Prescribing Without an Exam?

The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined.  For example, a friend might call me and say something like “I have a sore throat.  Will you call me in a prescription for antibiotics?”  I’m sure that almost everyone who has practiced medicine has received such phone calls!  The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.

In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.

Examining a patient through the phone.

Coming back to my friend with the sore throat, if I respond to their request for an antibiotic by saying “Sure!  What pharmacy do you want me to use?”—well the Board of Medicine (and other medical organizations) consider that to be ethically wrong.  But! What if my friend really needs an antibiotic and is not in a position to easily get to an ER or Urgent Care Center? Refusing to help could be the wrong thing to do medically!

Fortunately, there is a way around this dilemma that will satisfy the Board of Medicine’s concerns.   I simply must treat my friend like any other patient and treat this request like any other I might receive when on-call:

  1. Make sure that the prescription is medically warranted.  In the sore throat case, I would ask relevant questions to see if the patient really had a strep throat that needed to be treated.
  2. The friend has to come see me for an exam.  This could occur a couple of days later when convenient but I would have to actually see and examine the patient to whom I have prescribed medications.
  3. I must document the initial phone call and subsequent exam in a medical record.

Now, when friends call me for prescriptions (and it seems legitimate), I say “I’ll do it but you must come to see me at my office.  I won’t charge you but this visit is not optional.” Some (ala SNL’s Emily Litella) say “Never mind!” But most agree and show up for a quick exam a day or two later.  Not only does this allow me to make this medical encounter legitimate, I can make sure they are doing better.  The key to making the telephone prescription legitimate is to actually see the patient.

A similar situation arises in correctional medicine, especially jails.  Inmate medical needs are almost always first evaluated by nurses.  And since jails tend to have a constant flow of inmates coming and going, practitioners get lots of calls about individual patients who they have never seen before.   If a jail nurse calls about a newly booked patient showing signs of alcohol withdrawal and the jail doc prescribes Valium, should the jail doc actually see the patient personally at the next clinic? The answer, of course, is “Yes!”  When a practitioner prescribes a controlled substance (Valium) for a patient with a potentially life-threatening condition (alcohol withdrawal), that patient must be personally evaluated by the practitioner!

What about non-controlled medications for less severe conditions?  For example, if a Nurse Practitioner is called about a new inmate with a MRSA infection and prescribes Bactrim; does the NP need to see that patient in the next medical clinic? Again, the answer is “Yes.” It is not enough (in my opinion) to never see such a patient personally and rely on nurses exclusively to do all of follow up evaluations.

How about more routine prescriptions?  For example, what about the patient who needs to have lisinopril (which he had not been taking for several months) restarted?  Does he need to be seen in clinic?  “Yes” once again!  It’s no different (in my opinion) than the situation outside of jail.  If my friend outside of jail calls me and asks me to call in a prescription of his lisinopril, I can do it (if appropriate), but I still need to see that patient in my office and do an exam and chart note as discussed initially.  The jail patient is no different.  He is my patient, I am prescribing him medications, and that obligates me to actually meet him and establish a doctor patient relationship. 

Summary: If a jail practitioner prescribe a new medication to someone, they should see that person in personally to establish a doctor-patient relationship—just like what should be done outside of the jail. 

As always, what I have written here is my opinion, based on my training, experience and research.  I could be wrong!  If you think I am wrong, please say why in comments!

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3 thoughts on “Prescribing Without an Exam?

  1. AvatarBertram Moshier

    Hello,

    I’m not looking for you to post this email, but I hope you’ll reply.

    This is a topic I’ve been wondering about on and off for years. Say someone comes in voluntarily and expects to stay awhile waiting for trial. (S)he is on lots of medication including some scheduled drugs (e.g. methadone, Oxy, and/or Fentanyl, anti-depressants, etc), other drugs (insulin, spironolactone, metformin, provigil, and a long list of drugs). The person has been on these drugs for years and for documented reasons.

    What should the person expect in the continuation of their health care? What about drugs prescribed on a PRN basis (as break through pain) or as needed based upon events?

    Its obvious what happens on the outside, but not what occurs on the inside (at least to me).

    Thank you and I hope you’ll find time to reply.

    Bertram Moshier

    Reply
  2. AvatarMichael Bennett

    I have been a nurse for over 15 years now. During this time, I have worked in various settings including correctional nursing, long term care, home health, and on med surg / ER units. While, I mostly agree with the article, to me there seems to be variances between the different settings. From my experience, it is common place, for nurses in the home health setting and long term care setting to send correspondence to doctors by phone or fax in regards to a pt that may have a medical condition and the doctor never physically sees the pt before prescribing a treatment. In these cases, I understand that most of the time they are established pt’s with the prescribing doctor, but regardless it may be weeks, months, or longer until the doctor actually routinely makes rounds or the person is seen in the clinic. In many cases, I would not expect a doctor to remember or even mention it, much less document anything seemingly minor such as prescribing something for a sore throat or maybe adjusting a blood pressure medication because the readings were trending high. I would say that in nearly 100% of these instances, the doctors rely on the home health nurse or long term care nurse to notify the doctor if something is not improving with the current treatment. Currently, I work in corrections and in general this is how things operate at the facility I work at. Depending on the circumstance, the doctor does not personally see everyone that has a change in medication or is started on a new medication. Many times, the inmate may only be in the facility for one to several days, before bonding out etc. and currently our doctor is only at the jail one day a week. In these cases, we do have the jail doctor sign off on the orders that were given / protocols that were implemented. Just reaching out to see what your thoughts were in regards to the different clinical settings etc.

    Also as an after thought, how is OTC medications treated at your facilities. Can any inmate get things such as tylenol, ibuprofen, and so forth off of the med cart as needed during med pass or do these things also require a doctor order and do you then personally follow up with each one after that? Can they purchase certain meds off of commissary? Or if they can’t afford to purchase OTC meds off of commissary does the jail routinely give OTC meds on a PRN basis?

    Thank you for the site and articles! I have recently come across the site and I have enjoyed it.

    Sincerely,

    Michael Bennett

    Reply
  3. Avatarrichard

    There is an obvious power imbalance between the Jail doctor and patient.
    Knowledge, freedom, familiarity of circumstance, fear and self respect.

    How do you balance being right with being kind with being fair while avoiding hubris a certainty of being right and not being blind to their suffering and need for comfort ?
    Does the routine nature sharpen or dull your empathy ?
    Do you need to maintain emotional detachment like ER workers, or does the long-term patient doctor relationship encourage a compassionate outlook?

    I’m sorry but I wouldn’t enjoy it myself. Keep up the good work.

    Reply

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