Collaborating Physician/Homeopath

[mgriffiths]

I am asking for advice both in how to handle the situation, and how to plan moving forward in regards to the situation I will describe below.  I am specifically NOT asking to get into a discussion about the validity or stupidity of homeopathic treatments.

I have worked in family medicine for approaching 3 years, and in January 2019 I changed jobs.  My last job was wonderful except for a change in leadership that created an incredibly toxic and illegal situation regarding changing of billing codes to withhold bonuses, committing insurance fraud, etc.  The job was an amazing learning opportunity and provided me with an incredible foundation that I have been able to build upon - but of course fully understand that after 3 years of experience I obviously do NOT know everything...

Jumping to my current job, so far I have been pretty impressed with the organization.  Overall, I am supported, my concerns are heard...even as a new employee, I am not treated like trash, I am congratulated when I do a good job...etc.  I like my coworkers, I have a good MA who is learning quickly and works hard, I could go on.  A lot of these things shouldn't stand out, and simply should ALWAYS be expected of an employer, but there are enough posts here and I have enough life experience to know that having an employer who isn't a jerk is nothing to take for granted.

My problem: my collaborating physician (MD for 30+ years) is a wonderful man, we get along well personally and professionally, in a short time we have developed the beginning of a relationship outside of work - which is great.  Unfortunately as I have been working with him I continue to come across more and more homeopathic treatments that he is using:

• taking patients off statins for NO reason and introducing niacin to raise HDL - straight from UpToDate "While nicotinic acid raises high density lipoprotein-cholesterol (HDL-C) significantly, there is no evidence that this use leads to improved patient outcomes [38-40]. In addition, the use of nicotinic acid is often limited by poor tolerability, and there are concerns about the safety of nicotinic acid as well as its efficacy for clinical end points."  I do not support the use of niacin instead of statins...it's just bad medicine.
• Alkaline water - he recommends to patients regularly...it has been shown over and over to be junk science, and a rudimentary understanding of human physiology supports this.
• Furthermore, there are numerous issues with poor care - missed A1cs being drawn on uncontrolled diabetics, no changes to initial metformin dose for multiple years despite rising A1c, missed statin treatment on MANY patients, history of multiple DVT/PEs and no anticoagulation, choosing armor thyroid over levothyroxine, titrating levothyroxine backward from a TSH result, etc.
• There are many more examples I could provide, but will move on.

In my opinion, this is not allopathic medicine, but instead homeopathy and then on top of that just bad medicine.  To me, WHATEVER...he can do what he wants, but the problem is that I often see my collaborating physician's patients when he is on vacation, or when his schedule is full - and because I'm still relatively new I have openings.  Thankfully this is slowly but surely changing as patients transfer or establish as new with me.  But, I have seen multiple patients having side effects from one or more supplements, so I obviously recommended stopping the supplement, or their treatment is inappropriate and I start/stop meds as appropriate.  Then when my collaborating physician reviews the chart he discusses with me that this was an inappropriate decision for me to make because I'm "overruling" him, and often calls the patient to recommend restarting said supplement or stopping meds I started that are medically indicated in the most basic way.  He doesn't completely throw me under the bus stating I'm wrong, but it's a logical jump that I'm sure enough patients are capable of making.

Essentially, I'm uncomfortable being a part of treatment for a patient that is considered potentially harmful, and against medical recommendations at best.  Therefore, how do I move forward treating patients who are on potentially harmful supplements, when they ask me for my opinion on unproven (at best) supplements/water products, treating patients with basic medicine knowing he is going to "overrule me," etc.?  Do I simply just say I won't see his patients anymore?  Politically that would look bad and would kind of be against one of the main reasons I was hired.  There is a NP who has been here approximately 2 years who is pretty decent and is more hesitant about a lot of the homeopathy, but the three of us function as a team overlapping a lot with patients - even though technically we do have our own patient panels.  She also has noticed some of the missed treatments and what I "hope" is lazy medicine, and not just ineptitude or loss of cognitive ability (I haven't been here long enough to know).

Just curious how others have handled this in the past, and what others would recommend or do themselves?  Also, how would you handle knowing a physician is making bad treatment choices that are effecting patients?

Example: 01/2019 hypothyroid patient already on levothyroxine has elevated TSH and levothyroxine dose is decreased.  Approximately 1 month later he began to notice some difficulty swallowing and fatigue.  He saw me recently for progressive difficulty swallowing and fatigue.  Saw the error from January, on PE he has a goiter, redrew a TSH and was sky high and I am now in the process of titrating his levothyroxine and further workup being done.  Had a conversation today with my collaborating physician where he tells me my titration of levothyroxine is backwards because he is "hyperthyroid with an elevated TSH" (and yes, that is a quote with EXACT words).

Edited July 16, 2019 by mgriffiths

[SHU-CH]

Run. If it's bad medicine, it's bad to be around.

 

 

Edited July 16, 2019 by SHU-CH

[CAdamsPAC]

3 hours ago, mgriffiths said:

I am asking for advice both in how to handle the situation, and how to plan moving forward in regards to the situation I will describe below.  I am specifically NOT asking to get into a discussion about the validity or stupidity of homeopathic treatments.

I have worked in family medicine for approaching 3 years, and in January 2019 I changed jobs.  My last job was wonderful except for a change in leadership that created an incredibly toxic and illegal situation regarding changing of billing codes to withhold bonuses, committing insurance fraud, etc.  The job was an amazing learning opportunity and provided me with an incredible foundation that I have been able to build upon - but of course fully understand that after 3 years of experience I obviously do NOT know everything...

Jumping to my current job, so far I have been pretty impressed with the organization.  Overall, I am supported, my concerns are heard...even as a new employee, I am not treated like trash, I am congratulated when I do a good job...etc.  I like my coworkers, I have a good MA who is learning quickly and works hard, I could go on.  A lot of these things shouldn't stand out, and simply should ALWAYS be expected of an employer, but there are enough posts here and I have enough life experience to know that having an employer who isn't a jerk is nothing to take for granted.

My problem: my collaborating physician (MD for 30+ years) is a wonderful man, we get along well personally and professionally, in a short time we have developed the beginning of a relationship outside of work - which is great.  Unfortunately as I have been working with him I continue to come across more and more homeopathic treatments that he is using:

• taking patients off statins for NO reason and introducing niacin to raise HDL - straight from UpToDate "While nicotinic acid raises high density lipoprotein-cholesterol (HDL-C) significantly, there is no evidence that this use leads to improved patient outcomes [38-40]. In addition, the use of nicotinic acid is often limited by poor tolerability, and there are concerns about the safety of nicotinic acid as well as its efficacy for clinical end points."  I do not support the use of niacin instead of statins...it's just bad medicine.
• Alkaline water - he recommends to patients regularly...it has been shown over and over to be junk science, and a rudimentary understanding of human physiology supports this.
• Furthermore, there are numerous issues with poor care - missed A1cs being drawn on uncontrolled diabetics, no changes to initial metformin dose for multiple years despite rising A1c, missed statin treatment on MANY patients, history of multiple DVT/PEs and no anticoagulation, choosing armor thyroid over levothyroxine, titrating levothyroxine backward from a TSH result, etc.
• There are many more examples I could provide, but will move on.

In my opinion, this is not allopathic medicine, but instead homeopathy and then on top of that just bad medicine.  To me, WHATEVER...he can do what he wants, but the problem is that I often see my collaborating physician's patients when he is on vacation, or when his schedule is full - and because I'm still relatively new I have openings.  Thankfully this is slowly but surely changing as patients transfer or establish as new with me.  But, I have seen multiple patients having side effects from one or more supplements, so I obviously recommended stopping the supplement, or their treatment is inappropriate and I start/stop meds as appropriate.  Then when my collaborating physician reviews the chart he discusses with me that this was an inappropriate decision for me to make because I'm "overruling" him, and often calls the patient to recommend restarting said supplement or stopping meds I started that are medically indicated in the most basic way.  He doesn't completely throw me under the bus stating I'm wrong, but it's a logical jump that I'm sure enough patients are capable of making.

Essentially, I'm uncomfortable being a part of treatment for a patient that is considered potentially harmful, and against medical recommendations at best.  Therefore, how do I move forward treating patients who are on potentially harmful supplements, when they ask me for my opinion on unproven (at best) supplements/water products, treating patients with basic medicine knowing he is going to "overrule me," etc.?  Do I simply just say I won't see his patients anymore?  Politically that would look bad and would kind of be against one of the main reasons I was hired.  There is a NP who has been here approximately 2 years who is pretty decent and is more hesitant about a lot of the homeopathy, but the three of us function as a team overlapping a lot with patients - even though technically we do have our own patient panels.  She also has noticed some of the missed treatments and what I "hope" is lazy medicine, and not just ineptitude or loss of cognitive ability (I haven't been here long enough to know).

Just curious how others have handled this in the past, and what others would recommend or do themselves?  Also, how would you handle knowing a physician is making bad treatment choices that are effecting patients?

Example: 01/2019 hypothyroid patient already on levothyroxine has elevated TSH and levothyroxine dose is decreased.  Approximately 1 month later he began to notice some difficulty swallowing and fatigue.  He saw me recently for progressive difficulty swallowing and fatigue.  Saw the error from January, on PE he has a goiter, redrew a TSH and was sky high and I am now in the process of titrating his levothyroxine and further workup being done.  Had a conversation today with my collaborating physician where he tells me my titration of levothyroxine is backwards because he is "hyperthyroid with an elevated TSH" (and yes, that is a quote with EXACT words).

If you truly believe that you are being pressured into doing bad medicine, you must decide on a course of action that protects you and your patients. I doubt the physician will change so you will  have to chart a pathway that is best for you.

 

[LKPAC]

17 hours ago, mgriffiths said:

 

My problem: my collaborating physician (MD for 30+ years) is a wonderful man, we get along well personally and professionally, in a short time we have developed the beginning of a relationship outside of work - which is great. 

Have you discussed your concerns with him directly as colleagues?  That's always a first step in my book.

[mgriffiths]

16 hours ago, SHU-CH said:

Run. If it's bad medicine, it's bad to be around.

I wish this was a real option...but not feasible having started this job 6 months ago, buying a home, etc., etc.  I am personally guilty of it myself, but this forum jumps too quickly to just recommending "change jobs."  Also, from what I have seen, the bad medicine seems limited to this physician, not the entire system itself.

1 hour ago, LKPAC said:

Have you discussed your concerns with him directly as colleagues?  That's always a first step in my book.

I have not specifically sat down with him and mentioned my concerns, but as mentioned, we have discussed the supplements and thyroid treatments when he has questioned my medical decision making.

 

I guess the biggest question is how do I go about protecting myself and patients without getting into a pissing match with an MD, or at least mitigating the pissing match?  Also, at what point do I get concerned about significant patient harm and report him to administration and/or medical licensing boards for review? 

[rev ronin]

How does this physician keep up on stuff?  I was tried on Niacin to raise HDL ~15 years ago, and I know my PCP (who is also one of my CPs now) has moved away from doing that because the evidence didn't pan out and the recommendation changed.  Is this guy reading the right sorts of journals? Going to reasonable conferences?

[mgriffiths]

17 minutes ago, rev ronin said:

How does this physician keep up on stuff?  I was tried on Niacin to raise HDL ~15 years ago, and I know my PCP (who is also one of my CPs now) has moved away from doing that because the evidence didn't pan out and the recommendation changed.  Is this guy reading the right sorts of journals? Going to reasonable conferences?

I don't know what true medical journals he reads, but in terms of CME he goes to a 1 week "crash course" review I believe in Kentucky that he says is "great" - maybe it is, maybe it isn't - I have no idea.  But, your surprise is what mine was.

 

1 hour ago, Lightspeed said:

This situation is why we ask questions in the job interview when they ask us if we have any questions. One of the questions we ask is “can you take a few minutes and discuss with me what your philosophy and approach to care is for the patients here, so I know what kinds of methodology is expected of me?”

I would agree with you...and while I attempted to ask a question similar, it probably wasn't direct enough.

 

1 hour ago, Lightspeed said:

Folks may indeed be quick to jump to the suggestion to move on, but with the circumstances you are up against in practice, that option seems tailor made for you. You have a physician employer that mandates that you practice something other than what the board of medicine will want to see from you. What will you tell them when it’s your turn to answer for yourself? That will complicate your future significantly more than finding a different job. 

 

A good approach with the doc goes like this: “Doc, You might have noticed that my approach to treatment doesn’t match yours, and that I’m struggling to keep up with how you want things done. I’ve looked at how I can improve to match what you are doing, and see where we take different avenues in our treatments, and it seems to me that my perspective on practice is heavily flavored by the way I was trained, and the resources I use. I’m just not familiar with some of the approaches that you are familiar with, and I’m wondering what you think would help me align with your perspective.”

 

That sets you up for the exit later on when after a few weeks of trying to keep practicing, you go to him with the realization that you love he environment, and want to keep on practicing with him, but you can’t adapt to using methodology that you aren’t familiar with. Tell him that you only ever have managed things like thyroid issues according to the textbook, and that you can only stay if you can stick to things that you feel like you can defend in front of other people who practice with those same constraints if you are called to the carpet.

Not necessarily a bad way to handle it...I'm always looking at what's available, but I do believe I would request for a transfer - or at least a new CP - within my current organization before truly looking to leave completely...partially due to only being here 6 months, but also I could not even imaging uprooting my family again, and that would be the likely result.

As for being complicit in my CP's homeopathic treatments, I have not once complied or made a recommendation to a patient that was against medical recommendations (that I know of, of course) - and I have ZERO plans to.  Patient care comes first...not my job security or similar.  Therefore, I will NOT bow to the MD and just go along with his poor medicine.  But, you are correct that I need to be vigilant and begin exploring options more fully.

[DogLovingPA]

The thyroid thing is just scary and as we all know, just plain wrong medicine.  What I have done in the past when the physician I am working with says something that I know is just flat out wrong and I know they won't react well to that being pointed out is approach it like I am asking for their help.  So I bring them the medical evidence (from Medscape, up to date, wherever) of the correct information and word it like "I'm confused" and ask for their "help" in explaining it.  I've only done this a couple times but when I have done it, I've usually been answered with "crap, you're right".  Folks I have a more collegial relationship with I just talk to them like a normal person of "Actually I think that's incorrect".   

Edited July 17, 2019 by DogLovingPA
spelling error

[rev ronin]

Have you considered talking with the organization's medical director, informally?  I'm doubting that this guy's habits are entirely unknown in a larger organization.  While he may be tolerated, I suspect you might get some organizational support that didn't amount to transferring you, especially when you demonstrate to them that you're 1) not being insubordinate, but 2) trying to practice EBM.  Just an idea...

[LKPAC]

PAs don't need to be clones of their CPs.  You do your thing, let him do his.  My CP and I don't do everything exactly alike, there's some differences in the practice of medicine.  He can respect that.  And I'm always able to back up what I do with evidence.

[Guest Paula]

He has dementia.  He's confused about the TSH like he was his first year in medical school until he figured out the feedback loop.  We remember primacy and recency.    So he remembers studying the  TSH feedback loop from his initial confusion when he was 23 and now in the most recent years he remembers the homeopathic stuff he has "studied".  

How old is he?  Has he gotten lost driving?  Does he repeat himself again and again?  FH of AD?  

Go talk to him directly as others have said and then go to administration if he blows his cork.  His reaction will give you a clue where his brain and memory are at and the stress he can and cannot handle. 

This is said somewhat tongue in cheek but I am also serious.  

[mgriffiths]

10 hours ago, Paula said:

He has dementia.  

How old is he?  Has he gotten lost driving?  Does he repeat himself again and again?  FH of AD?  

Go talk to him directly as others have said and then go to administration if he blows his cork.  His reaction will give you a clue where his brain and memory are at and the stress he can and cannot handle. 

This is said somewhat tongue in cheek but I am also serious.  

This is definitely a significant concern of mine, but as stated I've only been here 6 months so hard to have any kind of frame of reference.  But, as I've been thinking about this and reading responses it does appear imperative I begin action both for the safety of patients and myself.

 

10 hours ago, Lightspeed said:

But you can handle it very carefully and extricate yourself with more grace than if you set him off. It looks better to act with gentleness to a man that everyone there respects and has a history with than if you lock horns. 

This will be the tricky part.  The nice thing is that I have actually been asked to review his "risk stratifications" for the last 12 months as they seem to be significantly higher than local and national averages.  It is a tremendous amount of work and normally I would have stated clearly, "NO!!," but I think in this situation it is actually a blessing in disguise.  Heck, maybe even the practice manager is aware of my concerns, or she has her own, and is giving me an opportunity to data mine more of his recent patients to put together more pieces for how to proceed.

 

But, I will be treading carefully, documenting like heck, and working hard to understand what is going on.

 

Thank you to all who have taken the time to read, think about, and respond to my post.  The insights have been helpful and I will update as appropriate. 

[sas5814]

Tough spot. 

In artillery there is an expression called "area of effect" that essentially means you weren't hit by the exploding round but killed by a piece of schrapnel 200 yards away. This is your risk here. It is highly likely when something bad happens from this physician's pracctice you are going to get splashed.

With your patients do what you know is right. When you have to see his patients make whatever changes you think are appropriate and explain to the patient why they need to be made. It will get back to him I'm sure and I'd be interested in seeing what happens. In any case you always do what is best. It is hard to go wrong with that approach.

I had to change jobs once in similar circumstances. I had a house and a family and there were no other jobs nearby because I was in a rural area. It sucked like a Hoover but worked out well eventually after a lot of lost nights sleep.

Good luck. One of these days you will be telling this story as a cautionary tale to some other PA.

[GetMeOuttaThisMess]

“Hi, state medical board? I have a concern about a health care provider...”

[mgriffiths]

UPDATE

Well I have an unfortunate - or potentially fortunate depending on your perspective - update...was doing a well child/sports physical on a kid earlier today and auscultated a murmur...new murmur...ugh.  Serious talk with needing an echo before continuing with participation in athletics...never fun.  But then mother mentions that another "provider" did a sports physical on her other son a while back and never even listened to the heart!!!  I knew even before I looked in the kids chart to confirm, but yep...my collaborating physician.

Result = immediate notification to our chief of medicine...she wasn't happy, definitely took me seriously (thankfully we've had some interaction since I started where I've had the ability to build some rapport).  I won't share further, but she made a few comments that were telling enough that others have raised some concerns.  Due to her comments I shared some of what I have previously posted and have "officially" been asked to put together a report auditing charts.  Within 1 hour paperwork was signed making her my "official" collaborating physician - which was a relief. 

On 7/17/2019 at 5:06 PM, rev ronin said:

Have you considered talking with the organization's medical director, informally?  I'm doubting that this guy's habits are entirely unknown in a larger organization.  While he may be tolerated, I suspect you might get some organizational support that didn't amount to transferring you, especially when you demonstrate to them that you're 1) not being insubordinate, but 2) trying to practice EBM.  Just an idea...

Basically, sounds like this ended up the right path.  Thanks Rev...I guess...now I have this lump in my belly that I ruined this nice man's career, but time will tell the result and what needed to be done has been done.  Patients have been protected.

[rev ronin]

18 minutes ago, mgriffiths said:

Thanks Rev...I guess...now I have this lump in my belly that I ruined this nice man's career, but time will tell the result and what needed to be done has been done.  Patients have been protected.

You get that the first time you do the right thing and someone experiences a "bad result" due to their poor choices.  I know I did the first time I helped the FBI gather evidence on some of my co-workers when I was doing Information Security.  My office partner, an ex-cop responsible for the non-IT side of investigations, gave me some good advice:

You didn't choose that path for them.  They did whatever they did, and all we're doing is what is necessary to determine what the truth is.  We aren't the judge, or jury, just the people in the right position to gather the facts accurately and ethically, and let the other parts of the process do their work based on the best possible input.

It sounds like you did the right thing, and the organization might actually back you up.  Good job.

[sas5814]

1 hour ago, mgriffiths said:

Patients have been protected.

This is really all that matters. You didn't act cruelly or out of some sort of avarice. You did what was right. It's OK to have sympathy for his situation but not to feel guilty. Never feels guilty about doing the right thing.