Edited Because I Don't Want to Get Fired

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

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[Sushirolls]

I had a patient whose sibling was writing for non-controlled substance, an SSRI.
I told the patient (s)he should inform the sibling now, they better have a legitimate chart note and record of A/P backing up their prescription. And better yet, not ever prescribe.

Each state is different. Some care. Some don't.
Controlled substances, more care than those who don't.

So it really depends on what's the laws in your state? And secondly, did this husband actually make a chart note with full A/P for treating the spouse as a patient. Knowing the state law might shape your response.

 

[dl2dp2]

There are clear guidelines on this:

Should You Treat Yourself, Family or Friends?

It boils down to a personal decision in most situations.

www.aafp.org

In order for this to be kosher:
1. short-term, minor problems
2. physician must prepare and keep a proper written record of that treatment

ADHD and benzos several times can be a bigger problem, so I think I would discuss with the patient that this is improper and she should tell her husband to stop doing that. I am not sure this rises to the level of board complaint unless you think there's misuse or diversion, or that it represents a pattern of practicing outside of the scope of expertise. That being said: I've written Ambien/Klonopin once or twice for my immediate family member and I kept a note in my EMR for this person, so perhaps this husband also had kept a note.

 

[jbomba]

I've definitely written a script of zofran for my wife once when we were leaving for a trip out of town. Didn't leave a note (not that I have my own EMR to leave a note in anyways). Is this something that could come back and bite me?

 

[calvnandhobbs68]

I've definitely written a script of zofran for my wife once when we were leaving for a trip out of town. Didn't leave a note (not that I have my own EMR to leave a note in anyways). Is this something that could come back and bite me?

No. Nobody cares. Only time people actually care is if you're doing stuff like OP with controlled meds. DEA can then wonder why exactly you're writing meds for a family member with a legally defined risk of abuse or diversion. So yeah OP I'd tell the patient to tell her husband to cut it out cause everyone can see it in PDMP, this ain't the 1980s.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[comp1]

I think you have a duty to tell the wife that this is inappropriate. I'm sure the laws vary by state, but all specialty societies oppose prescribing controlled substances to friends and family.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[Jules A]

Unfortunately the NP who was seeing the pt before me and who was titrating her Adderall did not catch this aberrant prescribing on the PDMP.

Or they did and either discreetly discussed with patient as you plan or decided it was poor form but not a reportable event.

 

[Sushirolls]

People can see the published summaries for medical board actions.
One state I've been in used to mail quarterly letters. And it included summaries of license/name/infraction and little blurp and action details.
Prescribing without a corresponding medical chart note was one of those things that frequently popped up.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[Sushirolls]

You've surveyed the herd, what are you going to do?

 

[Candidate2017]

OP, have you considered having a podcast series?

Because each of your posts slowly reveals and deepens the mystery doo doo. First it was Adderall from Dr. Hubby maybe just bridging her, then Oxy #30 for unknown reasons, then you reveal she was inherited from an NP, who's in the midst of upper her Adderall without checking PDMP. What next? I can't wait. Nice work. It goes from a one clown show, to 20 clowns exiting a small car, to 50 clowns juggling flaming balloon animals.

At best, you have clueless idiots and your state board is lax, and you can treat this as a coordination of care issue by discussing with her your controlled substance rules (Adderall from you only, random UDS, etc.) and faxing the plan, which states such, to Dr. Hubby.

At worse, there will be some bad juju coming. Inherited patients, especially on controlleds, tend to have some juju in the background. Exponentially worse with inherited NP patients. Let's not discount the fact physicians often enable family members and can be in deep denial of their loved one's real psychiatric issues, and Dr. Hubby will be taking it out on you. Maybe in the end, she just needs to be discharged back to the care of Dr. Hubby.

 

[TexasPhysician]

I've definitely written a script of zofran for my wife once when we were leaving for a trip out of town. Didn't leave a note (not that I have my own EMR to leave a note in anyways). Is this something that could come back and bite me?

Yes it could. Always create a note. It could literally be on a Word document at home. It could be an email to yourself. Medical boards police records. You need a record even if it isn’t great documentation. This isn’t the worst infraction, but you could be publicly chastised and required to complete CME on medical record maintenance.

 

[TexasPhysician]

You have a stable inherited outpatient, being seen primarily for ADHD, on Adderall 10 mg BID.

She mentions her husband is a physician. After leaving the appointment, you check the PDMP again and realize that she's gotten a few scripts of Adderall and short-acting benzos for insomnia from him several times (field unrelated to psychiatry). Nothing majorly concerning from the fills, appears like it was bridging refills and/or sporadic, nothing majorly concerning for abuse.

Clown ****.

What would you do? At minimum tell the patient to cut that **** out.... and....?

I feel like I could report the MD, aka her husband to the medical board, and he would get a minimum of a talking to, and at most in some serious trouble. As it stands, I will discuss this for clarification with the patient first, and if it continues, report.

This is a major infraction with serious punishments that could involve a revoked license.

I know someone that did this and then realizing it was such a huge infraction, this person self-reported themselves. The punishment involved someone monitoring their practice and not being allowed to prescribe any controlled meds. This seriously affected job options.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[calvnandhobbs68]

I will probably ask the chief medical officer and the medical director but I don’t know how helpful they will be.

I guess my options are to carefully spend more time looking at the PDMP, make 10000000% sure it is in fact her husband. I spent a few minutes today looking at it, it didn’t take me long to confirm, but I will have to double and triple check.

Then I have two options.

1) Tell the wife never to do that again

Or

2) Report him immediately to the board. Ethically no board will be happy to see controlled medications in 3 separate classes, with opiates, amphetamines, and benzos prescribed by a husband. No matter the low ish doses for a shortish period of time. He is ballsy or just dumb as f*ck bc these scripts aren’t even for like 7 days or something but for a full 30 days.

I am leaning to #2 after telling the MD/CMO

Yeah I mean it's pretty easy to double check even if her husband has a name like "john smith" or something. You just start the next visit with "hey last visit we talked about your husband being a doctor, would he happen to be John Smith the orthopedic surgeon who works out of X hospital/clinic?" (cause PDMP shows your DEA address).

When she says "why yes he is", gives an easy lead into "oh interesting because when I pulled your controlled medication report I saw a that a John Smith orthopedic surgeon at that address prescribed you X, X and X".

If she says "whatcha talkin bout Willis?" then you just go "oh my mistake, I saw that John Smith orthopedic surgeon at that address prescribed you X, X and X, just so I have a complete medical history, when did you go see this doctor for those controlled medications, I'd like to get prior records from them." and see what happens.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[calvnandhobbs68]

During the visit she told me his specialty. Which is not the common run of the mill family medicine, or internal, etc, but a pediatric sub specialty.

When I googled the doctors name from the PDMP it came up as that exact speciality.

In honesty I then googled his name and the patients name, and confirmed it very quickly. I had to google because they did not share the same last name. Ethically we are not supposed to google our patients name, is that correct?

Or is it justified in this case because I had a specific, clinically relevant question?

Edit: re social media searching i came across this article and read it briefly.

https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201800495#:~:text=It%20is%20advisable%20to%20obtain%20consent%20from%20the%20patient%20before,the%20patient%20or%20family%20members.&text=Using%20social%20networking%20sites%20to,damage%20the%20physician%2Dpatient%20relationship.

I need to read it in its entirety tomorrow. But I believe the reason I searched is mainly justified.

You're completely justified in googling the doctor from the PDMP to figure out who was prescribing this controlled med to your current patient. I mean I wouldn't approach it with her as if you already googled them and found out they could live at the same address because who knows....but I wouldn't worry about the google search itself.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[PikminOC]

I report to the board.

 

[allantois]

Idk why you are so surprised tbh. I see this all the time. Anesthesiologist father refilling Adderall for daughter, etc. Pharmacies around here are pretty good and will more often than not will even call to alert/refuse to fill, etc

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[allantois]

So you would not report?

I find the BOM in my state utterly useless when it comes to this stuff and the BON even more useless. Your state may be different. DEA may be more interested in this idk.. If your state requires that PMP be checked, it is pretty egregious that this was missed by NP/previous MD and if this is at your organization I would definitely bring it up internally as there may be bigger issues with other patients getting multiple scripts from different places if no one is checking and pharmacies don't care

 

[annoyedpsychiatrist]

also agree that its pretty stupid to be writing prescriptions for controlled medications for family/spouse. I think its unlikely to get too much fallout from something minor like writing your spouse a rx of antibiotics or something minor, or zofran as stated above, but controlled rx is a whole different ballgame. Some people may look at it as the doctor writing it for himself- who is to say that hes not writing for the wife, who in turn gives it to him?

 

[littlefred]

I'm going to report OP if he doesn't report that doc.

 

[jbomba]

Yes it could. Always create a note. It could literally be on a Word document at home. It could be an email to yourself. Medical boards police records. You need a record even if it isn’t great documentation. This isn’t the worst infraction, but you could be publicly chastised and required to complete CME on medical record maintenance.

I've since written a note for this encounter/rx. I'm guessing I'm fine now - Its really that simple?

 

[Merovinge]

Maybe you are right.

Just more annoyed than anything. If it was 1 script I would be less surprised. However this is oxy, triazolam, ambien, klonopin, adderall sprinkled throughout, for 30 days, some BID - TID.

I am more annoyed that the NP/prior MD did not catch this when I did on the first day I had her.

I was not going to list the exact medications, but I did just to show a point, and am debating deleting this thread ASAP because I feel it is too detailed.

By a pediatrician no less. That's pretty bad. I lean towards not reporting in all cases and I think even I would report this, I have concerns what that doctor is doing in their practice if rxing those 5 scripts to their adult spouse as a pediatrician.

 

[Sushirolls]

I've since written a note for this encounter/rx. I'm guessing I'm fine now - Its really that simple?

Possibly, just depends, does your state have laws that say no Rx for people XYZ?
Or laws that say just ABC prescriptions XYZ?

But actually having a chart, with full H&P and even SOAP notes helps.

I know of one doc who was a resident, had Rx substance dependence, started using license to write fake scripts in spouse name and other people, to then go pick them up to further their usage. As expected got caught. Non-doc spouse got questioned by LEO and was like uh, what? That marriage ended in divorce.

 

[littlefred]

By a pediatrician no less. That's pretty bad. I lean towards not reporting in all cases and I think even I would report this, I have concerns what that doctor is doing in their practice if rxing those 5 scripts to their adult spouse as a pediatrician.

PDMPs can verify all controlled prescriptions by a particular DEA number. I bet that pediatricians report must be juicy. Medical board is going to be like this > 🧐

 

[ObsequiousAplomb]

Maybe you are right.

Just more annoyed than anything. If it was 1 script I would be less surprised. However this is oxy, triazolam, ambien, klonopin, adderall sprinkled throughout, for 30 days, some BID - TID.

I am more annoyed that the NP/prior MD did not catch this when I did on the first day I had her.

I was not going to list the exact medications, but I did just to show a point, and am debating deleting this thread ASAP because I feel it is too detailed.

Honestly, the one that shocks me the most is the Halcion. I've never seen it prescribed by anyone. I've always wondered about considering it for the right patient, but haven't found the right one yet, I guess. Sorry to derail, but have any of you guys ever prescribed Halcion before?

 

[Ironspy]

Honestly, the one that shocks me the most is the Halcion. I've never seen it prescribed by anyone. I've always wondered about considering it for the right patient, but haven't found the right one yet, I guess. Sorry to derail, but have any of you guys ever prescribed Halcion before?

I’ve inherited patients started on it by very old psychiatrists but never started it myself

 

[clausewitz2]

Honestly, the one that shocks me the most is the Halcion. I've never seen it prescribed by anyone. I've always wondered about considering it for the right patient, but haven't found the right one yet, I guess. Sorry to derail, but have any of you guys ever prescribed Halcion before?

Never prescribed it. A relative who was very anxious about getting dental work done had it prescribed by a dentist a few years ago. They disliked the experience relative to other BZDs (which unfortunately they had enough experience with to have specific opinions about).

 

[TexasPhysician]

I've since written a note for this encounter/rx. I'm guessing I'm fine now - Its really that simple?

For my medical board, that should be fine. For non-controlled meds, they don’t care as long as it’s treated like anyone else. If a patient came to your clinic, would you ever prescribe them any med without a note? Never right? It should be the same with anyone, even a spouse or child of yours.

As there isn’t abuse potential for Azithromycin etc, there isn’t much good in pressing a MD for a Rx for family. It’s probably what would occur with a 5 second minute clinic. That said, medical documentation is required by each state to substantiate the Rx.

 

[Geraltofrivia]

People ask me for medical advice and stuff all the time and my response is always "I'm not your doctor so please don't share anything with me. I don't want to know your information. If you want, I can recommend you somebody but I will not advise you with particular therapies or whatnot" or something like that because I'm scared somebody will sue me. Am I being too paranoid lol

 

[allantois]

People ask me for medical advice and stuff all the time and my response is always "I'm not your doctor so please don't share anything with me. I don't want to know your information. If you want, I can recommend you somebody but I will not advise you with particular therapies or whatnot" or something like that because I'm scared somebody will sue me. Am I being too paranoid lol

I feel like we often don't get many medical questions due to the field we work in.. at least I don't and tbh I can't really provide sound medical advise on most medical topics these days. Or do you mean getting asked psych related questions? I will answer general questions (such as is EMDR a good therapy for PTSD but never anything specific to anyone..)

As far as Halcion.. I see a lot of foreign patients so I have prescribed someone Halcion because they've been on it before. Doesn't seem to be much different from a bzo

 

[Bartelby]

I agree with allantois, general education is great! Specific advice you have to be much more cautious. For example:

-Someone shares they have been diagnosed with PTSD and asks about what kinds of therapy are helpful for PTSD. You tell them that in general, time-limited protocols such as Cognitive Processing Therapy or Prolonged Exposure are first-line therapy options for PTSD.

-Someone shares small bits of a problem they are dealing with. You conclude (without a real history) that they have PTSD and recommend a specific course of treatment.

I try to explain to people that I would need to know a lot more than either of us should be comfortable with to give them a fully informed opinion, which is what they deserve. I encourage them to connect with an appropriate provider.

For general medical questions, if the answer is obvious I will share it. If I am at all unsure, I tell them it's been a while since I dealt with that and that they should check in with their PCP / urgent care / etc. The guiding principle should be not giving false reassurance (being the reason they do not take an issue as seriously as they should).

 

[Psych Person]

I had a patient whose sibling was writing for non-controlled substance, an SSRI.
I told the patient (s)he should inform the sibling now, they better have a legitimate chart note and record of A/P backing up their prescription. And better yet, not ever prescribe.

Each state is different. Some care. Some don't.
Controlled substances, more care than those who don't.

So it really depends on what's the laws in your state? And secondly, did this husband actually make a chart note with full A/P for treating the spouse as a patient. Knowing the state law might shape your response.

daddy chill

You’re right that it would be ideal to have a chart note for those controlling bureaucratic losers who want to continue to castrate and restrict physicians. Practicing medicine had been one of the final professions where a physician had autonomy to act independently and be limited in who they had to answer to, and while I know some physicians have abused this privilege, I don’t agree with how modern practice autonomy is so heavily infringed upon by these borderline IQ robotic dweebs who I have no respect for.

If I or my family member have a minor, localized, and self-limiting illness like a sinus infection, with lungs that are clear and without constitutional symptoms/systemic involvement, and that is clearly bacterial based on exam and HPI, along with unremarkable past medical history, I’m going to prescribe an appropriate antibiotic, and I’m not going to document shi*. There’s no need to be paranoid thinking the surgeon general is coming for me. And if one pharmacist gives me push-back, I’ll call another pharmacy. This is so damn easy and insulting to even a half-competent physician to interfere with. I would still make sure that my loved one had a family doc that they made an effort to see every once and a while, however, in order to avoid me becoming the primary care of the family.

If I or my family member are clearly systemically unwell, such as having fever, malaise, and signs of lung involvement for example, unless for whatever reason they will be unable to see a physician (family doc, urgent care, ER) today or the next day and have been deteriorating quickly, I am going to send their sick butt to a doc with a facility to thoroughly address the whole person’s needs, monitor appropriately, and take on the liability that comes with that. I’m still going to be involved peripherally (keeping my eyes and ears open, but not getting involved unless necessary) to make sure that what is being done makes sense and is up to the gold standard/standard of care in the community.

Any psychiatrist that went into psychiatry because they weren’t sufficiently competent in general medicine, I don’t view favorably. “Basic medicine”, like what is done in Urgent Cares, isn’t hard, and all physicians are supposed to be capable of demonstrating sufficient competence in it. And if you forget something, it’s as easy as riding a bicycle to quickly shake off the rust and get back into. Many of these Urgent Cares are run by suspect mid-levels and physicians who didn’t even complete a residency but did intern year.

When it comes to controlled substances, I would never prescribe these for myself or a loved one. It is clearly a no-no, ethically, morally, and legally.

Also with respect to psychotropics of all kinds, I also would never start these, not even an SSRI or Trazodone, for myself or a loved one. Personally, and professionally, I don’t believe that the patient-physician relationship required for effective, objective psychiatric treatment can be achieved any longer once there is a pre-existing close personal relationship. If the circumstances were highly unusual and a short bridge of a long-standing consistently adhered to non-controlled, uncomplicated psychotropic were needed, only in this situation would I consider bridging a loved one MAYBE. I wouldn’t do it even for myself though, not even refills, as when it comes to one’s self in psychiatry, this is probably the kind of self-treatment in all of medicine in all the specialties that would be the least likely to be objective, and having a relationship with a psychiatrist who provides this for you and is the only one who can provide it for you is important for the therapeutic alliance.

P.S. - I hate bureaucrats.

 

[Psych Person]

You have a stable inherited outpatient, being seen primarily for ADHD, on Adderall 10 mg BID.

She mentions her husband is a physician. After leaving the appointment, you check the PDMP again and realize that she's gotten a few scripts of Adderall and short-acting benzos for insomnia from him several times (field unrelated to psychiatry). Nothing majorly concerning from the fills, appears like it was bridging refills and/or sporadic, nothing majorly concerning for abuse.

Clown ****.

What would you do? At minimum tell the patient to cut that **** out.... and....?

I feel like I could report the MD, aka her husband to the medical board, and he would get a minimum of a talking to, and at most in some serious trouble. As it stands, I will discuss this for clarification with the patient first, and if it continues, report.

Great post. It has led to a lot of meaningful discussion. I respect you for being open-minded and motivated to learn about what your options and responsibility are and how to address this in reality given the potential complex outcomes taking action could result in.

Most importantly, I love that someone with a username like yoloswagpoop42069 became a doc and is a colleague of mine. Glad to have you on the team, brother.

 

[whopper]

There shouldn't be any prescriptions from husband to wife.

That's what they teach.

Do I see docs sometimes do a script now and then? Yes. Is if ever a serious bad thing? So far no from what I've seen. Family member has Strept throat, person calls his doc and that guy can't fill him in for weeks, brother who's a doc prescribes him an antibiotic. Seriously is this worth the effort to report?

Controlled substances? If it's small I'd tell the patient it's not supposed to be done, let's try to avoid it in the future but I'm not going to call the authorities over it.

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[allantois]

If you are going to report, you don't need permission from your employer to do so

 

[yoloswagpoop42069]

Edited Because I Don't Want to Get Fired

 

[allantois]

Yeah I agree.

But if I was going to report, I should have done it without asking the chief medical officer of the company first. I think I asked him in part because I wanted to defer to his judgement, consciously or subconsciously. The interim medical director for this location, has not provided any response, likely because the CMO sits above her anyway.

Whether or not this is the correct outcome, I believe this is what I will be doing. Or is the correct thing to do ask my CMO, he asks legal, they say don't report... so he says don't report, and then report anyway? Just made it harder for myself. To be honest I don't want to rustle jimmies at a place I will be at for 6 months, being paid as a 1099, with plans to go to fellowship after.

Alternatively, for my state, a complaint could have been made anonymously. Should have just done that, but it opts you out of updates if you do.

The husband in question is a radiation oncologist for the hospital system that is a financial partner with this company at this location. I'm sure he makes some cash for this health system. Shouldn't matter but that's also related.

Since you are a locums 1099 I wouldn't even worry about this too much and report anonymously if you are inclined to report. Very unlikely the husband will loose his license (at worst they will limit his ability to Rx controlled substances) which should not limit his professional practice

 

[Merovinge]

The husband in question is a radiation oncologist for the hospital system that is a financial partner with this company at this location. I'm sure he makes some cash for this health system. Shouldn't matter but that's also related.

The husband is fueling the executive's yacht fund and who knows, might also be rxing them Addies.

 

[calvnandhobbs68]

He said he spoke to the legal team, and the legal team stated that I am not allowed to report the husband to the medical board, unless the patient herself gives me consent/permission to... which is absolutely horse ****, incorrect, and doesn't make any sense whatsoever.

lol yeah either the lawyers are *****s or the place just doesn't want to rustle any feathers. I'd love to know on what exactly ruling/regulation they're basing that opinion on.