The risks of informal prescribing, and how to avoid them

More than four in five doctors (83%) reported they’ve prescribed medicine for a family member, according to one well-known study. But writing a prescription for a relative or friend, however well intentioned, often risks skirting a physician’s responsibility to uphold the standard of care, according to Richard J. Baron, MD, president and chief executive officer, American Board of Internal Medicine (ABIM) and the ABIM Foundation.

“There’s a core authority and responsibility that we have,” Dr. Baron said in an exclusive interview with MDLinx. “We are licensed and have the authority and ability to write prescriptions. But we have the responsibility to do that consistent with professional standards.”

Professional standards

The go-to standard is outlined by the American Medical Association (AMA) in its ethics statement on treating yourself or your family:

“When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing so. They may also be inclined to treat problems that are beyond their expertise or training.”

The AMA stresses that patients who are close to the prescriber may also feel uncomfortable receiving care from a family member. These patients may avoid disclosing personal details about their condition. Moreover, physicians should—in the vast majority of instances—not self-prescribe.

But, according to AMA, there are times when exceptions can be made:

• In an emergency, when no other physician is available, the physician may prescribe to self or family members.
• In the case of short-term, minor problems (eg, prescription topical steroid cream for a minor rash or an anti-inflammatory for minor pain and swelling).

When treating self or family members, the physicians must do the following:

• Document treatment and send this documentation to the patient’s primary care physician.
• Realize that if a problem stems from a prescription provided to a family member, the family member may get upset and this could affect personal ties.
• Avoid sensitive care (ie, genital exams).
• Realize that the patient may conceal information due to shame, fear, or embarrassment.

Standard of care

“We are trained as physicians to understand standard of care,” Dr. Baron said. In a formal physician-patient relationship, “[w]hat we do is we meet and talk to patients, and we are well within our expertise to make competent judgments about prescribing. We’re trained about the kind of information and the level of confidence we should have before we prescribe.”

But what if it’s not a formal physician-patient relationship?

"With family members, neighbors, friends, and community members, the risk in prescribing is that we fail to offer them the same level of care that our training says is what we ought to do before we write a prescription,” he said. “In an effort to accommodate a friend or family member, we [may] cut corners in a way that creates risk.”

Dr. Baron explained that there’s at least three risks to informal prescribing. These include physical risks to the patient, as well as professional and psychological risks to the physician.

Risk 1: You don’t have the patient’s complete medical history and information. “We’re trained to have certain kinds of information,” Dr. Baron said. “In the more casual prescribing scenarios, we don’t have that kind of information [we need]. Somebody says, ‘Will you write a prescription for X?’ You shouldn’t do it with less information than you think is the amount of information [you would need] if it were a real patient in your office.”

Dr. Baron explained that when casually prescribing, the prescriber lacks access to necessary information, including details of physical exam findings, laboratory results, medication lists, and comprehensive history, which are available, for example, when the prescriber has access to electronic health records.

Risk 2: Your relationship may color your judgment, leading to inadequate care. “In the years that I practiced, and I practiced 30 years in the community in which I lived, I faced this situation a lot,” he said. “Like many doctors, I have family members, and I always thought they shouldn’t get worse care because they are family members, friends, or colleagues than they would get if they were real patients. That was my threshold when thinking about that kind of prescribing. In an effort to accommodate them—to be friendly, be convenient, and respond to a request—am I going to wind up providing care below the level of standard that I would have provided if they were really my patient?” Dr. Baron asked.

Even though a physician knows the family history of immediate family members, such as children, Dr. Baron views the personal stakes as being particularly high in these situations.

“Practicing medicine is really hard and scary,” he said. “Every decision you make is a decision that fits your best judgment; you hope it’s the right one. Every decision can go wrong in a way that you didn’t want it to. I don’t want to bear the responsibility of the burden for close family members by doing the wrong things. Those judgments are colored deeply when they apply to family members. I wanted them to have the benefit of good, independent medical advice.”

Risk 3: You leave behind an incomplete patient record, jeopardizing future care. Another issue that crops up with casual prescribing involves documentation—or the lack thereof.

“What record gets created of the professional action that you took? So this is another red flag if you’re prescribing but you don’t have a chart in which to record…the basis on which you prescribed. You are not only putting yourself at risk but you’re putting your patient at risk because that chart becomes the basis on which future clinicians make decisions. When we chart decisions to prescribe, there’s an accompanying physical exam, there’s a description of what we were thinking, there’s a date on which the prescription was provided, and there’s a state of affairs documented at the time the prescription was provided,” he said.

“All of those things become important down the road if things aren’t going well,” he continued. “The first thing an expert clinician wants to know is where we were then, and now you don’t have any record about that. Creating records is itself a part of the standard of care. If you’re prescribing in a situation where you can’t create a record, you are already playing fast and loose with the standard of care.”

Stories from the field

Dr. Baron recounted one situation in which a child’s parent in his school carpool asked him for a prescription for high blood pressure medications. The person asking was actually a psychiatrist who could have probably prescribed the medications to himself but decided to lay that responsibility on Dr. Baron.

Dr. Baron declined the request, explaining that he didn’t even know the patient’s blood pressure or history. The psychiatrist complained that Dr. Baron was an internist and prescribes blood pressure medications all the time. Dr. Baron answered, “Not like this.”

He described another time when a person who married into his family was very uncomfortable with an upper respiratory infection and asked for antibiotics. Although Dr. Baron knew the woman well, he didn’t know anything about her medical history, including allergies, pregnancy, and other medications. He also didn’t know whether antibiotics were the right choice for her condition.

“You can really make some bad decisions in an effort to be friendly and accommodating,” he said. “You need to take this very seriously. If you’re the prescriber, you’re responsible for these prescriptions. You should be applying the same standards you would be applying with actual patients.”

But it’s not just harmful to the patient; informal prescribing can be harmful to your career as well. Dr. Baron recalled a case of improper prescription reported in the media. The situation involved a judge who didn’t want anyone to know about the medication he was taking. Consequently, the judge asked his physician to write the medication for a member of his staff, a person who was not being treated by the prescriber. When it became publicly known, the physician was disciplined for writing a prescription for a person who was not his patient.

Finally, Dr. Baron laments that formal guidance regarding informal prescription isn’t stressed in training. “To me, it falls in the category of professional hygiene—how to behave professionally,” he said. “I wish this advice was more widespread.”

Just say no

Saying no to informal prescription requests may seem uncomfortable, but remember that it is within your right to deny a request that you disagree with—especially a casual one.

Here are some tips on saying no:

• Be clear and concise when you say no. Don’t leave room for interpretation.
• Explain why you must say no.
• Offer alternatives, like the name of a good specialist.
• Be polite and kind. Remember that whoever is asking may be experiencing pain and discomfort and is only looking for help.
• Don’t argue and remember to be empathetic.
• Be consistent in your responses.