Shocked by MD attitude

[FullGlass]

I'm a new grad NP on my first job, so am on a steep learning curve in a rural primary care clinic. A female patient came in with her children and hubby for an urgent appointment. She had seen her regular doctor the day before for what she thought was a cold or flu, but now reported she felt worse and was jaundiced since this morning. She looked really sick and as I began the physical exam, she began crying due to anxiety and just feeling horrible. She was slightly jaundiced and had abdominal tenderness over her entire abdomen. The patient and her husband were also upset because when they saw their regular MD the day before, just as he was leaving he said her annual labs indicated some liver issues, but that they would have to come in for another appointment to discuss those (LFTs elevated twice the high end of normal). While the patient was in the bathroom leaving a urine sample, her husband told me he was thinking of taking his wife to the ER. He also said he knew his wife was an emotional person (which I remembered from the one other time I saw her), but he strongly felt there was something really wrong. He wondered if he should take her to the ER. My honest response was he knew his wife better than me and he needed to trust his gut feeling. I also felt something was seriously wrong.

I have a good relationship with this MD and I later reported to him what had happened. to my astonishment, he was upset because "it make him look bad" that I had said to go to the ER! He ranted on and on, said her liver issues were trivial, they were (several four letter words) and so on. He never asked how she was doing. I asserted that 1) I didn't want him blindsided if they complained about him (he doesn't have the best interpersonal skills), 2) I couldn't forbid them from going to the ER, 3) we are in a rural area and if I had ordered more tests, it would have been a 48 hour turnaround and 4) in my clinical judgment something was really wrong with her. That shut him up.

The next morning, as I walked into the office we share, first thing the MD said was ranting about that patient and he bet there was nothing wrong with her and I should call her. A couple hours later during a break, I did call her. She was glad I called and said she was admitted to the hospital and still there; a lot of tests had been run and no diagnosis had yet been made. When I reported this to the MD, he was visibly surprised, but then began ranting again! I was shocked and dismayed. Again, he didn't ask how the patient was doing. If the hospital admitted her, this clearly was not a trivial issue.

My school taught us to trust the patient and their family if they felt something was seriously wrong, and also to trust our own gut. This is because a toddler had died in that hospital when staff ignored the mother's conviction that something was seriously wrong with her child, prompting a vigorous quality improvement program for the hospital and associated schools.

I feel I did the right thing, but was very upset by this MD's attitude. If the roles had been reversed, my first concern would have been for the patient. Is his attitude common?

[BostonFNP, APRN]

BostonFNP you are so right!!!! The first year I worked I think half of my orders in the hospital were canceled by the MD!!! If I had a dime for every time I was asked "why did you order the test and what are you going to do with the results?" (in a very constructive / teaching manner). When I look back I am amazed at how much I learned in that first year. I ask myself that same question when I'm having trouble making a decision.

I think we have all gone through this, and while self-reflective practice is crucial to build our practice foundation, it also speaks to the importance of having mentors/collaborators in practice.

I use that same technique with students! I make them give a solid rationale for each test they want to order with what they are looking for and what they are going to do with the results.

[Jules A, MSN]

Did the patient need to be in the ED or admitted? Maybe, maybe not, it doesn't really matter. There was a clinical presentation you weren't comfortable with and you sent the patient for further eval: this is good practice. Are LFTs in the 2xULN an emergency? No, but you can't make decisions in a vacuum, it takes your assessment of the patient. You can follow this patient's admission, see what else was ordered, and then adjust your practice accordingly for the next patient you see with similar presentation.

And consult the MD next time as he made it clear that at this time he prefers patients aren't sent out without his oversight.

[BostonFNP, APRN]

And consult the MD next time as he made it clear that at this time he prefers patients aren't sent out without his oversight.

Yeah I think my big question would be (if I were the PCP) is that the ED is not a place for mystery diagnoses: what did you send the patient to the ED for? What was your differential? There should be a solid clinical suspicion to discharge to the ED. We call expects into our ED so when training I make sure that students are fully prepared to answer the ED providers questions, most of all, why are you sending this patient. I hate getting dinged on quality measures for ED visits, but sometimes there is just no avoiding it.

[rachelwestern]

You were doing your job... I always imagine the outcome of my actions (or non-actions). If I don't suggest she go to the ER and follow my gut feelings... what can happen? Well in worst case scenario she could die. So you made the right call. It's your patient too, and her outcome is your outcome as well as that MD. Whether he cares about her personal well-being over his ego is his problem. You can stand by your decision knowing you made the right call. :)

[traumaRUs, MSN, APRN]

Sending a newly jaundiced pt with diffuse abd pain to the ED is acceptable IMHO and I'm an experienced APRN in a rural setting. There would be no way to obtain quick testing or referral in my areas.

[BostonFNP, APRN]

Sending a newly jaundiced pt with diffuse abd pain to the ED is acceptable IMHO and I'm an experienced APRN in a rural setting. There would be no way to obtain quick testing or referral in my areas.

I don't think the ED referral was necessarily inappropriate, but we are missing some information.

The patient was seen the day before and had labs done. Had the symptoms acutely changed since that visit/draw?

What was the bili from the day before?

Was there an obstructive pattern on the LFTs?

What was the transaminase ratio?

Jaundice on exam include icterus?

CBC normal?

[FullGlass, BSN, MSN, NP]

This MD is not my boss and I don't have to ask his permission. I have provided a separate response with additional updated detail.

[FullGlass, BSN, MSN, NP]

Update: The patient was in the hospital for 2 days. I don't want to be too specific. She had an internal abscess that was hard to find and there is no way we would have found it at our clinic. She was going into sepsis. Therefore, I made the right call in sending her to the ER. The MD admitted that. Now, to answer some of the points that have been raised:

1. Yes, the patient's condition had worsened in the 24 hours after seeing the MD. That's why she came back in and she saw me because that MD did not have an appt available.

2. My concern was that the MD did not give a hoot about the patient, only about his ego and looking bad. He can rant at me all he wants - I can handle that.

3. I did inform him of my decision to send the patient to the ER in a professional manner and wanted to give him a heads up. I also had a feeling the patient would complain and didn't want the MD blindsided. Given that I am used to dealing with Fortune 500 senior executives, I am confident in my interpersonal skills.

4. His behavior made me wonder if I can trust an MD myself. Will they be more concerned about being "right" or about a patient's welfare? Pretty troubling.

5. This patient and her family lodged a formal complaint against the MD and refuse to see him again.

6. It is not my job to provide a definitive diagnosis to the ER. I would have had no way to do that in this case. A large hospital does have all the equipment and personnel to handle this type of issue.

7. I was taught to trust my gut - my clinical judgment. This patient looked bad and my gut said something was seriously wrong. I was right.

8. One must consider liability. If a patient and their family are convinced something is seriously wrong, then poo pooing it could lead to serious legal consequences if something is indeed wrong, as it was in this case. At any rate, I can't forbid the patient from going to the ER, either.

9. Finally, this MD has serious deficits in interpersonal skills. Until this week, I have actually defended him staunchly because he is generally a good MD and we need MDs out here. However, pretty much everyone in the clinic hates him. He is rude to anyone he does not consider his "equal." He has made the Medical Assistants (MA) cry. He has been talked to by the Medical Director at least three times that I am aware of. It got so bad that his own MA refused to work with him anymore, so the MAs had to take turns working with him. So now he has disrupted and annoyed all the other providers in the clinic, including the other MDs and finally, me. He has also upset other MDs in the community outside of our clinic. I have an excellent MA and work well with her. She had to work with him this week, and while I am fine with all the MAs in the clinic, I had 3 different MAs in 2 days this week, which really threw me off at work, because it takes time to establish a work rhythm with a new person. My MA was upset, too. I took this job offer over the other 8 I received because I just had just a good vibe from all the people at this clinic. Until this MD arrived, it was a very harmonious place and he caused all this disruption and unhappiness. In addition, while some patients like him, several patients have complained about him. So, the latest is the CEO of our system called the MD in for a talk. That is not good.

This man clearly knows how to be nice and polite. He just chooses not to be so to people he considers "beneath" him or who won't stand up to him. Not good.

[yogagal]

Sounds like he might not last long there. I've come across those types of docs over the years at FQHCs, sometimes I think they end up there because no one else will hire them and as you know all FQHCs are usually in desperate need of MDs. Sounds like you did everything right. But now that you have experienced his toxicity first hand I would just send him an EHR message if something similar happens again: "FYI, saw your patient, she was worse, sent her to the ER, see my note for details. Let me know how she is if you see her again." Make sure its a very detailed note.

[Nurse Beth, MSN]

As to the physician - I have had a few who have ranted and sworn at me. However, I am old and mean and I tell them (very quietly) that when they can control themselves, I will be glad to discuss the issue as professionals. Then, I walk away.

When I was a new APN, there was a doctor that I worked with who would throw me under the bus, get in the drivers seat and run over me a couple of times just to make sure I understood my position in life. However, he was not well thought of as a physician or person and ended up leaving the practice.

I spoke to another physician whom I trusted and he gave me some pointers on dealing with physicians like this:

1. Realize they have interpersonal issues. Sometimes its best not to give too much info. So, in this case, I would say, "the husband wanted his wife seen in the ED." And end the conversation there. As you stated, you had nothing more to add as the physician already knew about the test results and he deemed them "okay."

2. If a physician or any colleague starts to get out of control, stop them by making good eye contact, speak very softly and tell them this behavior is unacceptable. Then leave the situation. There is never a reason to tolerate an out of control person.

3. Always keep your focus on your patients' well-being. YOU were the one seeing the patient the next day, not the physician. In instances where I have contacted a physican and felt the patient was more ill then what the physician thought, I always state, "in seeing the pt today, they appear acutely ill and have changed from when you last saw them due to (and then name the new symptoms), "shie is now jaundiced with sceral icterus and diffuse belly pain." Very few physicians that are not seeing the patient with you will disagree with this strategy.

4. As to making him "look bad" oh well. Its not about US, its about the patient.

Excellent advice. Should be included in NP programs and nursing programs!