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?