Lessons from NCMB’s Disciplinary Committee: Licensee Treatment of Self and Family
MD is a family medicine physician with 30 years of clinical experience. MD’s current patient panel includes about 10 percent children under age 18 and 25 percent adults over the age of 55. MD has no prior history of regulatory actions with the North Carolina Medical Board (Board).
MD comes to the Board’s attention after a pharmacist submitted a complaint alleging that MD routinely prescribes medications, including controlled substances, to himself and to family members. In the complaint, the pharmacist stated that she contacted MD by telephone to advise him that it was not appropriate for him to prescribe to his immediate family members. She further stated that MD seemed irritated at the call and responded that he is a “Board-certified family medicine physician and perfectly well qualified to treat my family members” and planned to keep doing just that.
An investigation is opened and the Board obtains prescription records for MD and his mother, wife, and two sons.
• MD took over writing his mother’s prescriptions when her longtime physician retired from the practice of medicine, approximately two years ago. Prescriptions include levothyroxine, rosuvastatin and sertraline. MD does not have detailed medical records for her, and there is no documentation that indicates he has examined her or ordered bloodwork to support his prescribing. When questioned, MD acknowledges that he simply continued to prescribe his mother the same doses of medications prescribed by her former physician. MD indicates that his mother has inquired about finding a new physician, but the handful of practices she has contacted told her they are not accepting new Medicare patients.
• MD has two sons, ages 14 and 17. Both boys have been patients in the same pediatric practice since birth and continue to be seen there for most medical needs. MD has a recent history of prescribing penicillin to both boys to treat strep throat, which they developed over Thanksgiving break. MD documented the boys’ diagnosis and his subsequent prescriptions for them and sent the note to his sons’ pediatrician.
• Review of prescribing records for MD and his spouse reveal that MD prescribes multiple medications to himself and his wife. Prescriptions are mostly for non-controlled medications and include simvastatin, levothyroxine and lisinopril. No records are created to document this prescribing. MD also recently prescribed oral semaglutide to his wife for weight loss without documenting an examination or creating a medical record. MD’s prescription history also reveals several instances of MD prescribing controlled substances to himself and to his wife, including a prescription for an opiate for himself during recovery from shoulder surgery and a prescription for hydrocodone cough syrup for his wife during a bout of bronchitis. When questioned about his prescribing, MD indicates that he and his wife both have primary care physicians they typically see annually. However, as MD is a family physician himself, he sometimes augments care or prescribes refills. His justification for this prescribing is that it saves the trouble of going in for follow up medical appointments if MD or his wife want to change medications or try a different dose.
Discussion
Views on clinicians prescribing for themselves or family members vary from state to state. While some state regulatory boards have no restrictions on the practice, it is the position of the North Carolina Medical Board that, except in the case of minor, acute illnesses or emergencies, licensees should not prescribe medications to themselves, to immediate family members or to anyone they share a significant emotional relationship with, such as a close friend. Further, physicians and PAs are expressly prohibited from prescribing controlled substances to immediate family members, sexual partners, and anyone with whom they reside, pursuant to NC administrative rules 21 NCAC 32B.1001 and 32S.0212.
The Board’s perspective is discussed in the position statement entitled, “Self-Treatment and Treatment of Family Members”. Essentially, the Board’s concern is that professional objectivity may be compromised when treating family members or close friends and could result in the licensee allowing personal feelings to influence their medical decision-making. In addition, when prescribing to family members or close friends, a licensee may be less likely to perform an appropriate examination or create meaningful (or any) documentation of the encounter. This type of prescribing can quickly fall below the standards of accepted and prevailing medical practice and puts the licensee at risk of providing substandard care to the people who are most important to them.
While the Board’s position statements do not hold the force of law, licensees who inappropriately treat themselves, their family members, or others with whom they have a significant emotional relationship may be subject to disciplinary action by the Board.
In bounds or over the line?
In the scenario presented, some of MD’s prescribing to family members could be consistent with the exceptions stated in the Board’s position statement and some is clearly not compliant.
• With respect to MD’s mother, the prescribing for a chronic condition over a two-year period would not be consistent with the Board’s guidance warning against licensees managing family members’ chronic conditions. It could be defensible for MD to write refill prescriptions for his mother for a limited time if she had a difficult time finding a new doctor and was at risk of running out of her medications. However, his failure to conduct an appropriate examination or to document his care would almost certainly be a breach of the applicable standard of care. In such a case, it would be advisable for MD to create a written record documenting his care and the circumstances under which the prescriptions were provided, with a clear statement that MD was providing refills on an emergency basis until a new physician could take over his mother’s care.
• MD’s prescribing to treat his sons’ strep throat infections represents a good example of the type of “minor acute illnesses” that may be appropriate for this MD to treat so long as this MD also provides care within standard, including conducting appropriate diagnostic testing and documenting his care. Sending a short note documenting the episode of care and sending it to the physician of record is recommended.
• MD’s prescribing of opiates to himself and his wife is a clear violation of Board regulations and would likely result in disciplinary action. MD’s other prescribing to his wife is also not consistent with the standard of care or the Board’s guidance, as he has failed to conduct an appropriate examination or document his care.
It is the Board’s concern that treating oneself and one’s family members, increases the likelihood that essential elements of acceptable medical care – such as conducting a thorough examination and documenting the care provided– will be skipped or insufficient. The hectic pace of clinical practice and life in general notwithstanding, licensees are best served by prioritizing their own health and the health of their loved ones by making time to receive appropriate medical care.
Conclusion
The Board recognizes that some licensees may feel that they can care for themselves and family members. Nonetheless, the Board expects licensees to familiarize themselves with the relevant regulations and position statements and prescribe appropriately. Remember that any time you exercise your prescriptive authority you are creating a clinician-patient relationship and, with it, a professional obligation to provide care that meets at least minimum accepted standards of care. Deciding or agreeing to prescribe to family, friends, romantic partners, or others with whom you share a significant emotional relationship invites situations where it is more likely for a licensee to forgo the thorough, formal process they use with patients in clinic. If loved ones press, the Board encourages you to use the Board’s position statement and rules to politely deflect their requests. The Board is happy to be the “bad guy” if it helps a licensee protect themselves, their loved ones, and their license.