How do you respond personally to poor medical care by others

[mgriffiths]

I have posted here before asking for input regarding ethics and how to report poor medical care.  I'm sure I'm not unique in this, but this is not what this post is about.

My question is when you witness poor medical care significantly impacting a patient, including their death, how do you personally deal with it (again...apart from reporting to pertinent admin and licensing boards)?  I am finding that over time I am becoming more and more angry about it, and it is affecting me.  Cases where I was involved in the patient's care, but due to a different provider's sub-par evaluation/treatment the patient suffered a bad outcome.  Maybe counseling is the answer...but I HATE the idea of taking more time away from family and personal money to pay for counseling due to other's bad medicine.

I understand that sometimes a "call" has to be made during an emergent situation when all the information isn't available, and sometimes that "call" ends up being wrong and the patient is harmed, and IF the call had been different the patient would not have been harmed.  That is NOT what I'm referring to - that is just an unfortunate reality of practicing medicine and outcomes are not going to be universally good even when everything is done perfectly.  I'm not even referring to individual cases of a provider making an error...a simple example would be titrating thyroid medication wrong.  It shouldn't happen...but good providers can make mistakes, especially when the vast majority of us are overworked even when there isn't a global pandemic happening.  Really, what I am referring to is someone who is known to be a poor medical provider reported to admin and licensing boards multiple times, cases discussed in M&M equivalent meetings multiple times...but nothing happens to the provider (no sanctions, no termination, no loss of license, etc.) and said provider performs universally agreed upon bad medicine each time that was completely avoidable and caused significant harm, including death, to a patient...and it just keeps happening.  Going even further...often these providers don't even have the knowledge to review the case and understand or acknowledge how bad it was.

An example I will give is at a walk-in clinic, NOT a fully functioning urgent care, a 70+yo male with diabetes (and other related comorbidities) presents with a 9cmx12cm (yes...confirmed size by the provider's own measurements in their charting) abscess on his left buttock x 4 days; actively draining, reports shakes, dizziness, and wife reports intermittent disorientation.  The charted vitals include a BP and respiration rate.  No temperature, no heart rate, no O2 saturation.  The provider did look at the abscess...but didn't touch it, didn't mark the edges, didn't attempt to I&D (shouldn't have in this type of clinic anyway)...just looked at it and measured it.  Provider prescribed augmentin and directed the patient to f/u with his PCP in 4-5 days.  Provider failed to realize patient had listed ANAPHYLACTIC allergy to penicillin (not sure how since our EMR has 4 pop-ups you have to go through to send a script with listed allergy), and because the provider prescribed "augmentin" the patient didn't recognize to catch it when told the medicine.  But, the pharmacy caught it the next day when he went to fill the script and so the patient declined to pick up the prescription.  The patient was scheduled to f/u with his PCP in 5 days so didn't worry about not going on the antibiotics for a bit.  But, he came back to the walk-in clinic 3 days after initial presentation (when I was there) because the abscess "seemed worse" and he didn't feel well.  Patient looked toxic with fever, dyspnea, etc. and immediately sent to ED by EMS (with appropriate supportive care in meantime)...ended up dying from sepsis 3-4 days later.  During our case review at the hospital the provider's defense was that the patient didn't follow her orders to take the antibiotics...again ignoring the patient's known history of anaphylactic reaction AND blamed the MA for not getting a full set of vitals when chastised for not having at minimum a temperature on a sick patient.  The provider claims she directed the patient to go the ED and he declined, but absolutely NOTHING charted stating this.  The result was a universal vote that standard of care was not met...without any disciplinary action.  This is the 6th case we've reviewed from this provider in the last 3 months...with all 6 cases resulting in significant harm to patients with 3 of them dying (including this case) and universal votes of substandard care given.  NO DISCIPLINARY ACTION...and so far nothing from this provider's licensing board even though I have personally reported all 6 of these cases and other cases that weren't quite as severe but still evident of poor medical understanding (like prescribing approximately 20mg/kg of amoxicillin for a child's otitis media because, "I didn't think the infection was that severe so thought a lower dose was appropriate." - this is the exact quoted response from her to me IN WRITING when I asked about the dosing after the child followed up with me for unresolved ear infection.  This was forwarded to the hospital AND the appropriate licensing board for review.  Nothing.).

How do you personally handle that knowledge and keep it from affecting you?  It makes me angry and I notice that as I am involved in more and more of these cases my anger over the cases doesn't go away.  I don't mean that I'm angry at all times.  I mean that when the cases cross my mind randomly my feelings haven't mellowed and for some cases it's been years...and the reality is that the longer I am in medicine I'm going to be involved in more and more of these cases...it's inevitable.  I am not even on the committee that reviews all of these cases before bringing them to the M&M conference equivalent...I just become aware of these through my own time in clinic, and just as often as poor medical understanding causes a bad outcome it is also laziness.  Like the child diagnosed with 3 non-displaced metacarpal fractures by his PCP that was "immobilized" with an ace wrap and referred to ortho without any instruction to be non-weightbearing.  The PCP just didn't take the time to call our ortho office requesting for the patient to be splinted that day...which is hospital protocol.  Patient came to me 3 days later with severely displaced metacarpal fractures, one which was now open and infected.  He required surgery but due to infection ended up losing his dominant side 5th finger - and is still within the window where he could lose more.  Obviously anything can happen, but the reality is that if he had been immobilized properly he'd still have his pinky.

Of course losing patients is part of the job...and I get that.  When I worked in FM I lost my fair share of patients due to a variety of causes, but am proud to say that in my time as a PA I am not aware of any cases that I have contributed to or directly caused significant patient harm or death - unless they had a listed DNR or similar that means THEY limited the care THEY wanted to receive...which I view completely different.  I cannot say the same for my colleagues. I'm not going to claim that I am the best provider in the world.  No...and I really should do more reading, learning, etc. and honestly I've taken the easier way out for my CME over the last several years just using UpToDate CME filings...but it angers me that providers I work with are so nonchalant with patient's lives and a growing part of me is telling me to leave medicine before it consumes me.

After writing this, editing it, reading it over probably 20 times...I've already called to make a counseling appointment.  But, I would still appreciate other's input.

Edited September 23, 2021 by mgriffiths

[sas5814]

+1 on counseling. I do it from time to time just because, as my wife says, almost everyone needs a tune up every once in a while.

My problem with these thing is I tend to ruminate about them almost obsessively and, the more I work it in my head, the more frustrated I get and the snowball rolls downhill.

I have a few trusted confidants I can discuss these types of things with and sometimes, just being heard, helps me decompress a bit. Particularly valuable is the validation from my friends in the profession. It lets me know it isn't just me acting crazy.

Figuring out how to get settled with these things, for me, always circles back to some kind of counseling. Meditation helps a bit. I have a book called "Thoughts and Feelings. Taking Control of Your Mood and Your Life" that was recommended to me probably 15 years ago. It's pretty neat because it is broken down into relevant sections like "anxiety" or "depression" and it has worksheets that gives me self care tasks to do. I have used it so many times I can't even count.

I have to repeatedly teach myself there are things I can't control. Worrying about them or, in my case, getting angry about them accomplishes nothing but making me and everyone around me miserable.

Lastly my wife (again...a very smart lady) taught me that letting people who care about you help you when you need it is a gift to them. Lean on folks who want to help you. Many of us were raised to "tough it out". That doesn't work.

 

Good luck.

[mgriffiths]

9 minutes ago, sas5814 said:

My problem with these thing is I tend to ruminate about them almost obsessively and, the more I work it in my head, the more frustrated I get and the snowball rolls downhill.

 

yep...definitely a big part of the problem in how I respond

[rev ronin]

I deal with all injustice that I can't personally change in pretty much the same way, which is only open to those who happen to hold a belief system that posits an afterlife, judgment day, and appropriate justice of some sort.  There are a few; I happen to like mine the best.

Now, as far as dealing with this specific situation? One of my old bosses, in a non-medical field, talked about keeping a "Barbara Walters" file of times they'd made a call that went against management's ultimate decision, so that if there was ever a trial-by-press (this was in the 90s and 00s, when such things weren't quite as common as they are now) they would have documentation to show their true role in the situation.  I understand that some of this was done in the 737-MAX mass murder case: engineers tend to be the sorts of people who do this.

In the case of medicine, I'd be careful about how you go about doing this in a way that doesn't transgress HIPAA, but if you're dealing with a professional board that doesn't like to take action, dropping a dime on an incompetent or maleficent provider to the press might be the only thing you ethically CAN do.  When Kxxx or Wyyy or the Local Post starts calling, boards might double check a bit more closely.

Of course, the sad reality is that WHO the victims are tacitly matters. Inner city minorities? Good luck getting the press interested.

[CAdamsPAC]

I've found myself aware of situations where there was either, incompetence, neglect, or  extreme lassitude on the part of providers that I've worked with, some I considered friends others were just co-workers or worse physicians! Incompetence could be addressed by education or counseling. But those who just didn't care to do what was right were spoken to and advised that I would report my concerns up through our lines of medical supervision. In many cases the issues were addressed but my trust in their judgement was forever altered. These lapses remained in my thoughts and to tumble around in my mind for years reflecting on if or how I could have made the situation better.

[kargiver]

This is a tough one... but a few thoughts.

I am assuming based on your post, you do surgery?  Is it primarily ortho or do you cover other stuff as well (like a trauma service for example).  Are there residents?  I assume these people making mistakes are not residents? 

Are these votes being done in M+M rounds or quality rounds?  If so, those are considered protected and a state agency may choose not to pursue it.  Reporting out of them may constitute an ethical breech on your end as they are meant to be confidential for all.  Please be careful if this is the case... people tend to turn things around.

Agree with counseling.  We are practicing medicine in a brutal time, a perfect storm if you will, and an otherwise highly stressful job is even more so.  Getting it out there will be of benefit.  I'm glad to see you've reached out. 

Others have voiced other approaches, and to each there own, but that which I come back to every time is that I can only control how I react to anything - I cannot control what others do.  It helps to keep a "stoic" mindset in medicine which has been immensely beneficial over the years.  When I have witnessed serious injustice, I have had no problem going provider to provider and calling them out; but I tend to do this personally as I think most rounds format tend to be punitive whether intentional or not.

Unfortunately though, what you have voiced is far too common, and western medicine has accepted this lot without placement of real mechanisms to address these disparities appropriately.  And that's how they are viewed.  One-off instances where someone was adversely affected but on the whole, "the system works."  This is a big ole crock of sh*t of course, as what you are describing is the definition of systemic. It appears there are failures on multiple levels here (for example, how is this person still employed) and it makes me think there is a real culture issue where you are.  Cultures can change - but usually not without martyrs.

G

 

 

[ohiovolffemtp]

The hardest thing for me is accepting that whatever I do, even if it pushes the bounds a bit, can't fix many things.  In particular, I have a hard time accepting the fact that I almost always have very little to no influence on what management, committees, organizations, etc do.  If it's a consultant, I make sure I never refer to them.  In your situation, where it sounds more like a co-worker, I don't have a good answer other than to make sure that any cases from that person that you are even tangentially involved in gets completely reviewed, orders changed, etc.  That doesn't fix the root cause, but likely is all you can do.

[mgriffiths]

9 hours ago, kargiver said:

I am assuming based on your post, you do surgery?

I am an ortho PA working both clinic and surgery, but help cover our walk-in clinics. They are meant to basically be family medicine acute care, so we don't treat chronic conditions (unless an acute flare that needs attention) or do med refills or follow ups.  We may or may not have XR on site, and have extremely limited lab capabilities on site (basically normal urine and URI swabs, but nothing blood other than blood glucose).  It is NOT an academic hospital, we are a semi-rural community hospital with numerous outpatient clinics, but no residents...although there is discussion of starting a family medicine residency.  For ALL of the cases I referenced they are actually a singular NP...but others I didn't get into include two other NPs and an MD.

 

9 hours ago, kargiver said:

Are these votes being done in M+M rounds or quality rounds?

I'm honestly not even sure what to call them.  They're called "outpatient section meetings."  The beginning is discussing a variety of policies, procedures, updated medical recommendations, etc. that all basically have to do with primary care...then after this all non-provides leave the meeting and we review whatever cases that need to be discussed.  It's not a true M&M conference, but it's the only thing I could think to describe it as.  At the conclusion of discussing each case the providers all vote on whether standard of care was met.  Then the committee who reviews these cases and brings them to the meeting discusses whether disciplinary action is appropriate and that decision is made public to the providers.

9 hours ago, kargiver said:

If so, those are considered protected and a state agency may choose not to pursue it.  Reporting out of them may constitute an ethical breech on your end as they are meant to be confidential for all.  Please be careful if this is the case... people tend to turn things around.

As for me reporting these cases to licensing boards.  That is done prior to the "M&M conference."  When I reported the case to the medical admin at the hospital I also reported to the licensing board...not after.  But I fully understand and agree with your point.

[mgriffiths]

I want to thank everyone who has responded.  I've obviously been thinking more about this...kind of non-stop... and have decided I am going to have a meeting with our chief of medicine, along with the physician who oversees the walk-in clinics...and then of course the counseling I've already mentioned.  No idea where those meetings will go, but I also want to ensure that they are aware 100% aware of my concerns regarding the singular NP who is harming patients on a consistent basis.  After that I will sit back and pay attention and down the line it could be a job change is required that gets me away from the culture.  Being a smaller community hospital there definitely is a "set in your way" aspect.  Unfortunately a job change wouldn't fix the issue here, and of course there will always be other bad providers or other systemic issues...but sometimes change is necessary because you don't become aware of other's behavior.

[ventana]

good luck

 

I have never had any luck standing up for what is right....  I would polish up that CV

 

Work on your own self health as ultimately that is all we have left

 

If you really want to blow it up

 

1) continue to make specific reports to the nursing board

2) try not to share patients with this provider - ever

3) complain to management - but make no ultimatums - just say you want to make sure they are aware of what you see going on.

 

 

do what feels right to you, at the end of the day that is all we have left.

[mgriffiths]

11 minutes ago, ventana said:

3) complain to management - but make no ultimatums - just say you want to make sure they are aware of what you see going on.

 

absolutely...I'm not a martyr...and with a family it would be selfish to become one over this.  Furthermore, I would just become more collateral in this NPs conquest of bad medicine.

[mgriffiths]

Well an update regarding the specific NP I was referring to...my employer just recently mandated the vaccine as a condition of employment.  I wasn't aware, but this NP is not vaccinated and has no plans to, so unless something changes she'll be out of a job by November 1 anyway.

Doesn't fix everything or take care of all of the cases of negligence or just poor care, but at least one of the major repeat offenders will be gone.

[rev ronin]

I'm happy, sort of, for this development, but it's just kicking the problem down the road.  This NP can hang out her own shingle and kill people now, without you to catch and fix the errors,.

[LT_Oneal_PAC]

My way probably isn't the right way, but I was going to quit over stuff like this. I was too depressed, clinically, over the terrible things I was seeing. 

However, justice ultimately comes to these people...

I too have been struggling with an NP ( not that I think credentials matter because the last dolt they had was even worse and was an MD) at hospital that was awful. Reprimanded as an RN for opioid diversion. Fired from last job for unknown reasons, just rumors of unable to take direction. I sent 2 people he put into renal failure for emergent dialysis. I suspect he sees himself as a angel of mercy because not a single parkinson's patient has survived admission since he started a little over a year ago. A patient with a ileocolic anastomis leak developed an abscess with puss and fecal matter draining from abdominal incision after retroperitoneal mass was removed, on TPN and hasn't been able to eat in over a month. Patient refused transfer back to the surgeon and discussed hospice. He told them it was inappropriate that I discussed hospice with them, and some other not nice things about me. Failed to intubate a COVID patient on the floor x4 before ED provider arrived. Then next time he has to intubate and I hear about and come to the floor, tells me to butt out. These are just a few things he has done. 

I arrived at work this weekend expecting to tell my boss, who also wants this guy gone but both of our complaints have fallen on deaf ears, that I quit if he isn't gone by my next shift in 2 weeks. I couldn't be apart of an organization that would subject their community to this guy. A miracle was granted as before I had that conversation I see an email that he is on leave indefinitely. He has a disciplinary hearing this month for sleeping with a patient of his that was a minor at his last job. Sad that is what it took, but I had the best weekend shift I have had in a while with the knowledge he wasn't going to come in and destroy all the work I put into patients. 

Give them enough time and they hang themselves....Now if I can just keep them from hiring a 3rd dope in a row as hospitalist I'll be golden. 

[mgriffiths]

Wanted to provide an update regarding this situation:

So the NP that I referenced above ended up not leaving.  While our hospital instituted a COVID vaccine mandate the enforcement had no teeth...basically any "medical" or religious exemption that was submitted was approved and admin has zero plans to review the exemptions unless required to by a federal mandate.  Therefore, the NP is still a coworker of mine...ugh.

So, last week I had deja vu...a 45yo male with h/o DMII and other comorbidities presented to me at the walk-in clinic with fever, tachycardia, and tachypnea. He was seen by the aforementioned NP two days earlier for an abscess on his buttock.  No charting regarding size or measurements, no marking of margins, no charting regarding the way it looked or felt.  Furthermore, at the visit 2 days prior he had fever with tachycardia, no listed RR or O2 saturation.  Her treatment was "warm compresses and return if it gets worse."  She didn't even prescribe antibiotics.

When the patient returned he told me that the abscess hadn't changed, but he came back because he was now having redness extending down his leg.  He had cellulitis extending below his knee and the abscess encompassed his entire left buttock.  Obviously with his vitals I was massively concerned for sepsis.  Supportive care given, EMS called, and he ended up helevaced to a different state because SW Michigan is a  show right now.  Fortunately/Unfortunately I don't know anything about his further care after being helevaced.

I'm done...I am now 100% actively looking to leave patient care.  Between cases like this and how they affect me (and therefore how they affect my family), the fact that hospital admin won't leave me alone to do my job in ortho because I'm one of the few who has the skills to cover the walk-in clinics...but then won't compensate me for the work, and many other factors...I'm done.  Maybe things will get better before I actually make the leap...but this is one burned out provider who just wishes he could put his head down and be left alone to do the orthopedic job he enjoys.

 

Edit: also, still waiting to get into counseling...employer provides free visits with our psych group, but they're booked out for new patients for 6+ months and the other local groups either only accept medicaid or are out of network.  Mental health is fun!

Edited December 23, 2021 by mgriffiths

[sas5814]

Do get some counseling. I recently called our EAP program for similar reasons. I have never even thought of such a thing before. 

I'll get up to 6 counseling sessions. The first was just me venting my spleen but man....it felt good to just dump it all out and know it wasn't, somehow, going to bite me on the ass. Hopefully they will be able to give me some tools in the upcoming visits.

4 years and 2 months to retirement.

[mgriffiths]

3 hours ago, sas5814 said:

Do get some counseling. I recently called our EAP program for similar reasons. I have never even thought of such a thing before. 

Yea, we usually get 6, but with the pandemic they made it 12.  That's what I'm trying to get into but has the 6 month wait...which seems kind of counter productive.

I'm not anywhere close to retirement, but am saving to hopefully be financially independent in approximately 7 years.

[rev ronin]

Any M&M? Did you call risk management on the NP? Nursing practice board?

[mgriffiths]

4 hours ago, rev ronin said:

Any M&M? Did you call risk management on the NP? Nursing practice board?

All of the above on every case, including many I haven't mentioned that haven't been quite as egregious or as dramatic of outcome.  This latest has also been reported, so we'll see where that goes.  I'm sure it will be discussed in our M&M, but my assumption is there again won't be any disciplinary action because why would they change now?

[kettle]

I'll echo SAS on the counseling. I understand not wanting to take time away from family but addressing your mental health will be advantageous to make the time you have with them better.

What I learned in the fire service was if there is an issue with someone try and take it up with that person before going up the chain of command. We all communicate differently and handle criticism differently so sometimes the appoprach of, hey I saw one of your patients who was pretty sick, what were your train of thoughts? Was A,B or C ever on your differential? If it's less of a direct statement that they did something wrong they might be more receptive and it also gives a teaching moment and by this teaching moment it might in turn make you feel more fulfilled by passing on your knowledge 

[ventana]

honestly in these cases, make a complaint to the board....  It is not an isolated case, there is many by the sounds, and not just a "bad day at work".

we as a profession are overworked, underpaid, underappreciated, and devalued.

Make it anonymous so that maybe (unlikely) it won't come back to haunt you.  Think James Bond here by covering any tracks you might leave, and do not put any identifying info in the complaint

 

I am jus tired of covering for others crappy care and the stress we are all facing.    Had an older PA tell me "the patient did not tell me they had renal disease" when patient looked awful, and had FULL records directly in the EMR the PA was using detailing full hx - this was the 3rd patient he put into ARF for using Bactrim in CRI 3b/4 patients with no dose adjustment - one he gave motrin 800mg tabs to!!   guy is useless and harming society - (this was 3 years ago and I regret not reporting him)