Dear Director: Our chairman has told us to stop writing prescriptions for nurses in our department. Isn’t it my decision how I use my license? Why would they have a policy like this?
One of the great benefits of being a physician is that we can write prescriptions. Calling in a script allows us to easily help our friends save money and time and feel better. But with this right comes responsibility and that’s where many people trip up when writing prescriptions “off the record.”
I suspect every one of us has been approached to write a prescription for a friend, co-worker, family member, or neighbor outside of the official medical encounter. Some of us have probably even offered to write a script without being prompted because we just want to help someone feel better. It’s possible, especially if you’re the chairman or a senior physician, that you’ve even been called by someone in the executive suite to evaluate a problem without them being registered as a patient.
To be clear, our professional organizations generally frown on prescribing for family members. In fact, the Health and Ethics Policies of the American Medical Association (AMA) state that physicians should not generally treat themselves or their immediate family for several reasons. The American College of Physicians also advises against treating close friends or employees. The rationale includes the loss of objectivity; embarrassment caused by a thorough history and exam; tendency to treat conditions outside our specialty; and potential for bad outcomes causing bad blood. Treating ED staff puts us at risk for the same types of issues, especially potential embarrassment by doing a thorough history and exam, which then leads to a very superficial medical evaluation.
The letter of the law
When we click “agree” on our license renewal application, we are agreeing to the myriad of laws and responsibilities that come with being a physician. I suspect most of us have never read all of the laws we’re agreeing to, and even though prescription writing laws are state specific, they all essentially say that we can write prescriptions when there is a patient-physician relationship. The definition of this relationship includes doing a thorough evaluation that mirrors how you would take care of a typical patient, and then like a typical patient, properly documenting the evaluation. And that’s where many people stumble—in the failure to document (don’t forget that we need to keep our documentation in a HIPAA compliant and protected manner). While some state laws may be less restrictive, others may explicitly prohibit writing a prescription for yourself or family members.
A good friend told me about an environmental services employee who would come to his ED with a cough asking the docs for an antibiotic prescription because he was a smoker. Everyone wanted to be helpful and gave him an Rx. The problem was that no one actually knew how often he was getting prescriptions (nothing documented in the EMR because he was never officially a patient) and no one considered working him up or even asking a few questions. The docs were just trying to be helpful. The problem came when the “patient” did finally see a doctor and got a chest x-ray. By then he had advanced metastatic lung cancer, which ultimately took his life. Before dying, he sued every doctor who had “helped him” by giving him a script without properly evaluating him. It wasn’t hard to get a record of all the docs because literally every prescription we write (that is filled) is recorded in a data bank. Though I don’t think I would worry much about malpractice if I wrote a script for Zofran for my neighbor, your malpractice policy probably doesn’t protect you from this kind of “hallway medicine.”
The next problem you face is how you write the prescriptions for your nurses, since almost no one still hand writes their scripts. Are you going into your hospital’s discharge instruction program and creating data for someone who’s not a patient? The hospital won’t like this. Alternatively, the nurses could be getting you a paper script from the Pyxis in which case they are probably typing a patient’s name and thus linking that prescription to a patient and now they’ve falsified the medical record. Your hospital administration won’t like this either. You can see how both of these scenarios can create issues for the hospital and the nurse. I used to have my own prescription pad and I’m sure many docs still do, but I doubt that most people keep the proper records for every prescription they write for an off-the-books visit.
It goes without saying that because of how controlled substances are tracked, and that penalties for writing controlled substances outside of the patient-physician relationship can be serious, at no time should you be writing for a controlled substance on anyone who isn’t your actual patient.
I’d like to help, but…
Probably not a week goes by that a friend doesn’t ask me a medical question about an acute issue. I usually can reassure them that they’re going to be fine or else I send them to an ED, an urgent care or their PMD. I can’t remember the last script I wrote for anyone. In a non-scientific random survey I conducted of friends and co-workers, most people told me they’ve written prescriptions (usually antibiotics) for family and close friends. Hopefully, they’re keeping the documentation that’s required and calling in the prescription rather than using anything associated with the hospital.
When we call in a script for a family member, we’re doing so as a physician but also as an individual, away from our ED. When we take care of an ED team member, we do so as a representative of the hospital and our physician group. And that is a big distinction. Our work environment is different than our home life and how we handle a request from a nurse can impact the ED relationship. Our ED team can take great offense if we don’t help them out – as can someone from the C-Suite who is hoping for a free script.
For these reasons, some departments have instituted policies prohibiting prescribing to co-workers outside of the official patient-physician relationship. If the decision is that no one from your group should prescribe to non-patients, the very least that should be done is a joint memo from the medical and nursing directors to everyone who works in the ED saying that it’s not appropriate for people to ask for prescriptions without being a registered patient and that doctors are potentially breaking the law by writing these scripts. The executives in the C-Suite should be CC’d on the email so they don’t ask for favors. On the flip side, the doctors need to be consistent with this practice and not prescribe for co-workers. What we can do is offer to treat the person if they register as a patient and we can offer to write off our physician fee (if your group allows that). You can say something like, “I can’t speak for the hospital fee, but I’d be happy to waive my fee if you register as a patient so that we can properly evaluate and document your visit.”
We went into medicine to help people. It seems so easy to just write the antibiotic prescription when a nurse says she has a UTI and she tells you that she even dipped her own urine. Don’t get me wrong: having the privilege of writing prescriptions is a perk of the profession. However, we need to follow the policies that we’ve agreed to through our board of medicine (appropriate evaluation and documentation), not use hospital equipment for work not involving hospital patients, and be aware of the malpractice risk when we care for people off the books.