Doctors’ self prescribing
Authors: Kathy Oxtoby
Publication date: 10 янв 2012
It’s dangerous and unethical but legal and widespread. Kathy Oxtoby looks at the minefield of self medication
Doctors who prescribe drugs for and treat themselves, their family, and friends often see this as a professional privilege. But clinicians who use their expertise to prescribe drugs for themselves and those close to them could be fuelling addictions. This practice can also have devastating effects if doctors misdiagnose and can ultimately cause them to be struck off.
Self prescribing is legal in the United Kingdom: registered and licensed doctors can have access to any prescription drug and can purchase private prescriptions from pharmacies. However, guidance from the General Medical Council emphasises that doctors should avoid providing medical care to themselves or those close to them, which includes prescribing drugs. “We also recommend that doctors and their families should be registered with a general practitioner (GP) outside the family so they receive objective medical advice,” says a GMC spokesperson.
The broad legal right for doctors to prescribe for themselves, family, and friends also raises ethical questions about whether they should do so, because that was not the intention when they were granted that right, says Tony Calland, chairman of the BMA’s medical ethics committee.
“It is universally recognised that self prescribing and even prescribing for your family is ethically unsound,” says Dr Calland. This is because to make an accurate diagnosis and have a dispassionate appreciation of any medical situation, the prescriber should not be emotionally involved in the decision.
The practice is also not advisable because of the wide range of drugs available, such as powerful opiates and tranquillisers. Prescribing such drugs for yourself, your family, and your friends can, in many circumstances, lead to addiction, warns Dr Calland.
Another risk in prescribing for family and friends is that their own doctor may not be aware of it and could prescribe drugs that will interact with your treatment, which may have a detrimental effect, says Dr Calland.
The BMA also advises doctors to consult their GP if they are feeling unwell and to avoid self medicating.
It is not only senior doctors who are at risk of the dangers of treating themselves, families, or friends. Sally Old, medicolegal adviser at the Medical Defence Union, explains that during their foundation year junior doctors work under approved practice setting restrictions for 12 months, after which they must apply to the GMC to have these lifted. One of the restrictions is that they are not allowed to give private prescriptions, and to do so could make them subject to a GMC investigation, warns Dr Old.
Severe consequences of self prescribing
The consequences of self prescribing and treating family and friends can be severe, and even fatal. One clinician who asked not to be named knows of two doctors who self medicated for depression and committed suicide. “This shows that such serious conditions need proper supervision and that self medication is not the way forward,” the doctor said.
The GMC has struck off doctors who have self medicated or prescribed drugs to their families and friends. Doctors told BMJ Careers of cases of clinicians who had appeared before GMC fitness to practise panels as a result of this practice and of those who were suspended from practice for prescribing opiates for friends and family.
Despite these consequences, a poll conducted in 2007 by the GPs’ magazine Pulse found that 43% of GPs admitted to writing prescriptions for their own personal use, including antibiotics and strong painkillers.
A recent analysis by the Medical Defence Union of cases of self prescribing—its first such analysis since the GMC issued revised guidance on the issue in 2008—shows that pharmacists and medical colleagues are reporting GPs who self prescribe to the GMC and primary care trusts. Between 2008 and 2011 the Medical Defence Union handled 36 cases of self prescribing; antibiotics were the second most common class of drug behind benzodiazepines.
Dr Old says that the Medical Defence Union’s report does not necessarily mean that self prescribing has become more widespread but that there is a more regulatory climate now in medicine. She believes that people are more aware that GPs should not be self medicating and that as a result of GMC guidance it has become much more of an issue—even with the seemingly innocuous practice of prescribing antibiotics.
“What this survey highlights is that even when doctors prescribe antibiotics it can get them into trouble,” says Dr Old.
Times have changed
Some of the doctors interviewed by BMJ Careers have changed their practice over the years because they believe it is no longer appropriate to self medicate or to treat family and friends. “When I came into practice 30 years ago, we did tend to self treat and treat our families,” says Mike Dixon of the College Surgery, Cullompton, Devon.
“I’m now registered with a different practice, which 30 years ago would have been unheard of and almost thought to be bad manners. But now it’s the right thing to do,” he says.
Some have found that the drawbacks of self prescribing outweigh the benefits. Keith Hopcroft, a GP in Basildon, Essex, says that he used to prescribe himself asthma treatments, but he has changed practice. He says that the negative effects of bypassing medical records make it harder for GPs to give themselves or their family effective medical care. It can also effectively lead to a falsified medical record, as it does not include information about when doctors have self medicated or treated friends and family.
Dr Hopcroft points out that if doctors are not registered at their own practice and use their own prescription pad, this will affect their prescribing budget, so they should write a private prescription.
Deciding to prescribe for family and friends is also fraught with difficulties, and doctors’ experiences have made them aware of the dangers of giving advice and drugs to those close to them. One doctor needed to advise a colleague who thought there was nothing wrong with his child, even though the child was clearly displaying symptoms of appendicitis. Another remembers how a doctor he knew was keen to operate on her own child who had a hernia and how he had to dissuade her from doing so.
Even prescribing antibiotics for family members is now seen as inappropriate by some clinicians. One doctor recalls that as a GP he occasionally gave antibiotics to his children. Now he believes that, although this is fairly common, “I was probably denying my children their optimal medical care. It’s better to send them to a GP who will view them as they would any other patient.”
Another clinician says that he stopped treating his family before he stopped treating himself because there was a danger he was losing objectivity. “You’re in a relationship with your family where you have a desire to be all knowing and useful. But with that comes all sorts of baggage, and it made me think, ‘I can’t be a husband, a father, and a doctor, and I’d rather be a husband and a father and not treat my family.’”
Keep things in perspective
While recognising that there are many situations when doctors should not treat themselves or their friends or families, clinicians emphasise the importance of keeping the potential risks in perspective.
Clare Gerada, chairwoman of the Royal College of General Practitioners, is also medical director of the Practitioner Health Programme (BMJ Careers, 25 Mar, 2009, http://careers.bmj.com/careers/advice/view-article.html?id=20000099), a service for doctors and dentists who may have mental health or addiction problems and have been unable to access care. Her role in the service has meant that she has come across cases where doctors have been reprimanded by their employers for self prescribing.
She says that although objectivity is vital when self medicating, and although doctors should not prescribe themselves drugs such as strong opiates, there is also a need to recognise doctors’ qualifications and competence when it comes to treating minor illnesses for themselves and those close to them. “We’ve got to be sensible and not unnecessarily criminalise or traumatise those doctors who are perfectly capable and competent of distinguishing when they should and shouldn’t prescribe for themselves, their friends, and family,” she says.
Some doctors are concerned that the guidance does not value or show trust in doctors’ judgments. “I’m concerned that in this new world GPs are unable to write prescriptions for themselves because the implication is that we can’t be trusted to judge what is appropriate,” says Martyn Lobley, a GP in southeast London.
He adds, “If you think about other professions, you would want to be able to trust a car mechanic to fix their own car. Apply that logic to doctors, and if patients can’t trust us to know when it’s appropriate and when it’s not to treat ourselves, then where is the confidence in our profession?”
Some believe that the guidance does not support doctors when it comes to more complex situations. “Extremes are easy to see, but what about those grey areas?” asks Richard Marks, a consultant anaesthetist in London. He points out that although GMC guidance advises doctors to treat only minor illnesses or emergencies, “How are they supposed to know if the illness is minor until they have made a diagnosis?”
Certain doctors decide that they would rather self prescribe, because going to see their GP would mean loss of valuable time seeing NHS patients. One doctor says, “It was a better and more effective use of my time to treat myself for a fungal infection in my toenail. The alternative was to see a doctor—and then not see 20 patients that morning.”
It is also possible that by choosing to use their expertise to support family and friends, doctors can also save on NHS resources. One doctor recalls how she prescribed antibiotics for a grandparent for an easily treatable complaint. “If I hadn’t done this they would have had to see their GP out of hours and could have ended up in hospital. Instead they made a good recovery,” she says.
Faced with a law that allows clinicians to self medicate and prescribe for family and friends and guidance that warns against it, doctors are still dealing with the dilemma of whether or not they should do this. A pragmatic approach to self prescribing and to treating family and friends is perhaps the way forward. As Dr Marks urges, “There is a need to view this guidance in a flexible and sympathetic way, because it’s hard for us to know at what point we’ve stepped over the line.”
General Medical Council. Good Medical Practice: Providing Good Clinical Care—www.gmc-uk.org/guidance/good_medical_practice/good_clinical_care_index.asp
BMA. Medical Ethics—www.bma.org.uk/ethics/index.jsp
Practitioner Health Programme—www.php.nhs.uk
Competing interests: None declared.
Kathy Oxtoby freelance journalist