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Is it Really Unprofessional to Write Prescriptions Outside the Office?

07/09/18 2:11 PM

A famous US Supreme Court Justice Potter Stewart once opined on obscenity: “I know it when I see it.”

The Maryland Board of Medicine weighed in on whether it was unprofessional to write a prescription for a patient at a restaurant / bar. Excerpts from the legal case tell the tale.

On October 1, 2012, Dr. Kozachuk met with Patient A and his father in the Daniels (restaurant and bar) parking lot and wrote a prescription for 100 tablets of Roxicodone (an opioid pain reliever), without taking a history or physical examination and without documenting the prescriptions in his medical records. The Supervisor saw Dr. Kozachuk in the parking lot and contacted the Howard County Police Department and the Special Agent. After the police and the Special Agent arrived, the Special Agent interviewed Dr. Kozachuk. During the interview, Dr. Kozachuk admitted to prescribing Roxicodone to Patient A in the parking lot, admitted to writing prescriptions for Xanax and oxycodone in exchange for $100 per prescriptions to Patient C and F at Daniels, and admitted to writing prescriptions at G.L. Shacks. After the interview, Dr. Kozachuk agreed to surrender his DEA Certificate of Registration.

G.L. Shacks is another restaurant and bar.

Dr. Kozachuk also told Agent Yeager that he had prescribed medication to patients at G.L. Shacks Grill. When Agent Yeager asked Dr. Kozachuk why he would prescribe there rather than in his office, Dr. Kozachuk told him that, “after the office visit the patient wanted to go to buy him something, like a beer, so they would go down to G.L. Shacks and he would write the prescription at the bar as opposed to his office.”

The Maryland Board of Medicine disciplined the doctor for unprofessionalism.

The Board rejected Dr. Kozachuk’s argument that “there is no legal basis for finding unprofessional conduct because there is no statutory provision, no regulation, and no American Medical Association Ethics Opinion that specifically prohibits prescribing outside of an office setting.”

This caser was appealed from the Board to an administrative law court.

Dr. Kozachuk’s prescribing practices, including selling prescriptions for opioids in the parking lot and in a restaurant constitutes unprofessional conduct in the practice of medicine. Seeing a patient in a public location, such as a restaurant, eliminates, or, at least, greatly reduces the privacy needed to ensure patient confidentiality. At a restaurant, individuals sitting nearby and restaurant employees are in a position to overhear details regarding the patient’s medical history, medications the patient takes, and the patient’s treatment options. A physician also cannot conduct a thorough physical examination in a restaurant. The option to perform a thorough medical examination must, at the very least, be available when prescribing opioids. Writing prescriptions in exchange for cash in public is a flagrant abandonment of professionalism. This is especially disturbing when the drugs prescribed possess such a high risk for diversion and abuse, such as opioids and benzodiazepines that Dr. Kozachuk prescribed. Selling prescriptions in a public space endangers the public, breaches patient confidentiality, see Salerian, 176 Md. App. at 249, and diminishes the standing of the medical profession in the eyes of the members of the general public.

While this case might have unique facts which resulted in a bad outcome for the doctor, where is the line?

If you are with friends and have zero professional relationship with them (meaning they are just your friends), and one announces he has symptoms A, B, and C. You do the most cursory physical exam in public. You write a prescription. You even document that in the medical record. Is that unprofessional?

How about someone you have no long-term relationship with? You are at the airport waiting to catch the plane. You make friends with a person in the airport lounge. He describes some symptoms. It seems straightforward. You feel as if you bonded with him. You write a prescription for him to fill when he gets home. You tell him to follow up with his regular doctor. He buys you a drink. You even document that in the medical record. Is that unprofessional?

My point is the definition of unprofessionalism is not straight forward. It is easy to imagine a regulatory body abusing its position of power because they don’t like how something “looks.” Seems like a slippery slope.

What do you think?

Posted by Medical Justice | in Legal | 10 Comments »

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Mike PappollaLouise B Andrew MD JDJosephMarkJoseph Horton Recent comment authors
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retired

This is pretty clearly inappropriate. But so are all of the other examples cited. Just because some physicians do this is not going to make it any more appropriate. Friends in an airport lounge doesn’t constitute a physician patient relationship and it is inappropriate to prescribe something in that context. That is no better than the itinerant surgeon, that the American College of Surgeons had railed against for years. Friends with no professional relationship and ABC symptoms? I would never write prescriptions for friends. You don’t know their history because you have not taken one. You cannot be objective. And… Read more »

William
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William

I do not carry a prescription pad with me If anyone ask me for prescriptions I refer them to make an appointment at the office. Fortunately, I do not get those request very often On one trip I did a counter prescription in a different state for Transderm-Scop for my nurse. The pharmacy checked with my office by phone. In the past when I had a private office, if one of my staff had symptoms I would examine them and treat them and there was a office note. Even though they were not my regular patients they had their own… Read more »

Steven B. Perlmutter, M.D., J.D.
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I believe the “airport case” would be very difficult to defend. To write a prescription without a history and physical is problematic.

I am more sanguine about the “friend case.” In my view, a physician-patient relationship is established once you take your friend’s history, perform a physical, and create a medical record. Whether this would pass medical board muster becomes very fact specific. Bottom line – you may prevail with a board complaint, but there will be plenty of anguish and loss of sleep. Common sense dictates it is best to avoid this type of situation.

Stacy Childs
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Stacy Childs

My biggest problem is family members asking for non opioid drugs for sore throat or pink eye or chest cold. I do not feel comfortable doing this as a urologist, but I want to save them $150 and a long wait.

James
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James

I think the location of prescription writing is a bit of a slippery slope. I can imagine a hypothetical case where a postoperative patient (say, fingernail surgery) is asking for additional pain medication, and yet is reluctant to come into the office on the weekend to be checked. You agree to meet him and his wife at Walmart where they are shopping, so you can determine that there is no spreading redness up the arm, interrogate him a bit in person in a private are whether he really needs that strong a pain medication, and get him to agree to… Read more »

Joseph Horton
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Joseph Horton

Confidentiality is a non-issue if a patient and doctor meet in a parking lot, in a bar, or in CostCo. The patient has implicitly agreed that there will be no confidentiality. If the patient prefers to go elsewhere and the doctor says, in effect, it’s here or nowhere, that’s coercion and would be clearly inappropriate. But if it’s mutually agreeable, then it’s been agreed to. Does this sound odd to me? Yes, it does. But odd isn’t the same as unprofessional. I know it when I see it as well. This ain’t it, at least on its face. HIPAA only… Read more »

Mark
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Mark

Clearly inappropriate. Regardless of the situations. Google Dr. John’s and DEA and see what happened to him. It gives the rest of us bad name. Furthermore, my advice is to NEVER EVER write a prescription for qty”100” unless you personnaly write out easily recognizable in YOUR handwriting “ Confirm: QTY ‘100’ “ I never used qty 100z why? It’s extremely easy to add a “0” to “qty 10” 10 100 That simple. Also? Write dangerous addictive scripts and purposefully write over any lines on the script. I had a partner write a patient for tramadol #90 The kid scanned it… Read more »

Joseph
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Joseph

Thanks Medical Justice for another great topic. Along these lines, there is a far more provocative issue that we will be encountering soon. In the not too distant future, people will get their first prescription from a Chat Bot. This technology is already available and in use.

Louise B Andrew MD JD
Guest

These vignettes describe several slippery slopes, all of which lead directly to a cesspool of consequences. The crux of this matter is the lack of a physician patient relationship and a formal record in the patient’s chart. (Though obviously the controlled substance prescribing in large quantities and being public enough to accept cash while being observed by a “supervisor” suggests this was no “One-Off”!) Almost every state prohibits the writing of prescriptions without these things being in evidence, regardless of the substance prescribed. Ignoring these two requirements is often the basis for charges of unprofessional conduct in physicians who treat… Read more »

Mike Pappolla
Guest

This situation is obviously inappropriate. It would have been inappropriate even in the office. However, what about writing a prescription for statin refill to a well-known established patient in a public place? Everything is a matter of judgment and common sense. Unfortunately, a small minority of our colleagues are missing both. They are in part responsible for having the rest of us gasping for air in an overregulated practice environment.