|Prescribing Without an Exam?|
|By Jeffrey E. Keller MD|
The State Board of Medicine in my home state recently sent out a bulletin about the practice of “friendly prescribing” to people who the practitioner has not examined. For example, a friend might call me and say something like “I have a sore throat. Will you call me in a prescription for antibiotics?” I’m sure that almost everyone who has practiced medicine has received such phone calls! The Board of Medicine was concerned about this. They went so far as to to condemn as unethical the practice of issuing such prescriptions without ever examining the patient or documenting the encounter.
In my opinion, this applies to correctional physicians prescribing to new inmates they have never seen, as well.
Coming back to my friend with the sore throat, if I respond to their request for an antibiotic by saying “Sure! What pharmacy do you want me to use?”—well the Board of Medicine (and other medical organizations) consider that to be ethically wrong. But! What if my friend really needs an antibiotic and is not in a position to easily get to an ER or Urgent Care Center? Refusing to help could be the wrong thing to do medically!
Fortunately, there is a way around this dilemma that will satisfy the Board of Medicine’s concerns. I simply must treat my friend like any other patient and treat this request like any other I might receive when on-call:
A similar situation arises in correctional medicine, especially jails. Inmate medical needs are almost always first evaluated by nurses. And since jails tend to have a constant flow of inmates coming and going, practitioners get lots of calls about individual patients who they have never seen before. If a jail nurse calls about a newly booked patient showing signs of alcohol withdrawal and the jail doc prescribes Valium, should the jail doc actually see the patient personally at the next clinic? The answer, of course, is “Yes!” When a practitioner prescribes a controlled substance (Valium) for a patient with a potentially life-threatening condition (alcohol withdrawal), that patient must be personally evaluated by the practitioner!
What about non-controlled medications for less severe conditions? For example, if a Nurse Practitioner is called about a new inmate with a MRSA infection and prescribes Bactrim; does the NP need to see that patient in the next medical clinic? Again, the answer is “Yes.” It is not enough (in my opinion) to never see such a patient personally and rely on nurses exclusively to do all of follow up evaluations.
How about more routine prescriptions? For example, what about the patient who needs to have lisinopril (which he had not been taking for several months) restarted? Does he need to be seen in clinic? “Yes” once again! It’s no different (in my opinion) than the situation outside of jail. If my friend outside of jail calls me and asks me to call in a prescription of his lisinopril, I can do it (if appropriate), but I still need to see that patient in my office and do an exam and chart note as discussed initially. The jail patient is no different. He is my patient, I am prescribing him medications, and that obligates me to actually meet him and establish a doctor patient relationship.
Summary: If a jail practitioner prescribe a new medication to someone, they should see that person in personally to establish a doctor-patient relationship—just like what should be done outside of the jail.
As always, what I have written here is my opinion, based on my training, experience and research. I could be wrong! If you think I am wrong, please say why in comments!
Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical care to inmates in several jails throughout Idaho. He is also the author of the "Jail Medicine" blog
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