of Self-Prescribing and Prescribingfor Family MembersMEDICINE & HEALTH/RHODE ISLANDMarilyn Price, MD, and Bruce W. McIntyre, JDPhysicians prescribe for themselves andtheir family members despite ethicalguidelines that discourage the practiceand stress the need to avoid treatmentsituations in which objectivity may becompromised. 1 Many physicians are unawarethat state medical licensing boardshave regulations vis a vis treating and/orprescribing for themselves and familymembers absent an emergency. Additionalregulations govern the prescribingof controlled substances. While manyjurisdictions do not have explicit prohibitions,there will be regulations relatedto the doctor/patient relationship suchas those requiring that a history and physicalexam be performed and documented.Rhode Island law and regulation do notexplicitly prohibit self-prescribing, althougha number of legal requirementsplace restrictions on the practice. 2, 3In spite of the ethical considerationsand regulations discouraging the practice,Toyry noted that self-treatment wascommon and physicians begin self-prescribingearly in their careers. 4 A surveyof internal medicine residents demonstratedthat 52% had self-prescribed inthe past year. Convenience and the readyavailability of medication have beenviewed as factors promoting this practice.5 Christie and colleagues noted that42% of the residents who had self-prescribedmedications, obtained the medicationsfrom a sample cabinet; and 11%had obtained medications directly froma pharmaceutical representative. 5Self-prescribing appears to extendbeyond the first years of practice. Hemet al) surveyed all the medical graduatesfrom all 4 medical schools in Norway atone-year post graduation and then againat 4 and 10 years post graduation. 6 Ofthe physicians who had used any prescriptionmedications over the past year, 90%of those who were one year post graduation,86% of those 4 years post graduationand 84% of those who were 10 yearspost graduation had self-prescribed. Themost frequently prescribed medicationswere antibiotics, contraceptives, analgesicsand hypnotics. Those who had a mentalhealth problem needing treatmentwere more likely to self-prescribehypnotics and sedatives than those withoutperceived health problems. In thestudy by Christie the most commonly selfprescribedmedications included antibiotics,allergy medication and contraceptives.5 Westfall et al found that only 2 of55 physicians or staff members in a residenttraining setting had not takensamples for their personal or a familymember’s use in the past year. 7Self-prescribing can result in a delayin obtaining appropriate treatment.This can be seen as especially problematicwhen a mental illness could be affectingthe judgment of the physician.While only 2% of the residents inChristie’s sample admitted to self-prescribingpsychotropic medications, Toyryreported that two thirds of the physicianswho acknowledged having a mental disorderhad self-treated. 4 McCauliffe et alfound that 25% of their sample of physiciansin practice had treated themselveswith a psychotropic medication in thepast year. 8 Reinhardt and colleaguesfound that 5% of their sample of housestaff admitted using a sedative or hypnoticwithout a prescription in the previousyear. While the prevalence of recentdepressive symptoms was 30%, only 11%had consulted with a mental health professionalduring that same time period. 9The American Medical Association’sCode of Ethics, Opinion E-8.19 articulatesthe very real dangers inherent in prescribingfor self or family members. 1 TheAMA recommends that: “Physicians generallyshould not treat themselves or membersof their families.” The rationale isthat:Professional objectivity may becompromised when an immediatefamily member or thephysician is the patient; thephysician’s personal feelingsmay unduly influence his or herprofessional medical judgment,thereby interfering with thecare being delivered. Physiciansmay fail to probe sensitive areaswhen taking the medical historyor fail to perform intimate partsof the physical exam. Similarlypatients may feel uncomfortabledisclosing sensitive informationor undergoing an intimateexamination when thephysician is an immediate familymember.These factors are seen as especiallypertinent when the patient is a child. 1There are further fears that when treatingthemselves or family members, physiciansmay be more likely to treat problemsoutside expertise. Physicians arewarned that if problems arise as a resultof a negative medical outcome, therecould be ramifications in the personalrelationship. In addition Opinion E-8.19points out that the process of informedconsent is significantly impacted. Familymembers may feel that by seeking a secondopinion they are insulting the physicianor indicating a lack of confidence inhis/her ability.The AMA does allow for exceptions.“In emergency settings or isolated settingswhere there is no other qualified physicianavailable, physicians should not hesitateto treat themselves or their familymembers until another physician becomesavailable. In addition while physiciansshould not serve as a primary orregular care provider for immediate familymembers, there are situations in whichroutine care is acceptable for short-term,minor problems. Except in emergencies,it is not appropriate for physicians towrite prescriptions for controlled substancesfor themselves or immediate familymembers (I, II, IV).”The medical licensing boards havetaken various approaches in dealing withphysicians who prescribe for themselvesor family members. The College of Physiciansand Surgeons of Ontario recentlyrevised the policy about treating self and
family members. 10 The provincial regulationstates that:Physicians should not treat eitherthemselves or family members,except for a minor conditionor in an emergency situation,and only when anotherqualified health care professionalis not readily available.Where it is necessary to treatthemselves or family members,physicians must transfer care toanother qualified health professionalas soon as is practical.Physicians are advised that ifthey do not comply with thispolicy, they may be subject toallegations of professional misconduct.Even in states such as Rhode Islandthat do not explicitly ban this practice,the prescribing physician must meetpractice guidelines set by the state andthe United States Drug EnforcementAgency (DEA). A physician may not prescribefor a non therapeutic purpose andthere needs to be an adequate medicalrecord justifying the use of the medication.Rhode Island has a medical recordregulation, R5-37 MD/D0 sec 11.4which requires that the course of treatmentbe justified. 11 There needs to bedocumentation of the history, test results,drug prescribed or administered, reportsof consultations and hospitalizations. 11Physicians need to consider that the adequacyof their documentation will be animportant issue should there be a complaint.Documentation requirements arerarely considered by physicians prescribingfor themselves or a family member. 12When the prescribed medication isa controlled substance there could be furtherrequirements or restrictions. TheRhode Island Board of Medical Licensureand Discipline has issued guidelinesfor the administration of controlled substancesthat require the following be provided;history and physical examinations,treatment plan and objectives, informedconsent, periodic review of plan andtreatment, consultations with experts, accurateand complete records, and compliancewith State and Federal Laws(Rhode Island-225 ILCS60/MedicalAct of 1987).There are usually grounds for disciplininga physician who prescribes a controlledsubstance other than for a legitimatemedical purpose. Under Rhode IslandGeneral Laws § 21-28-3.04 (2006)one of the conditions for suspension orrevocation of registration includes “possessing,using, prescribing, dispensing, oradministering controlled substances exceptfor a legitimate medical or scientificpurpose.” 2 In addition, in defining unprofessionalconduct of a physician, R.I.General Laws §5-37-5.1 (2006) one ofthe behaviors noted is “violating any stateor federal law or regulation relating tocontrolled substances.” 3Physicians who selfprescribecontrolledsubstances such assedatives andnarcotics raisesuspicion of drugabuse/dependence.In Kentucky prescribing to self or tofamily members is not a violation of Kentuckylaw, but KRS 311.597 (1) statesthat “self-prescribing and prescribing toimmediate family members is contrary tothe law when the physician knows or hasreason to know that an abuse of controlledsubstances is occurring, or mayresult from such a practice.” 13The College of Physicians and Surgeonsof Ontario also makes it clear thatphysicians should never write a prescriptionfor themselves or family members fornarcotics, controlled drugs, psychotropicdrugs, or any drugs that are addicting orhabituating, even when another physicianis in charge of managing those medications.10In 2001, The Commonwealth ofMassachusetts Board of Registration inMedicine issued “Prescribing Practices:Policy and Guidelines.” Physicians are advisedto “maintain records that are detailedenough in nature that thephysician’s clinical reasoning is implicit inhis or her documentation. Treatmentplans should be explicitly recorded. Allpatients visit and telephone calls relatingto treatment should be documented. Prescriptionsshould be documented andchanges in medication dosage should beexplained.” 14 The Massachusetts guidelines(2001) warn:Prescribing to immediate familymembers is frequently associatedwith problems of selfmedicationand chemical dependencyby physicians and istherefore carefully scrutinizedby the Board. Treatment of immediatefamily members withcontrolled substances over a sustainedperiod of time may indicatea lack of objectivity andclinical detachment on the partof the physician. Physicians whoprescribe controlled substancesfor family members must takeextra precautions to insure thatthis privilege is not abused.The guideline/policy further cautionsthat “[t]he same examination requirementsapplicable to patients whoare not related to the physician applywhen the physician is prescribing controlledsubstances to the physician’s immediatefamily. Physicians should documentexamination results carefully andaccurately.”Massachusetts prohibits the prescriptionof Schedule II Controlled Substancesto family members. “Schedule IIcontrolled Substances, because of theirhigh potential for abuse, may not be prescribedto a member of a licensee’s immediatefamily, including a parent, child,sibling, parent-in-law, son/daughter-inlaw,brother/sister-in-law, step-parent, orspouse or equivalent, except in an emergency.”This prohibition includes otherrelatives permanently residing in the sameresidence as the licensee. The Board suggeststhat physicians consider refrainingfrom prescribing all controlled substancesfor family members and significant othersin non-emergency situations. 14The Board of Registration in Medicinein Massachusetts has even graverconcerns about self-prescribing. 14 Thesame document advises:Physician self-prescribing presentseven deeper concernsthan prescribing to family members.The prescription of drugsto oneself creates an enormousVOLUME 90 NO. 6 JUNE 2007179
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June, No.6 - Rhode Island Medical Society

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