Board complaints

[Celexa]

Another Sunday morning without tongue in cheek commentary today. We've had some threads here about patients filing frivolous board complaints. I am interested in hearing perspectives and experiences when you file a board complaint on another physician.

My service (CL) had a case come in this week that was egregious. It has been decided we will file a complaint with the medical board. For obvious reasons I will not get into specifics except to say that it involved more than just over prescribing of controlled substances for unclear indications and that service leadership has concurred a report is appropriate.

---

Members don't see this ad.

 

[forchinet121]

Another Sunday morning without tongue in cheek commentary today. We've had some threads here about patients filing frivolous board complaints. I am interested in hearing perspectives and experiences when you file a board complaint on another physician.

My service (CL) had a case come in this week that was egregious. It has been decided we will file a complaint with the medical board. For obvious reasons I will not get into specifics except to say that it involved more than just over prescribing of controlled substances for unclear indications and that service leadership has concurred a report is appropriate.

You’re going to report another physician to the medical board on a patient you saw on CL but the physician is the outpatient psychiatrist? I’m assuming you talked with the outpatient doc first?

 

[Celexa]

You’re going to report another physician to the medical board on a patient you saw on CL but the physician is the outpatient psychiatrist? I’m assuming you talked with the outpatient doc first?

We did. As I said above, this case is not the standard "outpatient psychiatrist nonsense med list". I am always cognizant as a consultant that I am meeting the patient briefly and cannot over-read my limited interactions. Suffice it to say the decision to file a complaint is in no way being taken lightly and is the consensus of multiple senior psychiatrists based on objective facts.

 

[littlefred]

We did. As I said above, this case is not the standard "outpatient psychiatrist nonsense med list". I am always cognizant as a consultant that I am meeting the patient briefly and cannot over-read my limited interactions. Suffice it to say the decision to file a complaint is in no way being taken lightly and is the consensus of multiple senior psychiatrists based on objective facts.

Well, what were the findings? You can use metaphors.

 

[forchinet121]

We did. As I said above, this case is not the standard "outpatient psychiatrist nonsense med list". I am always cognizant as a consultant that I am meeting the patient briefly and cannot over-read my limited interactions. Suffice it to say the decision to file a complaint is in no way being taken lightly and is the consensus of multiple senior psychiatrists based on objective facts.

does he know he’s being reported? That must’ve been an awkward conversation

 

[Celexa]

does he know he’s being reported? That must’ve been an awkward conversation

No, they do not. The conversation was limited to purely fact finding for the clinical care of the patient. The decision was made to file a complaint after that and other collateral information had been obtained.

 

[Celexa]

Well, what were the findings? You can use metaphors.

I will just say that the patient was admitted for dangerous and severe medication adverse effect(s).

 

[forchinet121]

No, they do not. The conversation was limited to purely fact finding for the clinical care of the patient. The decision was made to file a complaint after that and other collateral information had been obtained.

Would you have still reported him if you weren’t able to talk with him on the phone? Did his answers sway you one way or another?

 

[Celexa]

Would you have still reported him if you weren’t able to talk with him on the phone? Did his answers sway you one way or another?

The answers were relevant. They were not the sole determining factor. Collateral from other outpatient physicians (non psychiatrists) was also obtained. Had we been completely UNABLE to reach the outpatient psychiatrist over several days and many attempts, that would also have factored in (and potentially been more concerning than not speaking with us at all).

It is conceivable that had the conversation gone another way we would not have landed where we did. We start from the position of giving all the benefit of the doubt.

 

[forchinet121]

The answers were relevant. They were not the sole determining factor. Collateral from other outpatient physicians (non psychiatrists) was also obtained. Had we been completely UNABLE to reach the outpatient psychiatrist over several days and many attempts, that would also have factored in (and potentially been more concerning than not speaking with us at all).

It is conceivable that had the conversation gone another way we would not have landed where we did. We start from the position of giving all the benefit of the doubt.

What was the biggest concern? Can you give an example similar to the case as to why you were so concerned? Is it similar to a psychiatrist prescribing an opioid and a benzo to the same patient for example?

 

[ObsequiousAplomb]

What was the biggest concern? Can you give an example similar to the case as to why you were so concerned? Is it similar to a psychiatrist prescribing an opioid and a benzo to the same patient for example?

Based on the way they're hinting I was thinking they're more concerned about a MAJOR risk like MAOI + SSRI or 3 SSRIs at once. Opioid + benzo is more risky than either alone but not an automatic violation of community standards.

 

[forchinet121]

Based on the way they're hinting I was thinking they're more concerned about a MAJOR risk like MAOI + SSRI or 3 SSRIs at once. Opioid + benzo is more risky than either alone but not an automatic violation of community standards.

I agree that’s why I wanted some more clarity on how severe we are talking

 

[Sushirolls]

I assisted a family member in making a board complaint against a doc once. Not going into details, but was clearly unprofessional.
Type of thing if it were a medical student I'd fail them on the spot, tell them to leave and not set foot on the rotation for the remainder of time they had.

If it were a resident, I pulled them aside and use stronger words to say how uncalled for their conduct was, and note it would be on their review too. Then pick up the phone to talk with their PD.

Nothing that rose to level of malpractice, but just something you don't do, and the opposite of how we are supposed to interact with patients.

 

[TexasPhysician]

In my state, a psychiatrist prescribing opioids is an automatic board complaint from me. If this psychiatrist was related to the patient and prescribing controlled meds, that would also prompt a complaint. Otherwise I’m not sure what would prompt me to file a complaint.

There are studies demonstrating 12+mg of Lorazepam are helpful at stabilizing Bipolar. Recommendations changed regarding Rx of benzos to those on MAT - deemed appropriate to help not deter treatment, use clinical judgement. 2-3 neuroleptics at fair dosages is sometimes needed. Stimulant studies focused on mg/kg, so Harvard faculty go 100+mg of Adderall. While I’m not riding these trains, I’m also not reporting psychiatrists that do as there is evidence supporting some fairly aggressive things.

So I am also wondering how intense these issues are

 

[calvnandhobbs68]

In my state, a psychiatrist prescribing opioids is an automatic board complaint from me.

What? I mean yeah I can't think of a bunch of great situations for this unless someone is heavily into pain management but to say this is an "automatic board complaint" is a little ridiculous. I'd at least be willing to give people the benefit of the doubt and pick up the phone to ask about it.

 

[nexus73]

In my state, a psychiatrist prescribing opioids is an automatic board complaint from me. If this psychiatrist was related to the patient and prescribing controlled meds, that would also prompt a complaint. Otherwise I’m not sure what would prompt me to file a complaint.

There are studies demonstrating 12+mg of Lorazepam are helpful at stabilizing Bipolar. Recommendations changed regarding Rx of benzos to those on MAT - deemed appropriate to help not deter treatment, use clinical judgement. 2-3 neuroleptics at fair dosages is sometimes needed. Stimulant studies focused on mg/kg, so Harvard faculty go 100+mg of Adderall. While I’m not riding these trains, I’m also not reporting psychiatrists that do as there is evidence supporting some fairly aggressive things.

So I am also wondering how intense these issues are

I just rx’d a 7 day supply of opiates to bridge a discharging patient to their primary care appointment. Would you report me?

 

[TexasPhysician]

What? I mean yeah I can't think of a bunch of great situations for this unless someone is heavily into pain management but to say this is an "automatic board complaint" is a little ridiculous. I'd at least be willing to give people the benefit of the doubt and pick up the phone to ask about it.

My state requires physicians to register as a pain clinic if they prescribe chronic pain meds (not MAT). This comes with extra requirements and monitoring. Acute pain can be treated on a limited basis if you are treating the physical condition related to the physical pain with clear documentation.

An outpatient psychiatrist treating acute medical injuries or running a pain clinic (not MAT) is highly unusual. I’ve never seen either done in my state by a psychiatrist.

The few instances where I have seen a psychiatrist do so have all resulted in board actions. This is hypothetical as I’ve never seen this done legally, but in the instance where my inpatient patient recently got opioids (not MAT) from their outpatient psychiatrist, the likelihood of wrongdoing is incredibly high.

 

[TexasPhysician]

I just rx’d a 7 day supply of opiates to bridge a discharging patient to their primary care appointment. Would you report me?

I need more context. When I check the PMP, i don’t generally review the specialty of physicians prescribing a 7 day course of pain meds. People have procedures all the time that result in 7 days of pain meds. I’d likely never catch it, unless the patient mentions something unusual.

If I was the inpatient psychiatrist and you just discharged a highly suicidal patient from an addiction center on non-MAT opioids, I probably would report. If you were the outpatient psychiatrist prescribing chronic pain meds, id report. If you are the inpatient psychiatrist prescribing a few days of chronic pain meds to reach a pain med appointment, I’m unlikely to catch or notice it.

More in regards to how I could see an inpatient psychiatrist being quick to report an outpatient psychiatrist would be opioid prescribing.

I’ve never reported anyone regarding opioid prescribing. I’ve just seen psychiatrists get in trouble for prescribing Tramadol.

 

[littlefred]

In my state, a psychiatrist prescribing opioids is an automatic board complaint from me. If this psychiatrist was related to the patient and prescribing controlled meds, that would also prompt a complaint. Otherwise I’m not sure what would prompt me to file a complaint.

There are studies demonstrating 12+mg of Lorazepam are helpful at stabilizing Bipolar. Recommendations changed regarding Rx of benzos to those on MAT - deemed appropriate to help not deter treatment, use clinical judgement. 2-3 neuroleptics at fair dosages is sometimes needed. Stimulant studies focused on mg/kg, so Harvard faculty go 100+mg of Adderall. While I’m not riding these trains, I’m also not reporting psychiatrists that do as there is evidence supporting some fairly aggressive things.

So I am also wondering how intense these issues are

This reminds me of a hospital I used to work at... they banned psychiatrist from prescribing opiates for pain. Like an actual ban from the admins where they did not allow anyone credentialed in the EMR as psych to e-prescribe opiates.

 

[TexasPhysician]

This reminds me of a hospital I used to work at... they banned psychiatrist from prescribing opiates for pain. Like an actual ban from the admins where they did not allow anyone credentialed in the EMR as psych to e-prescribe opiates.

Might as well in my state. It was banned in my residency and highly ingrained to never do so in Texas.

 

[comp1]

When I was in residency, we had a patient repeatedly be given mega amounts of benzos while everyone knew she was also getting opiates from multiple EDs. She was admitted for delirium repeatedly related to the combination We had no less than four separate discussions during separate admissions with the outpatient provider to please stop this. He sometimes agreed, but then continued to provide the meds. After multiple attempts to rectify the situation between us, my attending did file a board complaint. I'm not sure if they did anything (they certainly won't be telling you). He did end up moving states and seems to still have a thriving practice. I would say have a very high bar for these sorts of reports while also having a relatively low expectation of change. This was a very rare case where inter-provider communication just didn't seem to work out. If you're literally getting demonstrably nowhere with communicating with the outside physician, then you might consider it. I'm not sure how your team can jump to this level after one encounter with the physician's patient, but without details, I guess we'll never know.

 

[Stagg737]

I need more context. When I check the PMP, i don’t generally review the specialty of physicians prescribing a 7 day course of pain meds. People have procedures all the time that result in 7 days of pain meds. I’d likely never catch it, unless the patient mentions something unusual.

If I was the inpatient psychiatrist and you just discharged a highly suicidal patient from an addiction center on non-MAT opioids, I probably would report. If you were the outpatient psychiatrist prescribing chronic pain meds, id report. If you are the inpatient psychiatrist prescribing a few days of chronic pain meds to reach a pain med appointment, I’m unlikely to catch or notice it.

More in regards to how I could see an inpatient psychiatrist being quick to report an outpatient psychiatrist would be opioid prescribing.

I’ve never reported anyone regarding opioid prescribing. I’ve just seen psychiatrists get in trouble for prescribing Tramadol.

This is interesting, because where I'm at and where I did residency the major academic pain clinics were run by psychiatrists for med Rx (typically opiates) with an anesthesiologist for procedural treatments. Psychiatrists prescribing opiates for chronic pain treatment in those states is actually the norm. Granted, one of those states has ridiculous controlled substance laws, but the other is fairly strict and opiates prescribed by FM or non-pain accredited IM is more problematic.

 

[Candidate2017]

This reminds me of a hospital I used to work at... they banned psychiatrist from prescribing opiates for pain. Like an actual ban from the admins where they did not allow anyone credentialed in the EMR as psych to e-prescribe opiates.

Hospital admin (an RN, RN-MBA, or MBA) telling physicians how to practice medicine? I've never heard of such a thing. File a complaint with the nursing board and local prosecutor, forthwith!

 

[Stagg737]

More relevant to thread topic I've come close to reporting a fellow physician twice:

1. My wife had our first kid and had some post-partum complications while I was on my IM rotation. Took her to our local ER a week after d/c from the hospital d/t concerns for a PE. She was medically cleared and couldn't have been happier with her care, the whole team was fantastic. A week later she got extremely pale, like paper white with lips being the same color, and was short of breath. Took her back to the same ER and got a different doc, he looked at her vitals which were stable and was going to d/c without any further work-up, didn't even order labs or do a physical.

I mentioned I was an intern and asked if it wasn't standard to at least get a CBC and he got labs but no imaging. Hgb was ~6.5 and it had been around 10 the previous week. He said that it wasn't an issue and whenever he calls the OB/gyn they say not to worry about it as it's probably just still post-partum bleeding (2.5 weeks after birth...). Meanwhile, she's oozing blood from her c-section wound. When I pointed it out, he did a 10-second physical exam on the wound (only physical exam he did the entire encounter) and used liquid sutures to try and close it without actually cleaning the area WHILE IT WAS ACTIVELY BLEEDING. Said it was fine and discharged her. Couple hours later she's still feeling awful, the sutures have oozed away, and I'm still worried.

So I called my senior resident who was married to the OB/gyn chief resident where our kid was born to ask if I should take her somewhere else. His wife said to take her straight to their unit/office and they took her straight upstairs for exam. U/S showed she had a 7x13x3 cm hematoma near her open wound and IR got a stat consult with transfusion. She got admitted for 2-3 days for obs and stabilization. Every doc I talked to at that hospital was flabbergasted that the ER doc discharged her. I got talked out of reporting it by family because I was still an intern, but wish I had. Looking back the level of neglect still disgusts me.


2. A few months ago I had a situation in our ER that was more of a psych/legal issue that more pissed me off than anything. Patient took her highly inebriated husband to a different ER and while there became extremely agitated when they wouldn't let her back to talk to him. Apparently when hospital police arrived it triggered her PTSD and she lost control and attempted to strike several officers. So instead of taking her to jail they placed her on an involuntary psych hold in their ER, put her in an ambulance, and sent her to our ER because admin "banned her" from their ER the same day. Basically was an EMTALA violation as they have all the same level of services that our hospital does with a full inpatient psych unit and everything. I didn't file a board complaint on advice from out legal/RM teams, but it did elevate to risk management who are apparently dealing with the state regarding the issue. The other hospital is notorious for discharging patients from their ER who need admission (hospital has a psych unit at their facility) and then patients coming straight to us for admission, but this was the first time they'd actually broken a law in doing so.


I've seen plenty of other situations where the med management was just so awful that I wanted to report, but haven't because as others pointed out the standard of care/standard of what is unacceptable is absurdly low.

 

[comp1]

Oh filing complaints against hospital functioning, like EMTALA violations, should be a much lower bar. That's a very different thing and concrete, not a clinical judgement.