How does one supervise their supervising physician?

[Guest Paula]

I'm in a situation at a small clinic (on a reservation) where I work with an NP and an MD. Both of them have been at the clinic for 18-20 years. The MD never finished a residency, had the one year internship after med school and left his residency for medical reasons, and then never finished it after his issue was resolved. He landed at the rez and has been there ever since. I am required to have more CME's than him, and will have to re-cert every 10 years and do the CAQ's. His requirements are very little for renewal of his license. He does not seem to keep up with medicine very well. The NP is 70 years old, and good at her job. She is the walk-in provider and just renewed a one year contract with an option for one more year. She just suffered a TIA at work 3 weeks ago, missed two days of work, and is back without any deficits that I can tell. She is fiercely protective of her "pratice". She is not, however, the nicest person and if you cross her, watch out. I have seen her give outdated advice to young mothers, and she prescribes ALOT of abx for every case of URI that comes in the door, or snotty nose, etc. She went to the MD and complained that I was trying to take over her practice. (More on that later).

 

I have been there one year full-time, and previous to that was there 2 days a week while the NP was out caring for a terminally ill child. I was hired full-time with the understanding the NP was retiring soon after I started. She did give notice (she says under duress because the tribal council refused to initially renew her contract), then she raised He** with the help of another tribal council member who was on her side. So, she then retracted her resignation. (Sorry, this is a true soap opera story now that I look at this in retrospect as I type).

 

The issue: I take appointments only according to the NP. I do a lot of sports physicals, well-child exams, diabetes follow up exams and manage many complicated diabetics, plus HTN, etc. all the general simple and complicated stuff PAs do. Since I have been seeing most of the Well child exams I have been asking the parents to schedule appointments with me if there was an issue that needed recheck, or I told the parents if they wanted to see me, they could schedule a same day appointment. I have plenty of time. The MD said ok, no problem to do the schedule that way. NP got upset by that. The MD never told me she was upset and never dealt with the issue, I learn about it thru the grapevine of the NP's LPN. I still tell patients if they want to see me they need to schedule an appointment. The LPN had been refusing to room patients who asked to see me and would tell the receptionist that the NP will see those pts., and that I only take appointments, and if pts walked in asking for me, they had to see the NP. Thus, you see the issue. The MD will not come to us and discuss.

 

Another issue is the MD has asked his RN who works with him to come to me with anything he perceives that I have "done wrong". She is new to the clinic, like I am, each of us there a year or so. She came to me twice this week with 2 issues. One was the MD told her he was upset that I and the NP gave a patient vicodin for dental pain (it was real pain) and that the patient wasn't supposed to be put on narcotics. There was no mention or documentation of it in the chart by the MD. He has a habit of poor record keeping, writing prescriptions and not documenting, and not notifying patients of lab results, and lots of other issues. He also misses work frequently and hunts and fishes alot. He is off now on a fly-fishing trip. His days in the office working are limited by his use of cell phone, ipad, talking to friends and developing his side business during work hours. He is never there on Fridays. (He is paid over $250,000 a year.) I could not, therefore, confront him directly about him not confronting me directly! His RN did not confront the NP with the issue and won't. The NP would excoriate her, and I believe there is an underlying RN/NP alliance that won't be crossed. THe NP made it very clear to me that "I have independent practice, you know". (Except for her DEA license must have the MD's approval). The NPs LPN also will complain and sometimes refuse to do orders I put in for her. (I do not have my own nurse.) The NP backs her up every time.

 

So, what do I do? Low woman on the totem pole (pardon the pun), volatile politics, an MD without balls who doesn't work regularly, and generally the clinic is in a shambles. The billing structure is another story I won't go into.

 

How do I supervise my supervising physician? I am not one to let the shenanigans go on, and will probably get let go if I push too hard. I'm planning on confronting the whole situation on Monday when he is back, unless of course, he is sick, which happens alot after he is on his hunting and fishing trips.

[Just Steve]

Why do you stay?

[Guest Paula]

Why do you stay?

 

Fabulous salary, benefits and they are paying for my masters program. Plus, I love the patients. I'm in my middle 50's and jobs in my areas are hard to come by, being in a remote rural area.

 

Good question, tho. It comes down to not being unemployed for a period of time. I did just start looking at area opportunities the other day. Not much available. I'm keeping options open, however.

[EMEDPA]

is there a clinic board of directors or someone above the doc and np you can talk to?

you must be a lot more patient than me. I have left jobs for less in the past. that level of disrespect is unacceptable.

[Contrarian]

Different perspective...

 

Paula... as someone who has also worked on reservations... I can tell you that YOU are the "interloper" who stepped into their cozy little substandard world. Its all about the politics of personality and nothing you can do will change their entrenched "culture of mediocrity." As you may be learning... the reservations, like the correctional system is notorious for harboring the ill prepared and barely employable.

 

So its really difficult for the few there who promote and demand excellence to remain in these places long. If and when they do... they usually have to sink to that level to decrease friction and stress.

 

You are not going to change these entrenched individuals or the system that supports them while they BOTH are still there.

 

They have been there toooo long and are likely drinking, fishing, hunting, casino, crocheting buddies with key community Tribal leaders. They have been to all of the "pow-Wows," burnings, Blanket Ceromonies, Drum Circles, and Funerals of the community leaders. They are entrenched.

 

As you have stated above... if YOU push, it ain't gonna end well.

So you have to make a decision to stay, insulate yourself by practicing "Platinum Standard Medicine" with superb, bulletproof documentation and ride it out until either the NP has a full on CVA and quits or the doc goes hunting with Dick Cheney, OR find another job ASAP.

 

YMMV

[ventana]

70 years old with a TIA

 

she is not long for the clinic.....

 

as you are finding, deep roots are hard to pull up

 

if you like it and can see yourself there in the long time - hang in there - don't bow down to anyone - keep your CV up to date and document document document everything that goes on so you can defend your license if it ever came to that....

 

I would pull out the old passive aggressive approach and stroll through the watiing room collecting and rooming your patients that want to see you. DEMAND that the LPN follows your orders - heck threaten to file complaints against her license for not following orders (but don't do it - careful this might blow up on you)

 

befriend the doc - get him to see your side and come to your defense, if he is totally uninterested in the clinic you can't force him to care so then just don't piss him off

 

run with your head down, zig zag a lot so then never know where you are heading, defend you license and your skills and hold yourself to a high standard and don't care about them....

 

 

some of it is just life in the medical community and it is never going to change....

[Guest Paula]

Different perspective...

 

Paula... as someone who has also worked on reservations... I can tell you that YOU are the "interloper" who stepped into their cozy little substandard world. Its all about the politics of personality and nothing you can do will change their entrenched "culture of mediocrity." As you may be learning... the reservations, like the correctional system is notorious for harboring the ill prepared and barely employable.

 

So its really difficult for the few there who promote and demand excellence to remain in these places long. If and when they do... they usually have to sink to that level to decrease friction and stress.

 

You are not going to change these entrenched individuals or the system that supports them while they BOTH are still there.

 

They have been there toooo long and are likely drinking, fishing, hunting, casino, crocheting buddies with key community Tribal leaders. They have been to all of the "pow-Wows," burnings, Blanket Ceromonies, Drum Circles, and Funerals of the community leaders. They are entrenched.

 

As you have stated above... if YOU push, it ain't gonna end well.

So you have to make a decision to stay, insulate yourself by practicing "Platinum Standard Medicine" with superb, bulletproof documentation and ride it out until either the NP has a full on CVA and quits or the doc goes hunting with Dick Cheney, OR find another job ASAP.

 

YMMV

 

Oh, Contrarian, you have hit the nail on the head. The doc spends every Thursday morning in the round house with tribal leaders trying to figure out how to stop the alcoholism on the rez. 4 hours less a week he has to practice medicine. I wonder what they really do there! LOL. I have said to a few other newer employees that I am being beat into submission, and so are they! These other 2 employees are my only saving grace, and we have pledged to rise up with steel backbones. If they leave, I leave, too.

 

I will stay, document, practice "platinum standard medicine" and see how long it lasts. Like I said, I have started a search for other jobs in the area, but not much is available right now.

 

Oh, and far as documentation goes, did I mention when I first started the transcriptionist complained that my dictations were too long? She asked the doc to tell me to shorten them up. I refused stating that the correct way to make a note was to get rid of the SOAP notes he and the NP use, and be thorough, then discussed billing, coding and documentation using the standard CC, HPI, ROS, allergies, vitals, etc. He then told me my documentation was excellent and backed down. I eventually developed a template that I use to help the transcriptionist, but, as you can see, we are in the dark ages. EHR is expected to come in the next 6 months. I can't wait.

 

Thanks for your (and Ventana's) comments, too. It's appreciated

[MrBob]

I would start looking for a new relationship somewhere before this one gets you in trouble with your local medical board or you end up in a lawsuit with no one to back you up.....Sounds like a miserable place to wake up to every morning. Life is way too short for this kind of junk. I think Contrarian has given you good advice here.

 

Bob