Need advice in dealing with a "contrary" Psychiatrist

[Nikilea]

I would greatly appreciate any feedback/advice as to how to a handle a situation that occured today . I am currently working as a Nurse case manager for an agency that provides residential services for CMI patients. The Psychiatrist that oversees my clients is also employed by the company I work for. Yesterday at a routine appointment with a new admit he, in my mind, professionally berated me in the presence of the staff at the appointment, as well as the client.Staff reported to me today that he was quite verbal about the patient being inappropriately medicated. Some background... This patient transferred to our facility from another area, and 2 days later ran away from the Group Home. They were found darting in and out of traffic and very psychotic by the local police. Our agency through their Access folks obtained an immediate in-pt. stay for med stabilization. Upon discharge from the hospital, there were some medication increases. Nothing unexpected or greatly increased. Our Dr. proceeded to tell both the patient and the staff that I, and he used my name, had improperly medicated this patient. That the discharge orders from the in-pt. Doc were merely suggestions and HE is the patient's "attending physician". I have never had an incident like this occur in 14 years of nursing. I have always treated discharge orders as discharge "orders". I did not contact this Dr. as he was not familiar with this patient and had not seen them for initial intake. I am more than a little confused, and dismayed that he would make comments to the the patient and staff that were inappropriate and in reality not true. Would appreciate any comments/suggestions on what I might have done differently or better next time? ps I have only worked with this Doc a short time and have been told by colleagues that he is a little short tempered and "difficult" at times. Hellllpppp

[elkpark]

I have also been contemplating the many replies to my dilema. Maybe I wasn't too clear. The patient in question had been at our facility approximately 2 days; had not been treated as of yet, by of our out-pt. Psychiatrist when she went into the hospital.

Well, who-the-hecks' med orders were being followed to medicate the client for the two days she was at your facility before she went to the hospital? I have run into situations like this as a surveyor for my state -- the agency administration needs to explain to the doc(s) that he (they) are getting paid big bucks to be RESPONSIBLE FOR THESE CLIENTS, and he (they) need to step up to the plate and do their friggin' job! If not, the agency needs to find new docs who are willing to do so. Otherwise, client care suffers and the nurses get left to dangle in the wind ...

I am having a hard time understanding how any nurse could feel that it is better to go back to the old drug regimen pre-hospitalization for a stabilized patient while awaiting a reply from the out-pt. doc?

I was not suggesting that you return to the old regimen (esp. if that wasn't ordered by your treating psychiatrist, either!! Who was it ordered by? How can you admit someone without some kind of admitting orders from your doc?) The issue is that you have no valid (legal) medication orders for this client from a physician authorized/privileged by your agency to treat its clients. The docs need to be available to you, at least by 'phone, for these kind of situations -- that's what they are getting paid for, and what they are legally responsible for.

As for "suggestions"vs orders. The "suggestions" I received from the Hospital were on legal prescription pads.

Now, if you were admitting someone to an inpatient unit, psych or med-surg or whatever, and s/he arrived with a handful of Rxs written by a physician somewhere else who did not have practice privileges at your hospital, would you "honor" those Rxs and give the client the meds without orders from "your" physician? No, no, no, no, no ... This situation is no different. As maureeno noted, your most appropriate action is to at least contact the treating (agency) doc by 'phone, review with him/her the discharge med recommendations from the hospital, and get orders from your doc. That covers you until the doc can see the client ...

I think the lesson here for our agency is to develop a protocol that ensures the highest quality patient care!

This is always the lesson! :) I hate to sound like a nag, and I'm not trying to be critical of you, specifically -- you're just getting caught in the middle, and the agency administration and the docs need to sort all of this out. I have been a surveyor in psych facilities in my state for the state and the Feds for the last several years, and it has always amazed me how often I have had to explain the legal basics of predicaments like this to RNs, MDs, and administrators. You and your agency would be in serious trouble in my state in the situation you describe if the state regulatory agency found out about it. However, the rules in IN may be completely different and you may be fine ... But, the agency needs to be sure that y'all are in compliance with your state rules/regs, that the docs are doing the job they are getting well-paid to do, and that the clients' needs are getting met appropriately. Best wishes!

[steelcityrn, RN]

I am under th assumption the psychiatrist who seen this patient and tx this patient wrote their own orders, which just so happened to have been meds this person was on, with a alt in dosage. With this persons behaviors, that would be very possible to have similar orders, esp with psych meds. I still feel this nurse did nothing wrong.

Well, who-the-hecks' med orders were being followed to medicate the client for the two days she was at your facility before she went to the hospital? I have run into situations like this as a surveyor for my state -- the agency administration needs to explain to the doc(s) that he (they) are getting paid big bucks to be RESPONSIBLE FOR THESE CLIENTS, and he (they) need to step up to the plate and do their friggin' job! If not, the agency needs to find new docs who are willing to do so. Otherwise, client care suffers and the nurses get left to dangle in the wind ...

I was not suggesting that you return to the old regimen (esp. if that wasn't ordered by your treating psychiatrist, either!! Who was it ordered by? How can you admit someone without some kind of admitting orders from your doc?) The issue is that you have no valid (legal) medication orders for this client from a physician authorized/privileged by your agency to treat its clients. The docs need to be available to you, at least by 'phone, for these kind of situations -- that's what they are getting paid for, and what they are legally responsible for.

Now, if you were admitting someone to an inpatient unit, psych or med-surg or whatever, and s/he arrived with a handful of Rxs written by a physician somewhere else who did not have practice privileges at your hospital, would you "honor" those Rxs and give the client the meds without orders from "your" physician? No, no, no, no, no ... This situation is no different. As maureeno noted, your most appropriate action is to at least contact the treating (agency) doc by 'phone, review with him/her the discharge med recommendations from the hospital, and get orders from your doc. That covers you until the doc can see the client ...

This is always the lesson! :) I hate to sound like a nag, and I'm not trying to be critical of you, specifically -- you're just getting caught in the middle, and the agency administration and the docs need to sort all of this out. I have been a surveyor in psych facilities in my state for the state and the Feds for the last several years, and it has always amazed me how often I have had to explain the legal basics of predicaments like this to RNs, MDs, and administrators. You and your agency would be in serious trouble in my state in the situation you describe if the state regulatory agency found out about it. However, the rules in IN may be completely different and you may be fine ... But, the agency needs to be sure that y'all are in compliance with your state rules/regs, that the docs are doing the job they are getting well-paid to do, and that the clients' needs are getting met appropriately. Best wishes!

[CharlieRN]

Back when I was an EMT(emergency medical tech), many years ago, they taught us that when we came on an accident scene, to ask loudly, "Who is in charge?" If no one answered, the EMT was. That only works in emergencies. But the primery question always remains, who is in charge. With the power goes the responsiblity.

From my perspective, and if I am reading Nikki's situation correctly, she was left in a situation analogus to the EMT at an accident. As I understand it she had made vigorous and documented attempts to reach the doc of record and he had not responded in a timely manner. Her organization does not have a designated back up MD who can be called if the attending does not respond. Like the EMT, she is the highest ranking medical person present. She is responsible to treat the patient to the best of her ablity and judgement. If she judges that the patient will suffer significant harm by not being medicated, and judges that the pre-inpatient stay meds were inadequate to maintain safety, then her judgement to use the suggested discharge med doses is justified.

This defense does not claim that the scripts given by a doctor who had discharged the patient are valid orders. It does not deny that Nikki was practicing medicine. It says she had to do those things to maintain patient safety.

The practical problem with this defense is that it is based on the attending having abandoned his patient. Abandonment of a patient is a big time NO-NO. The doctor can lose his license over this. He is not going to say meekly "Sorry, my bad." He is going to fight tooth and claw. He is the doc, he has the unlimited licensure. He is the heavy weight, if you let him make it a fight between him and you he is the odds on favorite. So don't let it be between him and you. Forget that he was rude to you. You are not going to get an apology. If he apologizes he admits he was wrong and by extention that he had abandoned his patient. Make the issue be between your organization and him. The situation was that a nurse was forced to act outside her licensure to maintain patient safety. This is not a new situation, other docs had gotten away with dumping the responsiblity on the nurse by being polite and nice to her. That' bull s**t.

The question is always, "Who is in charge?" The concern is always, "patient safety". The standard is "Do no harm." As Elkpark said your facility needs to make the docs do what they are paid for. Or set policies in place so that the in patient doc's orders are to be followed until the out patient doc sees the client. Nikki and the other nurses at her facility need to know who to call when the attending does not respond to a page. Even a clear statement that the inpatient docs orders are never to be followed until contersigned by the attending is a victory for you.

[medpsychRN]

Making a "mistake" doesn't give someone else license to verbally abuse you. To do it in front of a patient (psych no less) is unprofessional. It is staff's responsibility to model appropriate behavior. The psychiatrist has now given a message to the patient that it's okay to behave this way. Which, depending on the circumstances, could land him in jail or restraints!

Once you've allowed the behavior to go unchallenged, it is an invitation for it to continue. I wonder since this psychiatrist sees no harm in treating staff this way, how he treats patients behind closed doors.

[CharlieRN]

Let's agree that Nikiki"s doc is an ***. There is no law saying he has to be polite to anyone, not even his patients. The things he called Nikik on were violations of law. The things he was guilty of were violations of law. Its a whole different level of bad.

If she wishes to make that complaint too, she can. It would damage her case since it would bring up a personal issue. The defense would be made that she was just accusing him of abandonment because she was offended by his manners. In fact, that is the case, but we will not win by letting it be seen to be so.

Perhaps later, if they are both still working in the same facility and he is still rude she could ask her supervisor to speak to his supervisor about it.

[nursethis]

Thought provoking thread. Work at a CMH and pick up many coming from inpt psych. Write our own orders before administering any meds.