Sick of other NPs abusing patients - psych practice

[FullGlass, BSN, MSN, NP]

Would greatly appreciate advice on dealing with this situation.  I am a PMHNP working in a psychiatric outpatient practice in California for 3 years.  The type of behaviors described below have happened a lot here and for the past 1.5 years, I have been one of the primary providers cleaning up these messes and I am sick of it.  I have repeatedly complained to management, to no avail.  NP AA, in particular, has done this over and over, also trying to dump any pt taking a controlled substance, including ADHD pts, on me.  This is a long post.

This pt, Jane, an older female, had her first appt with me recently.  Prior to that, she was seen by NP AA and NP BB (neither are PMHNPs).  I was appalled by what the patient told me and what was documented in her chart by AA and BB.  A summary of events is provided below.

1st appt - Intake by BB.  The pt reported that her previous psychiatrist, that she had seen for 20 years, had very suddenly died recently.  He had prescribed PRN Xanax for many years.  Pt was very distressed by his sudden death, as she liked him very much.  [The pt was stable on her med regimen at that time and did not ask for any adjustments.]  The pt does not take Xanax every day .   According to the pt, BB told pt that after her current RX of Xanax ran out, it would not be refilled.  BB insisted that pt switch to clonazepam instead. Per my CURES review, pt had only had 2 refills of clonazepam in 2 years prior to this appt.  Dx:  anxiety and depression.

2nd appt – Talk therapy intake

3rd appt – F/U w/BB.  BB wrote an RX for clonazepam and noted pt was compliant.

4th appt – F/U w/BB.  Per the chart note, the pt reported the clonazepam was not working.  This is consistent with what the pt told me.  Pt was switched to diazepam.

5th appt – F/U w/AA.  AA noted in chart:  "Patient has no HX of BZD dependence "can go days without taking it" . . . emotional dependence 30 years of Xanax noted.  States " No I won't take 80 mg of Prozac [this would be large increase].”  Comment:  Given pt's CURES record, this statement is ridiculous.

For some unfathomable reason, AA then proceeded to diagnose the patient with Narcissistic Personality Disorder!  She noted the following behaviors in the pt's chart:  "Jane exhibits symptoms of narcissistic personality disorder, characterized by a long-standing pattern of grandiosity (either in fantasy or actual behavior), an overwhelming need for admiration, and usually complete lack of empathy towards others. Jane has a grandiose sense of self-importance. Jane expects to be viewed as "special" even without appropriate achievement. She feels that her problems are unique and can only be understood by special people. Jane fishes for compliments, often with great charm. She has unreasonable expectations and expects favorable treatment from others. Jane has explosive outbursts, in which others are taken advantage of in order to gain an advantage.”

AA further documented:

N0 XANAX refills provided as requested - denied

NO future refills of BZD recommended

Vistaril 10 mg PRN

increased prozac 50 mg to 80 mg x 2 W recommended --patient resistant

FU w/ different provider in 2 W recommended

AA added following diagnoses to pt's chart:

Narcissistic personality disorder, F60.81 (ICD-10) (Active)

Patient's other noncompliance with medication regimen, Z91.14 (ICD-10) (Active)

Comments:  AA is NOT qualified to diagnose Narcissistic Personality Disorder, or any other personality disorder, for that matter.  In addition, personality disorders can't be diagnosed in one appt.  The talk therapist did not note any indications of a personality d/o.  Furthermore, during my appt with her, the pt did not exhibit ANY of the NPD behaviors noted in this chart note.  She was very pleasant.

Why did AA dx the pt with noncompliance?  The pt tried clonazepam and diazepam and reported those meds did not work for her.  The pt did not want to take an increased dose of Prozac, which is her right.  Her previous med regimen was working fine, and the pt was justified in not wanting to change it.

6th appt - f/u w/BB.  After the appt, BB wrote a rather hysterical and spiteful non-chart note containing many untruths:  "Patient had an appointment scheduled with me. She previously seen AA and was appalled that her medications are not working. She has been receiving Xanax from her previous provider, and per her story he cut her off Xanax.  [Comment:  Untrue.  Dr. Rogerson died].  She was unhappy with me as well and asked "Who in the damned office can prescribe me Xanax ? I stated that per our medical director this office/ practice does NOT prescribe Xanax.  [Comment:  Untrue. While efforts are made not to do so, sometimespProviders here do indeed prescribe Xanax if other antianxiety meds do not work].  She said that "well, I guess we have nothing to talk about, do we?" and hang up on me.  Patient does have a lengthy dependence on Benzodiazapines.  [Comment:  Untrue, and this is clear from CURES review].  In February 2023 I prescribed her 0.5mg of Clonazepam #60.  She complained that it " did nothing for her" explaining she has panic attacks all day long.  In March 2023 I prescribed Valium 5mg #60 and that did not work for her as well.  She is, as it seems has a benzodiazepine addiction and plans on doctor shop.”  [Comment:  This is not true, based on CURES review and there is nothing to indicate the pt plans to "doctor shop.”]  I advised for her to seek treatment before and she refused.”  [Comment:  Why would pt seek addiction treatment when she is not addicted?]

7th appt – f/u with me.  I restarted pt on her original med regimen, as she had been stable on that for a long time.

Conclusion:

This sequence of events almost made me cry and I alternated between sadness and anger for quite some time.  My philosophy when treating patients includes "if it ain't broke, don't fix it,” especially with older patients, as change can be upsetting for them.  I learned this from my mentor on my first NP job.  The conduct of the other NPs only further increased this pt's anxiety and caused her great distress.  BB and AA also had ridiculous interpretation's of pt's statements.  If a med does not work for patient, the patient has a right to say so and request an alternate med!  That is NOT "noncompliance.”  In addition, when a pt is treated as if they are an addict, they tend to get defensive!  If pressed, the pt can become frustrated and irritable, as well.  That does not mean they are an addict.  In criminal law, one is presumed innocent until proven guilty.  AA takes the opposite approach, guilty until proven innocent.  Treating patients who take controlled substances with such suspicion is not conducive to developing a therapeutic alliance, which is the most important factor in treatment success. 

It is clear that BB and AA either did not bother to actually review the pt's CURES hx or did not understand it.  As noted above, per CURES, the pt's RX history does NOT indicate benzo addiction!  The pt on had 2 Xanax refills in 2 years! 

AA wrote false documentation.  This is unethical and it is also a crime.  She is NOT qualified to dx narcissistic personality disorder and that dx can't be made based on 1 appt.  This was simply spiteful and vindictive, as well as unethical.  It is libel and could be viewed as elder abuse.  Therefore, it represents a significant liability risk.  This type of false documentation (personality d/o and addiction), if not corrected, can follow the pt and cause them a great deal of harm.  This is an additional liability risk. 

I am wondering if I should report the NPs to the State Nursing Board.  I am sick of complaining to management and they seem to do nothing, because the behavior does not change.  An especially outrageous example:  I was on Xmas vacation.  One of MY ADHD pts had his regular monthly appt w/another provider b/c I was out.  That provider demanded, on Xmas Eve! That the pt go get an MRI or he would not get a refill.  The pt was about to travel for his Xmas vacation, leaving later that day.  Mgt tells me they will talk to these NPs, but it keeps happening, especially by AA!

[Gentleman_nurse, MSN]

Hi FullGlass

First, breathe!

Second a few questions.
From your post, it seems the others are certified in primary care, not psychiatry. What is the current scope and practice of NP's in your state? For mine, primary care and psychiatry are separate licenses.

What is the organization of your setting? In most places I've worked psychiatry and primary care are separate departments.

What is the nature of your working relationship with these other NP's you have concerns with? Is it cordial or tense?

What is the level of their experience? early career or experienced?  

Lastly, have you obtained the patient's medical records from the last psychiatrist?

[egg122 NP, MSN, APRN]

May I ask if you have had a conversation with them before deciding you want to report them to the board?

 

Also, in psychiatry the customer is not always right - if that were true I'd be continuing a patient who recently came to me on Klonopin 1 mg qid + diazepam 10 mg tid+ Ativan 1 mg qid + Xanax 1 mg qd + lunesta 3 mg because their last prescriber gave it to them and "nothing else works.” Providers can decline to give meds they do not think are appropriate. 

[FullGlass, BSN, MSN, NP]

In California there is just an NP license.  It does not separate out by speciality.

This is telehealth, so I don't personally know these NPs.  We only do psych.

Yes, the customer is not always right, but in this case they were right.  I base this on chart review, state database controlled substances review (CURES), and my examination.  In addition, these pts usually ask to be my patient from now on and as I have more appointments with them I can see that they were indeed abused previously.   Note that for coverage while their designated provider is not available, I can review the chart notes for appointments with their designated provider, which supports the patient's case they were badly treated.

Basically, I have just seen so many of these examples I am in despair.  One NP, in particular, is constantly dumping patients that require controlled substances.  Honestly, in the past 2 years, I must have had to deal with about 100 of her patients!  This makes me angry, frustrated, and sad.  In addition, when I get such a patient, I have to calm them down and then figure out correct treatment.  There is no way I can do this in 20 minutes, so then I run late the rest of the day!  I see up to 24 pts per day.  One day, I literally had 4 pts from that NP in one day!  I ended up running over 1 hour behind and had to work overtime which I am not paid for  

I have repeatedly complained to mgt and they say they talk to these NPs, but nothing ever changes!

 

[egg122 NP, MSN, APRN]

For all of these patients on controlled substance, what's your plan when Ryan Haight comes back into play? You need to have a plan to either see them in person or get them off of the med. 

 

[FullGlass, BSN, MSN, NP]

The DEA just extended the telehealth practices during COVID.  So Ryan Haight is not an issue now.  In addition, there are congresspeople working on making the current telehealth practices permanent.

[FullGlass, BSN, MSN, NP]

egg122 NP said:

Also, in psychiatry the customer is not always right - if that were true I'd be continuing a patient who recently came to me on Klonopin 1 mg qid + diazepam 10 mg tid+ Ativan 1 mg qid + Xanax 1 mg qd + lunesta 3 mg because their last prescriber gave it to them and "nothing else works.” Providers can decline to give meds they do not think are appropriate. 

I follow best practice guidelines for prescribing controlled substances and would never continue all the meds for the pt in your example.

I am talking about pts like an older lady who takes a total of 30 alprazolam tabs in 6 (six) months.  She was told she was an addict.  That is just ridiculous.  She does not take any other meds.

[CommunityRNBSN, BSN, RN]

Unfortunately, this problem really goes beyond one NP.  I am a newly-minted PMHNP, and I've seen a lot of things in my prior RN work and in my clinicals.  We received patients from FNPs, PMHNPs, and MDs (psychiatrists) who were totally inappropriately treated.  Cutting off benzos was common, but so was over-prescribing benzos and amphetamines to those with addiction.  Drugging up schizophrenics until they were drooling, when lower doses would have been sufficient. People given stigmatizing diagnoses on the basis of zero real evidence. Etc. Etc. Etc.  It is awful and, as you said, can make you want to cry.  And it is NOT exclusive to non-specialists, or to people who just lack training.

The thing is, though, you are going to have to get some emotional distance from it.  You can make the choice to treat your patients to the very highest standard of clinical excellence, and to educate other providers whenever you have the opportunity, and to advocate within the profession.  OR you can choose to become totally overwhelmed and exhausted by all the terrible decisions you observe, burn yourself out, and leave the profession-- which would leave all these patients in the hands of lower-quality providers. 

[subee, MSN, CRNA]

FullGlass said:

In California there is just an NP license.  It does not separate out by speciality.

This is telehealth, so I don't personally know these NPs.  We only do psych.

Yes, the customer is not always right, but in this case they were right.  I base this on chart review, state database controlled substances review (CURES), and my examination.  In addition, these pts usually ask to be my patient from now on and as I have more appointments with them I can see that they were indeed abused previously.   Note that for coverage while their designated provider is not available, I can review the chart notes for appointments with their designated provider, which supports the patient's case they were badly treated.

Basically, I have just seen so many of these examples I am in despair.  One NP, in particular, is constantly dumping patients that require controlled substances.  Honestly, in the past 2 years, I must have had to deal with about 100 of her patients!  This makes me angry, frustrated, and sad.  In addition, when I get such a patient, I have to calm them down and then figure out correct treatment.  There is no way I can do this in 20 minutes, so then I run late the rest of the day!  I see up to 24 pts per day.  One day, I literally had 4 pts from that NP in one day!  I ended up running over 1 hour behind and had to work overtime which I am not paid for  

I have repeatedly complained to mgt and they say they talk to these NPs, but nothing ever changes!

 

Maybe the nurse dumping the substance abuse patients is under discipline and can't write the prescriptions.  If that isn't the case, you've got a problem with incompetent leaders.  Can you take it over their heads?

[FullGlass, BSN, MSN, NP]

subee said:

Maybe the nurse dumping the substance abuse patients is under discipline and can't write the prescriptions.  If that isn't the case, you've got a problem with incompetent leaders.  Can you take it over their heads?

After a lot of complaints, things are getting better, slowly.  It also appears that bunch of new PMHNPs were hired out of the same crappy school and those were the ones causing problems.  I've been asked to help recruit better people

[djmatte, ADN, MSN, RN, NP]

CommunityRNBSN said:

The thing is, though, you are going to have to get some emotional distance from it.  You can make the choice to treat your patients to the very highest standard of clinical excellence, and to educate other providers whenever you have the opportunity, and to advocate within the profession.  OR you can choose to become totally overwhelmed and exhausted by all the terrible decisions you observe, burn yourself out, and leave the profession-- which would leave all these patients in the hands of lower-quality providers. 

This!  Don't frustrate yourself with the shortfalls or failures around you. Mention it to those who need to know and move on. I see more providers burn themselves out just from bitching endlessly in their down time about patients/colleagues/or whatever is their current gripe of the minute. Correct what you can when you see it. Be honest with your patients about what you would do different. Otherwise you will hate every day you go to work. 

[FullGlass, BSN, MSN, NP]

djmatte said:

This!  Don't frustrate yourself with the shortfalls or failures around you. Mention it to those who need to know and move on. I see more providers burn themselves out just from bitching endlessly in their down time about patients/colleagues/or whatever is their current gripe of the minute. Correct what you can when you see it. Be honest with your patients about what you would do different. Otherwise you will hate every day you go to work. 

I appreciate what is being said, but this was seriously impacting my ability to work.  First, so many controlled substance patients were being dumped on me by some other NPs, I ended up with about 90% of my patients on controlled substances.  Those patients take more time, as I have to check the state database, can't do refills, etc.  Second, when patients are justifiably upset, it can take quite awhile to calm them down.  This means I end up running late, which is not fair to me or my other patients.  Third, these idiot NPs were also making serious mistakes that needed to be corrected - abruptly stopping benzos and patients ending up in the ER, prescribing meds that did not work, had serious side effects, etc.  Fourth, I had to document all those issues and convey them to management, talk the management, etc., which was very time-consuming.  Finally, in order to be a good mental health care provider, or any kind of NP, a good provider has to be compassionate and caring, in order to establish a therapeutic alliance.  In other words, a completely indifferent person is not going to be a good NP.  While I am generally good at establishing boundaries, seeing patient after patient needlessly suffering horribly takes an emotional toll on me.  If it didn't, then I shouldn't be an NP.