In February, six physicians were fined a total of $48 million for prescribing medication over the Internet. The doctors, fined by the Medical Board of California, practiced in Florida, Arizona, Tennessee, and my home state of Rhode Island. The prescriptions all went to consumers living in California. California passed a law two years ago to protect Californians from physicians prescribing medication on the Internet without first conducting an examination. Naturally, the California Board cannot revoke a medical license issued by another state, nor is there necessarily anything California can do to apply their own law to physicians in another state, but that’s not to say they aren’t trying. The state has informed the licensing board in each of the other states of the apparent misdeeds. One can assume that at the very least the doctors will be subject to investigation, possible licensure action, and penalties from their home states. According to American Medical News, 27 medical boards have now disciplined physicians for improperly prescribing medications online. Boards are considering it unprofessional to prescribe medication without first examining a patient.

There are several issues worthy of discussion here, but the most prominent appears to be a failure to properly define “examine.” Just a few years ago, a congressional aide asked me for my thoughts on how to stop online prescribing. As we discussed the matter, it quickly became clear she was referring to those sites that market prescriptions in bulk. I asked whether she also was talking about a single physician who, from time to time, would prescribe to an individual with whom he had established an online dialogue. She asked if the doctor had seen the patient in his office. “Imagine he hadn’t,” I replied. “Same issue,” she responded. “The patient hadn’t been seen.” Define “seen,” I asked, to which she said that the doctor hadn’t seen the patient in person. The visual cues were therefore not present. “So I suppose a blind doctor would not be permitted to prescribe,” I queried. She stopped at that point and started down several other paths, each time stopping herself upon realizing that any of a number of disabilities might lead to the lack of certain information. She also realized that no one has yet described the precise requirements of an examination.

In most specialties of medicine, a physical examination is fairly straightforward. It involves the doctor touching the patient with instrumentation or hands. That’s not the case in psychiatry and psychology. Without the requirement of touch, why must the doctor and patient be in the same room? One might speculate that olfactory, visual, and auditory cues all offer useful information. Research backs that up, but obviously we don’t stop physicians from prescribing if they are blind, deaf, or suffering from sinus congestion.

Let’s consider several types of patient-health professional contacts:

1) Telephone — we hear the patient but don’t see them.

2) Online discussion — we read what the patient says but neither see nor hear them.

3) Teleconference, either by computer or by video camera — we see and hear the patient but usually with some technological barrier; the quality of the contact lacks the caliber of a live discussion.

4) Holographic — some future technology allowing patients to look as if they are standing in our office, holding a discussion with the caliber of a live contact.

5) Live — all senses are stimulated through the interaction

Scenario 1: Now let’s say a physician has a busy day at the hospital where he works in the outpatient department. One new patient comes in, unscheduled, and the doctor agrees to squeeze him in. The patient says, “I’ve been on Zoloft for two years. It works well for the depression that I had for years before that. I just moved here for a new job, but my doctor told me he can’t write a prescription for me because he’s not licensed in this state. I’d be glad to come back when you have time for a full evaluation, but I need my medication renewed today if you could do that for me.”

Scenario 2: The same physician receives an e-mail from a homebound patient in a rural area. Her local psychiatrist has retired. The patient details her history of depression and agrees to send the doctor a copy of her previous medical record and pharmacy records indicating that she has been treated with Prozac in the past. She asks the physician to please renew her Prozac after he has had a chance to review all the information she is sending him.

It would seem that the “examination” which took place in Scenario 1 is far less thorough than the examination in Scenario 2. And yet renewing the homebound patient’s medication in this manner is considered unprofessional conduct. At this point, anything less than face-to-face contact during a live in-office interview appears to be considered unprofessional. Where will the line be drawn? Will the holographic device described above meet the standard? Or hasn’t a standard been considered yet?

Throughout this column, I’ve been talking about prescribing medication as a form of treatment. There are other types of treatment possible, particularly in the field of addictive disease. If an individual unknown to me sends me an e-mail asking me to discuss her history of alcoholism, and I respond to the individual, am I treating the individual? If I am, I’m obviously doing so without having conducted an examination in my office. How does that differ from someone walking into my office asking me to talk about her history of alcoholism? Yes, I’m aware that in one case the person is there in front of me, and that in the other she isn’t, but what is the real difference? How do you define examinations and treatments? Do you think the medical board issues discussed here will lead to similar situations for psychologists and social workers?

Stuart Gitlow, MD, MPH, is the author of Substance Use Disorders: A Practical Guide, from Lippincott Williams & Wilkins. He will be speaking at the Psychiatric Congress in Orlando in November 2003.

This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 66-67.

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