Residents' Prescription Writing for Nonpatients FREE

The ability to write prescriptions is one of the most important new responsibilities that residents acquire after graduating from medical school. During their regular duties, residents' prescription ordering is monitored. However, little is known about residents' prescription writing for individuals who are not their patients, which occurs outside of supervision by attending staff.

Previous studies have shown that 65% to 83% of physicians prescribe medications for themselves or family members.^{1 - 2} At least 2 studies have specifically examined resident prescribing patterns for nonpatients. Clark et al³ demonstrated that during an 8-month period, 23% of residents at a university medical center had written at least 1 nonpatient prescription for psychoactive drugs (eg, narcotic analgesics, muscle relaxants, and minor tranquilizers), mostly for family, friends, and fellow residents. More recently, Christie et al⁴ noted that 52% of residents at 4 internal medicine training programs prescribed medications for themselves. While these studies have established that many residents write prescriptions for nonpatients, little is known about the specific medications they prescribe or the variables that affect their decision to write such prescriptions. We studied which factors influence residents' decision to write prescriptions for nonpatients in a sample of internal medicine and family practice residents at a community hospital.

A 6-page survey was approved by the hospital's institutional review board and distributed in December 1997 to all internal medicine and family practice residents at Christiana Care Health System (Wilmington, Del). Questionnaires were completed anonymously and consisted of 12 hypothetical scenarios that detailed situations in which a prescription might be written for a nonpatient (), as well as questions eliciting residents' self-reports of having written prescriptions for nonpatients or having received a prescription as a nonpatient. We also obtained simple demographic information. We defined a nonpatient as an individual not under the resident's care during the course of his or her duties as a house officer.

In the 12 hypothetical scenarios, we varied a number of factors that might affect the likelihood of prescribing medication for a nonpatient. These included the individual's relationship to the house officer, the condition being treated, the medication requested, whether the nonpatient had a primary care physician, and the probability that the nonpatient had a history of substance abuse. Using a 4-point Likert scale (1, very likely; 2, likely; 3, unlikely; and 4, very unlikely), residents were asked to rate how likely they were to write the prescription. The association of demographic variables with the likelihood of writing prescriptions was analyzed using the χ² test or analysis of variance, as appropriate.

Seventy-four of 92 residents completed the survey (response rate, 80%); 57% were male. Thirty-five percent were in postgraduate year (PGY) 1, 30% in PGY 2, 25% in PGY 3, and 10% in PGY 4 or PGY 5. Sixty-five percent were in categorical or combined internal medicine (internal medicine/pediatrics and emergency medicine/internal medicine) and 27% were in family practice programs. Eighty-five percent reported having written at least 1 prescription for a nonpatient, most commonly for antibiotics (83%), antihistamines (56%), nonsteroidal anti-inflammatory drugs (35%), birth control pills (22%), and antidepressants (10%). Only 6% reported having written nonpatient prescriptions for muscle relaxants and 3% for benzodiazepines. None of the respondents reported writing prescriptions for narcotics. Seventy-four percent of respondents had refused to prescribe medication for a nonpatient on at least 1 occasion.

As medical students, 40% of respondents had received a prescription from an individual who was not their physician, and as residents, 47% had received a prescription from a fellow house officer. Seventeen percent had received a prescription from an attending physician who was not his or her physician.

There was significant variation among the 12 hypothetical scenarios in the percentage of residents likely to write a prescription (Table 1). For example, 95% of residents were willing to write a prescription for a visiting sibling needing an antibiotic for acute sinusitis, while only 1% would write a prescription for a college student with suspected drug and alcohol abuse who requested alprazolam for anxiety.

Residents appeared more likely to write a prescription for someone they knew well. For example, 62% of residents reported that they would likely prescribe a nonsteroidal anti-inflammatory drug for a neighbor with a flare-up of gout, but only 15% of residents were likely to prescribe an nonsteroidal anti-inflammatory drug for a recent acquaintance with acute low back pain. Similarly, residents reported that they were more likely to write an antibiotic prescription for a relative (sibling with acute sinusitis, 95%, or their own child with acute otitis media, 77%) than a nonrelative (nurse with a urinary tract infection, 32%). They also appeared more likely to write prescriptions for fellow residents. Sixty-five percent of residents reported that they would likely write a prescription for acetaminophen with codeine for a fellow resident experiencing pain from a fractured finger, while 40% reported that they would write the same medication for a family friend having pain from a fractured toe. The year of training, type of residency, and a history of having received a prescription as a nonpatient was unrelated to residents' prescription-writing inclinations.

Thirteen percent of residents stated that they were aware of ethical guidelines concerning prescription writing for nonpatients. Only 4% knew of any federal or state laws concerning the issue. None of the residents who stated they were aware of ethical guidelines or federal and state statutes were able to describe them.

Our study confirms that at least some residents have written prescriptions for nonpatients, including fellow residents. In fact, 85% of our respondents reported having written prescriptions for nonpatients. Our sample size is small and limited to community-based internal medicine and family practice residents in a single hospital. Although the results may not be generalizable to all residents, our study raises concern that the practice may be widespread.

Since ours is the first study to observe residents' prescription writing for a range of drugs, direct comparisons with the 2 previous studies examining resident prescription writing for nonpatients cannot be made. The study by Clark et al³ focused on psychoactive drug prescribing, although they also included several selected classes of nonpsychoactive drugs (antibiotics, antihistamines, nonsteroidal anti-inflammatory drugs) for comparison. While a significant number of prescriptions were written for nonpsychoactive drugs in that study, the reported results do not allow a determination of the percentage of residents who wrote prescriptions for these agents. The study by Christie et al⁴ examined prescription drug use among resident physicians. In that study, only 6% of residents had used prescriptions written by a fellow resident, in contrast with our results, in which 47% of residents reported receiving a prescription from a fellow resident. This difference may in part be explained by the fact that the residents in our institution do not have access to medication samples. Twenty-five percent of all medications in the study by Christie et al were obtained from a sample closet. All of our residents' medications, however, had to be obtained by a written prescription, and the residents may have thought it preferable to have someone else write the prescription rather than writing it for themselves.

Perhaps it is not surprising that residents appeared more likely to write prescriptions for individuals with whom they had a strong relationship. This finding may be due to residents' perceptions of being helpful toward a friend or family member. There may also be an assessment by the resident of their legal liability or of the abuse potential of the recipient. Residents seemed more likely to write a prescription for a narcotic analgesic for a fellow resident than for a close relative. Although our study did not identify the reason for this difference, one could speculate that there is peer pressure and the false belief that fellow residents are less likely to abuse prescription drugs than nonphysicians.^{5 - 6}

There are numerous ethical and medicolegal reasons why prescribing for nonpatients should be done with circumspection.^{7 - 8} The informal nature of the interaction between physician and nonpatient creates opportunities for mistakes and errors in judgment. Clinical evaluations are usually cursory and important information may be missed. The physician may either be too close or too uninvolved with the individual to elicit a thorough history and to perform an adequate physical examination. Objectivity may be affected when the individual is a family member, friend, or colleague. Involvement in a medical issue of family or friends of the resident may cause or intensify familial or interpersonal conflicts.

For lack of a better term, we used the term nonpatient to identify individuals seeking care from someone who is not their usual physician. The word nonpatient, however, does not, in ethical and legal terms, imply lack of a physician-patient relationship. By legal standards, once a physician commences treatment (eg, writes a prescription), a patient-physician relationship is established. By definition, the relationship is contractual and the physician incurs liability for the interaction and its consequences.⁹

Surprisingly few ethical guidelines address prescription writing for nonpatients. The American Medical Association (AMA) Code of Medical Ethics¹⁰ addresses only the issues of self-treatment and treatment of family members. It states that "physicians generally should not treat themselves or members of their immediate family." It goes on to state that "while physicians should not serve as primary or regular care providers for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems." Thus, the hypothetical scenarios in which the resident's child with acute otitis media or brother with acute sinusitis receives antibiotics would be allowed by the AMA Code of Medical Ethics. The AMA Council on Ethical and Judicial Affairs does not comment on the issue of caring for or writing prescriptions for other types of nonpatients.

Federal law in the area of prescription writing is limited to controlled substances. These laws require that the prescriber have a bona fide patient-physician relationship with any person for whom he or she prescribes controlled substances. This relationship includes maintenance of a written medical record. State laws, at a minimum, follow the federal statutes. A few states, such as Massachusetts, go a step further and address prescription writing of all drug classes. Its Board of Registration guideline states:

The taking of a medical history and conducting a physical examination are the minimum requirements before prescribing. Physicians who issue prescriptions at the request of colleagues or office workers without conducting an appropriate physical examination run the risk of Board sanctions. Accurate records of patient visits and examinations . . . are also required.¹¹

Although most of the residents we surveyed were not aware of published guidelines and statutes, we believe most had a vague notion of the legal and ethical arguments against prescribing for nonpatients, as 74% reported that they had refused to write a prescription at some time. Similarly, the responses to the hypothetical scenarios reveal that residents would frequently refuse to write prescriptions.

We recognize several limitations of our study. First, we surveyed only family practice and internal medicine residents at a single institution. Second, when faced with actual situations, residents may act differently than their responses to the hypothetical scenarios suggest. However, studies have shown that when scenarios contain enough information, participants' responses closely parallel their actual behaviors.^{12 - 13} Finally, our study relies on self-reported data and may not necessarily reflect the actual behaviors of the residents. However, if anything, we suspect that this would result in underreporting of resident prescription writing for nonpatients.

While our results may not apply to all residents, we have examined a group of community-based internal medicine and family practice residents who report unsupervised prescribing of medications for nonpatients and who had received prescriptions from fellow resident and attending physicians who were not their usual treating physicians. Our clinical vignettes have revealed factors that appear to influence residents' prescription-writing practices and suggest that residents assess some potential risk and impropriety of prescribing medication for a nonpatient prior to making a decision about whether to carry out the request. Few of the residents surveyed were aware of ethical guidelines or federal and states law on the subject. As such, a significant percentage of respondents reported they would write a prescription for a fellow resident for acetaminophen with codeine, a Schedule III controlled substance, in violation of federal law. Additional studies are needed to determine the pattern of resident prescribing for nonpatients. Finally, since residency training is a time when practice habits are established, residency training programs should include education on the ethical, legal, and liability implications of writing prescriptions for nonpatients.