Physician, heal thyself?

A colleague and I were enjoying the meal before an educational event. We were registered at each other’s practices, though not with each other. Sore throats were filling up our emergency surgeries, and we had both caught it.

“Don’t tell my GP” said my colleague, “I started myself on some penicillin and I feel a lot better.”

“Well, don’t tell my GP, but I have been taking penicillin too, and I feel a lot better.”

Doctors treating themselves and their families and friends is common, it’s legal, and it’s frowned upon.

Why do doctors self-medicate? Because they feel embarrassed admitting ill heath. Because it is easier than getting a prescription through the proper channels. Because they don’t want medication on their medical record. Because they are abusing medication.

In the old days GPs rarely registered with another GP. Real GPs didn’t take time off for colds, they battled on – and doubtless infected quite a few patients. Real GPs didn’t suffer from depression. But some ended up sectioned or committing suicide.

In the 1990s doctors began to accept their own fallibilities. LMCs promoted the need to register with another GP, and drew up lists of GPs who would accept colleagues as patients, even if they lived out of the practice area. Now, organisations such as the Practitioner Health Programme offer doctors independent medical advice. But some self-medication still goes on. Should it be stopped?

I don’t accept that self-prescribing is the slippery slope to addiction. Of all the missteps leading from upright professional to illicit opiate user, unremitting stress is a much more likely impetus than self-prescribing a course of flucloxacillin.

GPs who have self-prescribed often say they did so to save time. Self-medicating for a UTI will keep a GP in her surgery and out of someone else’s. It cuts corners around an imperfectly efficient NHS . That’s why I prescribed for my husband. One Sunday morning he awoke complaining of a burning pain over the ribs. O/E NAD. An hour later a band of lesions had appeared along T10 dermatome. We were about to leave for Argentina to trek across the Andes. I wrote him a prescription for anti-virals – he fell within the criteria so I was treating him as I would any patient – and as soon as I could I told my practice. They signed him on as a temporary resident and wished us a good holiday. Interestingly, the shingles was stopped in its tracks. Expecting the spots to go away, patients usually wait a couple of days before consulting, so it was a revelation to me how effective anti-virals can be if started early enough. I would do the same again.

Undoubtedly self-medications rarely get onto the patient’s medical record. But the GMC could recommend that the prescriber inform the regular GP. And perhaps the authorities should remember that in the real world there are now a host of prescribers – hospital doctors, pharmacists, community nurses and others (let alone alternative practitioners) – and lots of their prescriptions don’t get transferred into patients’ medication records.

Is self-prescribing really so unethical? Ethics are slippery things. In most of Europe far more medications, including antibiotics, are available without prescription, and in much of the world you can get almost any drug over the counter. So, many doctors now practising in UK will expect to treat themselves.

The NHS devotes a lot of money to encouraging patients to self-medicate for minor problems. Surely the same applies to doctors? And doctors don’t always need to write a prescription to obtain pills. How many GP migraineurs have not pocketed a drug company sample of a triptan? How many GPs have not slipped into their drawer a packet of diclofenac returned by a patient?

The GMC reminds us that putting yourself in a proper position to make a diagnosis (no car-park consultations) and knowing your limits (identifying a malignant melanoma) are essential when treating any patient. It cautions us whenever possible to avoid prescribing for family and friends. But it does not rule out prescribing even controlled drugs if they are essential to someone’s medical care, urgently required and otherwise unavailable. And if you exercise proper judgement and advise the patient (including yourself) to see their own doctor if the condition doesn’t respond as expected, the risks are small.

Many doctors feel that the pressure against self-prescribing is yet another case of ‘nanny state’. I wonder how many builders would risk taking on a large job for family or friends. The relative expects a cut rate, but is irritated when work on his house stops because his brother-in-law has to complete a commercial contract. And if something goes wrong, it can end a relationship. So wise builders, like wise doctors, have to deal with family expectations and to recognise boundaries.

Self-prescribing is increasingly under scrutiny. A small but growing number of self-prescribing cases come before the GMC, apparently following tip-offs by pharmacists and other doctors. Predictably, benzodiazepines head the list, but antibiotics come second.

Of course, there will be occasional abuses, but making self-prescribing illegal would not prevent them. It would be another bureaucratic overreaction: responding to isolated abuses by imposing universal sanctions. We trust doctors to prescribe for other people. In an imperfect world doctors should be able to prescribe for themselves – when the circumstances justify it. Doctors make mistakes, but medical care by algorithm isn’t perfect either. Doctors in general must be trusted.

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