Hemegroup Posted July 4, 2011 I've been working in my first position at a county clinic, with a large degree of autonomy. My SP is in the clinic on approximately two half days, but we've only interacted a few times. I was recently presented by him with a three month review, something that does not normally happen but is available if there are problems. I am deeply offended and confused about what was in the document, so I'm asking for help here on what to do next. I'll try and list some of the details of this situation ... The clinic has an adjoining county pharmacy, with it's own formulary. It's been challenging enough getting started in practice, much less tailoring treatment for the county insurance patients (we also see medi-cal, medicare, and private, but all to a lesser degree). The pharmacy has a Director who is megalomaniacal, and seems to think that he is Medical Director for the clinic. To make matters worse, my SP, who is the Medical Director, bows and cowers to anything the Pharmacy Director says and does. The document presented to me basically had a few of my prescribing errors in the past few months, but greatly embellished and with blatant lying in many parts. Examples: I had used Epocrates to lookup UTI in females, where it listed nitrofurantion 4 times daily for 7 days. Another pharmacist came and asked if I was sure I wanted Macrobid as 4 times daily, and I said that I did. When it was brought to my attention a few cases later, that Macrobid is to be written differently than generic (only Q12H), I immediately acknowledged the error and stopped prescribing it Q6H. No one had explained the nature of the error before this, and I had assumed that the directions on Epocrates were the same whether generic or Macrobid. The incident was stated as me aggressively arguing with multiple pharmacists. As you can see from the truth above, this was a total lie. As well, in my opinion, these are minor prescribing incidents that would be expected from any new grad, and certainly nothing to document and present in an official and threatening manner. However, as I said, my SP and I do not communicate (he's never entered my office once). He was also very insulting during the review, refusing to listen to my replies to the point where I had to tell him he was being very rude. Another incident was similar. Epocrates recommended levofloxacin 750 mg QD for community acquired pneumonia (the review stated I had prescribed it for "Walking Pneumonia", which I had not). Another pharmacist had said that they only had cipro, which I agreed to prescribe. They called to confirm if I wanted it 750mg QD, saying it was normally prescribed BID ... nothing was said about the 500 mg normally prescribed BID, which when it was explained to me I changed the prescription to without a problem (and even with a thank you). The review stated again that I had argued extensively and even that I was abusive towards the pharmacists. Here's where I should fill you in on some past history. The Pharmacy Director and his lynch man, another pharmacist (they're truly the nasty couple, who even their staff cannot stand due to their abusive natures), had been rude to me on the phone on multiple occasions. One Friday, I made a comment to one of them, which was misinterpreted (completely) as an insult. On Monday morning, I asked the Administrative Supervisor to be present when I explained what I had meant, to the pharmacist. He refused to accept my explanation, and grew livid to the point of shaking his finger in my face (imagine a snarling individual doing that, you get the picture). I calmly asked him to please stop pointing his finger in my face, that it was very rude. He got up from his chair and stormed out of the meeting, leaving both I and the Supervisor in a bit of shock. However, she got to see what he's like. So, fast forward back to the three month review. As I read the document, I quickly became offended due to the blatant lying and obvious attempts to make me appear difficult and abusive. There were one or two other issues with meds, not errors by me but one involving an abusive patient who had created problems at the pharmacy that were completely unrelated to me, but they tried saying that I was at the root of the problem (even though it was they who had denied the patient his pain medication ... he had necrosis of the finger all the way down to the bone, had been on Fentanyl and Dilaudid, yet they refused to prescribe the Perocet I had prescribed as his step-down continuation of managing his pain, which had sent him into a tizzy, understandably! They had insisted he was a seeker, to which I told them I wish they had been able to see his finger so that they could understand ... it was documented that I had said this, and they called it "unprofessional"). The only other complaint was not from my SPs, staff or patients. It was from a pediatrician I have never even met, who works at the rural clinic I'm only at one day a week. Her complaint was that I did not examine the genitals of a 6 year old girl, on a routine physical exam. I would never think to do that anyways, but even more so since my Peds SP had previously instructed me that there was no need to unclothe children for routine exams (there was no mention from him on the document). When the first finger-shaking incident occurred, I started covering my back and looking for other work. I interviewed recently with a good Doctor, who has an Occ Med practice which largely sees workers comp cases. It wouldn't be primary care, and I would greatly miss my underserved population (who many of request to see me exclusively now). I also wouldn't have my own huge office (like I do at my current clinic), I would be working on his desk with him at a different computer, although he his currently building a larger building which he stated would allow me my own office. He currently has one full time PA and a couple part time PAs although he seemed to indicate that he would rather have a full time PA, namely me. I don't know much about his turnover rate, but our interview went well ... we sat and talked for 4 hours straight. He also offered me a higher salary. Basically we're waiting to find out if he would be approved by the NHSC, although his zip code appears to qualify him as a loan repayment site. We'll find out more next week. What do I do? Give up a fight against this tyrannical Pharm Director, and leave a clinic where the patients and staff love me, but which could possibly involve another letter being written by the Pharm Director which could potentially cause my termination? It is glaringly obvious to me that he wishes to show he can cause the termination of a provider, this guy has serious power issues. How do I know they won't take his words seriously again? And honestly, I'm offended that anyone higher up reading that letter didn't see right through the BS ... the wording and tone was very extreme, as if I'm a total nightmare who yells and storms which I assure you, I am not. So I don't know what to do ... do I need a lawyer? I initialed the review with the opportunity to respond, but my nauseated stomach made me not want to sign a thing and I wonder if I even should have. What would you do?
rcdavis Posted July 4, 2011 (before macro bid was formulated, generic nitrofurantoin was and is a QID drug.. There is a little bit of apples and oranges here...a fact your med director should have appreciated.. IF. You original ex was written for nitrofurantoin and not macroBID..) I would leave. Without strong, compassionate and supportive SP/employer back up, which includes investigating complaints and helping guide you through any deficiencies noted, you are going to end up terminated as a result of the power demonstration being played by the pharm director. Only a senior very experienced and very proficient in matters pharmacy will survive in the situation.. One who can toe to toe with the pharm d... And your gut is telling you this.. You sound mature enough to separate the embarrassment and bruised ego of a negative review from he recognition of a futile situation. If the occ med position ( which will require some adjustment in priority.. You will in occ Ed be serving two masters; the patient and his employer) feels good.. Take it. Plan on staying 3-5 years ( to assure your resume doesn't look like you are jumping all around..), and don't let the lack of ego trappings ( large office) in he occ Ed offer sway you.. Somehow those things work themselves out. Good luck..
Joelseff Posted July 4, 2011 Sorry you are going through that crap Bro! I would leave too. I would however avoid Work Comp. This is a majority of my work (About 90% of my patients). It is a PITA. I also have the same working conditions now with what you describe with your future SP-No desk and working on his. We are not yet on EMR and my SP is adamant he won't switch despite the mountains of charts strewn throughout our tiny 3 exam room office-Can anyone say HIPAA? This is my last week there and CANNOT WAIT!!! I will be working with a great doc that I have heard of in reputation since he was friends with my mentor. Anyhoo, I hope you find something. If you must go to the WC Occ med place, I recommend shadowing him before signing. I should have done this and it would have saved me the headache I have had the past 4 mos. G'luck man! Joe
Hemegroup Posted July 4, 2011 Author Thanks guys. The thing with the Occ Med Doc is, he really is opening a larger clinic where I'd have my own office. We went over the blueprints together. He does have EMR, and the most appealing factor is his personality ... he's a kind and fair gentleman, I've seen some of his past patients who have had nothing but glowing things to say about him. I'm not looking forward to leaving FM/IM, but I can't be too picky as this is a small town and it will be lucky if he even qualifies as a NHSC site. Sure a bummer ... everything would be perfect if it weren't for that annoying PharmD. I don't understand why this has even been allowed to happen, the nurses are as upset as I am.
Guest Swennerb Posted July 4, 2011 No one is perfect- including the pharmacy director. It's one thing to offer constructive criticism, another to inflict your inflated, nasty ego onto a new grad. The way I see it, is there are environments created by destructive miserable people who thrive on gossip, lies, and arrogance. Then their are nurturing environments created by productive, humble, compassionate people. Now you know for your next interviews where you want to be, the burden is on you to make sure you don't end up w people like this again.
Hemegroup Posted July 4, 2011 Author No one is perfect- including the pharmacy director. It's one thing to offer constructive criticism, another to inflict your inflated, nasty ego onto a new grad. The way I see it, is there are environments created by destructive miserable people who thrive on gossip, lies, and arrogance. Then their are nurturing environments created by productive, humble, compassionate people. Now you know for your next interviews where you want to be, the burden is on you to make sure you don't end up w people like this again. It's true ... in fact, they recently released Depakote ER to one of my patients, instead of Depakote instant release. He ended up with side effects of severe tinnitus, and blurry vision. I will certainly be mentioning that in my rebuttal letter as a reminder that everyone makes mistakes, but honestly I'm foreseeing a petty flamewar that I'm not interested in. I'm considering requesting a meeting with the head MD Director for the county, so that we can discuss what's happened ... I would like to stay, but not if there's going to be this constant drama hanging over my head. I really appreciate what you say about environments. As to future endeavors, there's no way I could have known the personalities of these two pharmacists ... they weren't included on my interviewing, but jeez, the way they're acting, I guess they should have been!
ATCLATEMTB Posted July 4, 2011 Is there no Human Resources representative for support or to file complaint? Or at least build a paper trail while you are working other options. Keeping close records of interactions and exchanges might be beneficial should you need anything from HR or should your license become in peril.
bradtPA Posted July 4, 2011 A new grad versus management, management will win no matter how in the right you are. As long as you can get approved for the loan repayment, my advice is to leave. You will end up working with a physician on site and learning so much more from him being there than you can imagine, be in a better work environment, and have better pay.
mostrike1 Posted July 4, 2011 I'm sorry to hear about your situation. As a new grad, I find it so important to be supported by supervising and ancillary staff. I also work in a rural community, and had the same situation with the macrobid ( minus the angry PharmD ) ! The only thing I wonder is, will Occ Med qualify for NHSC? I thought it was for family practice/internal med...
just_me Posted July 4, 2011 since its a small town, isnt it possible you still may end up dealing with that pharmacy again? pehaps as a rebuttal you could get some sort of letter from Administrative Supervisor just noting the situation that seemed to ignite this whole thing? it would be nice if you could stay....seems you like the job itself but since you have bumped heads with the pharm director AND your sp (he probably didnt like being called rude too much) PS about the peds thing....my daughter has been going to the same peds office since she was born and they have always done a quick vaginal check.....so apparently it varies from pediatrician to pediatrician
Hemegroup Posted July 4, 2011 Author since its a small town, isnt it possible you still may end up dealing with that pharmacy again? pehaps as a rebuttal you could get some sort of letter from Administrative Supervisor just noting the situation that seemed to ignite this whole thing? it would be nice if you could stay....seems you like the job itself but since you have bumped heads with the pharm director AND your sp (he probably didnt like being called rude too much) PS about the peds thing....my daughter has been going to the same peds office since she was born and they have always done a quick vaginal check.....so apparently it varies from pediatrician to pediatrician That pharmacy only dispenses for the county sites, not for anyone else, so I wouldn't be running into them again. And I agree that I should ask the Admin Super for a letter of support, I will ask tomorrow. As for telling my SP he was being rude, he was not allowing me to respond to any of the allegations ... he was cutting me off whenever I tried to speak, and during the one time he was silent and letting me respond, he was working on his iPad and not even looking at me. He is Asian and doesn't speak good English, and when I was trying to explain and show the pathway I had used in Epocrates, all he would do was say loudly, "No, Epocrit! Epocrit!" (which I think meant Epocrates). He didn't seem to understand that it was the same program, except that I use the paid version on both my handheld as well as my desktop. It also looks different because we use different types of handhelds, so the program font/layout appears different. He just wasn't getting it, and was refusing to listen to me and try to understand what I was saying. It was extremely exasperating. He also would say things like, "why can't you be like *blank* PA" (who is Asian), "he has good books on his desk, not these things like this" (he was referring to the physiology textbook I had in my hands, as I had just come from a patient encounter where I had been using the text to explain the layout and function of the kidneys, and why compliance with his BP and DM meds was so important ... this was a patient with compliance issues that had resulted in him not taking his meds for months at a time. I've found that when you explain the function of the kidneys and how BP and DM can affect them, people usually end up saying, "I had no idea, no one has ever bothered to explain this to me before"). Yes, I don't know if the Occ med site will qualify ... altho that Doc said a PA had received it there before. I did put the zipcode into the NHSC site and it says his site would qualify at least on the zipcode (it's an underserved area, period). I don't know ... I guess I'll find out this week after we both call. The peds thing ... interesting to know. My peds SP had told me not to undress the patients without a reason, "just find out if they're a normal kid". I don't understand why a pediatrician who isn't my SP and who I've never even met was allowed to give input to the contrary, on the document.
just_me Posted July 4, 2011 That pharmacy only dispenses for the county sites, not for anyone else, so I wouldn't be running into them again. Well thats good to know! The peds thing ... interesting to know. My peds SP had told me not to undress the patients without a reason, "just find out if they're a normal kid". yeah she was always required to get down to a t-shirt and undies, when she laid back to check her abd they would always do a quick peek and that was it--as a side note I had a friend and thats how they caught on that he daughter had an infection from wiping incorrectly--turns out che never complained but when they did the check, the NP saw the discharge and had her swabbed I don't understand why a pediatrician who isn't my SP and who I've never even met was allowed to give input to the contrary, on the document. The doc does seem like a jerk...and if youre catching hell from both ends then it only makes sense to move on....if the pharmacist was the only problem then I would just deal with it As for the other complaint, do you think that perhaps he was just making notes of individual complaints and then compiled them into one document?
Just Steve Posted July 4, 2011 Man that sounds rough! You gotta have a solid wingman, especially as a new grad. As much of a Cowboy we want to be, if things go sideways, you need good support, supervision, and direction. It sounds like you are getting none of this at your current job. Instead you are left with the notion of "will this be the day I get fired" feeling every time you walk in the front door. That sucks. OccMed sounds like it's tough work but it also sounds like you'll have a solid SP to help you navigate the mine field. Trust your gut on both accounts....the old job and the new. Loan repayment be dammed. It's a huge bill, but it's not an impossible note to cover with a good wage. Good luck
Hemegroup Posted July 4, 2011 Author Thanks Steve ... but yea, paying 200K off for 20 years doesn't allow for much of a life at my age (40). Plus, I'm already signed, sealed and delivered with the NHSC ... the 60K will be dropping into my bank account any day now. The good news is, is that the NHSC, in a worst-case scenario situation, will drop you wherever there's a spot open ... if you can't find one on your own. So I'm guaranteed work, at the least. just_me, that's really interesting. I have no problem adopting that as procedure, IF my actual Peds SP deems it that I should! We never have employee meetings, so gee, maybe someone could bring it up to on the phone, rather than compiling it an official document? And yes, the pharmacist has obviously been brooding and stewing in wait, preparing for the pounce. To that I say, 'get a life, buddy'.
emfdj Posted July 4, 2011 I suggest you verify with NHSC that the new site will be eligible under the terms of your contract. Occupational medicine is probably not considered Primary Care and therefore, if you still have time on your NHSC contract, you would be in default if you went in that direction. My first site out of PA school was very similar to what you are experiencing, except the bully was the COO. It was a very difficult time for me and I empathize with what you are going through. I think that some NHSC sites use the NHSC to recruit health care providers from other areas because they have such a bad reputation they can't get any local people to work for them. I suggest you contact the NHSC and let them know what is going on. They may have had previous problems with your site (like mine did). They may help you work things out or, at the very least, let you know what your options are.
d2305 Posted July 4, 2011 I have been doing a few work comp for 10 years. It's easy, but you won't learn anything. I have never seen a work comp get better until the case is closed.
Hemegroup Posted July 4, 2011 Author I suggest you contact the NHSC and let them know what is going on. They may have had previous problems with your site (like mine did). They may help you work things out or, at the very least, let you know what your options are. I thought this myself a few moments ago. Thanks for your input.
Joelseff Posted July 6, 2011 I have been doing a few work comp for 10 years. It's easy, but you won't learn anything. I have never seen a work comp get better until the case is closed. I have been recommending my patients speak with their atty's regarding closing/settling out their cases and just using their regular medical to manage their conditions since WC takes weeks and in some cases literally MONTHS to approve/deny or even acknowledge they received my PR-2's (Prog notes/requests).
brookspa Posted July 6, 2011 three words...board of pharmacy and three other words...get another job.
LESH Posted July 7, 2011 Really sorry to hear about your situation. Considering its a small medical community, you might want to leave on as good as terms as possible. You never know who knows who (sorry if this is grammatically incorrect lol). If there is a PA program around you might see if they have NHSC ambassadors that might be able to help you relocate to an approved site or have a current job listing that you can see. LesH
Hemegroup Posted July 8, 2011 Author Things are actually working out better than I thought ... seems the clinic is already aware of the 'tone' that comes from the pharmacy. I've been assured that I'm good and my position is solid, so I'm staying put for now. Anyhow, I get to meet with the head above my SP and will have my chance to tell my side of the story. It helps that they complained when I prescribed penicillin for strep throat the other day ... I mean, really?? Really. They also complained about my dosage for dental abscess, which came straight from Epocrates ... so another point against them. They also released the wrong medication to one of my patients, who developed some severe side effects. So maybe they need to remember to pay attention to their own work, rather than mine.
Contrarian Posted July 8, 2011 Dude... You are missing the point and therefore addressing this in a inefficient manner. This has NOTHING to do with your practice of medicine, patient safety, substandard patient care or innapropriate prescribing. It is simply a "pissing contest" and the pharm simply wanting to "put you in your place." Don't play the game. How...Easy... Don't let them "Practice Medicine." Limit their practice to the "dispensing of pharmaceutical preparations, drugs and compounds as ordered by those trained to actually diagnose and treat." Write your orders/prescriptions but DO NOT include ICD-9s/Dxs. (its REALLY not their business) Their business is simply to safely dispense... NOT DIAGNOSE or PRESCRIBE... So they have NO idea why you write a script... it could be based upon long standing standards of care, a brand new novel experimental protocol, off-label treatment, a pre-op preparation, etc. They aren't trained to "practice medicine"... so stop them EVERYTIME they try. So, everytime they "inappropriately" try to direct your prescribing... personally, I'd politely remind them that there IS a reason why they don't have diagnostic AND/or prescriptive authority and if they want this... then there are ways to get it, but require more training. I remember a similar situation a few yrs ago. Since then, when I write my notes, I include a Dx and a Rx/Tx for each distinct Dx in the note that stays in the chart. I do NOT send this note/info to the pharmacy. They simply get a written order for what I want the patient to have. As far as I'm concerned, they don't need to know that my patient has thin, odiferous, copious clear vag discharge. It ain't they busines...!!! All they need to know is that they have a legal and valid order to dispense this patient 2gms of Metronidazole x 1, and 1gm of Azithromycin x 1. I'm NOT going to get into a discussion with a pharm about why I didn't order a 7-14day Flagyl and/or Azithro course/regimen for this patient. As far as I care... this pharm doesn't really need to know about the complience concerns, mental illness, homelessness, substance abuse/dependence or other issues that steered my decision to prescribe this single dose treatment versus the 14 day one. As far as I'm concerned... If they need to know why... they need a ROI from the patient. Its just the way I've delt with a similar situation with a very young new grad pharmD who made a habit of being rude and abrasive to the nurses that would call in or fax orders AND tried to insist that we call her DOCTOR...!! This was a funny one because she got snippity, dissmissive and rude with me... so I hung up the phone... and drove to the pharmacy, stood quietly in line behind 8 customers and when it was my turn, introduced myself and explained that I came to look her in the eye during this discussion to "facillitate an understanding." She $hit a brick... backed away from the counter and was UBER/ULTRA polite... then called my Supervisor and claimed that I threatened her... :heheh: YMMV Contrarian
brookspa Posted July 8, 2011 ancillary services....are just that. Contrarian is dead on. Know who you are, then know who they are...when they tote the liability they can make the call, till then, I got it.
Moderator ventana Posted July 8, 2011 Moderator Interesting to read the different thoughts.... I would be hesitant to adopt "I can dx and treat and you can only dispense" attitude with anyone except the troubled pharm doc - is just a little to adversarial and remember the patient is depending on everyone doing the best we can - ? why that has anything to do with this....... we should (and I try to) function as a team and this is not helped by being a pompus as* to the other people also caring for the patients - I have had many very educational discussions with pharm folks over the years and they have helped many many times - I consider them a great resource for info. Also, the statement that they can not Dx is simply not globally true. In many states they are allowing Pharmacists to Dx and treat simple medical issues and in the VA they can actually carry their own panel of patients. Sounds like this particular pharmacist is a bit of a jerk - but I would not get in the habit of putting down pharmacist (or anyone else for that matter) unless they have already stepped on you badly. In this case stand up and defend your position and training (but I still would not put them down) and show that you are a provider and serious about your job. As for driving down to the pharmacy and confronting the person - sounds like a great idea - but is way confrontational and likely a very dangerous thing to do if the pharmacist has any control/power in the same organization - would be way to easy to get yourself in hot water in a face to face discussion. I would approach it this way: Make sure all scripts are perfect (if you are not sure rather marcobid is BID or QID figure it out before writing the script) Do not put any Dx on the script (I have never dont that except for DME) Document Document Document the adversarial actions that this guy is making with out actually giving him any hint that you are doing so bring in the Administration on the concerns of the pharmacist not working as a team and in fact encouraging bad moral (higher ups usually will respond to someone that is saying someone else is threatening and making a bad work enviroment as long as it is not the boss) if it comes to it hold your ground and simply state "I saw and evaluated the patient and this is the course of treatment I prescribed. If there is not anything wrong with the script or dangerous to the patient please filll it. I am now ending this conversation and will be hanging up the phone. Thank you for your concern" and merely hang up. Do it with a calm quite voice so they have to listen to you. If you have a supervisor you can team with do it good luck and don't be afraid to provide examples to supervision of how this guy overstepping bounds - also be receptive to learning from him (seems contradictory but it REALLLY makes him look like an as# if you are trying to learn from him and he is just abusing him...... not team work....)
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