The Risks of Cutting Out the Middle-Doctor

pharmacyFor most people, when they or their child becomes sick with and illness that over-the-counter medicine can’t treat, the path to a prescription goes through a doctor’s office. But what if you yourself were a doctor? And you were reasonably confident that you knew what was causing a mild illness in you or your child? Would you still go through the formality of a doctor’s appointment, or would you prescribe the necessary treatment yourself – or find a physician friend to write the prescription?

Most medical associations have recommendations on when it is okay for physicians to write a prescription without a formal exam. But little is known about how often those “informal” prescriptions occur, especially in pediatricians for whom dealing with sick children is the focus of their workday, not just an occasional issue at home.

Pediatric resident Jennifer Walter and Lainie Ross, professor of pediatrics and clinical ethics, sought to test those presumptions through a survey of their fellow pediatricians. With questions about prescribing for one’s children or other family members, self-prescribing, and “curbside” prescribing (when a physician asks another physician for a prescription), they looked to characterize how often such informal prescribing occurs, and what the consequences of those actions. What they found, published as two separate articles in The Journal of Clinical Ethics and The Journal of Medical Ethics, was that such practices were overwhelmingly the rule, not an exception.

A whopping 75 percent of pediatricians reported prescribing drugs for their own child at some point – with antibiotics and inhalers the most common prescription. Doctors treating themselves also came in at 75 percent, with 50 percent reporting that they had written a scrip for themselves at least once and another 50 percent reporting they had asked a physician friend to do it for them (50 + 50 = 75 because there was an overlap of self-prescribers and curbside prescribers).

Those high percentages didn’t surprise Walter and Ross. One would expect pediatrician-parents, who may see a dozen ear infections in a routine workday, to feel comfortable in prescribing an antibiotic for their own son or daughter’s illness, they said.

“I don’t think it’s reasonable for people to say you should take your pediatrician hat off when you’re looking at your own kid,” Ross said. “That’s part of who you are, that’s how you look at people.”

Meanwhile, some physicians are prone to save time by DIY prescribing whatever they need to fight off an illness. For those who feel uncomfortable showing up at a pharmacy bearing a scrip with their own name (a practice that’s legal in many states), it’s common to ask a colleague for an assist.

“The residents will write prescriptions for each other and there’s almost a camaraderie about it,” Ross said. “Rather than going to a doctor, you say ‘I’ll write for you, you write for me and we’ll all get our prescriptions.’ Part of that is just to avoid missing work.”

But just because these practices are common, doesn’t mean they aren’t occasionally dangerous from medical, legal, and ethical perspectives. Curbside prescribing carries a significant risk that a physician is not disclosing all relevant information about their illness to the prescribing colleague, whether out of embarrassment or haste. Should something happen to the person taking the drugs, their friend who wrote the prescription could be liable. As such, Walter and Ross suggested that prescribing for yourself was actually ethically preferable to curbside prescribing…a conclusion that caused many of their own colleagues to reconsider their own behavior.

“Many physicians see it as a relatively harmless request of a colleague and assume they’re taking on the majority of the responsibility by being the person that determines that this is their illness and this is the appropriate medication,” Walter said. “They don’t actually realize the ways in which they’re putting the other person in a morally confliciting position, or potentially even in a legally compromised position.”

When a physician prescribes a drug for his or her own child, Ross said, the danger isn’t so much in the prescription itself, but in the failure to have appropriate follow-up care. The parent-physician may not remember to inform their child’s primary care doctor, who then does not realize that the child has had illnesses since their last appointment – and how those illnesses may fit into a pattern of a more chronic or more serious illness. Pediatricians should also ask parent-physicians during the child’s appointments if they have been prescribing drugs for their child, Ross said.

Encouraging such honesty is one reason why most physician associations recommend that their members should not informally prescribe drugs to themselves or family members, instead of outright banning the practice. A more beneficial practice would be to inform family members of physicians that it is inappropriate to ask for prescriptions from their doctor son, daughter, brother,  sister, wife or husband, the authors said.

“Parents believe that once they’ve sent their kid to medical school that they now have a lifetime prescription to anything they want,” Ross said. “So there needs to be a lot of education for family members to understand the risks they are exposing their kids and loved ones to.”

To educate family members of physicians on the ethics of informal prescriptions, Walter suggested that an announcement could be made at graduation ceremonies for medical students and residents.

“It could be some kind of recognition that while the abilty of that person to be trained as a physician was no doubt a result of all the hard work and support they’ve received from their families, this doesn’t equal a lifetime supply of prescriptions and free medical advice,” Walter said. “To respect the bind you’ll be putting your child or partner in by coming to them with these requests, that this is something that is actually more problematic than you would ever imagine it was.”

Walter, J., Lang, C., & Ross, L. (2009). When physicians forego the doctor-patient relationship, should they elect to self-prescribe or curbside? An empirical and ethical analysis Journal of Medical Ethics, 36 (1), 19-23 DOI: 10.1136/jme.2009.032169

Walter JK, Pappano E, & Ross LF (2009). A descriptive and moral evaluation of providing informal medical care to one’s own children. The Journal of clinical ethics, 20 (4), 353-61 PMID: 20120855

About Rob Mitchum (525 Articles)
Rob Mitchum is communications manager at the Computation Institute, a joint initiative between The University of Chicago and Argonne National Laboratory.
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