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Colleague Making Dangerous Decisions


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Hello all. I need some help navigating a situation at work. I am a new grad working primary care with one other PA (my boss) who has been in practice for 7 years. We share a collaborating physician, but we live in a state where the MD/DO merely needs to be in phone call distance for questions. I've been here for 9 months and I haven't once seen him at the office, and only spoken to him twice. My colleague defines "subclinical hypothyroidism" as having normal thyroid levels in the presence of fatigue and/or weight gain. I've never seen so many people in their 20s and 30s (and even children at times) on levothyroxine. When I investigate the EMR, they always have normal T4 and TSH levels, but at the time were complaining of fatigue. I have caught several patients who were catapulted into iatrogenic hyperthyroidism, with TSH <0.01 and T4 in the high teens, associated with excessive sweating, tachycardia, insomnia, diarrhea. Interestingly enough, he apparently also saw this happening and instead of taking them off levo, he orders thyroid ultrasounds and sends them to nuclear medicine for an uptake scan. WHAT?! I feel this is SO inappropriate, and harming patients both physically and financially. I have mentioned this several times, but he says I need to "treat patients clinically" and "not focus solely on the numbers". I find this hard to do when the disease state of subclinical hypothyroidism is a disease state defined by an abnormal TSH and a normal T4. I have already reported this to my supervising physician but he still hasn't replied in over 2 weeks. There are also several other instances I am worried about. For example, in my first 2 months here, I took at least 10 women off unopposed estrogen with uteruses, who have been on estrogen for over 3 years. One of which I had to send to OB for enlarged uterus. What am I supposed to do now?

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Tough situation. You’ve gone through the proper channels. Is there anyone higher than your boss, or is it a small private group? If not, and you truly feel patients are in danger, then you need to list specific grievances, specific dates, and send to whatever board regulates the license in your state. You need to be sure though because it will make both your lives difficult. I recommend having an exit strategy at your job because it’s going to become contentious. Won’t be hard to figure who was pointing fingers after you brought it up.

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Yea...tough spot. Practice good medicine. Document well and thoroughly. If you see his patients treat them correctly and tell the patients why you are making the changes without bashing anyone. Always do what you know is right.

Also keep a record of any conversations you have with the powers that be. When the poop slinging starts you need to be prepared.

As stated above have a good exit strategy.

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have you spoken to the pa directly?

 

very challenging and might blow up but it is professional courtesy to bring this up

it would be exceptionally helpful if the SP was involved and honestly you might 'force' a meeting with both at the same time to bring up your concerns - but calling out someone in front of the SP is dangerous....

 

in any event PROTECT your own license and the lives and well being of the patients

 

in a prior job I was faced with this and the only solution I could come up with was refusing to see, touch or be involved with this providers patients.  Period, never saw them..... 

 

good luck - just be 110% professional in every interaction and take notes.....

 

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2 hours ago, mkngj said:

Guys, he prescribes fluconazole 100mg once daily x 7-10 days for run-of-the-mill vaginal candidiasis, after I repeatedly told him it only takes one 150mg, maybe another in 3 days. It's just in one ear and out of the other. 

Where has he been getting CME?  This is obviously less dangerous than iatrogenic hyperthyroidism, but still pointlessly bad medicine.

The SP is an employee.  Do not expect him to rock the boat, because he is replaceable and supervising a PA is essentially free money for an MD/DO, in exchange for a bit of risk. It's entirely possible that this SP has various board complaints/actions and/or malpractice suits that make him or her otherwise unemployable. 😞

Bad, bad situation.  As above: Document, with full dates/times/indications.  A previous boss (before healthcare, and back when CNN actually did investigative journalism) referred to these records as his "CNN file" that would show anything he had recommended against, should it come to light, had indeed been recommended against by him and he had proof his management chain had gotten detailed documentation about why he thought it was a bad idea.

Given that the proprietor is the bad actor, expect your job to be toast and plan accordingly: do right by the patients, and secondarily protect yourself as much as possible.

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7 hours ago, mkngj said:

Hello all. I need some help navigating a situation at work. I am a new grad working primary care with one other PA (my boss) who has been in practice for 7 years. We share a collaborating physician, but we live in a state where the MD/DO merely needs to be in phone call distance for questions. I've been here for 9 months and I haven't once seen him at the office, and only spoken to him twice. My colleague defines "subclinical hypothyroidism" as having normal thyroid levels in the presence of fatigue and/or weight gain. I've never seen so many people in their 20s and 30s (and even children at times) on levothyroxine. When I investigate the EMR, they always have normal T4 and TSH levels, but at the time were complaining of fatigue. I have caught several patients who were catapulted into iatrogenic hyperthyroidism, with TSH <0.01 and T4 in the high teens, associated with excessive sweating, tachycardia, insomnia, diarrhea. Interestingly enough, he apparently also saw this happening and instead of taking them off levo, he orders thyroid ultrasounds and sends them to nuclear medicine for an uptake scan. WHAT?! I feel this is SO inappropriate, and harming patients both physically and financially. I have mentioned this several times, but he says I need to "treat patients clinically" and "not focus solely on the numbers". I find this hard to do when the disease state of subclinical hypothyroidism is a disease state defined by an abnormal TSH and a normal T4. I have already reported this to my supervising physician but he still hasn't replied in over 2 weeks. There are also several other instances I am worried about. For example, in my first 2 months here, I took at least 10 women off unopposed estrogen with uteruses, who have been on estrogen for over 3 years. One of which I had to send to OB for enlarged uterus. What am I supposed to do now?

The overt hyperthyroidism and doing testing is not good medicine. 

Maybe he/she is trying to do a more functional approach keeping the TSH between 1-2 and getting Free t4/t3 on the upper limit of normal (more optimal?), does he/she test TPO/TGA? There are difference in WNL and optimal ranges. This can be argued by traditional vs functional medicine providers. Overall sounds like he/she has ZERO idea what they are doing but you can only worry about what you are doing and focus on your patients. I think you have done your duty and you need to focus on learning/taking care of YOUR patients and keep looking forward. You might want to look for a new job in the next 6 months - 1 year. Keep us updated!

https://academic.oup.com/jcem/article/98/9/3584/2833082

Edited by camoman1234
added interesting article
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