Prescription Meds

Pod Stud said:

Can a podiatrist write a prescription for an antibiotic to treat a stomach infection like gastroenteritis or for a strep throat? Or write a prescription for a medicine for a cold sore in the lips like Valtrex? Or like a pain med like Vicodin for pain in the arm or neck? Especially for friends or family members?

Or is it simply prescribe any medicine only for diseases or injuries of the feet? Thanks.

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You prescribe medicine for what you treat. Don't even THINK about ever prescribing Vicodin or any other narcotic for a friend, relative, etc., if that patient isn't under your active care AND you have documentation to prove it. It shouldn't be done for any medication, but especially a narcotic.

Don't be the good guy in the neighborhood who writes prescriptions for the neighbors. It will bite you in the ass. If there is ever a problem such as an allergic reaction, serious side effect, interaction with another medication that you don't know the patient is taking, you are screwed.

Never, yes never write a prescription for anyone if you don't have a chart for that person. And when you do write an RX, there must be some medical justification for that RX.

Will you be locked up behind bars if you write an RX for an antibiotic for a neighbor??? I don't think so, but it's a habit that shouldn't start.

A colleague I know played tennis every week with the same guys. One was a dentist and the other an orthopod. The orthopod was away, and my friend the podiatrist played tennis with the dentist one week. After the match, the dentist said he had a problem with his lower back, and the orthopod usually gives him Vicodin when it acts up. So he asked the podiatrist if he could just write an RX for a few until the orthopod returned from vacation.

Of course since they were long time friends, the pod wrote the RX for 10 Vicodin. Two weeks later the Feds/DEA knocked on his door asking to see the dentist's chart. Of course the pod didn't have a chart. It ends up the dentist had an addiction problem and was getting Rxs from a bunch of different doctors.

As a result of writing the narcotic RX without a chart or documentation, the pod lost his DEA license for 3 years.

Start your career the right way and you'll sleep better at night and not have any skeletons in your closet.

Sorry if my answer may be long winded or a little harsh. I just don't want to see anyone end up like my friend. His intentions were good, but the end result was bad.

PADPM said:

You prescribe medicine for what you treat. Don't even THINK about ever prescribing Vicodin or any other narcotic for a friend, relative, etc., if that patient isn't under your active care AND you have documentation to prove it. It shouldn't be done for any medication, but especially a narcotic.

Don't be the good guy in the neighborhood who writes prescriptions for the neighbors. It will bite you in the ass. If there is ever a problem such as an allergic reaction, serious side effect, interaction with another medication that you don't know the patient is taking, you are screwed.

Never, yes never write a prescription for anyone if you don't have a chart for that person. And when you do write an RX, there must be some medical justification for that RX.

Will you be locked up behind bars if you write an RX for an antibiotic for a neighbor??? I don't think so, but it's a habit that shouldn't start.

A colleague I know played tennis every week with the same guys. One was a dentist and the other an orthopod. The orthopod was away, and my friend the podiatrist played tennis with the dentist one week. After the match, the dentist said he had a problem with his lower back, and the orthopod usually gives him Vicodin when it acts up. So he asked the podiatrist if he could just write an RX for a few until the orthopod returned from vacation.

Of course since they were long time friends, the pod wrote the RX for 10 Vicodin. Two weeks later the Feds/DEA knocked on his door asking to see the dentist's chart. Of course the pod didn't have a chart. It ends up the dentist had an addiction problem and was getting Rxs from a bunch of different doctors.

As a result of writing the narcotic RX without a chart or documentation, the pod lost his DEA license for 3 years.

Start your career the right way and you'll sleep better at night and not have any skeletons in your closet.

Sorry if my answer may be long winded or a little harsh. I just don't want to see anyone end up like my friend. His intentions were good, but the end result was bad.

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So the moral of the story is don't play tennis with dentists
Sorry I had to...great story though

Shinobiz11 said:

So the moral of the story is don't play tennis with dentists
Sorry I had to...great story though

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I should have seen that one coming!

Unfortunately, the story is true.

A doctor that I knew who was on the AZ State Medical Board said the single biggest reason they took disciplinary action was doctors writing prescriptions for friends or colleagues without having a legitimate doctor-patient relationship (i.e., they had no medical chart to justify what they did).

A podiatrist can write for meds that have non-podiatric applications, but if a podiatrist treats conditions that are not legitimately podiatric in nature (out of the scope of practice) then he or she can become the target of inquiry. If you write for a drug that might be more often used for non-podiatric reasons then you'd best document exactly why you're prescribing that drug.

Example: "Aldara, 24 packets, apply M/W/F prn plantar verruca" (in order to let the world know you're not treating peri-anal warts).

Pod Stud said:

Hmmm? So it is illegal for a podiatrist to write a script for Valtrex to treat cold sores in the lips, or for Amoxicillin for strep infection of the throat. Pods do not treat lips and throat, they treat diseases and injuries below the knee (i.e. feet, ankles, and leg)

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Yeah, don't do it.

dyk343 said:

What about long term drugs things like HCTZ for LE edema? That seems risky to prescribe/manage yet totally related to the Foot/ankle. I think I know the answer already, or at least what my attendings would say, but I'm curious what others have to say.

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The cause of lower extremity edema is rarely a pure foot/ankle problem in the absence of trauma. The etiology is usually from a systemic cause such as cardiac disease, CHF, kidney disease, vascular disease and obviously many other causes. Therefore, prescribing a diuretic can potentially mask symptoms that need further investigation.

Some podiatrists have prescribed a diuretic temporarily for post op edema, but in my opinion you must always investigate the cause prior to treating the symptom. Lower extremity edema is a great opportunity to interact with a PCP or specialist to discuss your concerns and refer for medical work up.

On a side note, if a patient enters your office with unilateral edema of relatively recent onset, always consider DVT and direct your exam and recommendations (Duplex Doppler ultrasound, etc) to rule out this potentially life threatening but relatively common pathology.

Pod Stud said:

Is it legal for a podiatrist to do an H&P? I shadowed MD clinics and they do these all the time.

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I believe this depends mostly on the hospital system that you are working through. We admit patients to our own service occasionally (post-op usually, but sometimes post-trauma) and when we do that we do our own H&P's. There are also a few surgery centers that we work out where we do our own pre-op H&P's. While on outside rotations, we do H&P's all the time. But on our podiatry service, usually our patients are admitted to the medicine service and we are on consult so we don't do full H&P's for most of the patients. Just my experience.

The most sketchy RX that I saw a pod prescribe was Lunesta. The patient said she was having trouble sleeping after the surgery, so the pod prescribed Lunesta. I wasn't really sure how appropriate this is/was, but I guess if it was related to the surgery....

Thoughts?

MaxillofacialMN said:

The most sketchy RX that I saw a pod prescribe was Lunesta. The patient said she was having trouble sleeping after the surgery, so the pod prescribed Lunesta. I wasn't really sure how appropriate this is/was, but I guess if it was related to the surgery....

Thoughts?

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Not sketchy.

Granted you have legit paperwork, could you possibly prescribe Viagra for yourself? I would find that rather embarrassing to see a doctor about.

Regarding the H&P, pods are legitimately allowed to the perform them, let's say moonlighting in a clinic? Or in a field hospital? Disaster center?

Shinobiz11 said:

Granted you have legit paperwork, could you possibly prescribe Viagra for yourself? I would find that rather embarrassing to see a doctor about.

Regarding the H&P, pods are legitimately allowed to the perform them, let's say moonlighting in a clinic? Or in a field hospital? Disaster center?

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You're a student and you're already concerned about writing Viagra prescriptions for yourself????!!!!!!

The answer to your question regarding writing a prescription for Viagra is not hard......don't do it. You never know if a disciplinary board will hit you with a stiff penalty.

PADPM said:

The answer to your question regarding writing a prescription for Viagra is not hard......don't do it. You never know if a disciplinary board will hit you with a stiff penalty.

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[groan]

dyk343 said:

OK HCTZ was a bad example... what about drugs like allopurinol and gabapentin?

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What have you seen allopurinol and gaba rx'd for that would make you question wether pods could medically manage their patients with these drugs? Just curious if you've seen them used for something other than gout/neuropathic pain? Are DPM's writing for family members with kidney stones? I guess I could see a lot of pods not wanting to mess with gout management though.

it happened as a consequence of the Lapidus surgery in the foot.

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2 questions for anyone. Is there even a prescription strength Dulcolax (thought it was all OTC)? And I'm not missing something special about a Lapidus causing constipation...it was the narcotics right?

Maybe the screws for the Lapidus were too long and went across the colon.

You are completely right, the simple solution is to d/c the narcotics or have them take on OTC med such as Dulcolax. Eating a dozen White Castle "sliders" would also probably resolve the problem quickly.

PADPM said:

You're a student and you're already concerned about writing Viagra prescriptions for yourself????!!!!!!

The answer to your question regarding writing a prescription for Viagra is not hard......don't do it. You never know if a disciplinary board will hit you with a stiff penalty.

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Haha I never said I was traditional jk jk

Nah, was just wondering. That seems like something that wouldn't be too big of a deal, unless you are selling the pills discounted to your friends.

dyk343 said:

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This. My attendings send them out the door with Indomethacin and a referral to their primary. We hand out Gabapentin all the time. I was just curious what others say.

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Got it. The allopurinol made sense when I actually thought about it. As far as gaba or amytriptyline, I would hope that if there are pods that don't manage a patient's neuropathy that it is not because they don't feel qualified/competent...

Shinobiz11 said:

Haha I never said I was traditional jk jk

Nah, was just wondering. That seems like something that wouldn't be too big of a deal, unless you are selling the pills discounted to your friends.

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I just think it isn't a good idea to write prescriptions for yourself.

dyk343 said:

[/B]
This. My attendings send them out the door with Indomethacin and a referral to their primary. We hand out Gabapentin all the time. I was just curious what others say.

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I have written prescriptions for gabapentin, Cymbalta, Lyrica amd Metanx for neuropathy and can justify it's use. When a patient has gout, I do not prescribe allopurinol which is my individual decision. Just as I do not prescribe meds to control a diabetic's glucose (though I will treat the neuropathy), I do not treat the systemic cause of gout, though once again I do treat the symptoms via injection, NSAID, etc.

I will often send a letter or call the PCP and send copies of labs or reports, and will often discuss my concern if a patient is taking furosemide or HCTZ, which can cause an acute attack.

There is no right or wrong answer. I simply choose not to treat the systemic problem. I feel that's not really my expertise.

PADPM said:

I have written prescriptions for gabapentin, Cymbalta, Lyrica amd Metanx for neuropathy and can justify it's use. When a patient has gout, I do not prescribe allopurinol which is my individual decision. Just as I do not prescribe meds to control a diabetic's glucose (though I will treat the neuropathy), I do not treat the systemic cause of gout, though once again I do treat the symptoms via injection, NSAID, etc.

I will often send a letter or call the PCP and send copies of labs or reports, and will often discuss my concern if a patient is taking furosemide or HCTZ, which can cause an acute attack.

There is no right or wrong answer. I simply choose not to treat the systemic problem. I feel that's not really my expertise.

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This is how I plan on treating this as well. At my residency, I have usualy seen that we will do something for the acute attack and leave long term management of gout to the patients PCP. For neuropathy, we will prescribe gabapentin, amitriptyline, etc. We also work closely with a great PM&R doc that we feel confident sending a patient to if we need help in management (he also does a lot of NCV/EMG testing for us).

ldsrmdude said:

This is how I plan on treating this as well. At my residency, I have usualy seen that we will do something for the acute attack and leave long term management of gout to the patients PCP. For neuropathy, we will prescribe gabapentin, amitriptyline, etc. We also work closely with a great PM&R doc that we feel confident sending a patient to if we need help in management (he also does a lot of NCV/EMG testing for us).

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Hey, ,maybe you're one of the residents where I work, and neither one of us knows it, since that is similar to my protocol. Though I usually avoid amitryptiline due to the side effects.

PADPM said:

Hey, ,maybe you're one of the residents where I work, and neither one of us knows it, since that is similar to my protocol. Though I usually avoid amitryptiline due to the side effects.

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Hmm, could be. Or great minds could just think alike

From my limited experience, I see amitriptyline prescribed mostly when patients have most of their neuropathic pain at night and they can just take a dose before bedtime and not have to worry about drowsiness (or have it even be beneficial for them). I don't have the benefit of much follow-up so far, but it's seemed to work pretty well.

I claim no expertise on how statutes are interpreted, but it seems like this (some of the prescription questions above) could have some state to state scope implications. I've posted a few excerpts below from various state scope websites. All I'll say is that I intend to know my future scope language backwards and fowards.

Additionally: when I compiled the state scopes I found some to be very concise and some to be verbose. Please do not interpret the excerpts below to represent the full text.

Consider:

Missouri:
The definitions of the words "podiatrist" or "physician of the foot" shall for the purpose of this section be held to be the diagnosis, medical, physical, or surgical treatment of the ailments of the human foot, with the exception of administration of general anesthetics, or amputation of the foot and with the further exception that the definitions shall not apply to bone surgery on children under the age of one year. The use of such drugs and medicines in the treatment of ailments of the human foot shall not include the treatment of any systemic diseases.

Connecticus:
Sec. 20-50. Podiatric medicine defined. "Podiatric medicine" means the diagnosis and treatment, including medical and surgical treatment, of ailments of the foot and the anatomical structures of the foot and the administration and prescription of drugs incidental thereto. It shall include treatment of local manifestations of systemic diseases as they appear on the foot. A doctor of podiatric medicine, licensed pursuant to this chapter may prescribe, administer and dispense drugs and controlled substances in schedule II, III, IV or V, in accordance with section 21a-252, in connection with the practice of podiatric medicine.

Massachusetts:
Practice of Podiatry means the following conduct: the maintenance of human podiatric health by the prevention, alleviation or cure of disorders, injuries or disease of the human foot and ankle by medical, mechanical, surgical, manipulative and electrical means, and the prescription and administration of drugs for the relief of disease or adverse physical podiatric conditions. The scope of practice of podiatry includes resections of the foot; as well as surgical procedures involving the ankle joint. In the course of treating the human foot or ankle, a registered podiatrist may perform an Achilles tendon lengthening and he or she may also perform tendon transfers that require incisions into the lower leg. The scope of practice of podiatry includes the diagnosis of systemic diseases.

Nebraska:
A podiatric physician and surgeon may diagnose or treat an ailment of the human foot caused by a systemic condition provided an appropriate consultation or referral for the systemic condition is made to a licensed health care practitioner authorized by law to treat systemic conditions.

I'm just going to guess that for most states, podiatrists can prescribe anything that they need to in order to treat their patients. If the scope of practice for Missouri that states podiatrists can't prescribe meds for systemic diseases was interpreted to mean that we couldn't prescribe any medication for any disease that has some systemic manifestation, I am having a hard time coming up with meds that we would be able to prescribe.

dyk343 said:

Lets get controversial... assuming you live in a state where it is legal, what about medical marijuana?

Other than chronic pain, I really cant think of any reason why it would be prescribed but I do remember an attending posting awhile back that his partner would prescribe it every now and then.

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I think that would be begging for trouble. Managing chronic pain even without MMJ would be begging for trouble. IMO, that's the role of a Physiatrist or other Pain Management specialist.

NatCh said:

I think that would be begging for trouble. Managing chronic pain even without MMJ would be begging for trouble. IMO, that's the role of a Physiatrist or other Pain Management specialist.

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Would chronic foot pain not fall under the scope of a pod?

Shinobiz11 said:

Would chronic foot pain not fall under the scope of a pod?

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When dyk343 wrote "chronic pain" I took it as referring to "chronic pain syndrome," which is a complex constellation of syndromes including fibromyalgia, CRPS, myofascial pain, psychogenic pain, etc.

Chronic foot pain (e.g. hallux rigidus, plantar fasciitis for several months) is a different entity and would be within scope. I would choose any number of treatments rather than MMJ though.

It's legal here but I haven't heard of any podiatrists prescribing it.

NatCh said:

When dyk343 wrote "chronic pain" I took it as referring to "chronic pain syndrome," which is a complex constellation of syndromes including fibromyalgia, CRPS, myofascial pain, psychogenic pain, etc.

Chronic foot pain (e.g. hallux rigidus, plantar fasciitis for several months) is a different entity and would be within scope. I would choose any number of treatments rather than MMJ though.

It's legal here but I haven't heard of any podiatrists prescribing it.

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You could be the first

Shinobiz11 said:

You could be the first

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LOL, I'm not sure I'd want that notoriety.

PADPM said:

You prescribe medicine for what you treat. ...
...Don't be the good guy in the neighborhood who writes prescriptions for the neighbors. It will bite you in the ass. If there is ever a problem such as an allergic reaction, serious side effect, interaction with another medication that you don't know the patient is taking, you are screwed.

Never, yes never write a prescription for anyone if you don't have a chart for that person. And when you do write an RX, there must be some medical justification for that RX. ...

...Start your career the right way and you'll sleep better at night and not have any skeletons in your closet....

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I couldn't agree more^

I get at least monthly requests for Rx. "I just need a favor this one time" or "I don't have insurance right now" or whatever. They might appeal to your ego or to your sympathy. DON'T do it. It's a very slippery slope, and once you become known for it, people ask you more and more. I saw it with many attendings during residency... people know that "Dr. X down in the ER will write it for you, just go ask him."

You will probably get burned, and besides having to look at yourself in the mirror, I doubt any doc really needs any additional stress in beyond work, loans, family, etc. Worst of all, you could very well lose EVERYTHING you've worked for (DEA lic, hospital privileges, etc) as NatCh alluded to. Malpractice will hurt you, but mostly just in the wallet. Losing a license or hospital privileges can very well end a physician's career... or at least put it on life support. Illegitimate Rx (esp narcs) are the most common form of DPM (and MD/DO) license discipline and license loss. You will see during residency that you'll get a lot of calls questioning the many Rx you write when off service... and fyi, do whatever you can to use the hospital's DEA and NPI numbers and not your own when you write residency Rx.

I know anecdotal examples are a bit cliche, but to drive the point home, consider this:
One "nice guy" doc wrote Rx frequently for employees, hospital staff, etc. As it turns out, one of the many people he was writing for was an extramarital affair partner (classy guy). When that fizzled, in addition to a sex harassment suit and loss of hospital privileges, she reported him for the phony Rx and he had license discipline also. Use your smarts, and don't be a black eye to the profession. We are all judged by our lowest common denominator.

Shinobiz11 said:

Granted you have legit paperwork, could you possibly prescribe Viagra for yourself? I would find that rather embarrassing to see a doctor about....

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You don't write Rx for yourself.
1) It's illegal to write Rx for yourself (chart or not).
2) It's out of scope (and beyond your knowledge).
2) The doc who treats himself has a fool for a patient.

Feli,

That's very interesting, thanks for chiming in. So to clarify, so it is not only faux pas but actually illegal for a pod to diagnose his/her own foot pathology and to provide self Rx?

It's not illegal to order tests or prescribe medication for yourself.

diabeticfootdr said:

It's not illegal to order tests or prescribe medication for yourself.

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1). Welcome back.

2). I agree completely that it is not illegal to write an RX for yourself. I simply don't believe it is prudent.

3). Of course there are always exceptions. Several years ago on a weekend I had an allergic reaction. I immediately took some diphenhydramine (it wasn't severe enough to warrant epi), but still had some residual hives, etc., so called the pharmacy for a Medrol dose-pack.

4). As I stated, I don't think anyone is going to do hard time for calling in an RX for Keflex for a relative, friend, etc. I just believe it's best to not make it a habit and to not write an RX without a chart.

5). My wife injured her Achilles while working out, so I wrote an RX for an NSAID, but I actually have a chart on my wife and my kids to keep everything legit.

6). I have a neighbor who is a dentist and he writes scripts for everyone as if he's handing out gift cards. Sure, he a nice guy with good intentions, but those good intentions could haunt him in the near future.

PADPM said:

1). Welcome back.

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Thanks. Wish I could have been more active over the past year or so, but I've been too busy doing 'you know what'.

I agree with all your points. I keep a chart on all family members I've written meds for.

I know you didn't say this, but I was just correcting the misconception that it is illegal to write for yourself. Prudent, smart, ethical, all up for question and probably determined by the circumstances. But illegal, no.

So the Viagra situation is good now?

Shinobiz11 said:

So the Viagra situation is good now?

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As I stated before, it's hard to say.............but you don't want to get a rise out of the authorities.

diabeticfootdr said:

Thanks. Wish I could have been more active over the past year or so, but I've been too busy doing 'you know what'.

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Not to take this thread to off topic, but I followed the race somewhat closely and you gave it a good run. It takes a lot of energy to try for what you did, and I completely respect you for it.

MaxillofacialMN said:

Not to take this thread to off topic, but I followed the race somewhat closely and you gave it a good run. It takes a lot of energy to try for what you did, and I completely respect you for it.

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A lot of energy, time amd money, but not a lot of sleep.

MaxillofacialMN said:

Not to take this thread to off topic, but I followed the race somewhat closely and you gave it a good run. It takes a lot of energy to try for what you did, and I completely respect you for it.

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Thank you. It was an unbelievably hectic schedule. Busier than being a doctor or a medical student. I learned a lot, as well. But for the time being, back to being a doctor and a dad!

Ferocity said:

Feli,

That's very interesting, thanks for chiming in. So to clarify, so it is not only faux pas but actually illegal for a pod to diagnose his/her own foot pathology and to provide self Rx?

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diabeticfootdr said:

It's not illegal to order tests or prescribe medication for yourself.

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Thanks for clairifying. I was referring to the post I'd quoted and the Rx in question (Viagara). That's clearly out of scope and therefore would be a violate his DPM license (if/when he gets it) to write that for himself or anyone else.

As for Rx within DPM scope being written for oneself? Definitely not wise, but not technically illegal. For those who choose to write for themself within scope of practice, I sure wouldn't ever recommend it with any narcotic (illegal) or otherwise restricted or monitored Rx.

In the end, the people who want to push the limits will push the limits. They'll write self or friend/family Rx through friends, like minded other docs, etc. Some will get caught, some won't. Everyone's going to do what they're going to do, but when you spend 10+ years in higher education, it seems pretty reckless to me. Especially in the age of EMR, eRx, and much more transparency, why play with fire?