Lawsuit Brought Against NP Owned Clinic, DEA Now Investigating

[Stagg737]

So NP encroachment and standards of care are pretty common on here, but here's finally an example of a lawsuit being brought against 2 NPs for malpractice and one example of what can happen when people practice outside of their scope.

Here is a link to the Plaintiff's Original Court Petition for the case:


Some points for summary: The patient was a 47 year old man who was receiving testosterone and thyroid hormones from the NP being charged. He was inappropriately being prescribed these medications and the quantities prescribed were above recommended doses. The patient died from a heart attack which was later determined by pathology to be directly caused by high doses of exogenous hormones. The patient also had no previous history or family history of heart conditions or MI. Additionally, these medications were prescribed despite his lab panels showing normal levels (of both hormones) and were continued to be prescribed even after labs showed significant elevations of thyroid and testosterone panels.


Some relevant excerpts from the Plaintiff's Original Court Petition:

"At the time of his death, BRAD GUILBEAUX'S serum testosterone levels were so inordinately high that they were not measurable by the coroner's lab, his free testosterone levels were above normal, and his free T3 thyroid hormone levels were above normal."

"...n my opinion, the cause of death of BRAD GUILBEAUX is hypertensive cardiovascular disease with contributory cause chronic exogenous hormone therapy....BRAD GUILBEAUX's only hormone therapy use was that prescribed by Defendants." (excerpt from pathologist's autopsy report)

"Despite lab panels indicating thyroid hormone levels at normal levels, Defendants told BRAD GUILBEAUX he was thyroid deficient and initiated the use of thyroid hormone supplements contrary to the American Association of Clinical Endocrinologists' guidelines which say thyroid hormones should not be used, even in the presence of symptoms suggestive of hypothyroidism, unless lab values indicate below normal levels."

"Despite lab panels indicating thyroid hormone levels above normal levels and despite clear symptoms of hyperthyroidism (including hypertension and elevated heart rate), Defendants continued prescribing BRAD GUILBREAUX thyroid hormones under those circumstances was contrary to the relevant standards of care."

"There is no indication in the OPTIMUM records of a consultation between MARIAN QUERRY or GEORGE BROWN and KEVIN MORGAN - despite the fact that BRAD GUILBREAUX was receiving treatment outside of commonly accepted practices - indicating that they failed to establish adequate guidance and protocols for consultation between themselves as delegating physicians and KEVIN MORGAN contrary to relevant standards of care."

This one was important because Texas is a state which requires NP supervision by physicians, yet neither physician was on site or even worked at this facility (which was owned by 2 NPs). In fact none of the supervising physicians live or work within 100 miles of the NP owned clinic. So to those arguing that "independent midlevel practice" isn't occurring in states where supervision is required, here's an example where it happened (and led to 2 patient deaths).


Additionally, in a FB group that I am a part of, the NPs at this clinic have both been reported to the Texas Board of Nursing several times over the past several years and nothing was previously done. However, it has now been elevated to the federal level. The DEA is now investigating this clinic and even raided the clinic. These investigations have so far found at least 12 other cases where Kevin Morgan's treatments failed to meet minimum standards of nursing care, one of which led to another patient's death. His NP partner also had at least 11 cases where his treatments did not meet minimum standards of nursing care.


Here is a ~6:30 video which discusses the case and what has happened so far (actual medical info starts at 2:50, before that is talking about family's loss of their father/husband):




While mistakes happen and even physicians practice beyond their scope or treat inappropriately at times, this is a clear case where patients have been unnecessarily injured and killed due to NPs practicing beyond their education and not being properly supervised. I hope, for the sake of the family and the health care system in general, that this lawsuit is successful and serves as a precedent for midlevels being held liable for the patients they manage instead of liability getting dumped only on the supervising physician.

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[Money Moniker]

I highly doubt this has anything to do with incompetence. Any gymbrah knows testosterone dosing is a risk vs reward balancing act between gainz and health issues. I'm pretty sure both the NP in question and the dead patient were well aware that the dosing was well above that required for purely "medical" supplementation. At the end of the day, the patient wanted to be juiced to the gills for GAINZ and the NP obliged him to make MONEY. The end.

 

[Giovanotto]

I highly doubt this has anything to do with incompetence. Any gymbrah knows testosterone dosing is a risk vs reward balancing act between gainz and health issues. I'm pretty sure both the NP in question and the dead patient were well aware that the dosing was well above that required for purely "medical" supplementation. At the end of the day, the patient wanted to be juiced to the gills for GAINZ and the NP obliged him to make MONEY. The end.

What you're saying is still incompetence, although of a different nature.

 

[operaman]

Yeah I agree this case doesn't say anything about NP incompetence. There are a zillion of these medical weight loss clinics out there and they all prescribe some similar combo of meds. Obviously these off label uses are not mainstream practice, but there are plenty of docs out there making buckets of money peddling some similar system. My guess is this suit gets tossed out eventually. That or they refocus and go after lack of informed consent, though I'm sure they probably had him sign a waiver about off label uses and risks of treatment.

If this gets anywhere near a courtroom, the NP's attorney will put all the blame on the supervising MD

 

[W19]

Physicians are taking a big risk when they enter into a 'collaborative agreement' with someone who got their degree online with 5oo hrs of clinical preceptorship...

 

[Stagg737]

I highly doubt this has anything to do with incompetence. Any gymbrah knows testosterone dosing is a risk vs reward balancing act between gainz and health issues. I'm pretty sure both the NP in question and the dead patient were well aware that the dosing was well above that required for purely "medical" supplementation. At the end of the day, the patient wanted to be juiced to the gills for GAINZ and the NP obliged him to make MONEY. The end.

Did you read the court documentation? The patient was being treated for Low T and hypothyroidism and was told that's what he was being treated for despite labs saying otherwise. Then when his lab values got too high and he started displaying symptoms of excessive hormones the NP continued to prescribe those medications. If you read the document it also clearly states that the patient was never warned about any of the potential adverse effects of the hormones he was being given. Then the patient actually died as a result of that treatment.

Even if you want to try and make the argument that the patient knew about it, that doesn't change the fact that this NP was prescribing medications outside of the standard of care which led to the death of his patient. That's textbook medical malpractice and should be punished. Also, if you think that NPs would know that testosterone has potentially lethal side effects you're sadly very mistaken.

Yeah I agree this case doesn't say anything about NP incompetence. There are a zillion of these medical weight loss clinics out there and they all prescribe some similar combo of meds. Obviously these off label uses are not mainstream practice, but there are plenty of docs out there making buckets of money peddling some similar system. My guess is this suit gets tossed out eventually. That or they refocus and go after lack of informed consent, though I'm sure they probably had him sign a waiver about off label uses and risks of treatment.

If this gets anywhere near a courtroom, the NP's attorney will put all the blame on the supervising MD

Really? Did you read the Petition? If practicing well outside the standard of care and either completely ignoring lab values or not knowing what they mean isn't incompetence then Idk what is. And I very much doubt this case will get tossed out, especially now that the DEA has gotten involved and so many more cases of injury (and one death) from this clinic have been identified. I could see this ending in a settlement or the attorneys attempting to shift blame onto the supervising physicians, but after hearing what the physicians in the group I mentioned have said I don't think this one's just going to get thrown out.

Edit: Also, both NPs have had their licenses suspended for being "immenent threats to public welfare" and have hearings set with the Texas Board of Nursing as to whether they will permanently lose their licenses. I believe Morgan's hearing isn't until October while his partner's is on May 29. Here's a link to an article with the BoN's official documentation and reasoning for suspension of their licenses: Nurse's license temporarily revoked as "imminent threat to public welfare"

If you read the cases this wasn't an isolated incident and they demonstrate clear incompetency with multiple patients (including the other death which actually seems to be even more egregious than the one being discussed). Another quote from the article was, "We also learned this afternoon that more than 30 former patients are consulting with the Provost Umphrey Law Firm to seek legal action against the clinic." So even if this individual case gets thrown out, this issue doesn't seem to be going away for them anytime soon. In he meantime, the clinic has been shut down and both the DEA and Texas BoN are currently investigating other patients and asking other patients to step forward with information as well.

 

[dadaddadaBATMAN]

That's not malpractice, it's malfeasance.

 

[Treebeard]

I actually agree that care provided by NPs is sub-standard, however this doesn't mean much. There are plenty of idiot MDs in the world and they get sued too.

 

[Raryn]

There's plenty of doctors running these wellness clinics who prescribe huge amounts of testosterone, hcg, aromatase inhibtors, clomiphene, growth hormone, and thyroid hormones inappropriately.

Unfortunately, there's nothing unusual in this case.

 

[VA Hopeful Dr]

There's plenty of doctors running these wellness clinics who prescribe huge amounts of testosterone, hcg, aromatase inhibtors, clomiphene, growth hormone, and thyroid hormones inappropriately.

Unfortunately, there's nothing unusual in this case.

It'd be nice if this case served as an indictment of all of those shysters, but I doubt we'll be that lucky.

 

[libertyyne]

I was wondering if this was a "wellness, holistic, integrative" clinic, but this was just one of those terrible weight loss clinics. Nothing to see here, Physicians do this all the time. The physicians are also named in the suit. If anything this is fodder for independent practice since supervision "doesnt work" , or is basically a sham a point that proponents of independent practice will often make.

Individual settlements dont really matter that much until and unless insurance premiums reflect difference in outcome and risk, which they will not based on this one case. Long term high quality data is what will drive change considering it will become difficult to insure against malpractice. But the reality is the malpractice insurers do not see increased risk with NPs so expansion will continue unabated.

 

[Stagg737]

That's not malpractice, it's malfeasance.

How so? This case met all the criteria for malpractice: "doctor"-patient relationship existed (clearly), there is proof of substandard care (not following lab results and inappropriately diagnosing/prescribing medications with potential to harm), a clear link between "doctor's" care and harm (multiple reports of exogenous hormones causing hospitalization and death twice), and quantifiable proof of harm (I'd say death fits that criteria...). So I'd be interested as to why you think this wouldn't meet the standards for malpractice? The Texas legal system seems to think so and so does the Texas BoN.

I actually agree that care provided by NPs is sub-standard, however this doesn't mean much. There are plenty of idiot MDs in the world and they get sued too.

There's plenty of doctors running these wellness clinics who prescribe huge amounts of testosterone, hcg, aromatase inhibtors, clomiphene, growth hormone, and thyroid hormones inappropriately.

Nothing to see here, Physicians do this all the time.

You're all missing the point here, which isn't that "physicians do this too" (of course it happens, crappy people all over healthcare). The point is that this is a case where the NP is named as the primary defendant and is actually being held liable for his actions instead of the supervising physician or hospital (which is what pretty much always happens). It's the first example I've seen of a patient or family going after the NP with a good chance of actually winning instead of going after the supervising physicians alone or just the whole clinic/hospital. So the point wasn't "oh, this person screwed up". It's that an NP may actually be held liable for medical malpractice in a court of law, which as far as I know would be a precedent, especially in states where NP supervision is required.

Individual settlements dont really matter that much until and unless insurance premiums reflect difference in outcome and risk, which they will not based on this one case. Long term high quality data is what will drive change considering it will become difficult to insure against malpractice. But the reality is the malpractice insurers do not see increased risk with NPs so expansion will continue unabated.

Of course, and I'm not under the illusion that this case will suddenly turn any tides or even make a significant or immediate difference. However, I do hope they actually take this to trial and don't just settle, as it could be an initial signal that NPs have to be held to the same levels of liability as physicians when they decide to act as physicians. Is that likely to happen? Probably not, but it's nice to see that someone is at least trying to hold them accountable and not just letting them hide behind the supervision shield (especially since there was no supervising physician within 100 miles of the clinic).

 

[dadaddadaBATMAN]

How so? This case met all the criteria for malpractice: "doctor"-patient relationship existed (clearly), there is proof of substandard care (not following lab results and inappropriately diagnosing/prescribing medications with potential to harm), a clear link between "doctor's" care and harm (multiple reports of exogenous hormones causing hospitalization and death twice), and quantifiable proof of harm (I'd say death fits that criteria...). So I'd be interested as to why you think this wouldn't meet the standards for malpractice? The Texas legal system seems to think so and so does the Texas BoN.






You're all missing the point here, which isn't that "physicians do this too" (of course it happens, crappy people all over healthcare). The point is that this is a case where the NP is named as the primary defendant and is actually being held liable for his actions instead of the supervising physician or hospital (which is what pretty much always happens). It's the first example I've seen of a patient or family going after the NP with a good chance of actually winning instead of going after the supervising physicians alone or just the whole clinic/hospital. So the point wasn't "oh, this person screwed up". It's that an NP may actually be held liable for medical malpractice in a court of law, which as far as I know would be a precedent, especially in states where NP supervision is required.




Of course, and I'm not under the illusion that this case will suddenly turn any tides or even make a significant or immediate difference. However, I do hope they actually take this to trial and don't just settle, as it could be an initial signal that NPs have to be held to the same levels of liability as physicians when they decide to act as physicians. Is that likely to happen? Probably not, but it's nice to see that someone is at least trying to hold them accountable and not just letting them hide behind the supervision shield (especially since there was no supervising physician within 100 miles of the clinic).

I revised my statement to make it shorter, what it should have said is "it's not incompetence its malfeasance."

There is a zero percent chance that the people selling this as a therapy believed it would work. It's worse than being stupid or negligent, they actually intentionally deceived the guy while they sold him a worthless therapy that led to his death.

Your overarching point seemed to be that this shows nps are not competent and therefore dangerous. It doesn't demonstrate that, it shows that some nps are criminals. The same is true of mds, so it doesn't really help us much.

While I agree with some of the sentiment (that nps are poorly regulated, and many are incompetent), I disagree with the way you went from a-->b

 

[libertyyne]

How so? This case met all the criteria for malpractice: "doctor"-patient relationship existed (clearly), there is proof of substandard care (not following lab results and inappropriately diagnosing/prescribing medications with potential to harm), a clear link between "doctor's" care and harm (multiple reports of exogenous hormones causing hospitalization and death twice), and quantifiable proof of harm (I'd say death fits that criteria...). So I'd be interested as to why you think this wouldn't meet the standards for malpractice? The Texas legal system seems to think so and so does the Texas BoN.






You're all missing the point here, which isn't that "physicians do this too" (of course it happens, crappy people all over healthcare). The point is that this is a case where the NP is named as the primary defendant and is actually being held liable for his actions instead of the supervising physician or hospital (which is what pretty much always happens). It's the first example I've seen of a patient or family going after the NP with a good chance of actually winning instead of going after the supervising physicians alone or just the whole clinic/hospital. So the point wasn't "oh, this person screwed up". It's that an NP may actually be held liable for medical malpractice in a court of law, which as far as I know would be a precedent, especially in states where NP supervision is required.




Of course, and I'm not under the illusion that this case will suddenly turn any tides or even make a significant or immediate difference. However, I do hope they actually take this to trial and don't just settle, as it could be an initial signal that NPs have to be held to the same levels of liability as physicians when they decide to act as physicians. Is that likely to happen? Probably not, but it's nice to see that someone is at least trying to hold them accountable and not just letting them hide behind the supervision shield (especially since there was no supervising physician within 100 miles of the clinic).

The NP was named with the physicians. NP might get dropped, probably not in this instance since the NP owned the practice. This is not a ground shattering precedent considering this has happened many times before. Lawyers go after the biggest pockets. If NP owns the practice , those are some big malpractice insurance pockets to go after.
https://www.npjournal.org/article/S1555-4155(11)00478-8/abstract
Boy Dies After Call to NP for Flu Symptoms
Nurse Practitioners and Diagnostic Errors | CPH & Associates

Here is the thing, those physicians are still liable since they provided "oversight" in an oversight state.
Not sure what you are hoping will come of this, but most likely a settlement out of court and nothing else. Nothing to see here ,nothing special.

 

[Treebeard]

How so? This case met all the criteria for malpractice: "doctor"-patient relationship existed (clearly), there is proof of substandard care (not following lab results and inappropriately diagnosing/prescribing medications with potential to harm), a clear link between "doctor's" care and harm (multiple reports of exogenous hormones causing hospitalization and death twice), and quantifiable proof of harm (I'd say death fits that criteria...). So I'd be interested as to why you think this wouldn't meet the standards for malpractice? The Texas legal system seems to think so and so does the Texas BoN.


You're all missing the point here, which isn't that "physicians do this too" (of course it happens, crappy people all over healthcare). The point is that this is a case where the NP is named as the primary defendant and is actually being held liable for his actions instead of the supervising physician or hospital (which is what pretty much always happens). It's the first example I've seen of a patient or family going after the NP with a good chance of actually winning instead of going after the supervising physicians alone or just the whole clinic/hospital. So the point wasn't "oh, this person screwed up". It's that an NP may actually be held liable for medical malpractice in a court of law, which as far as I know would be a precedent, especially in states where NP supervision is required.

Interesting point. I actually didn't realize that - I assumed if an NP effs up, they are held accountable.

 

[Stagg737]

I revised my statement to make it shorter, what it should have said is "it's not incompetence its malfeasance."

There is a zero percent chance that the people selling this as a therapy believed it would work. It's worse than being stupid or negligent, they actually intentionally deceived the guy while they sold him a worthless therapy that led to his death.

Your overarching point seemed to be that this shows nps are not competent and therefore dangerous. It doesn't demonstrate that, it shows that some nps are criminals. The same is true of mds, so it doesn't really help us much.

While I agree with some of the sentiment (that nps are poorly regulated, and many are incompetent), I disagree with the way you went from a-->b

Gotcha, I can see that then. The thing Idk is if these individuals legitimately knew how much damage could be done by these hormones when used improperly. I've worked with some NPs whose lack of knowledge in the field they worked legitimately blew my mind. The one that always comes to mind was an ER NP I was on rotation with (she was getting hours to switch to an outpt FM clinic) with ~15 years of ER experience as an NP who not only didn't know what CURB-65, PSI/PORT, or SMART-COP was, she had never heard of any of them. My attending and I found this out when she recommended Medrol and "Maybe a ZPak?" to an elderly lady who clearly needed to get to the hospital ASAP.

My point was meant to be that NPs should be held liable for the treatment they administer, especially if acting in the capacity of a physician. The rest is just support for why this specific case is a good example of that.

The NP was named with the physicians. NP might get dropped, probably not in this instance since the NP owned the practice. This is not a ground shattering precedent considering this has happened many times before. Lawyers go after the biggest pockets. If NP owns the practice , those are some big malpractice insurance pockets to go after.
https://www.npjournal.org/article/S1555-4155(11)00478-8/abstract
Boy Dies After Call to NP for Flu Symptoms
Nurse Practitioners and Diagnostic Errors | CPH & Associates

Here is the thing, those physicians are still liable since they provided "oversight" in an oversight state.
Not sure what you are hoping will come of this, but most likely a settlement out of court and nothing else. Nothing to see here ,nothing special.

Interesting cases, I hadn't seen these before and hadn't seen instances where NPs had been held liable for their actions. This is still the first time I've seen the NP named as the primary defendant while under supervision of physicians though, would be interested in seeing if there were other precedents for that. I'm hoping to see that this doesn't get settled and actually goes to court. From the sounds of what the physician familiar with the case who lives near there said, it seems like this family doesn't want to settle. Idk though, I'd just like to see individuals who aren't qualified to practice independently be held accountable when they screw up, especially when they're killing patients. Seeing one of these voodoo weight loss/alternative clinics close down is a bonus, but that's irrelevant to the point about NPs in lawsuits.

 

[Stagg737]

Interesting point. I actually didn't realize that - I assumed if an NP effs up, they are held accountable.

As Libertyyne pointed out, it would depend on who has the deepest pockets to grab out of, which is rarely the NP. If it's a case where there's physician supervision the physician will almost always be sued, whether that is the ethically correct or not. Same goes for NPs who work in hospitals or hospital-owned clinics.

Edit: Depending on how bad they mess up, they may be held accountable by the state's BoN. However, after talking to a ton of physicians about this, it seems like most BoNs don't do jack 95% of the time unless a higher authority gets involved. Their standards are far lower than state medical boards, so something that would potentially cost a physician their license may not even be a slap on the wrist for a NP.

 

[operaman]

What will be interesting is how the NP defense attorney spins the standard of care argument. The standard is defined by what someone with similar training and background would do, so the NP will theoretically be judged against other nurses. You can see the groundwork for this in the petition, but the kind of exam elements they allege weren’t done would not have alerted anyone about his impending arrest. I think it will come down to whether the defense can convince a jury that nurses are trained to accurately order and interpret the labs and whether they would know other screening tests to detect complications of therapy. I suspect it will be pretty easy to find plenty of nurse witnesses who will testify that they don’t have any idea how to interpret endocrine labs and adjust medication dosing. Then the defense attorney will quickly push all the blame on the supervising docs.

 

[Mad Jack]

I highly doubt this has anything to do with incompetence. Any gymbrah knows testosterone dosing is a risk vs reward balancing act between gainz and health issues. I'm pretty sure both the NP in question and the dead patient were well aware that the dosing was well above that required for purely "medical" supplementation. At the end of the day, the patient wanted to be juiced to the gills for GAINZ and the NP obliged him to make MONEY. The end.

Sounds like one of those clinics that sells "anti-aging" medicine where they "properly balance" hormones completely outside of basic guidelines. This guy probably was sold a fountain of youth in the form of hormone replacement (I've fought about this with "anti-aging clinic" types before that thing this should be totally legal, and argued against it because of individuals like this guy).

 

[mistafab]

I think in this situation testosterone use is being focused on too much.

I am typically one to say steroids or T replacement is not without real risks, specifically for the liver. However, replacing thyroid hormone over physiologic levels is actually immediately very dangerous due to the serious risk of arrhythmia and heart/cv damage. This is why endocrinologists typically err on the side of hypothyroid when they begin replacement of thyroid hormone with meds, so they can very slowly titrate up.

So although I think the T replacement in this case was bad medicine, I think the thyroid hormone management was dangerous medicine. Testosterone is being unecessarily highlighted here, in my opinion, and doesnt really add to this case.

 

[Stagg737]

What will be interesting is how the NP defense attorney spins the standard of care argument. The standard is defined by what someone with similar training and background would do, so the NP will theoretically be judged against other nurses. You can see the groundwork for this in the petition, but the kind of exam elements they allege weren’t done would not have alerted anyone about his impending arrest. I think it will come down to whether the defense can convince a jury that nurses are trained to accurately order and interpret the labs and whether they would know other screening tests to detect complications of therapy. I suspect it will be pretty easy to find plenty of nurse witnesses who will testify that they don’t have any idea how to interpret endocrine labs and adjust medication dosing. Then the defense attorney will quickly push all the blame on the supervising docs.

I could see them trying that, but depending on what labs they used, it could clearly say on there "above normal range". I agree with mistafab that the Testosterone issue, while medically deplorable, likely won't carry much weight. However, even RNs I've worked with know that when thyroid hormone is high you don't give them more thyroid hormone, which is what this NP did on multiple occasions. I have a hard time believing they'll be able to dodge that one in court, especially since the NP was diagnosing patients as hypothyroid in the chart while the labs showed they were in fact hyperthyroid. Frankly, Idk how much it should matter even if they can prove the NP didn't know how to appropriately interpret the labs as it would then open an argument up for practicing outside of his scope. Since it's not an independent practice state I'm sure they could push that on the supervising physician though.

I agree that they will likely argue that the NP wasn't responsible and that the supervising physician was (which is a shame because they were basically practicing unsupervised). As much as I'd like to see these NPs get roasted, I'd also like to see they physicians held accountable for allowing this to happen allowing this crap to happen under their "supervision".

Sounds like one of those clinics that sells "anti-aging" medicine where they "properly balance" hormones completely outside of basic guidelines. This guy probably was sold a fountain of youth in the form of hormone replacement (I've fought about this with "anti-aging clinic" types before that thing this should be totally legal, and argued against it because of individuals like this guy).

Sounds like it. Although according the BoN documents this clinic was also diagnosing and managing actual medical diasnoses like Hashimoto's and other endocrine issues as well. Here's the link to the (now closed) clinic's website: Optimum Medical Weight Control And Family Wellness - Medical Weight Loss Programs, Hormone Therapy Biote, Best Weight Loss Program

I think in this situation testosterone use is being focused on too much.

I am typically one to say steroids or T replacement is not without real risks, specifically for the liver. However, replacing thyroid hormone over physiologic levels is actually immediately very dangerous due to the serious risk of arrhythmia and heart/cv damage. This is why endocrinologists typically err on the side of hypothyroid when they begin replacement of thyroid hormone with meds, so they can very slowly titrate up.

So although I think the T replacement in this case was bad medicine, I think the thyroid hormone management was dangerous medicine. Testosterone is being unecessarily highlighted here, in my opinion, and doesnt really add to this case.

I think you're pretty right. The misuse and inappropriate diagnosis regarding the thyroid stuff is what they should focus on if they really want to win. However, I do think the testosterone is relevant as it played a significant role in causing the myocardial hypertrophy and MI which eventually killed the patient. Also, if you read the BoN document for this particular case, they stated that part of their reasoning for him not meeting the standard of care was that he was prescribing Testosterone to this patient when the initial labs came back that his Test. levels were normal. So it is relevant in that sense, especially if the BoN ends up permanently taking his license away.

 

[libertyyne]

What will be interesting is how the NP defense attorney spins the standard of care argument. The standard is defined by what someone with similar training and background would do, so the NP will theoretically be judged against other nurses. You can see the groundwork for this in the petition, but the kind of exam elements they allege weren’t done would not have alerted anyone about his impending arrest. I think it will come down to whether the defense can convince a jury that nurses are trained to accurately order and interpret the labs and whether they would know other screening tests to detect complications of therapy. I suspect it will be pretty easy to find plenty of nurse witnesses who will testify that they don’t have any idea how to interpret endocrine labs and adjust medication dosing. Then the defense attorney will quickly push all the blame on the supervising docs.

Would it be other nurses or other NPs used for standard of care, considering the scope of this NP is beyond what a normal nurse would practice as.

 

[Stagg737]

Would it be other nurses or other NPs used for standard of care, considering the scope of this NP is beyond what a normal nurse would practice as.

For NPs it would be other advanced practioners/NPs and not just RNs. As far as I understand there is a distinct difference in training between the two and they are legally held to different standards. What the actual differences are idk, but the standards are not the same. I do not know if there's a difference between standards for DNPs vs. non-doctoral APRNs, though I would hope there would be if they're claiming to be "doctors" through "more education".

 

[W19]

For NPs it would be other advanced practioners/NPs and not just RNs. As far as I understand there is a distinct difference in training between the two and they are legally held to different standards. What the actual differences are idk, but the standards are not the same. I do not know if there's a difference between standards for DNPs vs. non-doctoral APRNs, though I would hope there would be if they're claiming to be "doctors" through "more education".

There won't be as the DNP is ~ with the NP... DNP is an attempt to blur the line.

 

[DPTinthemaking15]

I'm just a lowly pre-med trying to gain some insight. Why do physicians agree to oversee clinics like this? I understand you want to earn a few quick bucks, but I panic whenever my wife attempts to make the coffee. Are most clinics like this? I come from a small town and all of the clinics are ran by MD/DO's with no NP's on site.

 

[Raryn]

I'm just a lowly pre-med trying to gain some insight. Why do physicians agree to oversee clinics like this? I understand you want to earn a few quick bucks, but I panic whenever my wife attempts to make the coffee. Are most clinics like this? I come from a small town and all of the clinics are ran by MD/DO's with no NP's on site.

Money money money...

 

[Treebeard]

As Libertyyne pointed out, it would depend on who has the deepest pockets to grab out of, which is rarely the NP. If it's a case where there's physician supervision the physician will almost always be sued, whether that is the ethically correct or not. Same goes for NPs who work in hospitals or hospital-owned clinics.

Edit: Depending on how bad they mess up, they may be held accountable by the state's BoN. However, after talking to a ton of physicians about this, it seems like most BoNs don't do jack 95% of the time unless a higher authority gets involved. Their standards are far lower than state medical boards, so something that would potentially cost a physician their license may not even be a slap on the wrist for a NP.

If filing safety reports at hospitals is any indication, nurses are more interested in protecting their own than protecting patients.

 

[Psai]

If filing safety reports at hospitals is any indication, nurses are more interested in protecting their own than protecting patients.

There are so many ******ed safety reports that they aren't even worth bothering with.

They complained about eye redness after patient's eyes were taped. Yeah sorry that the redness that isn't bothering anyone else is bothering you. Maybe they needed their eyes not dried out to ****.

 

[Mr.Monster]

Although I am only an incoming MS1, I think the lawsuit only provides further reason to not hire an NP, or back an NP in practice, as a partner unless you fully trust them. Even then, I would be wary of their treatment methods and ensure to remain vigilant when reviewing their charts as the supervising physician. I could be 100% wrong, but that is what I learned after reviewing the case and the thread.

 

[Stagg737]

I'm just a lowly pre-med trying to gain some insight. Why do physicians agree to oversee clinics like this? I understand you want to earn a few quick bucks, but I panic whenever my wife attempts to make the coffee. Are most clinics like this? I come from a small town and all of the clinics are ran by MD/DO's with no NP's on site.

Mostly money. In some areas where there are legitimate physician shortages, physicians will supervise them so that more patients can be seen under the argument "sub-standard care is better than no care at all". Which would be fine if poor care didn't harm patients, but cases like the one above are a perfect example of how that's just not true.

 

[MedicineZ0Z]

There's plenty of doctors running these wellness clinics who prescribe huge amounts of testosterone, hcg, aromatase inhibtors, clomiphene, growth hormone, and thyroid hormones inappropriately.

Unfortunately, there's nothing unusual in this case.

Define inappropriate. AIs are an important part of your typical tren dbol test cycle and the serms which follow them of course. HCG has its role too, especially after years of cruise and blasting.

 

[libertyyne]

Although I am only an incoming MS1, I think the lawsuit only provides further reason to not hire an NP, or back an NP in practice, as a partner unless you fully trust them. Even then, I would be wary of their treatment methods and ensure to remain vigilant when reviewing their charts as the supervising physician. I could be 100% wrong, but that is what I learned after reviewing the case and the thread.

I am not a proponent of np independent practice. But generalizing to all NPs based on this one np is like generalizing to all physians based on dr.oz. these alternative and integrative wellness clinical are well-known for practicing lots of pseudoscience and over use of thyroid and testosterone. These doctors fully knew what they were signing on to.

 

[Raryn]

Define inappropriate. AIs are an important part of your typical tren dbol test cycle and the serms which follow them of course. HCG has its role too, especially after years of cruise and blasting.

A "test dbol cycle" using those things is not within the practice of medicine. I know very well what those things are used for by people abusing anabolic steroids - I just don't believe in that and don't believe medical providers should be participating in it.

 

[MedicineZ0Z]

A "test dbol cycle" using those things is not within the practice of medicine. I know very well what those things are used for by people abusing anabolic steroids - I just don't believe in that and don't believe medical providers should be participating in it.

Certainly not standard of care but the question is... when it does improve outcomes, why not?

 

[Treebeard]

There are so many ******ed safety reports that they aren't even worth bothering with.

They complained about eye redness after patient's eyes were taped. Yeah sorry that the redness that isn't bothering anyone else is bothering you. Maybe they needed their eyes not dried out to ****.

I had a nurse do ZERO vital signs checks all day long on a patient receiving a phase 1 first in human chemotherapeutic agent. This was both a protocol violation and insanely stupid.

Ultimately I got reprimanded by the head of nursing for filing a safety report stating this, because if the hospital ever gets sued the safety reports could be brought in as evidence.

As such, I will never file one of those again.

 

[libertyyne]

I had a nurse do ZERO vital signs checks all day long on a patient receiving a phase 1 first in human chemotherapeutic agent. This was both a protocol violation and insanely stupid.

Ultimately I got reprimanded by the head of nursing for filing a safety report stating this, because if the hospital ever gets sued the safety reports could be brought in as evidence.

As such, I will never file one of those again.

Unless you work in Florida those safety reports are protected. You should have reported the 'reprimand' to your supervisor.

 

[Raryn]

Certainly not standard of care but the question is... when it does improve outcomes, why not?

Because it improves outcomes *in abuse of testosterone*.

Aromatase inhibitors stop gynecomastia and clomiphene/hcg stop testicular atrophy it's true, but it's also true that most of these "patients" wouldn't be at risk for these complications if they weren't taking overly generous doses of testosterone for presumed gain. The drugs have a role in treating truly hypogonadal patients, but not when utilized as part of a cocktail from a random wellness clinic.

 

[wholeheartedly]

I had a nurse do ZERO vital signs checks all day long on a patient receiving a phase 1 first in human chemotherapeutic agent. This was both a protocol violation and insanely stupid.

Ultimately I got reprimanded by the head of nursing for filing a safety report stating this, because if the hospital ever gets sued the safety reports could be brought in as evidence.

As such, I will never file one of those again.

I'm a bit skeptical about this. Those types of things are generally protected from discovery or they wouldn't exist. You could always check with risk mgmt as to whats protected. If the head of nursing lied to you, that's a pretty big problem.

 

[Treebeard]

I'm a bit skeptical about this. Those types of things are generally protected from discovery or they wouldn't exist. You could always check with risk mgmt as to whats protected. If the head of nursing lied to you, that's a pretty big problem.

I no longer work at that institution, but I would not be surprised if she was lying. Unfortunately that particular hospital had an extremely toxic nursing culture.

 

[MedicineZ0Z]

Because it improves outcomes *in abuse of testosterone*.

Aromatase inhibitors stop gynecomastia and clomiphene/hcg stop testicular atrophy it's true, but it's also true that most of these "patients" wouldn't be at risk for these complications if they weren't taking overly generous doses of testosterone for presumed gain. The drugs have a role in treating truly hypogonadal patients, but not when utilized as part of a cocktail from a random wellness clinic.

Testosterone is just a base. It's not really the 500mg of test that's causing a lot of their issues (a minority at best), but rather the other compounds.

So you have a patient with a variety of side effects, including hormonal ones. What's your solution then when they refuse to get off the steroids yet you hold the cure in your hand? I mean safe injection sites are viewed as a positive thing yet medically helping steroid users is not?

 

[Raryn]

Testosterone is just a base. It's not really the 500mg of test that's causing a lot of their issues (a minority at best), but rather the other compounds.

So you have a patient with a variety of side effects, including hormonal ones. What's your solution then when they refuse to get off the steroids yet you hold the cure in your hand? I mean safe injection sites are viewed as a positive thing yet medically helping steroid users is not?

I tell them to stop and if they don't I dismiss them from my clinic. If they do have a willingness to stop, I'll work with them on a safe way to do so, and treat their subsequent symptoms.

I don't contribute to the continued abuse.

Similarly, if someone is abusing thyroid hormone (which you can easily buy online if you know what you're looking for) I don't continue to see them regularly to manage them with beta blockers and bisphosphonates for their arrythmias and osteoporosis. I advise them of the dangers of what they're doing and if they're not willing to change to a sane regimen I no longer see them. I suppose if their PCP sends them to me explicitly for the osteoporosis, I may treat that with clear documentation of my recommendations regarding the thyroid... But even then it would be +/-

 

[MedicineZ0Z]

I tell them to stop and if they don't I dismiss them from my clinic. If they do have a willingness to stop, I'll work with them on a safe way to do so, and treat their subsequent symptoms.

I don't contribute to the continued abuse.

Similarly, if someone is abusing thyroid hormone (which you can easily buy online if you know what you're looking for) I don't continue to see them regularly to manage them with beta blockers and bisphosphonates for their arrythmias and osteoporosis. I advise them of the dangers of what they're doing and if they're not willing to change to a sane regimen I no longer see them. I suppose if their PCP sends them to me explicitly for the osteoporosis, I may treat that with clear documentation of my recommendations regarding the thyroid... But even then it would be +/-

What if they're looking to come off? Why not give them the AI/Serms then?

And good to remember that most steroids used are not and never have been used pharmaceutically. In this case, why is it wrong to manage side effects? And side effects aside, what about risks? Ex. Winstrol can cause LVH and anyone on it should have an echo done. Orals are liver toxic and need constant liver monitoring. Is it no one's job to check these?

 

[Osteoth]

Yeah I agree this case doesn't say anything about NP incompetence. There are a zillion of these medical weight loss clinics out there and they all prescribe some similar combo of meds. Obviously these off label uses are not mainstream practice, but there are plenty of docs out there making buckets of money peddling some similar system. My guess is this suit gets tossed out eventually. That or they refocus and go after lack of informed consent, though I'm sure they probably had him sign a waiver about off label uses and risks of treatment.

If this gets anywhere near a courtroom, the NP's attorney will put all the blame on the supervising MD

Yeah my question is if it was just another weight loss clinic and they were being prescribed off-brand amphetamine & thyroid supplements, would this suit even exist?

There's plenty of doctors running these wellness clinics who prescribe huge amounts of testosterone, hcg, aromatase inhibtors, clomiphene, growth hormone, and thyroid hormones inappropriately.

Unfortunately, there's nothing unusual in this case.

If its properly communicated to the patients what the risks and benefits are and they use "supplements" instead of actual hormones, what's wrong with that?

It'd be nice if this case served as an indictment of all of those shysters, but I doubt we'll be that lucky.

Haven't you heard friend, medicine is a business now. As a profession we're being incentivized day in and day out to make more money, make more money.

Let the fools enjoy the ruin they've created.

You're all missing the point here, which isn't that "physicians do this too" (of course it happens, crappy people all over healthcare). The point is that this is a case where the NP is named as the primary defendant and is actually being held liable for his actions instead of the supervising physician or hospital (which is what pretty much always happens). It's the first example I've seen of a patient or family going after the NP with a good chance of actually winning instead of going after the supervising physicians alone or just the whole clinic/hospital. So the point wasn't "oh, this person screwed up". It's that an NP may actually be held liable for medical malpractice in a court of law, which as far as I know would be a precedent, especially in states where NP supervision is required.

Of course, and I'm not under the illusion that this case will suddenly turn any tides or even make a significant or immediate difference. However, I do hope they actually take this to trial and don't just settle, as it could be an initial signal that NPs have to be held to the same levels of liability as physicians when they decide to act as physicians. Is that likely to happen? Probably not, but it's nice to see that someone is at least trying to hold them accountable and not just letting them hide behind the supervision shield (especially since there was no supervising physician within 100 miles of the clinic).

Firstly, I think the idea of it being about practice is a little off. To me its more about ownership. Regardless of who committed the crime they are going after the people with the most liquid assets they can pilfer, the NPs who own the clinic. If it was the docs they would most likely be on the suit alone I assume.

I doubt the case goes to court for the simple reason that in cases where mistakes are made malpractice attorneys have a fairly high limit (~$500k IIRC) they can offer to plaintants to just go away. Versus the prospect of spending huge chunks of time & money in a long protracted court battle, most people settle.