Physician, don’t heal thyself: the perils of self prescribing
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7401 (Published 08 December 2014) Cite this as: BMJ 2014;349:g7401
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It is high time that the issue of doctors treating themselves and/or close family members was viewed through the prism of what members of the general public do, what they have done throughout history, and what they are now now actually encouraged to do by the state, i.e. to manage their own health within the limits of their competence and prevailing notions of disease.
Somebody without so much as a GCSE in biology can buy increasing numbers of medications (steroid sprays and creams, anti-fungals, PPIs, codeine combinations etc etc.) in the UK and many more within the EU. They can refer themselves to all sorts of practitioners and the Department of Health wants people with chronic conditions to manage themselves as much as possible. The belief that a qualified doctor must NEVER prescribe anything for themselves or their family runs strangely against this trend. Further, as the GMC definition of 'prescribing' includes advising a patient about using OTC medication, does Anita Sharma think I should be struck-off if I give my child a paracetamol? Can I give myself a paracetamol or do I have to wait until I have retired to do that?
Commonsense has to prevail. The GMC's guidance does not proscribe self prescribing or prescribing for relatives. It just makes clear that this should generally be avoided and, if done, should have a clear justification and be properly recorded. There is a world of difference between a one-off prescription for a relatively minor condition and self-prescribing psycho-active medication or controlled drugs. Maybe the next version of the GMC's guidance could draw clearer dividing lines?
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I am retiring next month, so have no fear of the GMC. The question that this article and other immediate responses raises is whether there is any alternative to the Draconian GMC philosophy on self-prescribing: NoNE (No, Never or Ever). The simple fact of widespread self-prescribing for simple problems raises the possibility of a safe alternative. I suggest a traffic lights code:
Red = No, Never and would include strong analgesics, opiates and psychotropics.
Amber = Proceed with caution and would include antibiotics such as I have self-prescribed in the past for cellulitis and recurrent chest infection. My practice has been to self-prescribe an antibiotic in an emergency such as a bank holiday scenario, but always to pass full details on to my GP within a week.
Green = Proceed with reasonable confidence (always check side effects and interactions) and would include such items as carbocistine syrup, which could probably be safely dispensed OTC anyway (so far as GIT side effects are concerned, they are far less likely to occur with carbocistine that with OTC aspirin).
Prescribing for relatives, friends and colleagues is rather more complicated, but I think a similar, though slightly more restricted code, should also be possible for these groups.
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Although this is a legitimate subject for debate, sadly this article falls into the trap of attempting to "hype up" a relatively minor issue into a major problem. It seems odd that as doctors we are trained to assiduously follow guidelines and decision algorithms to treat patients and yet are assumed to leave all this discipline behind when we consider self prescribing or prescribing for a relative. The fact that a tiny minority of doctors choose to abuse opiates or psychotropic drugs is not a basis for draconian prohibition and policing of the entire profession. And making doctors conform by scaring them with the threat of the GMC smacks a bit of an Orwellian police state.
Where is the overwhelming evidence of harms to justify punitive regulation?
Am I really a danger to the public if I prescribe a repeat inhaler for a relative after the GP surgery has closed for the weekend? Should my competence be called into question if I self prescribe a tube of the appropriate cream for a long standing, previously diagnosed and recurrent psoriatic rash?
Is it too much to expect a sense of proportion to apply?
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Sadly much of the emotion around this subject is avoidable. The position in the UK has been made very clear by the GMC but the responsibility of pharmacists is not always as understood. Comments such as “NoNE—No, Never, or Ever” are so far beyond the GMC advice as to be unhelpful. Arguments based on psychotropics and drugs of addiction are largely irrelevant as most doctors clearly feel these should be tightly regulated. There is another problem with these : in inappropriate acquisition through other routes , eg via making out a prescription in a different name . This is illegal as well as bad practice.
There have been two major changes in recent years . Firstly , there is the range of drugs one can now buy over-the counter (OTC) or on pharmacist advice. In the distant past I have self prescribed – but almost always an NSAID when going on sporting holiday. Free samples were another source. Now a trip to the supermarket would be all that is needed - and a ppi to go with them in case “medical” as opposed to an “OTC” doses are needed. Similarly other medications – loperamide , acyclovir cream and many others - are also readily available. Secondly , within a hospital setting it used to be acceptable practice to prescribe certain drugs for colleagues , but this has become less relevant as cancelling a clinic for a GP appointment is no longer seen to be the personal responsibility of the doctor in the same way. There are likely to different pressures on the GP who leaves colleagues to cope for an appointment with another practice.
Self-prescribing of antibiotics is a real problem but has to be controlled. Seeing another doctor is no guarantee of optimal treatment but clearly many of those self-prescribing are also not as up to date as appropriate. An exception might be metronidazole for certain recurrent dental infections and I think there is a strong argument for that antibiotic to be available on pharmacist advice. Antibiotics for recurrent urinary tract infections are a frequent minefield but treatment needs to be part of a long term plan , not just ad hoc prescriptions. When travelling to less frequented places I used to have antibiotics for emergencies or severe travellers' diarrhoea , if not for myself but for companions . Only once were they needed – and on that occasion they really were needed. (A few sutures still form part of my kit – and is local anaesthetic really needed?)
Finally , the other side of self-prescribing is the refusal of treatment – there are many prescribing enthusiasts out there , statins an obvious example . Let us hope the GMC does not start seeing refusal to follow medical advice as a reason for disciplinary action….
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Re: Physician, don’t heal thyself: the perils of self prescribing
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At present, the GMC advice is not fit for purpose. The traffic light idea suggested above would be much better. Surely no doctor should be prescribing opioids or psychotropic drugs for themselves or their families? The same applies to immunosuppressants and the like. The conditions requiring these medicines need to be monitored by a third-party clinician, let alone the prescribing.
However, a number of years ago, when an insect bite progressed to cellulitis, I was able to save my wife from a long wait in a seaside A&E department by prescribing a suitable antibiotic; just like I used to do when I was working in A&E—can anyone seriously suggest that this was harmful? Today I would not do it and we would add to the congestion and costs in the local A&E, just to avoid the risk of GMC referral.
Bad rules weaken the standing of the rule-makers. There must be a doctor somewhere in the GMC who could spend ten minutes producing a short guidance note, listing the classes of medicine that may be prescribed, with the presumption that all others would be off-limits. The list could be refined over time. That would crack this nut without resorting to a pile-driver!
Competing interests: No competing interests