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?Ethics Question?


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I am intentionally going to keep this vague...for reasons...but, curious what others would do here.

Situation: A patient suffers a terrible outcome that is life altering to the patient and family members.  So far it does not appear to be the fault of the treating provider - more likely to just be an unfortunate result that just sometimes happens.  In the immediate aftermath the treating provider states a diagnosis that is not supported by the available information (including misreporting lab results* to the patient to support this diagnosis), lies about further results that again would conflict with the diagnosis, and continues to lie about results that have come back that completely rule out this initial diagnosis.  Again, this diagnosis was never supported by available data, but if it were true would 100% clear the provider of any fault in the situation.

This person is a "coworker" of mine who, in which I mean the provider works in a different specialty but we both have the same employer.  Initially I wanted to believe this individual just saw some of the results wrong due to the stress of the poor outcome, but further results days, weeks, and now months later have come back that not only don't support the initial diagnosis, but actually rule it out.  This provider is continuing to ignore these results and not discuss with the patient and family.

I want to be clear that I don't believe there is actual malpractice here in regards to the initial outcome...but I'm sure the patient could sue and win something just because of the result.  This is ONLY about how the provider is now handling the results in comparison to the 100% wrong diagnosis.

 

* (This is an example, not anything related to the actual situation) - like telling a patient they were anemic when their CBC was completely normal.

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So, do you have a patient/provider relationship with this patient?  If not, you might have a cause to approach the other provider and confront him/her, but I'm going to proceed on the assumption that this is your patient, because it fits the info you gave, and it gives me reason to comment further.

1) You owe your patient the truth as you see it.  Lying by omission may violate beneficence, non-maleficence, or probably both: there is no way stating a diagnosis contrary to evidence is in the patient's own best interest.  Now, you don't need to throw the other provider under the bus right away, but you can say. "He said you have anemia? [to continue with the fake example] That's odd, because the CBCs on dates X, Y, and Z are all normal.  I'm not sure what he was thinking, but I can't see how that can be correct."  Best outcome is if the lying provider corrects the lie.

2) If they can't trust this other provider to explain the truth, you owe a referral to someone unrelated to the probably dishonest provider to clarify the truth for them.

3) You may have an internal duty to report dishonesty.  You may have a duty to report dishonesty to the medical board. You may have a duty to report insurance fraud. But in my mind, those are all secondary to your obligation to find the truth for your patient, and I would consider getting all the facts together and talking with YOUR boss about what your obligations are.

Of course, if they say, "don't report it" and you think you need to, you need to do so regardless of consequences, so if and when it does come to light, you may need a new job and a whistleblower attorney, and/or be functionally blackballed.

 

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10 hours ago, rev ronin said:

So, do you have a patient/provider relationship with this patient?  If not, you might have a cause to approach the other provider and confront him/her, but I'm going to proceed on the assumption that this is your patient, because it fits the info you gave, and it gives me reason to comment further.

1) You owe your patient the truth as you see it.  Lying by omission may violate beneficence, non-maleficence, or probably both: there is no way stating a diagnosis contrary to evidence is in the patient's own best interest.  Now, you don't need to throw the other provider under the bus right away, but you can say. "He said you have anemia? [to continue with the fake example] That's odd, because the CBCs on dates X, Y, and Z are all normal.  I'm not sure what he was thinking, but I can't see how that can be correct."  Best outcome is if the lying provider corrects the lie.

2) If they can't trust this other provider to explain the truth, you owe a referral to someone unrelated to the probably dishonest provider to clarify the truth for them.

3) You may have an internal duty to report dishonesty.  You may have a duty to report dishonesty to the medical board. You may have a duty to report insurance fraud. But in my mind, those are all secondary to your obligation to find the truth for your patient, and I would consider getting all the facts together and talking with YOUR boss about what your obligations are.

Of course, if they say, "don't report it" and you think you need to, you need to do so regardless of consequences, so if and when it does come to light, you may need a new job and a whistleblower attorney, and/or be functionally blackballed.

 

agree with  1&2

 

3 - I would want more specifics before reporting anything to the board - this is fraught with issues - once had a nurse report to the board on a TOTAL BS issue - board saw it is such, kept it "off the books" and it still was a horrible number of months for me (I was totally 100% right)

 

I would stop referring to that provider for ever - total lack of trust

 

 

I would clearly tell the patient the medical facts  but not draw any conclusions from them.....

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Thank you both for your inputs.  But, let's throw a major wrench into the gears here because it's more pertinent than I initially assumed...the patient in question is my wife, and it is regarding the stillbirth of our full-term daughter in late April.  Basically the OB/GYN has diagnosed the cause of fetal death as a fetomateral hemorrhage.  He stated the Kleihauer–Betke was positive for fetal blood in my wife...except it wasn't.  Furthermore the pathology report on the placenta/umbilical cord rules out fetomaternal hemorrhage, and while not conclusive seems to support that it was likely a "silent" placental abruption.

Again, there doesn't appear to be any malpractice, except that the provider scoffed at the idea of kick-counts as "useless" (yes, the actual word he used, thankfully my wife listened to me and did them anyway...I think she would feel even more responsible than she already wrongly does if she wasn't doing them), but I don't have a way to prove that beyond "he said, she said."  Also, I'm really not trying to get into a malpractice lawsuit.  It would have to be pretty egregious stuff to get me to do that.

So, I am in NO way a treating provider for this patient, but obviously have obtained copies of all results, clinic notes, etc.  As for referring to another provider, we had a "preconception visit" with maternal fetal medicine recently which confirmed that there is zero supporting evidence of a fetomaternal hemorrhage.

In conclusion...Rev, #3 is really my question, and ventana basically stated the other side of the issue.  I'm not trying to ruin anyone's life/career here.  Let's be honest, malpractice or not, you put my wife in front of a jury with a dead baby as the result we would win something (even though we shouldn't)...but I have trouble just ignoring this blatant disregard for the truth.  Unfortunately we have zero concrete answers regarding what caused this, but that doesn't excuse the OB/GYN making a false statement/conclusion and then continuing to stand by that false statement.  Especially when his false diagnosis has ramifications on future decision-making, such as whether to try for more children.

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Wow... that's even closer to home.  I'm so sorry you went through that!

Before doing anything else, I would have all the evidence reviewed by someone else more knowledgeable than me: is there any reasonable way this is a series of mistakes--anchoring, tunnel vision, and whatnot--rather than intentional falsehood?  If there is, I'd formally inform the OB/GYN of their incorrect statements, through a letter if possible because I wouldn't trust myself to do it dispassionately enough when it's my own dead baby in focus.

But if no one else can see it as an error, only possibility being an intentional falsehood... I think something needs to happen.  It sounds like you have ample evidence of material medical misstatements to file a board complaint, which would likely result (in my state) in mandated CME, ethics training, and a modest fine: no one's life is going to be ruined if the complaint is made and sustained, but it would be a big black eye.

You know what you're seeing.  Does this OB/GYN even realize you're a PA?  Think of all the people this OB/GYN has lied to... I'm sure it's possible that you're the only ones ever, but let's be realistic: liars lie.  It's likely a pattern that has been going on for some time, and quite possibly in ways that have worse overall effects on the affected families than yours.

Maybe no one has been seriously hurt yet and a board complaint is just the thing to provide an ethics wake-up call. Maybe someone has, and a board investigation will uncover a pattern of worse issues, that have truly harmed families.

So, I guess what I'm advocating is a mix of Just Culture, and an understood or implied ethical obligation to the other patients who may have been affected by this provider, either making inexcusable mistakes or telling falsehoods.

If you haven't seen this before, I'd recommend it.  p. 30 is the one-page flowchart.

https://slideplayer.com/slide/10484932/

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9 hours ago, rev ronin said:

I would have all the evidence reviewed by someone else more knowledgeable than me: is there any reasonable way this is a series of mistakes--anchoring, tunnel vision, and whatnot--rather than intentional falsehood?

We had our MFM appointment...and while the MFM doc didn't truly throw the OB/GYN under the bus, he made it clear that since the initial lab results became available and from the OB/GYN's own delivery charting there is nothing to support fetomaternal hemorrhage.  As for whether this could be mistakes rather than falsehood, other than simply point-blank asking I don't think there is any way to truly know this (but, as you said...liars lie...so that may not even be helpful).

 

9 hours ago, rev ronin said:

Does this OB/GYN even realize you're a PA?

I would certainly hope so...we worked in the same office for over a year when I was still FM and see each other every few weeks in the surgery halls now that I'm in ortho...

 

But, thank you very much.  I will give it a few days and then reread your statements to give it some time to regurgitate.

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Totally changes it 

 

so sorry for you and your wife. 
issue #1 is what you and wife need to heal.  That is paramount. 
sevond you are a patient.....period.  Can’t be a provider and patient.   
third.  I think in this case Rev’s comment of liars lie is the biggest issue.  This would strongly direct me towards getting things reviewed by independent expert.  I read about two years ago of our awful still birth/infant mortality and it was linked to OB not following the standard of care    I have slightly better then a layperson level of medical knowledge on OB but I would be wanting to hear from experts that there was not malpractice issues.  
 

honestly forget being a PA.  Be a husband and father.  Take care if your family and yourself-if that means doing nothing or doing everything both are okay.  Just take care.  
 

again sorry that you experienced this.  

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