Prescribing yourself Insulin

[Tom&Jerry]

I ran into a doctor during some shadowing the other day who is a type 1 diabetic and he says that he writes his own insulin prescriptions to reduce hassle.

Is this ethical? I'm assuming in most cases people would raise an eyebrow?

He doesn't do this, but as a hypothetical could he use the insulin samples often given to those deal with patients who need it?

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[ciestar]

Happened all the time while I was at a pharmacy. I cannot comment on ethics of it, but from the pharmacy side, as long as it isn’t a control, it got filled.

Heck, one day I had a doctor come in and write an rx for herself for antibiotics right in front of me and the pharmacist filled it.

 

[DubbiDoctor]

I think it's considered a privilege of being a doctor. But times are changing, and it's probably best to avoid prescribing to yourself or for family members, unless in cases of emergency.

 

[getdown]

When I came down for the flu, I phoned in an order for tamiflu to my local pharmacy and had my wife pick it up. I knew the symptoms and that this was different from the regular colds I've had and I wasn't going to go to the ER or wait at a GPs office for hours to be told what I already knew. Even if I didn't want to write it myself I'd have had a friend call it in.

 

[VA Hopeful Dr]

I ran into a doctor during some shadowing the other day who is a type 1 diabetic and he says that he writes his own insulin prescriptions to reduce hassle.

Is this ethical? I'm assuming in most cases people would raise an eyebrow?

He doesn't do this, but as a hypothetical could he use the insulin samples often given to those deal with patients who need it?

Technically speaking, the AMA code of Ethics says we shouldn't treat ourselves or family members except in rare cases: Treating Self or Family | American Medical Association

That said, many if not most of us do it. If its for something minor (GI bug, poison ivy) or something chronic but stable (allergies, OCPs, longstanding anxiety/depression well controlled on an SSRI), there's no practical reason not to. Not sure I'd do it for insulin, especially in type 1 diabetes.

Also, no controls. Not ever.

Yes, you can use office samples yourself.

 

[HomeSkool]

I think it's always risky to self-prescribe. Even if what you're writing for is totally innocuous, people can get the wrong idea and gossip doesn't need to be true to spread like wildfire. Historically, physicians have often enjoyed reduced or waived charges when receiving care from colleagues, at least in part to discourage them from treating themselves and their loved ones; in fact, the medical profession is often regarded as the originator of the concept of professional courtesy. When I need medical attention, I always try to be smart about approaching a colleague for a prescription (i.e., a curbside consult) versus going through official channels that would result in more documentation. Generally, I err on the side of documented visits to maintain transparency and protect myself.

 

[libertyyne]

Someone correct me if I am wrong, but some states have more restrictions compared to others as in documented encounter etc.

 

[IMreshopeful]

It’s not illegal
I think it has to be within reason. I don’t prescribe anyone something without seeing them and nothing stronger than a Z pak if antibiotics
I have definitely gotten prescriptions for antihistamines for bad allergies. It’s not like I’m prescribing myself narcotics. It’s silly to be worried about this if something innocuous, I don’t care what the AMA says. If I’m worried then I’ll escalate to another provider

 

[IMreshopeful]

Technically speaking, the AMA code of Ethics says we shouldn't treat ourselves or family members except in rare cases: Treating Self or Family | American Medical Association

That said, many if not most of us do it. If its for something minor (GI bug, poison ivy) or something chronic but stable (allergies, OCPs, longstanding anxiety/depression well controlled on an SSRI), there's no practical reason not to. Not sure I'd do it for insulin, especially in type 1 diabetes.

Also, no controls. Not ever.

Yes, you can use office samples yourself.

Yeah I agree that for insulin and diabetic meds that’s a bit risky but benign stuff really shouldn’t be an issue

 

[VA Hopeful Dr]

Yeah I agree that for insulin and diabetic meds that’s a bit risky but benign stuff really shouldn’t be an issue

Yep. I prescribe my own allergy and cholesterol meds. I've called in zofran for my wife and a new antibiotic for a kid after the one her pediatrician wrote gave her bad diarrhea.

If I was on non-insulin meds, I'd be OK with that. I can check my own A1c in the office easily enough.

 

[Goro]

It’s not illegal
I think it has to be within reason. I don’t prescribe anyone something without seeing them and nothing stronger than a Z pak if antibiotics
I have definitely gotten prescriptions for antihistamines for bad allergies. It’s not like I’m prescribing myself narcotics. It’s silly to be worried about this if something innocuous, I don’t care what the AMA says. If I’m worried then I’ll escalate to another provider

How about insulin as in the case of the OP?

 

[VA Hopeful Dr]

How about insulin as in the case of the OP?

Short answer: probably unethical but its up to each state as to how much they are in these cases. Also probably just a bad idea clinically speaking, but if the guy has been a type one since age 10 he probably does know how to manage this better than an endocrinologist at this point.

 

[Mad Jack]

I ran into a doctor during some shadowing the other day who is a type 1 diabetic and he says that he writes his own insulin prescriptions to reduce hassle.

Is this ethical? I'm assuming in most cases people would raise an eyebrow?

He doesn't do this, but as a hypothetical could he use the insulin samples often given to those deal with patients who need it?

Why would this be an ethical issue? It is not a controlled substance and has no abuse potential. As a doctor you have the privilege to prescribe medication that is appropriate. There is no reason you could not prescribe yourself appropriate medication

 

[VA Hopeful Dr]

Why would this be an ethical issue? It is not a controlled substance and has no abuse potential. As a doctor you have the privilege to prescribe medication that is appropriate. There is no reason you could not prescribe yourself appropriate medication

Because the AMA says it is? And you lose an awful lot of objectivity treating yourself.

 

[Mad Jack]

Because the AMA says it is? And you lose an awful lot of objectivity treating yourself.

Treating Self or Family | American Medical Association

Per the AMA, treating yourself or family for short-term, minor problems is not unethical.

Longitudinal diabetes care is not in line with this, but writing yourself a script for antibiotics or something else that is minor should be fine.

 

[VA Hopeful Dr]

Treating Self or Family | American Medical Association

Per the AMA, treating yourself or family for short-term, minor problems is not unethical.

Longitudinal diabetes care is not in line with this, but writing yourself a script for antibiotics or something else that is minor should be fine.

Huh, its almost like I posted that exact same link earlier.

And since we both admit that longitudinal diabetes care (which was the OP question you answered) isn't a "short-term, minor problem", the AMA would consider it unethical.

 

[Mad Jack]

Huh, its almost like I posted that exact same link earlier.

And since we both admit that longitudinal diabetes care (which was the OP question you answered) isn't a "short-term, minor problem", the AMA would consider it unethical.

We agree lol. I'm so busy with residency my posting is quite sloppy

 

[VA Hopeful Dr]

We agree lol. I'm so busy with residency my posting is quite sloppy

Bah. Back in my day we didn't have time for full sentences as intern. EVERYTHING was abbreviated. Punctuation was for suck ups.

 

[Psai]

Bah. Back in my day we didn't have time for full sentences as intern. EVERYTHING was abbreviated. Punctuation was for suck ups.

Bah no time to write out all abbrev no punct suk up

 

[mehc012]

Bah no time to write out all abbrev no punct suk up

bimd interns dnht for FS.
punctuation = su

 

[atomi]

Antibiotics, yes. Whatever. Flexiril? Sure go nuts. If you regularly prescribe them anyway then things like antihypertensives are fine, but probably a bad idea if you’re a pathologist.
Psychotropics (ssris), no. Surprised someone would think it’s ok to self prescribe psych meds.

 

[Oso]

Psychotropics (ssris), no. Surprised someone would think it’s ok to self prescribe psych meds.

I mean, I don't think it would be unreasonable if someone was on a stable dose of an SSRI for a long time and ran out of meds before being able to see someone who could refill them. Don't think I would recommend doing this regularly, but maybe if someone was in between providers or something like that.

 

[sloop]

Antibiotics, yes. Whatever. Flexiril? Sure go nuts. If you regularly prescribe them anyway then things like antihypertensives are fine, but probably a bad idea if you’re a pathologist.
Psychotropics (ssris), no. Surprised someone would think it’s ok to self prescribe psych meds.

I encountered a patient who pretty clearly had an under the table prescription for an SSRI written by someone they knew and that seemed pretty sketchy.

Then again, I also generally find it sketchier to prescribe to close friends and family. It seems more clear why that would be frankly unethical (that you could harm someone else). The reasons it would be unethical to prescribe non-controlled meds to oneself seem much more vague and tenuous. Risk of harming yourself? I think people take those sorts of risks all the time. Some sort of distributive justice concern? Maybe.

That said, all of this is likely to have the appearance of impropriety to at least some people, so I’ve made it a rule not to prescribe to myself, friends or family. If you’re not paying for my services, I’m not writing a script.

 

[mehc012]

I encountered a patient who pretty clearly had an under the table prescription for an SSRI written by someone they knew and that seemed pretty sketchy.

Then again, I also generally find it sketchier to prescribe to close friends and family. It seems more clear why that would be frankly unethical (that you could harm someone else). The reasons it would be unethical to prescribe non-controlled meds to oneself seem much more vague and tenuous. Risk of harming yourself? I think people take those sorts of risks all the time. Some sort of distributive justice concern? Maybe.

That said, all of this is likely to have the appearance of impropriety to at least some people, so I’ve made it a rule not to prescribe to myself, friends or family. If you’re not paying for my services, I’m not writing a script.

Especially because insulin is, to a certain extent, managed by the patient regularly anyways (at least for those on a sliding scale). We, as a general rule, once someone has been determined to need insulin, trust that with some explanation on how it works and some clear guidelines, people can self administer it appropriately for the blood sugar they have. Obviously there are major differences between following an explicit scale and devising that scale for yourself, but...there's also a major difference between most peoples' understanding of blood sugar and an MD's.

I can't see any risk for abuse or misuse beyond what a diabetic with access to a month's supply would have anyway, so...where's the ethical quandary?

 

[sloop]

I mean, I don't think it would be unreasonable if someone was on a stable dose of an SSRI for a long time and ran out of meds before being able to see someone who could refill them. Don't think I would recommend doing this regularly, but maybe if someone was in between providers or something like that.

Yeah, although what happens if the person continues to not set up an appointment with the person who should be refilling the meds? Are you now responsible for them abruptly discontinuing their Paxil if you refuse to refill it? Are you going to counsel them on a taper? Are you on the hook for continuously refilling this until they finally wind up getting an appointment somewhere?

 

[Oso]

Yeah, although what happens if the person continues to not set up an appointment with the person who should be refilling the meds? Are you now responsible for them abruptly discontinuing their Paxil if you refuse to refill it? Are you going to counsel them on a taper? Are you on the hook for continuously refilling this until they finally wind up getting an appointment somewhere?

Not what I was talking about. My specific example was someone who did regularly see a prescribing provider but was filling the script themselves if an issue came up (such as being in between providers, not being able to get a hold of the provider, etc). But sure, feel free to endlessly extrapolate

 

[Planes2Doc]

You can actually buy insulin OTC at Walmart without a prescription. I agree with others that it's usually okay to write for non-controlled medications.

I recently had an awful experience, and needed help from a family member. I had my annual sinus infection (I was at day 3), which occurs in the winter, has the same symptoms, and always improves with antibiotics (it remains bad without antibiotics). I was working on nights and felt absolutely awful. Since our program does not allow residents to write prescriptions, I went to the family medicine clinic. I know the resident who saw me quite well, he's a very nice guy. Although he is nice, he is a very by-the-book guy. He gave me a lecture how it hasn't been 10 days and that it will probably get better without antibiotics. I had a blank stare on my face and was trying to control my inner-rage. It's tough enough to be working 12 hour shifts on a completely inverted schedule when you're healthy, and working these shifts when you feel beaten down by sinusitis doesn't make it better. With my fluticasone prescription in hand, I quickly called my family member. He called in cefdinir to the pharmacy, and my symptoms were markedly improved the next day. I discussed this later with one of the primary care internists, and he agreed that I should have gotten antibiotics given the fact that I know my body well, and that the same thing happens literally every year.

 

[VA Hopeful Dr]

Antibiotics, yes. Whatever. Flexiril? Sure go nuts. If you regularly prescribe them anyway then things like antihypertensives are fine, but probably a bad idea if you’re a pathologist.
Psychotropics (ssris), no. Surprised someone would think it’s ok to self prescribe psych meds.

Really? Lexapro is where you draw the line?

 

[VA Hopeful Dr]

You can actually buy insulin OTC at Walmart without a prescription. I agree with others that it's usually okay to write for non-controlled medications.

I recently had an awful experience, and needed help from a family member. I had my annual sinus infection (I was at day 3), which occurs in the winter, has the same symptoms, and always improves with antibiotics (it remains bad without antibiotics). I was working on nights and felt absolutely awful. Since our program does not allow residents to write prescriptions, I went to the family medicine clinic. I know the resident who saw me quite well, he's a very nice guy. Although he is nice, he is a very by-the-book guy. He gave me a lecture how it hasn't been 10 days and that it will probably get better without antibiotics. I had a blank stare on my face and was trying to control my inner-rage. It's tough enough to be working 12 hour shifts on a completely inverted schedule when you're healthy, and working these shifts when you feel beaten down by sinusitis doesn't make it better. With my fluticasone prescription in hand, I quickly called my family member. He called in cefdinir to the pharmacy, and my symptoms were markedly improved the next day. I discussed this later with one of the primary care internists, and he agreed that I should have gotten antibiotics given the fact that I know my body well, and that the same thing happens literally every year.

Great, thanks for validating every ****ty patient who "knows their body" when asking for stuff they don't need.

Also, cefdinir isn't indicted as monotherapy in sinus infections.

 

[Planes2Doc]

Great, thanks for validating every ****ty patient who "knows their body" when asking for stuff they don't need.

Also, cefdinir isn't indicted as monotherapy in sinus infections.

I'm not one of those people who run to get antibiotics every time I have a cold. This has been recurring every year since I was in high school. It would end up with 3 weeks of awful symptoms (longest I have gone), and then alleviated once I started antibiotics. I discussed this at length with the attending, and saw differing views when I did family medicine rotations in medical school.

 

[VA Hopeful Dr]

I'm not one of those people who run to get antibiotics every time I have a cold. This has been recurring every year since I was in high school. It would end up with 3 weeks of awful symptoms (longest I have gone), and then alleviated once I started antibiotics. I discussed this at length with the attending, and saw differing views when I did family medicine rotations in medical school.

Go see the ENTs as bacterial sinus infections are actually quite rare and recurrences like this can point to anatomical problems.

 

[Planes2Doc]

Go see the ENTs as bacterial sinus infections are actually quite rare and recurrences like this can point to anatomical problems.

Good point, I had extensive sinus surgery 14 years ago. I should probably see one.

 

[VA Hopeful Dr]

Good point, I had extensive sinus surgery 14 years ago. I should probably see one.

... yes, especially if that 14 years ago correlates with when these started being a problem

Also it might save you trouble in the future if you learn the criteria from the IDSA that warrant antibiotic treatment prior to the 10 day cut off:

1. The following clinical presentations (any of 3) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis:

• i. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement (strong, low-moderate);
  
  
• ii. Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness (strong, low-moderate); or
  
  
• iii. Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (“double-sickening”) (strong, low-moderate).

This is all hypothetical of course and not intended as medical advice. Its a learning experience in diagnosing bacterial sinus infections using the current evidenced based guidelines.

 

[atomi]

Really? Lexapro is where you draw the line?

Yes, I absolutely draw the line at psych meds. By the nature of psychiatric illness one should not be self medicating with mood altering substances.

 

[VA Hopeful Dr]

Yes, I absolutely draw the line at psych meds. By the nature of psychiatric illness one should not be self medicating with mood altering substances.

For mild depression or anxiety... meh. You can act however you see fit, but I wouldn't think twice at someone writing their own SSRI.

Anti-psychotics or mood stabilizers would be unwise sure, but I just can't get myself too worked up about a little Prozac.

 

[sloop]

Not what I was talking about. My specific example was someone who did regularly see a prescribing provider but was filling the script themselves if an issue came up (such as being in between providers, not being able to get a hold of the provider, etc). But sure, feel free to endlessly extrapolate

It’s not endless extrapolation.

My experience is that people and their medical care are not entirely predictable. Once you’ve prescribed a med for someone, you’ve entered into a relationship that it’s not necessarily possible to just walk away from.

Either the person is connected enough with care that they can somehow figure out a way to get their meds, or their provider situation is unstable enough that it’s reasonable to anticipate the possibility of future or ongoing problems.

If they have a provider and this is going to be a problem, the office should have the number of someone covering and they can get a script for a small amount until they’re seen.

If there’s really nobody who can do this for them . . . well first of all that’s a huge issue and possibly one that could be an abandonment issue, but also they can go to urgent care or the ED where someone can actually see them in an appropriate and documented setting with clearly defined responsibilities with regard to their care.

If they’re between providers, again I would think it could be abandonment if the initial provider did not prescribe enough meds to get to the intake or arrange for an urgent appointment for intake.

If they’re not my patient and not in imminent danger, this all falls under the category of “not my problem” and it only exposes me to unnecessary risk if I decide to make it my problem without going through the proper channels.

 

[AsianPersuasion]

I probably wouldn't do it...but I'm totally not against the idea of having my BFF / co-resident etc right me a script, if they're willing.

 

[evilbooyaa]

Antibiotics, yes. Whatever. Flexiril? Sure go nuts. If you regularly prescribe them anyway then things like antihypertensives are fine, but probably a bad idea if you’re a pathologist.
Psychotropics (ssris), no. Surprised someone would think it’s ok to self prescribe psych meds.

Meh I wouldn't really feel reasonable self-prescribing Flexeril.

Agree with you on most psych med scenarios.

 

[VA Hopeful Dr]

Meh I wouldn't really feel reasonable self-prescribing Flexeril.

Agree with you on most psych med scenarios.

Guess it depends on your comfort level with various meds

 

[sovereign0]

Considering you can buy Insulin R and NPH without a prescription at walmart, I don't see a problem with that scenario...

 

[NicMouse64]

... yes, especially if that 14 years ago correlates with when these started being a problem

Also it might save you trouble in the future if you learn the criteria from the IDSA that warrant antibiotic treatment prior to the 10 day cut off:

1. The following clinical presentations (any of 3) are recommended for identifying patients with acute bacterial vs viral rhinosinusitis:

• i. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for ≥10 days without any evidence of clinical improvement (strong, low-moderate);
  
  
• ii. Onset with severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal discharge or facial pain lasting for at least 3–4 consecutive days at the beginning of illness (strong, low-moderate); or
  
  
• iii. Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection (URI) that lasted 5–6 days and were initially improving (“double-sickening”) (strong, low-moderate).

This is all hypothetical of course and not intended as medical advice. Its a learning experience in diagnosing bacterial sinus infections using the current evidenced based guidelines.

I'm sure your HCAP scores suck and some of your patients hate you. I for one would love to have someone like you as both my doctor and an educator at my school. Evidence based and doesn't cave to or stoop down to the stupidity of others.

 

[Goro]

I'm sure your HCAP scores suck and some of your patients hate you. I for one would love to have someone like you as both my doctor and an educator at my school. Evidence based and doesn't cave to or stoop down to the stupidity of others.

As an aside, while I disagree with VA's views on politics (and he mine), I always love his take on Medicine and medical education!

 

[NicMouse64]

As an aside, while I disagree with VA's views on politics (and he mine), I always love his take on Medicine and medical education!

I'm pretty liberal myself. But I much prefer our outwardly conservative medical educators. They get straight to the point.

 

[Goro]

I'm pretty liberal myself. But I much prefer our outwardly conservative medical educators. They get straight to the point.

The surgeons especially!

 

[mistafab]

When I am an attending, I would not prescribe an antibiotic to you either.

EDIT: I actually got this question correct on Uworld. The correct answer was (c) reassurance and symptomatic treatment.

You can actually buy insulin OTC at Walmart without a prescription. I agree with others that it's usually okay to write for non-controlled medications.

I recently had an awful experience, and needed help from a family member. I had my annual sinus infection (I was at day 3), which occurs in the winter, has the same symptoms, and always improves with antibiotics (it remains bad without antibiotics). I was working on nights and felt absolutely awful. Since our program does not allow residents to write prescriptions, I went to the family medicine clinic. I know the resident who saw me quite well, he's a very nice guy. Although he is nice, he is a very by-the-book guy. He gave me a lecture how it hasn't been 10 days and that it will probably get better without antibiotics. I had a blank stare on my face and was trying to control my inner-rage. It's tough enough to be working 12 hour shifts on a completely inverted schedule when you're healthy, and working these shifts when you feel beaten down by sinusitis doesn't make it better. With my fluticasone prescription in hand, I quickly called my family member. He called in cefdinir to the pharmacy, and my symptoms were markedly improved the next day. I discussed this later with one of the primary care internists, and he agreed that I should have gotten antibiotics given the fact that I know my body well, and that the same thing happens literally every year.

 

[nimbus]

Because the AMA says it is? And you lose an awful lot of objectivity treating yourself.

The AMA is an arbiter of ethics? Seriously??

 

[VA Hopeful Dr]

The AMA is an arbiter of ethics? Seriously??

In my state, yes. Our state medical board says that the AMA Code of Ethics is what they use to determine ethical conduct.

Its not a hard and fast rule, but that's what they use as a guide.

 

[VA Hopeful Dr]

I'm sure your HCAP scores suck and some of your patients hate you. I for one would love to have someone like you as both my doctor and an educator at my school. Evidence based and doesn't cave to or stoop down to the stupidity of others.

Yep, and I've lost a few jobs over that. Now I give antibiotics to pretty much everyone because I just don't care anymore.

Plus azithromycin is essentially worthless these days anyway so I'm not making anything worse.

 

[NicMouse64]

Yep, and I've lost a few jobs over that. Now I give antibiotics to pretty much everyone because I just don't care anymore.

Plus azithromycin is essentially worthless these days anyway so I'm not making anything worse.

That's kind of sad and disheartening. Not because I think I am better than you and won't do that in the future, but likely that I know the system will beat me down just like it has to you.

 

[VA Hopeful Dr]

That's kind of sad and disheartening. Not because I think I am better than you and won't do that in the future, but likely that I know the system will beat me down just like it has to you.

Well its actually kinda weird. I was pretty strict in my DPC practice and in 2 years only lost 2 patients over it. I think part of it there was that patients could very easily get in touch with me so when I'd say "Give it a few days and let me know how you're doing" they knew that a) I meant it and b) it would be super easy to contact me.

But then doing UC and corporate DPC patients complained almost daily.

I guess long story short, if you're building your own practice you can train your patients on how you do things. If you're taking over someone else's practice and try to change thing, patients get pissed off.