Physician, don’t heal thyself: the perils of self prescribing

Official guidance

The concerns of self prescribing are reflected in guidance from medical authorities around the world, advising doctors against such practice. In some countries, such as Canada, guidance cautions against self prescribing except for minor conditions or in emergency situations when another qualified professional is not available. Guidance from other countries, such as the Netherlands, the Czech Republic, and Latvia, include restrictions on the reimbursement of prescriptions for self treatment or regulations. In Sweden, self prescribing can lead to limitations or suspension of prescribing rights or doctors being stripped of their licence to practise.

But many countries where official guidance advises against doctors treating themselves have also continued to record cases of self prescribing. Humayun Chaudhry, president and chief executive of the US Federation of State Medical Boards, which provides guidance and policies that individual state medical boards can choose to adopt and enforce, says cases continue to occur in the United States. “There are cases, sadly, of physicians who either prescribe to themselves or to their loved ones that slip through the cracks,” he says.

Guidance from New Zealand’s medical council states that doctors should avoid prescribing for themselves, friends, and family “wherever possible.” Yet a spokesman for the Medical Council of New Zealand told The BMJ, “There have been several cases recently of doctors coming to the attention of the council where prescribing to self or immediate family was an issue.”

A ministry spokesman from Grenada told The BMJ that “it is generally accepted as code of conduct that this [self prescribing] should not happen,” but that “it has become common practice for doctors to simply call a pharmacy or visit a pharmacy and receive medicines directly from the pharmacist.”

In the United Kingdom the General Medical Council (GMC) recommends that doctors do not prescribe for themselves or for friends or relatives. The council strengthened the wording of its guidance in February 2013, after a steep rise in doctors being reported for self prescribing. The number of cases of self prescribing, self treatment, or informal treatment of family and colleagues in the UK rose from 36 a year in 2010 to 98 in 2012. A spokeswoman for the council told The BMJ that these fitness to practise cases are “an indicator that not all doctors are following good practice.”

Where the previous guidance said that doctors should avoid self prescribing, the GMC’s updated guidance states, “Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.” The updated guidance also adds a requirement that any doctors who do prescribe for themselves should keep a clear record of this action, including the reason why it was necessary, and should tell their general practitioner of the action taken.

Despite this tightening up of the guidance concerns about the misuse of self prescribing rights in the UK have continued. In March 2014 NHS England issued advice to GPs on “treating yourself and family members,” including the key message, “In general, don’t do it.”4 In May 2014 GP representatives on local medical committees in England said that they had been aware of several GPs being reported to the GMC for self prescribing and advised GPs against prescribing for themselves “except in exceptional circumstances.”

Why doctors self prescribe

Providers of medical indemnity cover for doctors in the UK also continue to deal with cases of doctors who have been referred to the regulatory authorities for self prescribing. Pallavi Bradshaw, medicolegal adviser at the Medical Protection Society, said that it is “not unusual” to see such cases. Another indemnity provider, the Medical Defence Union, reviewed 36 recent cases of self prescribing notified to its officials. It found that the drugs most commonly prescribed in these cases were benzodiazepines (10 cases), and antibiotics and opiates (eight and seven cases, respectively).

Caroline Fryar, head of medical advisory services at the Medical Defence Union, thinks that ignorance about current guidance may be behind some cases of self prescribing. “I think the antibiotic ones, for example, are far more likely to be to do with somebody simply not being aware of the GMC guidance,” she says. “Whereas with doctors self prescribing benzodiazepines and opiates, although it may well be that they’re not aware of the ethical guidance, it’s more suggestive of potentially an underlying health problem.”

Des Spence, a Glasgow GP and a former columnist for The BMJ, says that most doctors think that the updated GMC restrictions on self prescribing are “a bit Draconian and over the top,” given the scale of the problem. “I’m sure the GMC are focused on the abuse of prescribing of painkillers and benzodiazepines, but they then have this kind of blanket rule that they’ve brought in and I think it’s a bit clumsy and bit crude,” he says. “People think ‘where’s the harm?’ in giving somebody an inhaler if they’ve run out, or an anti-inflammatory if they’re in pain, or an acne cream for their spots,” he says.

Doctors now feel “corralled” into avoiding self prescribing because of concerns about GMC censure, says Spence. “These days, I would be very careful, and I probably wouldn’t,” he says. “The current GMC guidance is very prescriptive. All of us are conscious of not wanting to fall foul of the GMC.” He says doctors take a dim view of the requirement to make an appointment with another doctor to be prescribed the treatment they know they need. “People think it is a needless waste of time for the other doctors with people traipsing back and forth.”

Fryar also believes that the convenience is one reason why some doctors prescribe treatment for themselves. “People know what treatment they are going to be given anyway, and therefore it is convenient for them and less strain on the health service generally if they just get on and do it,” she says. “Of course, that is naïve because, regardless of their best intentions, it is contravening the GMC guidance.”

Anita Sharma, clinical director for medicines management at Oldham Clinical Commissioning Group in the UK, is firm that self prescribing is not appropriate in any circumstances. “My view is NoNE—No, Never, or Ever—do self prescribing, as per the General Medical Council’s guidelines,” she says. “One should be registered with a GP outside the practice.”

Severe consequences

Doctors who breach the GMC’s guidance on self prescribing can face severe consequences. Around half of the cases referred to the GMC concluded with advice from the GMC to the doctor about best practice, but one in seven led to restrictions on doctors’ practice or their suspension or removal from the medical register. In addition to the regulatory consequences of breaching guidance, self prescribing can have severe consequences for doctors’ health.

The Practitioner Health Programme, a confidential health service for doctors in London, has treated doctors with health problems that have arisen as a result of self prescribing. “We have seen doctors who run into problems when they self prescribe anxiolytics, antidepressants, or strong painkillers and tending to prescribe for long periods or inappropriate doses or combinations,” says Clare Gerada, the service’s medical director.

Self prescribing by doctors is “a complex issue,” Gerada says. “There might be perfectly legitimate times when doctors could self prescribe, for example antibiotics, some analgesics, though steering clear of opiates, or other medicines as a one-off. We must accept, however, that best practice would be to seek the services of another doctor and to place oneself in the role of the patient. It is much better to take off your metaphorical white coat and seek appropriate confidential help from your own doctor.”

Role of pharmacists

Although doctors themselves may be the ones directly affected by self prescribing, cases are often first identified by pharmacists. Graham Phillips, a community pharmacist in Herfordshire, UK, has picked up on self prescribing and discussed it with the doctors. He would do so again. “If the pharmacist is any good and if the doctor is any good, then you should have that strong professional interplay,” he says.

Mark Donaghy, a pharmacist who manages staff development across a network of pharmacies, says that this can sometimes be a challenging area for pharmacists. One difficulty is the need to maintain good relationships with local GPs because community pharmacists rely on prescriptions from these doctors for their income.

“Raising the issue of prescribing for oneself or one’s family is never easy,” he says. “Some doctors appear to have come from a culture where they may have worked in hospitals which had a policy that facilitated dispensing of private prescriptions by doctors for their relatives. I am of the view that such practices then become ingrained as being normal to the prescriber and they then take umbrage when questioned by a pharmacist.”

How prevalent?

Apart from the surveys of doctors’ prescribing habits mentioned above, there are few data collected on the prevalence of self prescribing. Officials from 14 countries contacted for this article, including the UK, the US, Austria, Canada, the Republic of Ireland, the Netherlands, and Sweden, said they did not know of any official data that are collected on self prescribing.

Fryar says that she believes that self prescribing was “probably” more prevalent in the past than it is now. “I would like to think that it is on the decrease because it is becoming more well known that it is not appropriate, but we don’t have the figures to back that up,” she says. “I strongly suspect that the GMC seeing more of it reflects their tightening up on it, as opposed to a suggestion that it’s going on more than it used to.”

Chaudhry says that he does not know of data on self prescribing being collected in the US. “In the United States, as I suspect it is around the world, the medical regulatory authorities are complaint based,” he says. “They don’t always have the resources to proactively seek out these sorts of cases.”

He says that he sees the key role, and challenge, for regulatory authorities in this area to be the need to educate doctors about the dangers of self prescribing. “Often times—and we see this among medical students and residents as well as those who have much more experience—they don’t always recognise the consequences until something bad happens,” he says. “And that’s a bad time to learn.”