Reporting fellow “providers” to the state board.

[nexus73]

Recent inpatient consult. Patient has anorexia. Patient has been thru multiple residential eating disorder treatment programs. BMI is < 12. Admitted with weakness/malnutrition. Patient is managed outpatient by psych NP at clinic owned by a psychiatrist. Patient is on large doses of scheduled benzo plus prn benzo. Also, more concerning, patient is on Wellbutrin and a stimulant. surprisingly she’s “just not hungry.” /s

So recommending she return to eating disorder treatment which she says she does not need. Also recommending tapering Wellbutrin and stimulant quickly. Will contact NP to relay recommendations.

I’m hesitant to report someone to the board, but this seems egregious to have patient with such severe anorexia on both Wellbutrin and a stimulant. What would you do? Does the nursing board even care about this kind of stuff and will they do anything? Thinking about contacting clinic owner who is their medical director just to make sure he knows what his employed NP is doing. This is an independent practice state so no supervision required.

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[wolfvgang22]

I think your plan is sound. Why not talk to the supervising psychiatrist and NP first. Some collegial education might solve the problem. If they ignore you or act like it's no big deal, then you can report. Of course, this means you'll need to be in a position to follow up with the patient. If you can't do that I'd report after talking to the NP and her supervisor regardless.

 

[Crayola227]

Only wanted to add that I applaud your plan to take action over not bothering to do anything to address this inappropriate prescribing. Seems like a clear cut case where a change (not giving welbutrin to severely undernourished anorexic patients) may save lives.

 

[robellis]

Yes, talk with supervising psychiatrist/NP and see what their thoughts are, if he has a bad attitude/isn’t amenable to education, I would report

 

[Mass Effect]

Only wanted to add that I applaud your plan to take action over not bothering to do anything to address this inappropriate prescribing. Seems like a clear cut case where a change (not giving welbutrin to severely undernourished anorexic patients) may save lives.

Both Wellbutrin AND a stimulant. Never mind that Wellbutrin is contraindicated in eating disordered patients, this regimen will exacerbate this patient's eating disorder and puts her at very high risk. I would report regardless of their attitude when you talk to them. You have no idea who else is on this NP's panel who may be in a dangerous situation thanks to this type of prescribing.

 

[Crayola227]

Both Wellbutrin AND a stimulant. Never mind that Wellbutrin is contraindicated in eating disordered patients, this regimen will exacerbate this patient's eating disorder and puts her at very high risk. I would report regardless of their attitude when you talk to them. You have no idea who else is on this NP's panel who may be in a dangerous situation thanks to this type of prescribing.

The board question I recognized here is that severe anorexia lowers the seizure threshold (secondary to electrolyte derangements from severe anorexia) and wellbutrin does as well. So besides helping this patient starve herself, she could have a seizure and drop dead from the seizure itself or secondary to trauma resulting from the seizure.

I don't know if the stimulant adds to that risk, but then you also have the arrhythmias from electrolyte derangements. It's a very deadly cocktail. The pathology here isn't just from these drugs helping her not to eat. Somehow I feel that's an important point to make.

I think because you can't just look at someone's weight itself or how much they are or are not eating to comprehend the danger, it isn't as intuitive as that which is why I think these particular prescribing errors happen as much as they do. I've even heard some providers justify it saying, "If their depression/ADHD mental illness was treated and they felt better, maybe their eating disorder/eating will improve" or "they eat the same with or without the drugs at least this way they might have improvement in other symptoms" not really getting that the danger doesn't just exist because of the drugs' effect on appetite or weight.

ETA: Stimulants also lower the seizure threshold.

 

[NickNaylor]

I agree with trying to talk with the NP/psychiatrist directly, first. Filing a formal board complaint is a huge headache for the person receiving the complaint, and while that isn't in and of itself a great reason to not file one if needed, I think trying a less aggressive approach first is the more appropriate thing to do. I would still reach out to them directly even if you're going to file a board complaint since complaints may take a long time to work themselves out.

 

[PikminOC]

I agree with trying to talk with the NP/psychiatrist directly, first. Filing a formal board complaint is a huge headache for the person receiving the complaint, and while that isn't in and of itself a great reason to not file one if needed, I think trying a less aggressive approach first is the more appropriate thing to do. I would still reach out to them directly even if you're going to file a board complaint since complaints may take a long time to work themselves out.

Not every board is the med board. I have seen that the pharmacy board and sw and psychologist board are much easier and more lax than the med board

 

[Mass Effect]

The board question I recognized here is that severe anorexia lowers the seizure threshold (secondary to electrolyte derangements from severe anorexia) and wellbutrin does as well. So besides helping this patient starve herself, she could have a seizure and drop dead from the seizure itself or secondary to trauma resulting from the seizure.

I don't know if the stimulant adds to that risk, but then you also have the arrhythmias from electrolyte derangements. It's a very deadly cocktail. The pathology here isn't just from these drugs helping her not to eat. Somehow I feel that's an important point to make.

I think because you can't just look at someone's weight itself or how much they are or are not eating to comprehend the danger, it isn't as intuitive as that which is why I think these particular prescribing errors happen as much as they do. I've even heard some providers justify it saying, "If their depression/ADHD mental illness was treated and they felt better, maybe their eating disorder/eating will improve" or "they eat the same with or without the drugs at least this way they might have improvement in other symptoms" not really getting that the danger doesn't just exist because of the drugs' effect on appetite or weight.

ETA: Stimulants also lower the seizure threshold.

Yeah it was the seizure risk I was referring to when I said Wellbutrin is contraindicated in eating disordered patients. The two go hand in hand. The combination of Wellbutrin and a stimulant will continue to reduce appetite and increase HR. At the same time, the anorexia will continue to put her at risk of seizure due to the electrolyte derangements.

 

[Merovinge]

I agree with trying to talk with the NP/psychiatrist directly, first. Filing a formal board complaint is a huge headache for the person receiving the complaint, and while that isn't in and of itself a great reason to not file one if needed, I think trying a less aggressive approach first is the more appropriate thing to do. I would still reach out to them directly even if you're going to file a board complaint since complaints may take a long time to work themselves out.

If we aren't willing to push back against terrible care that most M3's could tell you is clinically contraindicated, then certainly patients are toast as the move to mid-level care moves forward.

Look I've seen Paxil prescribed for depression in adolescents, the big BBW study clear shows this being overwhelmingly the worst SSRI for suicidial ideation risk and honestly Paxil sucks for depression in any age group. I'm not reporting something like that because it's still a semi-reasonable medication choice, even if quite suboptimal. High dose BZD + Wellbutrin + Psychostimulant in BMI <12 is way on the other side of the line of poor care and I cannot come up with a single scenario in which that would make sense for the patient. I can't even see any reasonable psychiatrist disagreeing, but even so, that is the point of the board review.

 

[PikminOC]

If we aren't willing to push back against terrible care that most M3's could tell you is clinically contraindicated, then certainly patients are toast as the move to mid-level care moves forward.

Look I've seen Paxil prescribed for depression in adolescents, the big BBW study clear shows this being overwhelmingly the worst SSRI for suicidial ideation risk and honestly Paxil sucks for depression in any age group. I'm not reporting something like that because it's still a semi-reasonable medication choice, even if quite suboptimal. High dose BZD + Wellbutrin + Psychostimulant in BMI <12 is way on the other side of the line of poor care and I cannot come up with a single scenario in which that would make sense for the patient. I can't even see any reasonable psychiatrist disagreeing, but even so, that is the point of the board review.

But it will go to the nursing board, not med board. They don't care

 

[Crayola227]

Yeah it was the seizure risk I was referring to when I said Wellbutrin is contraindicated in eating disordered patients. The two go hand in hand. The combination of Wellbutrin and a stimulant will continue to reduce appetite and increase HR. At the same time, the anorexia will continue to put her at risk of seizure due to the electrolyte derangements.

Yeah I figured this was the risk you were referring to. I just thought it was still important to point out, that even if *we* as docs know this, why it's important to explain why these meds are dangerous for those with eating disorders. Because I think one way of thinking someone might think they might get away with it.

 

[Mass Effect]

If we aren't willing to push back against terrible care that most M3's could tell you is clinically contraindicated, then certainly patients are toast as the move to mid-level care moves forward.

Look I've seen Paxil prescribed for depression in adolescents, the big BBW study clear shows this being overwhelmingly the worst SSRI for suicidial ideation risk and honestly Paxil sucks for depression in any age group. I'm not reporting something like that because it's still a semi-reasonable medication choice, even if quite suboptimal. High dose BZD + Wellbutrin + Psychostimulant in BMI <12 is way on the other side of the line of poor care and I cannot come up with a single scenario in which that would make sense for the patient. I can't even see any reasonable psychiatrist disagreeing, but even so, that is the point of the board review.

So much this. We can disagree with what other providers are prescribing, but this is downright malpractice. It isn't a case of some cowboy trying a med combo that hasn't been studied or tried to deal with a complex case. It's dangerous. And frankly, it suggests a profound lack of knowledge on the part of the provider. Regardless of a conversation with that provider, there is nothing he/she could say that would assure me that there aren't other patients also receiving poor care. If the provider doesn't know something as simple as "don't prescribe Wellbutrin in a patient with a BMI of 12," I don't expect that person to know how to properly monitor clozapine or not to put patients on 3 or 4 antipsychotics or not to prescribe 15 mg of Xanax a day to someone with COPD and OSA. It isn't our job to figure out how carelessly and negligently this person is prescribing, but I'd argue it IS our job as physicians to raise such an egregious red flag to a board that can and will review it to insure patients are safe.

As for it going to the nursing board, I'd argue you could also send it to the medical board as the owner of the clinic is a physician (per what the OP stated). If the MD is employing incompetent employees, whether or not he/she is supervising the NP, then the medical board should also review this case. I'm sorry it'll be a pain for the MD or the NP to undergo a board review, but I'm pretty sure it's a bigger pain for patients who are getting not just sub-optimal, but dangerous care.

 

[NickNaylor]

If we aren't willing to push back against terrible care that most M3's could tell you is clinically contraindicated, then certainly patients are toast as the move to mid-level care moves forward.

Look I've seen Paxil prescribed for depression in adolescents, the big BBW study clear shows this being overwhelmingly the worst SSRI for suicidial ideation risk and honestly Paxil sucks for depression in any age group. I'm not reporting something like that because it's still a semi-reasonable medication choice, even if quite suboptimal. High dose BZD + Wellbutrin + Psychostimulant in BMI <12 is way on the other side of the line of poor care and I cannot come up with a single scenario in which that would make sense for the patient. I can't even see any reasonable psychiatrist disagreeing, but even so, that is the point of the board review.

I agree that it's poor care - arguably even mismanagement - I'm just not sure that it rises to the point of going straight to the medical or nursing board when there hasn't even been in an attempt to talk with the primary provider first.

 

[robellis]

I agree that it's poor care - arguably even mismanagement - I'm just not sure that it rises to the point of going straight to the medical or nursing board when there hasn't even been in an attempt to talk with the primary provider first.

I agree, I think you should always try to communicate with the doc before jumping straight to the nuclear option

 

[Mass Effect]

Just curious, but what would the provider say that would be an appropriate reason not to go to the board?

 

[robellis]

Just curious, but what would the provider say that would be an appropriate reason not to go to the board?

“We just inherited this patient and are currently tapering her, if you think this regimen is bad you won’t believe what she was on before”

 

[Mass Effect]

“We just inherited this patient and are currently tapering her, if you think this regimen is bad you won’t believe what she was on before”

Meh, Wellbutrin doesn't need to be tapered in a patient like this and I'd argue stimulants don't necessarily need to be tapered either given risk. Benzos should be obviously (and actually I wouldn't taper the benzos until the other two are off the regimen) so that would be a marginally decent answer, but I don't know. I still think this is malpractice unless the NP inherited the patient literally last week.

 

[Stagg737]

Not every board is the med board. I have seen that the pharmacy board and sw and psychologist board are much easier and more lax than the med board

Yep, many of the states with FPA for NPs have very lax nursing boards that likely won’t take action until a patient is severely harmed. I’d still report in this case though. Outside of the most extreme circumstances this is worse care than I’d expect pre-clinical med students to provide.

I agree that it's poor care - arguably even mismanagement - I'm just not sure that it rises to the point of going straight to the medical or nursing board when there hasn't even been in an attempt to talk with the primary provider first.

I don’t think there’s any argument to be made, it’s malpractice plain and simple. Only excuses I can think of are if this patient was just inherited as previously stated or her BMI and labs were WNL at the last appointment in the patient 2-3 months. Even then, this is a garbage treatment plan. Imo there’s no excuse for this patient to be on stimulants or Wellbutrin, and I don’t think tapering meds is a valid argument as someone previously said. Wellbutrin doesn’t need to be tapered and stimulant withdrawal won’t kill you. A seizure from being on Wellbutrin + stimulants with a BMI<12 can though.

I mean, this sounds like this NP lacks the most basic knowledge of meds they’re prescribing or is inappropriately relying on benzos to prevent a seizure. For the actual patient, I’d actually question their capacity given the terrible insight and the fact that their mental illness (with likely contributions from meds) led them to become so ill it required medical hospitalization and feels they don’t need the recommended treatment.

Agree with others about reaching out to NP and also very likely employing psychiatrist. 99.99% chance I’d still report this to the board anyway though.

 

[PikminOC]

Yep, many of the states with FPA for NPs have very lax nursing boards that likely won’t take action until a patient is severely harmed. I’d still report in this case though. Outside of the most extreme circumstances this is worse care than I’d expect pre-clinical med students to provide.



I don’t think there’s any argument to be made, it’s malpractice plain and simple. Only excuses I can think of are if this patient was just inherited as previously stated or her BMI and labs were WNL at the last appointment in the patient 2-3 months. Even then, this is a garbage treatment plan. Imo there’s no excuse for this patient to be on stimulants or Wellbutrin, and I don’t think tapering meds is a valid argument as someone previously said. Wellbutrin doesn’t need to be tapered and stimulant withdrawal won’t kill you. A seizure from being on Wellbutrin + stimulants with a BMI<12 can though.

I mean, this sounds like this NP lacks the most basic knowledge of meds they’re prescribing or is inappropriately relying on benzos to prevent a seizure. For the actual patient, I’d actually question their capacity given the terrible insight and the fact that their mental illness (with likely contributions from meds) led them to become so ill it required medical hospitalization and feels they don’t need the recommended treatment.

Agree with others about reaching out to NP and also very likely employing psychiatrist. 99.99% chance I’d still report this to the board anyway though.

Of course they lack basic knowledge. Look at the education

 

[hallowmann]

So much this. We can disagree with what other providers are prescribing, but this is downright malpractice. It isn't a case of some cowboy trying a med combo that hasn't been studied or tried to deal with a complex case. It's dangerous. And frankly, it suggests a profound lack of knowledge on the part of the provider. Regardless of a conversation with that provider, there is nothing he/she could say that would assure me that there aren't other patients also receiving poor care. If the provider doesn't know something as simple as "don't prescribe Wellbutrin in a patient with a BMI of 12," I don't expect that person to know how to properly monitor clozapine or not to put patients on 3 or 4 antipsychotics or not to prescribe 15 mg of Xanax a day to someone with COPD and OSA. It isn't our job to figure out how carelessly and negligently this person is prescribing, but I'd argue it IS our job as physicians to raise such an egregious red flag to a board that can and will review it to insure patients are safe.

As for it going to the nursing board, I'd argue you could also send it to the medical board as the owner of the clinic is a physician (per what the OP stated). If the MD is employing incompetent employees, whether or not he/she is supervising the NP, then the medical board should also review this case. I'm sorry it'll be a pain for the MD or the NP to undergo a board review, but I'm pretty sure it's a bigger pain for patients who are getting not just sub-optimal, but dangerous care.

I have seen this regimen before and its baffled me, but in an otherwise healthy young individual it would be hard to say for certain it was downright malpractice from the outside looking in. In this patient though, absolutely, 100%, this patient could literally die at any moment due at least in part to that medication regimen.

I would contact the nursing board regardless, and I would reach out to the psychiatrist that owns the practice and notify them. They might be able to help people getting problematic management by that NP. If they are appalled, its a good sign they weren't paying attention, and I might not contact the medical board. If there was any resistance, I probably would contact the medical board though.

Yep, many of the states with FPA for NPs have very lax nursing boards that likely won’t take action until a patient is severely harmed. I’d still report in this case though. Outside of the most extreme circumstances this is worse care than I’d expect pre-clinical med students to provide.



I don’t think there’s any argument to be made, it’s malpractice plain and simple. Only excuses I can think of are if this patient was just inherited as previously stated or her BMI and labs were WNL at the last appointment in the patient 2-3 months. Even then, this is a garbage treatment plan. Imo there’s no excuse for this patient to be on stimulants or Wellbutrin, and I don’t think tapering meds is a valid argument as someone previously said. Wellbutrin doesn’t need to be tapered and stimulant withdrawal won’t kill you. A seizure from being on Wellbutrin + stimulants with a BMI<12 can though.

I mean, this sounds like this NP lacks the most basic knowledge of meds they’re prescribing or is inappropriately relying on benzos to prevent a seizure. For the actual patient, I’d actually question their capacity given the terrible insight and the fact that their mental illness (with likely contributions from meds) led them to become so ill it required medical hospitalization and feels they don’t need the recommended treatment.

Agree with others about reaching out to NP and also very likely employing psychiatrist. 99.99% chance I’d still report this to the board anyway though.

A patient with a BMI of 12 likely has at least mild to moderate cognitive impairment associated with their illness, let alone the effects that the medication regimen may have on them. Most of those patients lack a lot of insight until they hit at least 75% ideal body weight. Committing patient's with BMIs of ~15 involuntarily can be a bit hard here, but every case I've seen with a BMI ~12 has been granted. Your brain at that BMI is not functioning how it would under anything close to a reasonable BMI.

To be honest, this is horrifying. I have one patient with an EDO that is on a low-moderate dose of Wellbutrin, but their EDO has been relatively well controlled for years and their BMI is well above 20. This is a ridiculous case, and I honestly don't know how things like this happen.

 

[NickNaylor]

This is a ridiculous case, and I honestly don't know how things like this happen.

Frankly these kinds of shenanigans don't even surprise me anymore. I've seen all kinds of crazy **** community-based psychiatrists and NPs put their patients on - there are very few things that would strike me as totally absurd because there are so many people utilizing odd to outright incorrect and contraindicated management plans.

 

[robellis]

Frankly these kinds of shenanigans don't even surprise me anymore. I've seen all kinds of crazy **** community-based psychiatrists and NPs put their patients on - there are very few things that would strike me as totally absurd because there are so many people utilizing odd to outright incorrect and contraindicated management plans.

To play devils advocate, some regimens that strike you as odd can actually be beneficial to the patient and they swear by them, I’m not defending the above post because it’s indefensible but it’s surprising what patients swear by

 

[VA Hopeful Dr]

To play devils advocate, some regimens that strike you as odd can actually be beneficial to the patient and they swear by them, I’m not defending the above post because it’s indefensible but it’s surprising what patients swear by

You mean like oxycodone and/or xanax chronically?

 

[robellis]

You mean like oxycodone and/or xanax chronically?

No those are drugs of abuse so not surprising

 

[Mass Effect]

To play devils advocate, some regimens that strike you as odd can actually be beneficial to the patient and they swear by them, I’m not defending the above post because it’s indefensible but it’s surprising what patients swear by

Medicine should be evidence-based rather than solely being about subjective interpretation of doing well. Sure there are patients who don't respond to evidence-based combinations and so you try other things. But that's not really what we're talking about. By "odd," I think the poster means ill-informed or bad. A patient can say that Xanax 3 mg tid is beneficial to them too (it likely is if they have severe anxiety), but that doesn't mean we prescribe it. We're the physician and we know that it's a bad drug especially at that dose, even if it makes the patient feel better right now. The same can be said for other regimens that are contraindicated or not in the patient's best interest.

 

[robellis]

Medicine should be evidence-based rather than solely being about subjective interpretation of doing well. Sure there are patients who don't respond to evidence-based combinations and so you try other things. But that's not really what we're talking about. By "odd," I think the poster means ill-informed or bad. A patient can say that Xanax 3 mg tid is beneficial to them too (it likely is if they have severe anxiety), but that doesn't mean we prescribe it. We're the physician and we know that it's a bad drug especially at that dose, even if it makes the patient feel better right now. The same can be said for other regimens that are contraindicated or not in the patient's best interest.

Beyond the first few steps in the treatment, there’s not much evidence especially when the patient is on multiple medications that interact in ways no one understands, that’s where the art part comes in

 

[Mass Effect]

Beyond the first few steps in the treatment, there’s not much evidence especially when the patient is on multiple medications that interact in ways no one understands, that’s where the art part comes in

I don't believe that's what the poster is referring to.

 

[ArdorAyurveda]

Look I've seen Paxil prescribed for depression in adolescents, the big BBW study clear shows this being overwhelmingly the worst SSRI for suicidial ideation risk and honestly Paxil sucks for depression in any age group.

I'm gonna need some clarification on this BBW study

 

[DoctwoB]

Not is psych but believe it should be reported. Giving the benefit of the doubt is why people like Dr. Death can assassinate patients for years. I’m sure people talked to him about his outcomes and he had a reasonable enough explanation to not get reported. NPs want to pretend to be a doctor? They can deal with the consequences.

 

[Merovinge]

I'm gonna need some clarification on this BBW study

The study that helped to create the black box warning for SSRI usage for suicidial ideation in those under 26 years of age. Here is a summation of the data at the time, to say the area still remains controversial given the limitations in the data would be fair.

2004 FDA Hammad.pdf

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