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Calling others out on mistakes...


Guest ERCat

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For the record - as a baby ER PA - I've been so grateful for nurses and docs and other PAs who have brought to my attention potential mistakes I've made, or important things I hadn't considered. We are all fallible. We all have potential to make mistakes either due to error or lack of knowledge or overconfidence or whatever. Especially when we are "new" I think it's important we alert other healthcare workers of mistakes they may have made...

 

We have a brand new baby doctor fresh out of residency who I felt has made some odd decisions. I.e. Told me to send an 89 year old with a history of HTN, A Fib, MI and AAA with an acute onset of severe back pain with no known injury home after only negative x-Rays - with a prescription for codeine and 250 mg (??????!!!!) of Robaxin every six hours... Or told me to put a 6 year old girl with a first metatarsal shaft fracture in a post op shoe for comfort. Both instances I did speak up. For back pain dude I advocated for CT and labs multiple times and questioned the Robaxin dosage ... Politely. Inquisitively. For the girl I whipped out my phone and was like "Oh, my Pepid app says she needs a short leg cast; what do you think about this?" Or at least I hope I appeared polite and inquisitive only. Just trying to do what is best for the patient.

 

Well. Today I had one of his bounce backs. 34 year old male with several days of pleuritic chest pain, hemoptysis and palpitations. Had been wrestling and play punching with his brother in the days leading up to it. This doc's chart said "CT scan showed no pulmonary embolism" and discharged him home. Unfortunately he should have ordered a CTA and not a CT, and the rad report did not even specifically make any mention about a PE! When I talked to the patient he also said he had a strong family history of clots -"my mom and dad and both uncles and grandma and grandpa all has blood clots in their 30s" -- also something this doc's chart didn't even mention. He also didn't even order an EKG for chest pain..The poor kid had to get rescanned so I could get my CTA as I obviously had to rule out PE. The study was kinda indeterminate and I admitted him because he was dyspneic and just looked awful.

 

So I thought he screwed up in many ways - one, not even asking about the family history or mentioning it but most of all ordering an inadequate study. And then saying "no PE"

Even when the rad report mentioned nothing about "no embolism." Especially with the strong family history this kid could've gone home and died of PE. My attending agreed with me and advised me to talk to our boss - I felt that was tattling so I decided to call this doc and tell him myself. Very nice text saying "I saw your guy and he also mentioned his strong family history of clots so I was concerned about PE... The way we order scans here is super confusing and for ruling out PE we need to order a CTA chest not CT chest; anyway just thought you would want to know, for what it's worth coming from a new grad PA!" And added a silly emoji for lightness. He basically just replied "Well I was only trying to rule out chest trauma, thanks for the tip" and I got a feeling he was annoyed.

 

So now I am feeling kind of bad like maybe I've presented myself as a know it all. Like I said I've been so grateful as a new provider when people tell me things like this. And also it's ultimately what is best for patients - you bet he won't miss a PE in our ER ever again now he knows the appropriate study to order here. On the other hand he might find it unsettling to be called out by a new PA.

 

How do you guys broach this kind of sensitive situation?

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I'm dealing with one right now, but it's an experienced UC physician and I get a lot of his return visits / follow ups in my family practice (working at 2 companies). One case for example was a balanitis in a 20 y/o male wth DM that he sent home with an Rx for polysporin.... I saw him he had complete phimosis with urinary obstruction. Another just came to me the other day from this person too who told a geriatric male with a diabetic foot Ulcer it was cancer and didn't give an Rx and said f/u with PCP. I treated with xerform and PO abx and had resolution of sxs after a couple of weeks. I approached telling this coworker / physician by alerting these cases to our medical director for case review. Not sure if it's the right thing to do, but that's how I handled it.

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I agree it would be simpler for me to bring cases to the director for review - at the same time if no patient was actually harmed (and this guy wasn't... It just could've been really bad) I opted to tell him personally. So that I don't make enemies. Ha.

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why are you pussyfooting around with this young doc? why are you afraid of him? just tell him like it is.  "You did this, you should/need to do this." It's just going to keep happening and he'll think you'll just lay down for him and mop up. Or if you're that non confrontational then snitch and tell his boss so he/she can clean up his mess.

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My opinion is to not throw people under the bus. I have a chat with them discussing the issues that I've seen in a collegial way. If they don't improve then I'll take it higher, but that's not yet happened. The IM doc I trained with who had been practicing 30 years taught me, after we saw a bone head move by another, that you can string him up, but everyone is going to remember what you did. The next mistake might be yours and you might be the one hung out to dry when looking around for friends.

 

This is one of the reasons I got out of nursing and got into medicine. Everyone in nursing was just waiting for you to make a human error so they could put in a report. Got to the point we were all paranoid and didn't trust each other. One nurse forbid anyone from entering her patient's room, lest you get an ass chewing.

 

I always start these conversations with "hey I noticed this, and I wasn't there, but I would think this would have been better." Don't worry about looking like a smart ass. Just be polite, say the issues you have and what you think could be done to enhance patient safety, and end with saying if they see something you could do better that you hope that they would feel comfortable telling you as well.

 

Not saying don't talk to the boss, just wanted to give some food for thought.

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If you have a good rapport with this doc, you could approach him as a "friend looking out". Just say "hey I saw a couple of cases that could really get you in hot water if something went wrong...just a word to the wise." That's what I would do. If that didnt work then you are justified going up the chain of command. Because if a patient DID have an adverse outcome and it was found out you KNEW about it and didnt intervene, you could be liable as well.

 

These situations are tricky because no physician is going to respond well to a 'subordinate' overtly calling them out on MDM. It will only make you look like a smug know-it-all, and doubtful they will change the behavior unless it comes from a superior. Yes I know nurses do this, but nurses are a separate entity from providers and are very well protected administratively. If you immediately go up the chain of command and tell the lead doc, you are kind of snitching, and while not ethically wrong you could get labelled as a busybody and then deal with prolonged interpersonal tension, which makes work suck. 

 

A PA would get absolutely sh!t on for making those decisions. Maybe even lose their job. This stuff really pushes my buttons because it happens to me all the time. I have 15 docs who are viewing my charts in one way or another. Anytime I do (or dont do) something the way that particular doc would have done it, I get talked to. It's like welp, how am I going to screw up today. You cant argue with them...if you do you are being insubordinate and they really dont give a crap about your explanation anyway. It's a no-win. 

 

From physician to physician, it's almost always written off as style differences.

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Good thoughts, guys. Seems like maybe I don't need to feel guilty about sending a text to this guy.

 

Seems like the doctors I work with - especially the new ones - a very reluctant to say they made a mistake or didn't know something. It's always excuses. Kind of annoying!

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Good thoughts, guys. Seems like maybe I don't need to feel guilty about sending a text to this guy.

 

 Never feel guilty about this.  Sounds like you are handling this appropriately and you are doing this doc a favor.  But think of the guilt you would feel if you didn't act and someone died.

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While "praise publicly, correct privately" is well known, using texts isn't exactly or totally private.  It's discoverable, which means it can be good for you and bad for him, should anything go wrong.  It might be a good balance of CYA (proving you said something at the time), while still not being immediately obvious to everyone around.  Email is also on the same spectrum, but anything other than 2 people in an unobserved conversation isn't totally private.

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why are you pussyfooting around with this young doc? why are you afraid of him? just tell him like it is.  "You did this, you should/need to do this." It's just going to keep happening and he'll think you'll just lay down for him and mop up. Or if you're that non confrontational then snitch and tell his boss so he/she can clean up his mess.

 

Then polish up your CV and start looking for a job.  Correcting any physician as a PA is riddled with dangers - as a new PA it is almost career suicide. Sometimes it is the initials after your name.  

 

 

If you have a good rapport with this doc, you could approach him as a "friend looking out". Just say "hey I saw a couple of cases that could really get you in hot water if something went wrong...just a word to the wise." That's what I would do. If that didnt work then you are justified going up the chain of command. Because if a patient DID have an adverse outcome and it was found out you KNEW about it and didnt intervene, you could be liable as well.

 

These situations are tricky because no physician is going to respond well to a 'subordinate' overtly calling them out on MDM. It will only make you look like a smug know-it-all, and doubtful they will change the behavior unless it comes from a superior. Yes I know nurses do this, but nurses are a separate entity from providers and are very well protected administratively. If you immediately go up the chain of command and tell the lead doc, you are kind of snitching, and while not ethically wrong you could get labelled as a busybody and then deal with prolonged interpersonal tension, which makes work suck. 

 

A PA would get absolutely sh!t on for making those decisions. Maybe even lose their job. This stuff really pushes my buttons because it happens to me all the time. I have 15 docs who are viewing my charts in one way or another. Anytime I do (or dont do) something the way that particular doc would have done it, I get talked to. It's like welp, how am I going to screw up today. You cant argue with them...if you do you are being insubordinate and they really dont give a crap about your explanation anyway. It's a no-win. 

 

From physician to physician, it's almost always written off as style differences.

 

Well said - but also don't forget we can defend ourselves when questioned - no one was in the exam room and no one could see how patient presented the first time - so try not to monday morning quaterback things... that just makes you look bad

 

Good thoughts, guys. Seems like maybe I don't need to feel guilty about sending a text to this guy.

 

Seems like the doctors I work with - especially the new ones - a very reluctant to say they made a mistake or didn't know something. It's always excuses. Kind of annoying!

 

 

Text = ????  What?  That would be a totally wrong way to handle any workplace issue.  I see this sometimes with younger folks thinking it is okayto text important issues - it is not.

 

As well give the guy the professional courtesy to seek him out and have a face to face with him

 

 

 

 

I think the best way to handle these "disagreements" is to go the the person that you "think" made a mistake and ask them to enlighten/teach you on their decision making process in the fact that you would have ordered a slightly different work up.  It opens the door to an education moment (for both) and is a very non-threatening way to address a challenging situation.

 

If you come out like a know it all as a new or even mildly seasoned PA you will get a major correction (likely rightfully so) from the Doc.  Prior military folks can talk about chain of command, and it sums it up.   Yes there are times you jump it, but in general you respect it.  (funniest thing I saw in the military is a 1rst LT trying to overrule a Chief Master Sargent based on "rank".....   That LT got a talking to from the squadron commander and never made that mistake again......  so times you can jump the chain of command, but unlikely as a new grad....

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Your SP should have handled and left you out of it. Correcting a physician is above my pay scale of headache...sorry you had to deal with that. Physician to physician would be my preference. I have a hard enough time getting negative feedback from my PA colleagues (like I cringe but still want to hear it). It's just unfortunate but you did what's right for the patient in the end

 

 

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While "praise publicly, correct privately" is well known, using texts isn't exactly or totally private.  It's discoverable, which means it can be good for you and bad for him, should anything go wrong.  It might be a good balance of CYA (proving you said something at the time), while still not being immediately obvious to everyone around.  Email is also on the same spectrum, but anything other than 2 people in an unobserved conversation isn't totally private.

 

Agreed- texting about patients is really not a good idea- always discuss matters like that face-to-face.  

 

Also, as an aside, when using CT to evaluate for undifferentiated chest trauma, CT with contrast is the standard- not a dry CT.  Doesn't necessarily have to be PE protocol, but if he was actually worried about "ruling out chest trauma", a CTA is the way to go

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I think you should definitely address issues like that as they arise, but I wouldn't present yourself as a new grad. I would start approaching the situation as an equal with specific concerns. Look at the literature to back yourself up if you need to. "According to such and such resource, we should do this for the patient so I'm ordering it." I run into similar problems sometimes and it generally goes over well when I present concerns confidently with research on my side. Best of luck.

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The idea of trying to handle an interpersonal issue via text is just vexing. Presumably you work with this person on a regular basis, and have the opportunity ta talk face-to-face?

 

I like what was said before about not throwing the guy under the bus. You don't want to come off as Little-Ms(orMr)-Perfect, or holier-than-thou, and the next mistake could indeed be your own (if you haven't messed up yet, don't worry, you will). Looking out for that patient and standing up and saying something is never wrong - that's why we practice medicine as a team. Just be civil and professional about it, and don't apologize for being "just a new PA" if you know you're right. If he chooses to make it personal, that's up to him and out of your control.

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Thanks, guys. This kid is about my age - I mean he's fresh out of residency. And we millennials communicate by text mainly! I agree it would have been better to be face to face but I don't see him more than once or twice every two weeks and I felt it was important enough to be mentioned right away. That said it probably would have been better to call him. Thanks for the support guys - glad I said something.

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Yes. Start looking for another job.

 

Wrong approach.

 

Why OP?

 

We are so vulnerable to quick termination. Literally! The MDs are not.

 

You must make peace with this MD. You've done the unthinkable. Texting about it. He'll save your text. You've created an enemy.

 

 

My 2c

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There should be a QA/QI mechanism in place to pick up on the bouncebacks for the provider in question.

Let that process do the heavy lifting, you get nothing extra for proving a colleague wrong in one situation. But patterns will develop and be noticed.

I also would recommend that any newbie spend a lot of time crafting your own diagnostic plan, assessment and treatment rather than relying on what an SP will tell you to do, particularly when they may not see the patient. Medicolegally, if they did not see the pt nor do a note, their liability is limited despite you putting their plan in place and documenting that you discussed the plan with an SP. Malpractice lawyers and juries don't care the SP told you to do something. If you thought that was not the correct thing to do, the public's expectation is for you to do the right thing.

Also, only communicate about patients only by official means, eg company or hospital secure email or in a protected environment such as monthly dept meeting during QA session. No texting ever about pts or anything else that involves work, too slippery of a slope.

At this stage of your career, let the folks you work with that have more time in take care of these things. You have other things to focus on. Do you have anyone there that is ID as a mentor? Senior PA? Go to them with this stuff.

Good luck.

George

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Next time you're working with him maybe you can go out of your way to be friendly / helpful? I don't want you thinking you have a long term enemy. If my patient load is lighter I will sometimes go to the back and ask my guys if they have any procedures that need doing that would save them time - abscess/lac etc. idk something that would smooth things over. I will sometimes sit next to the doc I don't necessarily care for and ask about family/opinion on something just to make it easier to talk to him the next time. And you're probably putting way more thought into it than he is :D

 

 

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KMD - look for another job? Texting someone is "unthinkable"? Wow, I feel like that is a little dramatic.

 

Just FYI, guys. Maybe I shouldn't have texted him but I saw him during my shift yesterday and there was no weirdness. He even chatted with me in a friendly way and told me the next time he has a code he's going to call me into the room to run it with him. So I don't think I've made an enemy! I got the feeling he didn't think anything of it.

 

That said it probably was not the best choice and I won't text about these matters again - and I think I will let my boss doc handle all this from here on out.

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Then polish up your CV and start looking for a job.  Correcting any physician as a PA is riddled with dangers - as a new PA it is almost career suicide. Sometimes it is the initials after your name.  

 

 

 

looks like you're the type of person (and this is fine, i know many people like this) who just lays down and cowers in the corner "oh sir yes sir so sorry sir, you're right sir i'm so sorry to question your holiness!!!" congrats this is real life and not the military. If someone is wrong and may kill someone (patient) and you are mopping up these bad decisions one after another, speak up. If you get fired for doing that, then it's a sh*tty organization with a sh*tty doc and a sh*tty HR and I'd rather have self respect (and less dead patients) than bowing down to save my job.

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  • 3 weeks later...

"why are you pussyfooting around with this young doc? why are you afraid of him? just tell him like it is. "

 

This.

 

Same thing was happening in our ED right before I left- handful of brand new ER docs making questionable decisions. Tough spot to be in as a newer PA. Had one tell me to order troponins on every chest pain that walks through the door. EVERY chest pain. "Yeah, not gonna do that, but thanks for the input."

 

Anyway, my opinion is to go straight to the source of the problem--- pull him aside, voice your thoughts/argument. Maybe text wasnt the best approach, but- meh.

 

Doesnt have to be a conflict unless he wants to make it one; at least you stood your ground.

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looks like you're the type of person (and this is fine, i know many people like this) who just lays down and cowers in the corner "oh sir yes sir so sorry sir, you're right sir i'm so sorry to question your holiness!!!" congrats this is real life and not the military. If someone is wrong and may kill someone (patient) and you are mopping up these bad decisions one after another, speak up. If you get fired for doing that, then it's a sh*tty organization with a sh*tty doc and a sh*tty HR and I'd rather have self respect (and less dead patients) than bowing down to save my job.

Wow

That is pretty uncalled for

 

If you read my entire prior post i was advocating to have the PA go directly to the Doc and start a conversation in a non-threatening way. I would NOT jump to conclusions, or "report" the doc with out having the PROFESSIONAL courtsey to address the doc directly. I have recently seen a few cases where young know it all PA and NP have tried to come in and upstage established providers and all they do is prove you ignorant they truly are as they just simply do not have the experience to truly understand what the heck is going on.

 

 

I am no roll over, I have stood up to doc's and have 15 years of experience in numerous different fields.

 

I really don't understand your reference to the military? have you ever served? I have and rank is not automatic respect. Time and knowledge is respect - exactly what a new grad does not have. Watch a butter bar (2Lt) try to over ride a senior enlisted NCO and you will quickly learn about the rank of "knowledge and experience". This rank would certainly apply to an seasoned PA, but a new grad PA is much closer to a butter bar......

 

As a new grad, (and I have seen a fair number) if you think you know MORE then a doc, and are going to correct them - well good luck. 98% chance you are going to come out on the loosing end. Think about this for a second. You have a whopping 6 semesters of education and no residency experience, going up against someone with at least twice that. (3+3).

 

Might you be correct? Yup

 

Might HR look at you and rightfully say that you are most likely a trouble maker - absolutely. Hence why trying to learn from the Doc (as they likely do have more knowledge then a new grad PA)

 

As well there is the whole learning the players in the whole medical field - what does the ER do for a work up versus a PCP or Heme/Onc - and no they are not the same work ups.... as they are all different in their presentation.....

 

 

 

Before you make assumptions about me I would encourage you to learn a bit about me. I owned the first PA owned medical practice in my county and according to the board possible the first on in my state. I have blazed more new paths for the PAs in my prior 15 years then I can even remember. I have attained new professional levels though out my career for PAs and have advocated constantly to utilize PAs at the top of our licenses. I have partnered with and work successfully with many different professionals and am highly respected as a medical provider. I put my pants on the same way as every physician out there (one leg at a time) and am more then willing to engage in a relevant clinical discussion where all parties can learn. I am not a push over, I advocate tirelessly for my patients and will continue to do so. In fact just one day ago I challenged a doc (and facility medical director) on a patient I was advocating for, and we came to an agreement that preserved my viewpoint.

 

 

I do however find it mildly offensive when someone on an anymous board claims that I am push over and will never question anyone with out even taking the time to learn about me(it is exceedingly easy).

 

I have stood up to a doc making a wrong call and had to stand tall, and was successful in my defense, but I was 8 years out of school and knew with out a doubt the doc was wrong. I have no problem with this approach when you truly understand. But a new grad is HIGHLY unlikely to have this type of understanding, and certainly should not be getting involved with such issues with in months of graduation - heck just focus on learning and not killing some one....

 

 

I will now climb off my soap box

 

Jeff Kellogg, BA, MS, MBA, PA-C (letters inserted for the OP reference not mine)

Founder Berkshire Mobile Medicine

Proud veteran of the USAF

~15 year PA

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