How to deal with paranoid psychotic health care providers in positions of power?

[deleted682700]

We all encounter difficult personalities when we deliver health care. How do we deal with them? Some of them have florid psychopathology with no or little insight.
How do we ensure that patient safety is not jeopardized when agreeing with these providers. Some of these providers bring in the bussiness, so the powers that be remain silent.
What psychological strategies do you guys have?
Thanks

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[PikminOC]

What safety issues have you seen? What providers?

 

[deleted682700]

Practicing beyond your scope of practice. Taking care of sick mothers and letting them have premature babies without the proper NICU facility. When things go down hill blaming the pediatrician instead of waiting for the transfer team from a bigger hospital to arrive.
Suturing the uterus with the uterine artery still bleeding and instead of securing he ostracism it still keeps bleeding but into the uterus and blaming anesthesia.
Operating on morbidly obsese with known DVT, despite being told that it is beyond the scope of the facility. Even the administrator was in on the conversation.
Documenting after the fact and retracting what they said when the outcome is suboptimal. I can go on and on

 

[splik]

GTFO of there before your license is on the line! Once you have extricated from the situation you can consider whistleblowing. The problem is despite all the bs that whistleblowers are supposed to be protected, usually they end up being ostracized and never work again. once you are no longer working there you may consider leaking something to the media.

nothing you have describe indicates any paranoid psychosis. maybe there are people with narcissistic or psychopathic personality pathology but this sounds more like professional, ethical, and medicolegal concerns.

 

[deleted682700]

Agree with you. There is something not right in this situation. Psychopathic personality/ narcissism
Does belittling nurses, internists, elderly physicians count fit narcissism?

Any way, you are right about letting go and moving on. As far as whistle blowing, the said personality already was under board sanction that just got lifted. So your intuition is right on. No need for me to do anything when they dig a hole for themselves.

 

[splik]

who knows. the most common reason for erratic unprofessional behavior in physicians is substance abuse (which may occur in the setting of personality disorder), followed by burnout. but certainly narcissism (normal and pathological) is a common reason for lack of insight, especially in physicians.

 

[birchswing]

It sounds like you're pathologizing incompetence and human indecency. I don't see how that can help. If they break whatever codes there are for standard of care, they break the code whether they're psychotic or not. But it doesn't sound psychotic to me (I'm not a doctor).

 

[Ceke2002]

Not a Doctor (full disclosure, I'm one of the patients who frequent the forum) so this is solely a lay person's opinion, but I do agree with what Splik and Birchswing have already said. To me it doesn't really sound like there's any sort of full blown psychotic process going on -- I actually have a diagnosis on the lower end of the psychotic illnesses spectrum, and whilst it can make me withdrawn, distracted, have difficulty processing thoughts and/or speech, etc etc, what it doesn't do is turn me into some sort of incompetent cowboy type, who plays fast and loose with the rules and then retracts and backtracks to cover their own ar5e. Whatever the actual reason for the behaviour though, whether there's psychopathology at play or not, it is still completely unacceptable in my book, especially from a medico ethic legal standpoint. Make sure you protect your licence and reputation, and I would also suggest looking into what avenues of divulgence are available to try and halt this (blatantly unacceptable) behaviour from continuing.

 

[whopper]

There's no real way for us to tell what's going on for real. There are bad doctors out there. There are good doctors that despite this get patients hating them. I am not surprised when I hear stories like the above because I've seen it with my own eyes either from colleagues or as a patient myself (though I've never had a psychiatrist). I recommend to go up the channels. If this physician is in the hospital you complain through the patient advocate (it's called different names in different hospitals, e.g. patient relations, etc). Otherwise make a complaint with the state medical board.

I never ever had a problem with a patient complaing about me through the patient advocate because when you're in a hospital, a competent patient advocate will judge your actions based on your longterm performance and the merits of the individual case. They also have given a lot of wide room for doctors. While I was in a state hospital, I had patients complain about me more than daily (remember many of these patients were and are antisocial people) and the advocate knew almost all the complaints were BS. E.g. "The doctor won't give me Xanax! You better get me a doctor that gives me Xanax!"

I remember the last time a patient complained. She had factitious disorder and wanted to be in the hospital. It was quite obvious she was not depressed and enjoying her hospital stay. Her family even agreed she had factitious disorder and shouldn't be in the hospital.

When I discharged her she threatened to get the patient advocate on board. When asked why she wanted to be in she told me she was partying very well with the other patients and wanted to continue this, and that hospitals should keep people as long as the patient wanted even if there was nothing wrong with them. I told her something to the effect of, "just be sure to tell the advocate what you told me in those exact words."

 

[deleted682700]

Lol at the pt partying in the hospital.

Are there any hospitals that mandate random urine testing for physicians. How can I get this passed in my hospital by laws?

 

[smalltownpsych]

One way of resolving ethical concerns is to address them in a stepwise fashion. Step one, try to resolve it informally and directly with the person whom you have concerns about. Step two, take it to whatever mechanism your organization has for addressing legal/ethical issues. Step three, report to licensing board. Personality pathology is magnified under stress, and when your way of coping magnifies the problem, then you can get on a pretty vicious treadmill. Maybe the guy needs some help or maybe he will continue to endanger patients and refuse to shift. That would be your judgement call and you could seek some consultation on this, as well.

 

[hamstergang]

Why is this in the psychiatry residency forum?

 

[Shikima]

Applies to all facets of medicine.

 

[hamstergang]

That doesn't really answer my question though. Why is a non-psych resident choosing to post this here and not the general residency section?

I suspect we know the answer. He feels his attendings have "florid psychopathology" based on his diagnoses and is looking for "psychological strategies" for dealing with these diagnoses which he feels we have due to out psychiatry training. Doesn't feel right to me, but maybe I'm alone in this feeling.

 

[birchswing]

That doesn't really answer my question though. Why is a non-psych resident choosing to post this here and not the general residency section?

I suspect we know the answer. He feels his attendings have "florid psychopathology" based on his diagnoses and is looking for "psychological strategies" for dealing with these diagnoses which he feels we have due to out psychiatry training. Doesn't feel right to me, but maybe I'm alone in this feeling.

No, I read it the same way. People do this every day outside the world of medicine. They'll say someone they don't like is crazy. Or a more popular one now is to identify narcissists. It might be true to some extent, but it's not an actual a diagnosis. To be guilty of the same thing (offering a semi-medical explanation for an unknown phenomenon), I would guess it's a way of compartmentalizing problems into neat little boxes and making people less threatening by taking away their position as rational actors. In this case maybe it's just to get some validation from people who could actually diagnose such behavior.

Cacogens abound.

 

[whopper]

I had a patient just yesterday tell me her psychiatrist put her on 1200 mg of Seroquel for bipolar disorder, loaded her up with benzos, and she developed TD. The psychiatrist never told the patient the 1200 mg was over the maximum FDA dosage of 800, when the patient wanted to be weaned off of benzos she said the psychiatrist told her there was nothing wrong with them, and when she developed TD, the psychiatrist told her nothing else would work other than the Seroquel and that she either stay on it or be terminated. The patient stated when asking to be weaned off the benzos the psychiatrist stated something to the effect of "Why do you want off of them? It's medication and it's good for you. That's what they're their for."

Now of course the patient could be lying but I see this type of practice going on all the time, and I do know for a fact that some doctors do practice this way cause several of them were my colleagues. I've seen several doctors practicing like this in NY, PA, NJ, Ohio, KY, Indiana, Iowa, and now Missouri. When I confronted some of those colleagues about it they gave me various answers, none of them IMHO sastifactory. E.g. "You're young and idealistic. I just want to go home early at the end of the day and when I give them Ativan they shut up."

Several of these patients with horror stories end up being very nice and friendly patients. Of course some of them are the ones that'll just complain about anyone, or had a disorder and is doctor-shopping (e.g. a delusional disorder patient wants me to tell she's not delusional--SHE IS! She's mad at me because I refused to give in).

In general I've found when 3 patients that don't know each other tell me of similar bad practice methods by another physician it almost always ends up being true.

 

[deleted682700]

Yes, where there is smoke there is fire. If independently, physicians , nurses, unit managers, secretaries all seem to have problem, then may be all of them are wrong and the narcisstic prince may be right?

 

[deleted682700]

Yes the stress and the Ob night calls takes its toll. When physicians get older they have difficulty going back to sleep once they are disturbed in the middle of the call. This might be the reason they drink alcohol and or have substance abuse/ legal pain pills etc. as someone aptly pointed all the above with personality problem doesn't help when a healthy pregnant patient is dying.
Medico legally the anesthesiologist, nurses, the hospital will be liable when this obstetrician gets into trouble repeatedly.
Like another poster said time to move on and work only with competent surgeons and have a contract as to how one will resolve conflicts among providers. Yes that is what I am going to demand.
The hospital is well aware of this problem child. There is a program in Vanderbilt especially for these characters and what will get them to have some insight is when they are made to pay for it from their pockets.
It's because the boards and regulatory agencies cannot legally prevent these characters, such as the neurosurgeon in Texas, dr christopher dunscth, read skeptical scalpel, till after the fact.
Regarding ethics, another obstetrician, who cut the iliac artery while doing a tubal ligation was sued and let go of the hospital. He went all the way to Maine where he got a job. The chief of medical staff went out of his way and tried to save more patients from being harmed and may be ethically so. When the other hospital really got to know, the obstetrician was fired. He promptly sued the chief of staff and the hospital and won A multimillion dollar law suit against both for damages (inability to earn livelihood). Medico legal ethics? Legal views seem to trump every other issue.
When physicians who are veterans and have done this for decades they have a look on their face reflects "therapeutic nihilism"
Btw: for full disclosure I was rejected by psych residency program and ended up doing anesthesia at the cleveland clinic

 

[Mass Effect]

That doesn't really answer my question though. Why is a non-psych resident choosing to post this here and not the general residency section?

I suspect we know the answer. He feels his attendings have "florid psychopathology" based on his diagnoses and is looking for "psychological strategies" for dealing with these diagnoses which he feels we have due to out psychiatry training. Doesn't feel right to me, but maybe I'm alone in this feeling.

You're not alone. The OP's experience has nothing to do with psychiatry or "florid psychopathology." It's incompetence and malpractice, but nothing to suggest it's psychiatric in nature.

 

[whopper]

At the AAPL review course that happens annually, Charles Scott MD presented a case he worked on with an OB that literally threw surgical tools including scalpels at the surgical team. She claimed ADHD as a defense. During the interview she basically said the team was incompetent and she was just reacting out of anger as if it were an appropriate defense.

Always wondered what happened with that case. A woman that can get into medschool, make it through OB residency suffering from ADHD to the degree where she's impulsive enough to throw a scalpel at someone? Sounds to me more like narcissism and antisocial traits. Of course I don't know the full story of what happened with that case.

 

[deleted682700]

At the AAPL review course that happens annually, Charles Scott MD presented a case he worked on with an OB that literally threw surgical tools including scalpels at the surgical team. She claimed ADHD as a defense. During the interview she basically said the team was incompetent and she was just reacting out of anger as if it were an appropriate defense.

Always wondered what happened with that case. A woman that can get into medschool, make it through OB residency suffering from ADHD to the degree where she's impulsive enough to throw a scalpel at someone? Sounds to me more like narcissism and antisocial traits. Of course I don't know the full story of what happened with that case.

Just wait till doctors sue each other for battery. That will fix erratic behavior. That will then improve patient care and safety. There used to be a psychiatrist who was a VPMA at a small hospital. Every doctor was scared of him and when the cardiac surgeon through a temper tantrum was promptly recorded by nurses and he was shown his place in the paradigm.

 

[heyjack70]

At the AAPL review course that happens annually, Charles Scott MD presented a case he worked on with an OB that literally threw surgical tools including scalpels at the surgical team. She claimed ADHD as a defense. During the interview she basically said the team was incompetent and she was just reacting out of anger as if it were an appropriate defense.

Always wondered what happened with that case. A woman that can get into medschool, make it through OB residency suffering from ADHD to the degree where she's impulsive enough to throw a scalpel at someone? Sounds to me more like narcissism and antisocial traits. Of course I don't know the full story of what happened with that case.

Who knows what was going on in that lady's personal life. Maybe her husband left her for his secretary and six months later her kid died. Not that it justifies it, but severe stressors can certainly lead to reactive anger like she had.