PAs sanctioned for prescribing to family and friends

[RURALMED]

3 PAs have been sanctioned at least in part for prescribing to family members and friends without proper documentation in my state last quarter. These actions reflect poorly on all PAs so I thought this would be a good opportunity to post the MQAC's and AMA's policy on self-treatment or treatment of immediate family members. 

 

"The Medical Quality Assurance Commission believes that practitioners generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the practitioner is the patient; the practitioner’s personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.

 

Practitioners may fail to probe sensitive areas when taking the medical history or may fail to perform intimate parts of the physical examination. Similarly, patients may feel uncomfortable disclosing sensitive information or undergoing an intimate examination when the practitioner is an immediate family member. This discomfort is particularly the case when the patient is a minor child, and sensitive or intimate care should especially be avoided for such patients.

 

When treating themselves or immediate family members, practitioners may be inclined to treat problems that are beyond their expertise or training. If tensions develop in a practitioner’s professional relationship with a family member, perhaps as a result of a negative medical outcome, such difficulties may be carried over into the family member’s personal relationship with the practitioner.

 

Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their immediate family. Family members may be reluctant to state their preference for another practitioner or decline a recommendation for fear of offending the practitioner. In particular, minor children will generally not feel free to refuse care from their parents. Likewise, practitioner may feel obligated to provide care to immediate family members even if they feel uncomfortable providing care.

 

It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified practitioner available, practitioners should not hesitate to treat themselves or family members until another practitioner becomes available. In addition, while practitioners should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems. Documentation of these encounters should be included in the patient’s medical records.

 

Practitioners should be aware that RCW 18.130.180 (6) prohibits a practitioner from prescribing controlled substances to him or herself. The Commission strongly discourages prescribing controlled substances to family members."

[Guest Paula]

What state are you in?  We've had this discussion on the Forum regarding prescribing for family and friends.  If I recall correctly, most of us do not prescribe for family unless it was in dire circumstances.  I avoid it like the plague, but admit I have had permission to take pharma samples for direct family members and the samples I used were for medications one of my children was on and he could not pay for it himself, when he was no longer on our insurance......remember the olden days?  Kids off insurance at age 18?  

 

Pharma closets are history, too.  

 

Your concern serves as a reminder to be very careful and follow the state laws for prescribing.     

[RURALMED]

What state are you in?  We've had this discussion on the Forum regarding prescribing for family and friends.  If I recall correctly, most of us do not prescribe for family unless it was in dire circumstances.  I avoid it like the plague, but admit I have had permission to take pharma samples for direct family members and the samples I used were for medications one of my children was on and he could not pay for it himself, when he was no longer on our insurance......remember the olden days?  Kids off insurance at age 18?  

 

Pharma closets are history, too.  

 

Your concern serves as a reminder to be very careful and follow the state laws for prescribing.     

Washington. 

[EMEDPA]

Agree with what you are saying here and the circumstances under which care of a family member is ok. a few years ago, I had to care for a family member when they came into an emergency facility I was staffing as a solo provider. makes the history a lot easier when you know all of it before the patient arrives....:)

[jmj11]

I follow the Washington State MQA newsletter and virtually all of these are without documentation. While I think caring for family is bad, except in those rare occasions as EMEDPA mentioned, the real clincher is not documenting the encounter.

[quietmedic]

I was wondering the same, as well as, and more importantly, prescribing to self.    In my case, I want to rx myself a maintenance med I've been on for years; currently recently switched to lousy obamacare insurance coverage with high deductible, and i don't feel like spending 200 bucks to walk in and get a script for the med I've been taking for years anyway.  This is a very benign med, by the way.

 

I personally called the NY Office of Professions Medical Board, specifically asking about physician assistants self-prescribing. I was told that as far as they are concerned, it is not illegal to self-prescribe (including scheduled's); However, beyond legality, there are ethics considerations which also come into play, and a prescriber must be prepared to defend themselves against such things as well. A pharmacist may refuse a script, and can trigger and ethics investigation as well. However, they said clearly that this was really only an issue with prescribing controlled substances...in their own words, as far as they were concerned, self-prescribing things such as "antibiotics and blood pressure medication" was perfectly fine from their perspective.

So as far as I can tell, in NY, as long as you keep medical records, and, if you are a PA, as long as your supervising doc is kept in the loop, there should be no issues in self-prescribing routine meds. 

 

I'd imagine as long as you document a full H&P, I don't see why the same wouldn't apply to calling in amoxicillin for your kid's ear infection or such.

 

Some statutes in some states require a "genuine patient-provider relationship", but I have no idea what qualifies as that beyond whats written on a piece of paper...if you documented an encounter, with full demographics and H&P, you have established a relationship, in my view.  Some people only see a doctor once, like in Urgent Care.  The fact that you aren't at your desk shouldn't make a difference as long as your SP is on board with the matter.

 

Regarding documentation...can you just write down the encounter on a scrap of paper?  Does it have to be officially on an approved EMR with unchangeable time stamp? I.e. why didn't those PAs who were reprimanded just write up the encounter after the fact? Those of us in busy EDs or UC clinics have all written our charts days later, after the encounter and our RXs for the patient, so don't see why they didn't just do that...is there a "legal" way to document an encounter which they could not complete after the fact?

 

As well, is there a particular way to document an encounter with yourself?   Perhaps as long as your SP reviews the chart, (even if that means just signing a piece of scrap paper with your encounter H&P and demographics on it), whether for yourself or a family member you are RXing to, that should qualify, no?

 

Your Thoughts...
 

[Reality Check 2]

Don't do it.

 

Bad precedent. Bad medicine.

 

Do not prescribe for oneself - even a one time antibiotic or a PPI or something "benign".

 

You do not want your patient's taking their family member's or friend's meds or buying it in Mexico - don't open the door to scrutiny or hypocrisy you don't want.

 

Corporate medicine has policies against this 99.9% of the time as well. 

 

I have seen a lot of bad things happen to folks for doing well intentioned things.

 

Be a good patient - develop a provider/patient relationship; get it documented and move on.

 

Not worth the perception, the risk or the potential consequences.

 

My very old 2 cents................................

[quietmedic]

HHmm.just out of curiosity, what do you see as the issues with self-prescribing so-called benign medications? Or, better yet, if you can recall any incidents of Pas being sanctioned for that....I'd be interested to hear about the specifics. As far as bad medicine... If it's something I've been prescribed for years, that hasn't changed, and as well, I am unlikely to sue myself, what is the clinical issue?

 

for what it's worth, at least here, in New York, almost every provider I have spoke with you, both PA and MD, say they have done it or do it on a regular basis., including self-prescribing low risk meds, and prescribing stuff like antibiotics for their kids.

 

for what it's worth, as I mentioned, the only reason I would do it now is to save the $200 fee. Money is tight...

 

not trying to challenge your experience, just really curious what the issues are and what you've encountered.

[Reality Check 2]

We, as medical providers are the worst judges of our own needs in many cases.

We can ignore things or justify them as something else while other forces are at play and our health is at risk.

NO medication is 100% benign -not even OTC PPIs.

 

I try to be a good patient as I expect my patients to be as well.

 

The State of Washington cited 2 PAs in the past 5 years for self prescribing inhalers, antibiotics or for prescribing to family - not controls - each fined $1000 and had to go to class and write a paper. Ethics charge - on their license forever and ever amen.

 

My doc now will see staff for ZERO charge or insurance only so they don't miss out on needed treatments. Maybe one of your partners can see you at a discount or pro-bono.

 

I am sorry you do not have insurance or good insurance. 

 

I think it is vitally important to handle onself with utmost professional decorum and beyond reproach by separating personal medical issues from professional practice. I have to do it with my kids - their doc knows to listen to me - I am right 99% of the time anyway.............. but that is Mom-sense, not medical. 

 

So, I wouldn't do it. 

[quietmedic]

some interesting points. Thanks for your feedback!

[rev ronin]

My doc now will see staff for ZERO charge or insurance only so they don't miss out on needed treatments. Maybe one of your partners can see you at a discount or pro-bono.

My doc does this as well.  I've written for a topical for him just to keep us from writing for ourselves.

[GetMeOuttaThisMess]

In Tx the rules are quite clear. If you haven't seen them in your practice or have a reasonable presumption of their being a patient (on-call) then it is illegal. Legally, be careful with "insurance only" charges since that constitutes insurance fraud, so say the billers. If I have a high deductible insurance and ask what the cash price is (I.e. discount fee) and the charges are diminished due to cash payment I've been told that that is also illegal IF I have insurance. Non-insured? You can discount or pro bono all you like.

[BruceBanner]

I disagree that it is always bad practice. That's kind of pious. Is it optimal? No, but it's a matter of case-by-case judgement. Think about it, unless you have the same last name....there has to be a reason for you to be investigated. And to my knowledge there is no master ledger of every drug a provider has ever prescribed. Only controlled drugs. 

 

I think it was the AAFP that did a study and found something like 98% of docs have either self-prescribed or prescribed for family and friends in their career, and just about every doc/PA I have asked does it on occasion.

 

I'm not advocating it--- but check with your state's laws, don't make a habit of it, and dont rx anything controlled or weird outside of the office.

[Reality Check 2]

One of the 2 PAs in Washington was turned in by a vindictive co-worker who knew about it happening and probably did not get what he/she wanted.

 

My journey with corporate medicine had a strict zero tolerance policy - do not access your own chart, do not access your family's chart; do not self prescribe; do not treat family - they fired a receptionist on site one afternoon for opening her daughter's chart - the IT police are always watching....................

 

I did Rx for one of the kids on a Saturday night in the past for a raging ear infection - wouldn't do it now.

[PACdan]

My journey with corporate medicine had a strict zero tolerance policy - do not access your own chart...

 

 

Interestingly, a hospital I worked at sent out an employee email saying not to access your own chart. Less than 24 hours later a redaction was sent. Apparently it's a big no-no to tell a patient, even if they are also an employee, that they cannot view their medical records. Of course you may only view your own chart, and you not make any entries or modifications.

[Reality Check 2]

Interestingly, a hospital I worked at sent out an employee email saying not to access your own chart. Less than 24 hours later a redaction was sent. Apparently it's a big no-no to tell a patient, even if they are also an employee, that they cannot view their medical records. Of course you may only view your own chart, and you not make any entries or modifications.

EVERY risk manager including the major malpractice carriers' RN/JD advisors say DO NOT ACCESS YOUR OWN CHART OR YOUR FAMILY PERIOD.

 

If you do not have a clinical purpose to be in a chart - don't.

 

We just had a meeting last week where the RN/JD said do not access your on chart - EVER.

[PACdan]

EVERY risk manager including the major malpractice carriers' RN/JD advisors say DO NOT ACCESS YOUR OWN CHART OR YOUR FAMILY PERIOD.

 

If you do not have a clinical purpose to be in a chart - don't.

 

We just had a meeting last week where the RN/JD said do not access your on chart - EVER.

 

 

Hmm. Maybe it varies by State and with State laws. Because the Technology Security Officer and hospital admins told us that we are specially allowed to access our own charts via the EMR (if we have them) when we started clinicals. And this is another major hospital system in the same state.

 

Your chart is your medical record. It cannot be withheld or censored from you in any way. You are always legally entitled to full and complete access of your records. And you always have a clinical purpose to review your own health information if you have any interest or investment in your own health or medical records. I don't see the difference between having them print every single page and document for your and accessing it all electronically. Either way, you cannot make any changes. But both ways you are legally allowed to view every piece of information entered under your record. One just wastes less paper.

 

Maybe they're saying don't access your own chart in case you ever want to sue one of the providers who has seen you? Their lawyers will try to say you accessing it negates something??? I don't know... But if you're ever involved in a malpractice case you're bringing, you are going to access your entire chart anyway.

[rev ronin]

At Group Health, the rule was the chart access we were to use (all providers are also insured by the system) was the patient portal, NOT our own access.  I got a warning for scheduling an appointment for my daughter with my SP using the scheduling module, even though I never opened her chart.

[ventana]

Few thoughts

 

Prescribing for yourself or close family is just stupid and takes advantage of your license and how on earth can you be non-judge mental....

 

Sure you can "think you way around it" but this is a classic case of missing the forest for the trees - about the $200 urgent care visit - that is cheaper then defending your license....

 

The exception is what EMDPA says - staffing, at work, and no alternative provider available and a family member shows up.... Yup treat them AFTER getting them checked in like any other patient

 

 

 

I have written meds for doc's and NP's and have have had both write meds for me in the past - simple stuff, no controlleds (I declined the doc that asked me to write Vicodin for his wife). At every single one of these incidents we would ALWAYS write of ups SOAP note and file it away for long term reference "just in case".

 

However, with all the attention and changes going on now with meds, and regulations - I just don't do it at all.... Ever.... Unless it is like the above example....

 

I will however go with family members to the ER and advocate for them, and clearly and strongly state my own case when I need something and have gone to the ER to get it (long story but took me almost demanding a LESSER med from the PA that I had trained in the past - too bad he sold his soul to through put times and not to giving good care.....

 

 

 

So, just don't ever do it.... Plain and simple - then you don't have to defend or argue it......

[Maverick87]

I guess it varies in different practice settings.

 

When I was in the military, we free prescribed each other medications without documentation, I frequently accessed my own chart, and I even (accidentally) prescribed myself eye drops before.

 

It's interesting to see that all of this would be a no-go in the civilian world. Good to know early since a situation like this hasn't come up yet.

[GetMeOuttaThisMess]

At Group Health, the rule was the chart access we were to use (all providers are also insured by the system) was the patient portal, NOT our own access. I got a warning for scheduling an appointment for my daughter with my SP using the scheduling module, even though I never opened her chart.

No such problem for me. I don't know that I even have access to the scheduling module in Cerner, and if I did, I wouldn't know how to use it. I have enough to deal with just using the provider module. [emoji6]

[Timon]

Different in each state and in some cases the board to which you belong to. I remember this conversation was discussed at length during my last month of PA school before going on rotations. 

 

In California, the law says:

 

There is no law which specifically prohibits a physician from evaluating, diagnosing, treating, or prescribing controlled substances to a family member, employee or friend. However, the practice is discouraged. There are laws to consider when assessing any prescribing issues which include, but are not limited to: 1) a physician cannot prescribe without an appropriate prior exam and a medical indication for the prescription, and 2) an adequate and accurate medical record relating to the provision of services to the patient and documenting the medical need for the prescription must be created and maintained by the physician. Basically, a physician must follow the same practice/protocol for any patient in which medications are prescribed.

http://www.mbc.ca.gov/Consumers/Complaints/Complaints_FAQ/Practices_and_Protocols_FAQ.aspx

 

However, in Nevada where I received my training, PAs are subjected to the medical board of their SP depending if they are MD or DO with DOs being allowed to write for their spouse and MDs not being allowed to write for their spouse (as long as not a controlled med).

[sk732]

Most places I've worked in, you're only allowed access to your file under someone else's scrutiny...same with family members.  When I was military, when we had paper charts, they were kept in the Base Senior Medical Officer's office or that of their AA.  If we wanted to see it, we made an appointment and went over it with them.  When we went electronic, same same - if I accessed my own or (like happened once to me by accident) my wife's chart, it was flagged and I'd get dragged up on the carpet to explain myself.,,and did once due to the accidental look see when I was covering the charts of a deployed buddy of mine.  I've dragged a few people up on the carpet for it as well - it's considered a breach of trust, and can actually affect your security clearance, and since it's a direct order that's in fact legal (even under our wishy washy Constitution) and in black and white on the form you sign to get the EMR account, persons could be charged under the National Defence Act (read Article 15 or worse under the UCMJ).

 

The College here has it written out in black and white about prescribing for self and for family/close friends.  Family and close friends only if an emergency.

 

SK

[Guest JMPA]

so mechanics should not be allowed to fix their own cars, janitors should not be allowed to clean their own houses, and police should not be able to protect their own families?, give me a break, more liberal socialism at work

[rev ronin]

so mechanics should not be allowed to fix their own cars, janitors should not be allowed to clean their own houses, and police should not be able to protect their own families?, give me a break, more liberal socialism at work

Abuses can happen anywhere, and I don't think the expected independence and impartiality of medicine is limited to socialist environments.  The emotional involvement in treating family members, and associated potential loss of objectivity, just make avoiding it essential in serious cases, and a good idea in any case.