OF THE APPROXIMATELY 30 Web sites advertising Cipro sales, at least eight connect purchasers to MedicalWeb.com (www.medicalweb.com). A company subsidiary, VirtualMedicalGroup.com (www.virtualmedicalgroup.com), hooks patients up with doctors, who write online prescriptions for various ailments. The drugs are shipped by another subsidiary, 1stOnlinePharmacy.com (www.1stonlinepharmacy.com), to the patient. The Web sites pay MedicalWeb.com a fee for its services.
       Work at the North Carolina company has been nonstop since the anthrax crisis began in early October. Employees, fueled by potato chips, are staying up late into the night to answer hundreds of calls and e-mails from patients trying to order Cipro. Before last month, the company was filling six to 10 orders for Cipro per month. Now it is more than 100 per day.

       But along with sales, the Cipro boom is drawing controversy to this obscure Internet operation. Last week, the North Carolina Medical Board showed up at the offices here demanding documents for an investigation. A person familiar with the situation says the board is gearing up to take more action against the Web venture soon.
       All this has Tania Malik, chief executive of all three operations, worried. “It’s almost, ‘Be careful what you wish for,’ ” she says. “We did want people to know about VirtualMedicalGroup, but my fear is people see the press and think we’re arrogant.”
       The issue with VirtualMedicalGroup — and other online operations like it — is its reliance on prescriptions from doctors who have never physically met the patients for whom they are prescribing medicine. Malik says the company has a network of 35 board-certified doctors who write prescriptions for customers with whom they interact online.

       “We only do conditions that we feel are appropriately treated over the Internet,” Malik says. Until recently, most of those prescriptions were for the impotence drug Viagra. Now, most of them are for Cipro.
       Although some medical experts say that an online interaction isn’t adequate to write a prescription, it isn’t illegal in most states. Some state medical boards oppose the practice — including the North Carolina board, which describes it as “inappropriate and unprofessional” — but few have taken action against the doctors involved.
       One problem is the virtual nature of Internet exchanges. “What is real challenging about these sites is to know what physician is involved and where they are licensed,” says Dale L. Austin, interim chief executive officer of the Federation of State Medical Boards of the United States.
       The federation has been investigating online prescription sites for the past year, but the probe has gained a new urgency with the recent run on Cipro. Now, the federation is working with the Food and Drug Administration and various law-enforcement agencies to crack down on the doctors who are doling out prescriptions on these sites.

       But it is tough to go after a practice that is legal in most states. Austin says they may use legal grounding based on “standards of care” or unprofessional conduct. The American Medical Association says prescriptions issued over the Internet based on a simple questionnaire “do not sufficiently meet the standards for good medical care” but that ultimately it is up to a doctor’s judgment.
       “I think it’s a question of professionalism and standards of practice,” says Timothy T. Flaherty, the AMA’s chairman. “Physicians have to ask themselves if they are doing what is the best for the patient.”
       Russell E. Randall says he thinks he is doing the best for his patients when he prescribes drugs for them online for VirtualMedicalGroup. “I’m very insistent that we only prescribe when it’s appropriate,” says Dr. Randall, a 73-year-old retired physician in Woodbury, Conn.; he still has a medical license.

       For example, Dr. Randall says he often turns down people who want drugs for urinary tract infections or depression because those are things that should be diagnosed in person. However, drugs to treat both illnesses are offered by 1stOnlinePharmacy.com. With Cipro, he says, he simply counsels people not to take it without a good reason, but says it is fine for consumers to keep some around in case of emergencies.
       “If I were in the Capitol building or a place where the anthrax had occurred, would I love to have it in my hip pocket? Sure, I would,” Dr. Randall says. “If you start taking it right away, then you are better off. Will there be misuse of it? Sure, probably.”
       Public-health officials are concerned that a flood of people buying Cipro unnecessarily could deplete supplies for those who need it, and potentially lead to the development of anthrax resistant to the antibiotic. VirtualMedicalGroup officials say they are being responsible by limiting customers to a seven-day supply of Cipro — rather than the 60 days’ worth believed to be needed to treat a full-blown case of anthrax. VirtualMedicalGroup buys its drugs from AmerisourceBergen Corp. of Valley Forge, Pa., a major pharmaceuticals wholesaler, and says that to date, it hasn’t had any trouble getting supplies.

       Malik, who manned the phones herself last week, says the interaction with physicians like Dr. Randall is what differentiates her online pharmacy from “rogue sites.” Some other sites only offer a checklist of questions before writing a prescription, she says. Her site has software that allows doctors and patients to conduct a “virtual office visit,” which is essentially a private online chat that costs $49, not including the price of the drugs.
       But the virtual office visit can be quite short. When a reporter ordered Cipro last week, the doctor posted a note in the chat room describing the possible side effects of Cipro and reiterating that it should only be used in case of a “credible anthrax exposure.” The reporter agreed and six tablets of the medicine were sent for $45, plus shipping. However, Malik says, some visits are quite long and involve lengthy questions and answers between the doctor and patient. The VirtualMedicalGroup’s online questionnaire does not ask patients to specify why they want a Cipro prescription (see example below).

       
       Malik’s brother, Steve, founded the company in 1996, and in 1999 recruited his sister Tania, who is an attorney, to run MedicalWeb, which is private and has no venture-capital backing. Malik says MedicalWeb has been profitable for the past four months and has annual sales of about $1 million. It operates with a staff of just 15. Even she has a sense that the Cipro crisis could be thrusting her company’s technology into the fore before society is ready. “We’re paving the way,” she says, “and maybe we’re too early.”
       
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