Prescribing as an intern

[romeno]

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As a brand new intern..

1) Can you legally prescribe non-controlled drugs (antibiotics for example) to patients not in the hospital (ie parents, friends)?

2) Can you morally prescribe non-controlled drugs (antibiotics for example) to patients not in the hospital (ie parents, friends)?

Or do you have to take step 3 first?

 

[Winged Scapula]

As a brand new intern..

1) Can you legally prescribe non-controlled drugs (antibiotics for example) to patients not in the hospital (ie parents, friends)?

Legally, yes. Ethically, you are wandering into a danger zone. Technically, you are supposed to have a medical record on each person you write a prescription for, which would not be the case for family, friends. Secondly, you do not want to be the person responsible for writing meds for these people, especially if there is a problem. There are TONS of threads about this topic which thoroughly discuss the ethics and technicalities of doing so in non-emergent situations.

2) Can you morally prescribe non-controlled drugs (antibiotics for example) to patients not in the hospital (ie parents, friends)?

Or do you have to take step 3 first?

Morally? That's up to you and your supreme being/religious faith.

But without having an unrestricted license (which requires passing Step 3), you cannot get a DEA # which is required to write scripts for controlled substances.

For non-controlled substances, you are not required to have a DEA nor have an unrestricted license.

Morally, legally or ethically, you can write prescriptions for friends and families for non-controlled substances. But you would be foolish to do so in all but most situations, IMHO.

 

[romeno]

Thanks for the answer, Winged Scapula. I did a search but only found a few threads that did not reference the need for Step 3.

If anyone has thread links I could look at, I'd appreciate it! 🙂

 

[Smurfette]

As an intern, I had a "training" DEA which allowed me to write narcotic prescriptions despite not having a permanent license. Actually, as a PGY-3, I still don't have my permanent license and am still using my institutional DEA without problem. However, this varies by what state you live in.

My own personal policy is that I do NOT give narcotic prescriptions to anyone who calls me for a refill as an outpatient. (bear in mind I only give people narcs for post-op pain, not for chronic back pain and such, which is prescribed by the patient's PCP).

The ONLY thing I've ever written for any friends/colleagues (I've never written for a family member) is for zofran for morning sickness and a couple Z-packs when they couldn't get into their regular doctor for a few days.

 

[Winged Scapula]

Be careful with the training license DEA. As noted above, some pharmacies will not honor it, or it is only honored at your "in-house" hospital pharmacy.

Therefore, I think for most intents and purposes, you cannot prescribe narcotics for patients outside of the hospital without a personal individual DEA which requires passing Step 3 (YMMV in the case of a training license).

 

[Blade28]

As an intern and PGY-2 I used an institutional DEA number provided by my residency program. We had two - one for our university hospital, and one for our county hospital. I only prescribed medications (narcotic and non-narcotic) to patients.

Once I passed Step 3 and got my own state medical license, I also applied for and received my own DEA number. I still haven't prescribed any medications (narcotic or otherwise) to non-patients of mine.

 

[Tired]

Technically, you are supposed to have a medical record on each person you write a prescription for, which would not be the case for family, friends.

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

 

[Winged Scapula]

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

Eh, maybe it is. Although I'd rather not find out.

 

[OldPsychDoc]

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

The "who" is the lawyer who is suing you for malpractice when something is claimed to have gone wrong because of the medication you used your legal authority to prescribe.

"So Dr. Tired, you prescribed this medication, according to the accepted standard of care--that is, after taking a careful history and making an appropriate physical exam of the plaintiff?"

"Yes".

"And where might I find the record of your findings?"

"Umm..."

"No further questions."

 

[NotAProgDirector]

Also, your training license is only good for practicing medicine under supervision. If you prescribe to family/friends outside of work, you are technically practicing without a license. Should something bad happen and you get sued, your med mal might not cover you for the same reason.

 

[Tired]

The "who" is the lawyer who is suing you for malpractice when something is claimed to have gone wrong because of the medication you used your legal authority to prescribe.

Thank you for trotting out the time-honored "you could be sued for it" argument. In the past two weeks, I have heard this applied to (1) why you can't have an IV in you during rounds, (2) why nurses can't inform physicians that they are busy with other patients, and (3) why living wills cannot be enforced if the family objects.

It's getting old.

Hyperbole aside, if you have any constructive input on where this supposed requirement came from, feel free to educate me.

 

[OldPsychDoc]

Thank you for trotting out the time-honored "you could be sued for it" argument. In the past two weeks, I have heard this applied to (1) why you can't have an IV in you during rounds, (2) why nurses can't inform physicians that they are busy with other patients, and (3) why living wills cannot be enforced if the family objects.

It's getting old.

Hyperbole aside, if you have any constructive input on where this supposed requirement came from, feel free to educate me.

I wasn't saying "you could get sued" for prescribing without keeping a medical record. I have always been taught that your best defense IF you do happen to get sued is clear documentation of what you did and why.

 

[Tired]

I wasn't saying "you could get sued" for prescribing without keeping a medical record. I have always been taught that your best defense IF you do happen to get sued is clear documentation of what you did and why.

I know that. But when people refer to keeping a medical record for all patients you prescribe for, they tend to present it as a requirement, not a suggestion. But is this a requirement of the medical licensing boards, residency programs, law, etc? No one seems to know. Hence my comment on it being an urban myth.

 

[tkim]

http://medrise.mediwire.com/main/Default.aspx?P=Content&ArticleID=301441

Beware these 7 charting pitfalls
Source: Medical Economics
By: M.P. Demos, MD, JD
Originally published: February 3, 2006

[...]

Case 7

Writing prescriptions for family and friends. A respected pathologist had been prescribing drugs for several years for two employees and a family member, without keeping formal records. When a pharmacy audit revealed seven pages' worth of prescriptions over those years, the case came to the attention of the state medical board. The board charged the physician with keeping inadequate records and inappropriate prescribing.

The board dropped the prescribing charges when its investigation showed that the drugs had been appropriately prescribed. But on the charge of inadequate record-keeping, the board fined the doctor $3,000 and ordered 20 CME hours in risk management and record-keeping.

LESSON

Professional services, no matter how informal, demand formal records. Anytime you provide a service, even for friends, neighbors, or employees, you must maintain a proper medical record. That's true for such minor services as writing prescriptions or treating colds and sore throats: All must be documented.

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http://www.medbd.ca.gov/consumer/complaint_info_questions_practice.html#13

Can a physician treat and prescribe to family, friends or employees?

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: 1) a physician cannot prescribe without a "good faith" exam and 2) a medical record must be created which documents the medical need for the prescription. Basically, a physician must follow the same practice/protocol for any patient in which medications are prescribed.

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[Samoa]

I'm an intern, and I have my own DEA number. Granted, it's restricted for use within state and federal institutions, but those happen to be the only kind of hospitals I work in as an intern. I haven't gotten any flak from outside pharmacies, though, when I've called in prescriptions for my patients.

But although I've passed step 3, I don't have an independent license, so I don't prescribe for friends or family, even in an emergency.

Some of my colleagues do. The chances are extremely low that you would ever get reported or sued by your friends or family, so as long as you're not running a clinic for the masses in your spare time (a la Fat Man), the "getting sued" argument isn't a huge concern.

The thing that gets people in trouble is prescribing narcotics without a documented exam and an established physician-patient relationship. But you could easily sidestep the whole issue and just keep a file at home to document your "Donated Medical Care." You could probably even deduct it from your taxes.

But really, unless you've done something else to warrant their attention, the Feds could really care less about whether you listened to your mom's lungs before prescribing a Z-pak.

Now if you turn around and bill her Medicare insurance for a patient visit, that's a whole different story...

 

[Mad Dog]

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

It is a requirement of your state medical board that treatment be based on a “bonafide patient-physician relationship” and that medical records be maintained documenting said relationship and treatment.

There are probably few people however who have not randomly handed out a script for an antibiotic to a family member while in residency. The pharmacy won’t care and who’s going to notify the state board, your sister?

Since ya really want to know though, yes, its against the rules, and yes, you’re supposed to have you own license to do so. Your training license technically only covers practice within the confines of your training program.

 

[deleted109597]

Well, from what I can tell, my DEA number is unrestricted, because the only people that ever questioned it were Eckerd pharmacies, because their computers couldn't figure out to do with the F at the beginning. However, it has worked in at least 4 states, and I haven't taken Step III.
My license is also unrestricted, because in my state that means I haven't had any kind of action taken on my by the state medical board. However, it is limited to my hospital, for what that means.

 

[Winged Scapula]

Well, from what I can tell, my DEA number is unrestricted, because the only people that ever questioned it were Eckerd pharmacies, because their computers couldn't figure out to do with the F at the beginning. However, it has worked in at least 4 states, and I haven't taken Step III.

DEA numbers starting with the letter "F" are the new series because the "B" series has been exhausted. Whether or not your DEA number works in other states does not mean it is unrestricted; it merely means that no one has checked it to see if it is an academic license number awarded to trainees.

My license is also unrestricted, because in my state that means I haven't had any kind of action taken on my by the state medical board. However, it is limited to my hospital, for what that means.

The state you practice in, like many, has several different types of medical licenses. You most likely have an Academic or Training medical license which does not require passing Step 3. However, the full and unrestricted or Permanent license, does require that you have passed Step 3 and be enrolled in or have completed a US or Canadian residency (you can get the details from your state medical board).

The fact that you state that your license is limited to your hospital tells me that it is an Academic or Training license. These types are not eligible for residents interested in moonlighting, who generally need a Permanent license.

An unrestricted, personal DEA requires a full and unrestricted license and can be used anywhere.

 

[Pir8DeacDoc]

I get the point of the thread but if your friends/family sue you then they should burn in hell anyway 🙂

Seriously, calling in a cipro or z-pack here or there is fine. I've only done it a time or two but it's no biggie. No reason for all the paranoia about this. If you start calling in percocets then you'll have a problem. Otherwise, no one will give a crap.

 

[Hiram Coggin]

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

I assure you that this is no "myth". I get a quarterly state medical newsletter and in the back section there is always a list of every single disciplinary action that the board has meted out. There are a few that are flat out crazy, like child molesters and felons. A few that cross "boundaries". A few that abuse drugs or alcohol and so on. An there are a few that write scripts that they shouldn't. Now they may be slapped on the wrist for prescribing for themselves, friends or family but the they also have a PERMANENT red mark on their record for something silly when they should have known better.

 

[deleted109597]

DEA numbers starting with the letter "F" are the new series because the "B" series has been exhausted. Whether or not your DEA number works in other states does not mean it is unrestricted; it merely means that no one has checked it to see if it is an academic license number awarded to trainees.

I know what the F means. I was saying the only places having trouble with my DEA are because of the F, not because it is a training license. All digits of mine are separate from all the digits of my intern class, and I have no specific program code that I add my last 4 to or anything like that. My wife has one that everyone has the same first 5, and they all add their specific last 4. I guess I will find out this year when I start in a new state at a new program if my DEA follows me or not.

The state you practice in, like many, has several different types of medical licenses. You most likely have an Academic or Training medical license which does not require passing Step 3. However, the full and unrestricted or Permanent license, does require that you have passed Step 3 and be enrolled in or have completed a US or Canadian residency (you can get the details from your state medical board.)

Nope. My application to the ACS required me to check restricted or unrestricted. I checked restricted, and my program coordinator made me do one because my state license is unrestricted (her words). However, it is limited. I still don't know what that means.

 

[Winged Scapula]

I know what the F means. I was saying the only places having trouble with my DEA are because of the F, not because it is a training license. All digits of mine are separate from all the digits of my intern class, and I have no specific program code that I add my last 4 to or anything like that. My wife has one that everyone has the same first 5, and they all add their specific last 4. I guess I will find out this year when I start in a new state at a new program if my DEA follows me or not.

I would be interested in hearing because I've always been told that you cannot have a permanent personal DEA without a full and unrestricted medical license which requires passing Step 3 (ie, ALL of the licensing exams).

Nope. My application to the ACS required me to check restricted or unrestricted. I checked restricted, and my program coordinator made me do one because my state license is unrestricted (her words). However, it is limited. I still don't know what that means.

ACS? American College of Surgeons? What does that have to do with whether or not your license is restricted. At any rate, I know where you are training at, and if you check your state medical board licensing page it lists: academic licenses, permanent licenses, limited and volunteer. YOu cannot get a permanent license without passing Step 3.

I suspect, boldly so, that your program coordinator is using the term unrestricted to mean that you can practice medicine without restrictions (ie, it is not a temporary or limited or volunteer license). But in the parlance of the field, an unrestricted license is a full permanent license which you cannot get without passing Step 3...in any US state. I venture this is just semantics.

When I say unrestricted, I mean a full permanent license, one that requires passing all 3 USMLE or COMLEX steps and allows you to apply for a personal DEA #.

 

[Pir8DeacDoc]

I assure you that this is no "myth". I get a quarterly state medical newsletter and in the back section there is always a list of every single disciplinary action that the board has meted out. There are a few that are flat out crazy, like child molesters and felons. A few that cross "boundaries". A few that abuse drugs or alcohol and so on. An there are a few that write scripts that they shouldn't. Now they may be slapped on the wrist for prescribing for themselves, friends or family but the they also have a PERMANENT red mark on their record for something silly when they should have known better.

What sort of things were they prescribing? Like I said, throwing around cipro or z-pack here or there is nothing. The folks in the state medical newsletter were no doubt writing narcotics.

Probably something like "I'll write you for a 100 and you give me 50 and you can have 50" type set up. Don't kid yourself into thinking these guys were writing z-packs.

 

[gudog]

I hear that thrown around a lot, but have never heard a good explanation of who says you're "supposed to" have a record. I get the impression it's a urban myth.

Look carefully at your state's licensing rules.

In my state, prescribing without documentation is grounds for revocation of your license. Definitely not an urban myth.

Granted, and they have admitted this in writing, the occasional antibiotic Rx or refill of a BP med probably won't get you into trouble.

But, there is a slippery slope here that you would be loath to start down.

 

[f_w]

- It has been said before but bears repeating: Your training license is restricted to activities within your training institutions while supervised by someone with an unrestricted license.
- It is your medical board that determines the scope of your practice, not your program secretary.
- Your sister will gladly sue you if your niece has something bad happen to her while under your care.

 

[Winged Scapula]

- It has been said before but bears repeating: Your training license is restricted to activities within your training institutions while supervised by someone with an unrestricted license.
- It is your medical board that determines the scope of your practice, not your program secretary.
- Your sister will gladly sue you if your niece has something bad happen to her while under your care.

This is worth repeating as well.

The layperson, even family members, think that suing a physician is "no big deal"...they assume that malpractice insurance will take care of it, and there will be no effect on the physician involved - financially or professionally. I've had my own family say as much.🙄

 

[Hiram Coggin]

What sort of things were they prescribing? Like I said, throwing around cipro or z-pack here or there is nothing. The folks in the state medical newsletter were no doubt writing narcotics.

Probably something like "I'll write you for a 100 and you give me 50 and you can have 50" type set up. Don't kid yourself into thinking these guys were writing z-packs.

I'm just going to quote a few examples from the most recent bullettin:

" Dr. X wrote prescriptions for family members and sometimes took prescription medicines from his office stock home for use by family members. He used some of these drugs himself. Dr. X is reprimanded."

"Dr X treated several family members for conditions the Board considers non-minor and nonemergent. He did not keep a record of prescriptions written and treatment given. It does not appear prescriptions or treatment were inappropriate for the conditions at issue. Dr X is reprimanded."

So you might not get sued, but it is certainly possible to get disciplined.

 

[Pir8DeacDoc]

you're making my point for me..


Read between the lines of those reports.

 

[f_w]

If you want to do this:
- check with your state medical board whether you are allowed to treat patients who are not patients of your institution
- go to office-depot and get yourself a $12 portable hanging file box and a set of jackets.
- keep a face-sheet on each of your patients containing name, how to contact them and a record of their allergies as well as a sheet where you can jot down your encounters and prescriptions written.

A medical career is a million$$ asset, don't throw it away to save someone else a $6 copay at their PCPs office.

 

[Tired]

In my state, prescribing without documentation is grounds for revocation of your license. Definitely not an urban myth.

I will. You can understand my susipicion about this. Even among those who are most stridently against the practice, few cite medical licensing rules. Most just say, "It's not a good idea."

Y'all should see how things work in the military system. I don't even have a temporary license or temporary DEA number.

 

[Rogue_Leader]

How do things work in terms of prescribing for yourself? Not narcotics obviously, but like when I need a refill of my albuterol?

 

[Mad Dog]

Lets all be clear what we're talking about.

Refilling someone's albuterol that they've needed like once a month for the past 10 years.

Giving a topical antibiotic for acne when the oxy-10 isn't cutting it.

Refilling someones flonase for the same seasonal allergies they get for the same 3 weeks every year.

You will not be sued. All the fear mongering here is just unnecessary.

Now, taking over your niece's chemotherapy management for her AIDS-related lymphoma-- sure, that's a lawsuit in the making.

Its true though, those medical board newsletters always hang someone for not updating their address, or equally rediculous crap. The next person they're going to make an example of could always be you. But the likelihood is not great.

 

[Winged Scapula]

How do things work in terms of prescribing for yourself? Not narcotics obviously, but like when I need a refill of my albuterol?

No difference.

Some pharmacies will fill medications you write for yourself and some will not. I've had no trouble getting self-prescribed birth control but could not get Imitrex.

Because inhalers have potential for abuse, I'd suspect its different than getting a refill on your Aciphex. Not good practice to write your own scripts (take with a grain of salt because many of us do it, especially in a pinch).

 

[Blade28]

If you want to do this:
- check with your state medical board whether you are allowed to treat patients who are not patients of your institution
- go to office-depot and get yourself a $12 portable hanging file box and a set of jackets.
- keep a face-sheet on each of your patients containing name, how to contact them and a record of their allergies as well as a sheet where you can jot down your encounters and prescriptions written.

A medical career is a million$$ asset, don't throw it away to save someone else a $6 copay at their PCPs office.

Great advice. 👍

 

[ekydrd]

I would like to point out that some states require a full year of residency training (+- Step 3) prior to issuing a license, and you must have a license of some form before you can write Rxs for meds outside of the training program. I occasionally write for the various inhalers, allergy meds, or antibiotics for family or friends, but would never ever write for a narcotic (even though I have my own DEA number). I rarely write for narcotics in the course of my work, even when I moonlight, much to the chagrin of those chronic LBP patients who insist that 2 Lortab 10's barely touch their pain, but jump up and walk out straight as a board with out the hint of a limp when I say no.

 

[Tired]

I would like to point out that some states require a full year of residency training (+- Step 3) prior to issuing a license

I'm not aware of any state that will grant a full unrestricted license without completing at least internship.

 

[Faebinder]

I'm not aware of any state that will grant a full unrestricted license without completing at least internship.

Tennessee osteopaths get a license without internship.

http://www.fsmb.org/usmle_eliinitial.html

 

[Tired]

Tennessee osteopaths get a license without internship.

http://www.fsmb.org/usmle_eliinitial.html

Oh, I thought we were talking about real doctors.

<ducks and covers>

I'm kidding, I'm kidding!

 

[ekydrd]

I'm not aware of any state that will grant a full unrestricted license without completing at least internship.

That's what I meant... that the license issued was usually a training license, but some states do not allow interns to prescibe outside of the hospital setting. Kentucky does not issue a training license until intern year completed, and that is only an In Program license. In order to get a less restrictive license you also have to take and pass Step3. This will then allow you to moonlight outside of your program (with the Program Directors approval of course) and get a DEA number. And here you have to complete 2 years in order to get a full unrestricted license.