Need advice in dealing with a "contrary" Psychiatrist

  1. 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
    Last edit by Nikilea on Feb 8, '05
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    About Nikilea

    Joined: Jan '00; Posts: 6
    RN/ Health Services Admin. ICF/MR

    17 Comments

  3. by   SarasotaRN2b
    He sounds like a peach...not! I think that I've gotten to that age where I would confront him, albeit more professionally done than he had, and would let him know that I DO NOT appreciate being talked to in that manner or tone. That if there is something that needs to be addressed, that I would be happy to meet with him. You did nothing wrong. He just seems to have a "God Complex" thinking that he is the be all, end all. Is he your supervisor? If not, I would speak with the supervisor and get advise to best handle this.

    Best of luck!

    Kris
  4. by   StuPer
    Firstly I suppose you have to give him an opportunity to apologise, it sounds like it is'nt likely to happen but still you are showing courtesy that he didnt by giving him that chance.
    Secondly does your company have an official complaints procedure, if so use it, however before you do ensure you have written statements from witnesses and any coroborating evidence which backs up what your saying. It has to be virtually written in stone that he inappropriately abused you infront of patients, fellow professionals and made statements which were untrue.
    This Should make the company take action, if this fails I would then use any professional unions you belong to to put pressure on the company to act.

    The biggest problem nurses run into in this situation is that comparatively nurses are 2 a penny comparied to psychiatrists, hence nurses can be seen as more expendable than doctors.... sad but unfortunately this can be a reality
    regards StuPer
  5. by   medpsychRN
    Unfortunately I had something similar happen when a psychiatrist complained to the staff in the nursing station about me. I asked to talk to him privately when he came to the floor and he ..well, went nuts! He reported me to my supervisor, the head of the department (MD and RN). It was awful. I was not in any way inappropriate. We had to have a meeting over it. It was bizzare. So bizzare I turned in my resignation about 20 minutes after the meeting. Turns out this guy had a reputation for this kind of nonsense.

    I'd try the supervisor route. Maybe they have some insight.
  6. by   elkpark
    I agree with everything the other posters have said about responding to the inappropriate and unprofessional treatment by the doc. However, I'm also struck by the other issue in your OP.

    When the doc talked about the patient being "inappropriately medicated" are you saying that the issue was that the patient was given the increased dosages from the inpatient discharge instructions without the physician who treats the person in the group home on an ongoing basis being aware that the dosages had been changed? Because that is a rather sticky wicket ... Once the person leaves the inpatient unit and returns to the group home, those physicians are not treating the person anymore, and the physician responsible for the group home is.

    I would not consider "discharge instructions" from the inpatient hospitalization to be valid "orders" for the group home staff to follow -- the inpatient unit docs have no authority or privileges to treat at the group home. Same as when a patient is admitted to an inpatient psych unit and has been taking meds on an outpatient basis -- the inpatient nursing staff can't automatically give meds prescribed by some psychiatrist out in the community; you have to get orders from the admitting or attending doc to give any meds to the person. Your situation at the group home is not really any different. Discharge instructions really are just "suggestions," not valid physician orders ... The argument could be made that the person was medicated without orders (from the legally responsible doc), in which case any licensed nurses involved would be well outside their scope of practice.

    Does your agency have a policy about this situation (which must come up fairly often ...)? If not, maybe a policy needs to be developed (with the involvement of the agency MD) so that everyone will be singing off the same page in the hymnbook the next time this happens. Perhaps the agency doc needs to be called for new orders when clients return to the group home from an inpt. hospitalization, or some other system developed for making the transition back to the care of the agency doc (y'know, of course, there's nothing stopping him from picking up the 'phone and calling the person's inpt. attending or attending a treatment team meeting at the hospital to keep up with what's going on with his client, but we all know how likely that is, right?)

    Again, I am not defending in any way the behavior of the doc towards you in this circumstance -- but the clinical issue is one that needs to be sorted out before the next time. Best wishes.
  7. by   lucianne
    That issue struck me as well, Elkpark. I don't think the psychiatrist handled it professionally, but he still should have been the one give any med orders once the patient was back in your facility.
  8. by   peaceful
    Quote from 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
    Wow i feel for you on this one. Thanks for sharing because we all can learn from your experience. My first reaction is what the doctor is accusing you of is serious. Of course we follow discharge orders but we are to call attending doc as soon as back at facility. Do you have support from your supervisor? I would definately use the chain of command. Do not talk directly to him about this yet. Remain professional. If there is no policy on this at your facility, suggest that this topic needs to be researched and written. Do you think this is one of those situations that will go just go away?
  9. by   CharlieRN
    Elkpark has it right. Discharge orders are suggestions. In following them rather than orders written by the attending at your facility, you are simply wrong.
    Worst case: charged with practicing medicine without a license. Theoretical jail time, quite possible loss of your RN. Best case: you are following established but, possibly not written, facility policy. You could approach your supervisor about that but I'd recommend you go through the policy book carefully before you do. Picture going in all huffy about how you had been mis-treated and being shown chapter and verse of company policy requiring that meds be given only according to the orders of the attending!

    I have had personal experience with following 'established practice' that was not accepable within the policys of our facility.
    I work in admissions and when we had out of control patients in the unlocked admission area we were in the habit of admitting them directly to the locked unit and doing the assessment there.
    Then one of my peers got reamed for doing that by one of the psychiatrits. We were all indignant since we felt we had been acting to maximize our own and patient safety.
    But admission legally is by doctor's order only. By physicaly putting a patient on a locked unit, we, not the doctor, had admitted them.
    There may be cases where, after assessment, we present the case to the doc and he determines that there is nothing we can do for a particular patient, or that inspite of fuss they were making in the admissions area, they don't meet level-of-care requirements for our facility. Perhaps the Doctor has had this client before and knows he has a history of intentionally disrupting the treatment of other patients, and does not want him back. If the patient is on the unit already we are stuck with him. If he is inappropriate for our facility, admitting him is malpractice. Understandably doctors like to make their own mistakes, not just be responsible for ours.
    Sorry to rain on the parade.
  10. by   maureeno
    we call the attending doctor
    informing of the discharge meds
    which are usually continued
    at least until the client sees our doctor
  11. by   medpsychRN
    I've been thinking about this post for several days. Yes, the OP should have followed policy and procedure regarding meds. Yes, the worst case would be she'd be fired and lose her license. But does the crime justify the punishment? No.

    There's something wrong here. The doc's behavior is way out of line. I would go to my supervisor admit my mistake and describe the incident. This is probably not the first time the doc has acted this way.
  12. by   Nikilea
    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. I know of no policy at my agency regarding notification. I have made several attempts to notify this Doc about the patients he is familiar with and usually end up getting no response, or a casual response if I am at the office where he sees our clients. As for "suggestions"vs orders. The "suggestions" I received from the Hospital were on legal prescription pads. 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 have the support of my superiors on this situation, as it has not been an issue with any of our other Docs. I do understand how this may be a protocol in certain systems, but our system is pretty scattered with no Docs doing in-patient rounds at any of the facilities we use. I think the lesson here for our agency is to develop a protocol that ensures the highest quality patient care!
    Last edit by Nikilea on Feb 12, '05
  13. by   steelcityrn
    IM sorry, but I totally disagree with those here saying what you did was wrong. In the first place, this impatient order was written post inpatient stay by the physician that seen him. I am sure this DR did not wright "AS A SUGGESTION" on his dch orders. For you to have excepted another physicians order, first off that hospital would have to have written permission to except or even share info with this patient. You stated this physician had not even seen this patient yet. This should even further release you from any fault, since this physician had not even physically seen this patient yet. Sure it sounds like communication could be improved in the future from this, but you in no way have done anything wrong here ...to me...I would not discuss this with the physician, just your manager and maybe brainstorm how if this very same situation were to occur, and after reading it several times I can see this would be rare, you two can think of a ways to improve the communication.
    Quote from 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
    Last edit by steelcityrn on Feb 12, '05
  14. by   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 *******' 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!

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