Reporting incompetent colleagues?

[Animal Mother]

There seem to be TONS of psychiatrists in the community who are not good, and sometimes, just plain scary and dangerous. These doctors still continue to practice for years, likely hurting patients, but due to the culture of medicine, they are rarely reported. We all took an oath to do no harm. Isn’t sitting by while colleagues practice incompetently harmful to patients? Do we not owe it to our communities to report these unsafe doctors to the state medical board?

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[FrustratedFamDoc]

 

[Merely]

Psychiatry is the last field where you could be reporting people because it’s extremely subjective...I agree that incompetent surgeon Dr death should’ve been reported since he was obviously incompetent and prolly some psychs too but if we reported everyone we disagreed with no one would be practicing..plus you should prolly talk to someone to understand their thought process before trying to destroy their life...

 

[Animal Mother]

Psychiatry is the last field where you could be reporting people because it’s extremely subjective...

Some things are subjective. Many things are not.

“19 yo. Saw psychiatrist before as kid. H/O Zoloft. Raped.
Start
—Abilify 30mg qhs
—Prazosin 5mg qhs
—Klonopin 2mg BID”

This is the quality of new patient intake notes i frequently see. They are often 1-2 sentences long with I think objectively poor medication choices. I get a few of these patients each week. Saw one last week with primary diagnoses of borderline and alcohol use disorder (still drinking a bottle each night) prescribed multiple concurrent benzos and multiple opiates by their last psychiatrist.

Never really saw stuff like this in residency. I feel some, at least like the second example I gave, need to be reported.

 

[whopper]

I agree with you but here's a problem. First off you didn't see it happen in front of you. Sometimes, just sometimes there's reasonable explanations. A patient on an MAO-I might've had the due diligence done where they were tried on many other meds. Sometimes the patients don't competently report what happened.

The other problem is from a legal-perspective, unless you see it actually with your own eyes your allegation is hearsay. Patients have to report incompetence.

I've seen bad practice quite a bit and rant about it here quite a bit, but unless you were there, if you complain yourself it's hearsay. I have, on a few occasions, recommended a patient to report what happened to the state medical board but always with the caveat that this is based on the report they are telling me and that report might not be accurate.

 

[nitemagi]

I have reported one doctor, ever, to the medical board. He was running a pill mill and gave multiple benzos and sedating medications to a constantly intoxicated patient (from alcohol), who died in his sleep. That was the only egregious case.

Others while concerning, comes down to practice style but often still falls within the bounds of the community standard of care. IMHO that standard is way way too low, and I'm all ears on a way to raise that (board certification obviously doesn't mean much).

 

[calvnandhobbs68]

The above people are right, psych is probably one of the last fields you could do this in. Even if you see poor documentation, it isn't a lawsuit, they can explain most things away. However, I don't see any actual harm in stating your concern to the state medical board if you're getting multiple patients on what you consider to be dangerous medication regimens. It just probably wont' get anywhere but if multiple people report stuff they might look into it.

One of the only times it might actually get any traction is like the above case where someone actually dies or is seriously injured likely directly from grossly inappropriately prescribed medications. I mean take the Christopher Duntsch story above, that guy was literally directly killing multiple people and permanently paralyzing others, had multiple doctors basically hounding the hospitals, medical board and DAs office about him and still took years to get anywhere.

 

[splik]

you have a duty to report dangerous practice to the medical board. However I really think it should be obviously bad. I recently recommended a colleague report a physician to the medical board. The psychiatrist was prescribing benzos and told the physician who requested records that he does not keep medical records "due to patient confidentiality". Failure to keep medical records, especially when prescribing controlled substances, is egregiously bad and clearly meets the standard for reporting. The example you gave above is not imo reportable.

 

[whopper]

Agree with Nitemagi. I forgot to add if you have reason to believe the practice is acutely dangerous you must report but in most cases it's just poor practice but not acutely dangerous practice.

 

[shahseh22]

Some things are subjective. Many things are not.

“19 yo. Saw psychiatrist before as kid. H/O Zoloft. Raped.
Start
—Abilify 30mg qhs
—Prazosin 5mg qhs
—Klonopin 2mg BID”

This is the quality of new patient intake notes i frequently see. They are often 1-2 sentences long with I think objectively poor medication choices. I get a few of these patients each week. Saw one last week with primary diagnoses of borderline and alcohol use disorder (still drinking a bottle each night) prescribed multiple concurrent benzos and multiple opiates by their last psychiatrist.

Never really saw stuff like this in residency. I feel some, at least like the second example I gave, need to be reported.

why is a psychiatrist prescribing opiates?

 

[Animal Mother]

Failure to keep medical records, especially when prescribing controlled substances, is egregiously bad and clearly meets the standard for reporting. The example you gave above is not imo reportable.

I’m not sure if having 1-2 sentence initial patient assessments qualifies as much of a medial record.

You dont think prescribing multiple concurrent benzos and opioids on a long term basis to an alcoholic borderline without much of any documentation of a prior examination of the patient or medical reason is a deviation from the standard of care or dangerous? Seems super unsafe and dumb to me.

 

[Animal Mother]

why is a psychiatrist prescribing opiates?

Low back pain. It wasn’t documented in the notes, but it’s what the patient told me. Two different opioids. Three benzos. If this type of patient care really isn’t substandard, then it’s pretty sad. I’m still going to report it. The state board can decide.

 

[splik]

Low back pain. It wasn’t documented in the notes, but it’s what the patient told me. Two different opioids. Three benzos. If this type of patient care really isn’t substandard, then it’s pretty sad. I’m still going to report it. The state board can decide.

sorry i missed that. i meant the first part of your post with the ptsd.

I agree this is reportable. failure to document indication for controlled substances etc is also a deviation. i treated a patient earlier this yr who was getting prescribed norco by her psychiatrist for depression. called the psychiatrist, he confirmed and said "she said it was the only thing that worked!"

 

[erg923]

The community standard of care outside of academics for psychiatry and clinical psychology is shocking low. This was jarring to me as well, having been "protected" with student training clinics, general academics and large academic VAs prior to completion of my training. Harm, or great risk of harm due to impairment, has to be what is reported by other professionals though.

Poor prescribing (and therapy) practices are not optimally helpful to patients, but does not always reach the degree of harm--"Common Factors" and the subjective nature of prescribing psychotropics in general and all.
Working in a formal training role or in a QI/QA/QO role is probably the best way to handle the overall poor practices we see. If you have enough time, peer-to-peer discussions should probably be had prior to reporting many things one regards as "poor practice." Reporting to boards should probably be saved for egregious cases where harm and death are likely, fraud, and obvious cases of impairment of cognitive and/or psychological functioning.

 

[ridethecliche]

sorry i missed that. i meant the first part of your post with the ptsd.

I agree this is reportable. failure to document indication for controlled substances etc is also a deviation. i treated a patient earlier this yr who was getting prescribed norco by her psychiatrist for depression. called the psychiatrist, he confirmed and said "she said it was the only thing that worked!"

Double U Tee Eff.

 

[TexasPhysician]

Outside of suboxone/methadone addiction treatment, psych should not Rx any opiates. Automatic report in my state.

 

[calvnandhobbs68]

sorry i missed that. i meant the first part of your post with the ptsd.

I agree this is reportable. failure to document indication for controlled substances etc is also a deviation. i treated a patient earlier this yr who was getting prescribed norco by her psychiatrist for depression. called the psychiatrist, he confirmed and said "she said it was the only thing that worked!"

lol wtf

 

[clausewitz2]

Outside of suboxone/methadone addiction treatment, psych should not Rx any opiates. Automatic report in my state.

If ALKS 5461 gets the greenlight in February this will change. Although a week ago the FDA Advisory Committee voted against it, so it may not be in the cards...

 

[whopper]

Outside of suboxone/methadone addiction treatment, psych should not Rx any opiates.

I agree except in one type of case. Using Tramadol to wean off of Buprenorphine. Buprenorphine, even at 0.5 mg daily if stopped can cause some very bad withdrawal in most patients.

 

[TexasPhysician]

If ALKS 5461 gets the greenlight in February this will change. Although a week ago the FDA Advisory Committee voted against it, so it may not be in the cards...

I think they are facing a steep mountain there.

I agree except in one type of case. Using Tramadol to wean off of Buprenorphine. Buprenorphine, even at 0.5 mg daily if stopped can cause some very bad withdrawal in most patients.

I wouldn’t argue against Tramadol for 1 month, but I haven’t found it necessary. I routinely drop from 2 to 0mg at inpatient. I manage side effects with Clonidine, gabapentin, robaxin, etc. The inpatient center I work is anti-maintenance. Outpatient if it is that difficult to get from 0.5 to 0, I’d recommend maintenance. More and more studies show much higher relapse rates when tapered completely.

 

[MedMan80]

Would a physician prescribing a family member a stimulant be considered reportable? I guess by above standards it would be as I don't think they were keeping records as it was a family member..

 

[Merely]

Would a physician prescribing a family member a stimulant be considered reportable? I guess by above standards it would be as I don't think they were keeping records as it was a family member..

The goal isn’t to go around reporting your colleagues for fun lol..a lot of people need to mind their own business if they don’t know the whole story

 

[MedMan80]

The goal isn’t to go around reporting your colleagues for fun lol..a lot of people need to mind their own business if they don’t know the whole story

Well in this case the child was admitted to inpatient (not 2/2 the stimulant) and we discovered that the family member was Rx the stim, we have a responsibility to protect patient's from unethical prescribing practices, just wanted to see if this made the mark..

 

[michaelrack]

Outside of suboxone/methadone addiction treatment, psych should not Rx any opiates. Automatic report in my state.

I don't know if it would be considered a psych disorder (but it is in the DSM-5)- but Restless legs sometimes requires opioids in cases of severe augmentation or in cases of severe iron deficiency that can't be treated (I have had a few patients with weird bone marrow disorders in which their oncologist did not want them to take iron)

 

[whopper]

Getting OT but I have prescribed Buprenorphine to treat depression. I only do it for very treatment resistant cases and only if the the patient tried ECT and TMS and both failed. So far only 6 patients have been tried with 3 of them having no benefit so I stopped it in those patients.

One of those patients had pretty much everything you can imagine done including Ketamine, VNS, pharmacogenetic testing, multiple combinations of pretty much every antidepressant. Only things that got her better were TMS-but it only helped for about 1 week, and she doesn't have the money to do weekly TMSs for the rest of her life, Latuda (yeah I know it's an antipsychotic but it worked) but the med caused very bad akathisia, Lithium that caused only a partial benefit and Buprenorphine that caused a partial benefit.

She was also seen by some top psychiatrists in the country who couldn't get her better. I even attempted to have her treated a U of Pittsburgh where they're researching using CSF-guided antidepressant treatment.

She probably was the most treatment-resistant case I've ever seen. I was even considering Tamoxifen because it has mood-stabilizing properties. I also considered her depression might've been from inflammation and was considering trying to work with a doctor to use various anti-inflammatory treatments for rheumatoid arthritis despite that she didn't have that disorder.

Last I saw of that patient she got a new psychiatrist. Not because she didn't like me but because I told her I couldn't think of anything else to do, Lithium/Buprenorphine was the best she apparently was going to get and she had to drive a long distance to see me. She settled on a closer one that was just going to continue the Lithium/Buprenorphine.

 

[TexasPhysician]

Well in this case the child was admitted to inpatient (not 2/2 the stimulant) and we discovered that the family member was Rx the stim, we have a responsibility to protect patient's from unethical prescribing practices, just wanted to see if this made the mark..

I knew a psych that did this. It was a reasonable dosage. This person elected to self-disclose to the board and is working through a probation type of situation.

 

[TexasPhysician]

I don't know if it would be considered a psych disorder (but it is in the DSM-5)- but Restless legs sometimes requires opioids in cases of severe augmentation or in cases of severe iron deficiency that can't be treated (I have had a few patients with weird bone marrow disorders in which their oncologist did not want them to take iron)

My state would consider this chronic pain management. Chronic pain clinics must be registered, are audited, etc.

 

[splik]

Would a physician prescribing a family member a stimulant be considered reportable? I guess by above standards it would be as I don't think they were keeping records as it was a family member..

Yes. I did a forensic case whether the drug addicted evaluee was being prescribed both stimulants and benzos by their alcoholic physician parent.

 

[whopper]

Yes. I did a forensic case whether the drug addicted evaluee was being prescribed both stimulants and benzos by their alcoholic physician parent.

Sounds like a train-wreck. I just saw a patient today and his ex-girlfriend was treating him and is now stalking him. She threatened to tell friends and family pretty intimate health details. I told him to report her to the state medical board and tell his lawyer.

 

[VA Hopeful Dr]

Sounds like a train-wreck. I just saw a patient today and his ex-girlfriend was treating him and is now stalking him. She threatened to tell friends and family pretty intimate health details. I told him to report her to the state medical board and tell his lawyer.

Long term controls to romantic partners is never a wise idea

 

[WisNeuro]

Jeez, I won't even get something as simple as an ABX script from my physician spouse because I think it's an ethical violation. The lines people will cross...

 

[Merely]

Jeez, I won't even get something as simple as an ABX script from my physician spouse because I think it's an ethical violation. The lines people will cross...

You’re taking it too far in the other direction...there’s a happy medium in there

 

[WisNeuro]

You’re taking it too far in the other direction...there’s a happy medium in there

Oh, I know, I'm definitely on the conservative side for ethical issues. And, in a case of simple cellulitis, my wife's good friend who is also a physician, just wrote the script. But, I do think it's a hard line for mental health issues. Those should be done with objective providers, and outside friends or family.

 

[Shufflin]

first, do no harm. prescribe what you know is safe and are comfortable prescribing.

opiates are harmful (only give if benefits > risks in acute pain states), the wrong antibiotic in the wrong situation is harmful, the list goes on.

 

[VA Hopeful Dr]

Oh, I know, I'm definitely on the conservative side for ethical issues. And, in a case of simple cellulitis, my wife's good friend who is also a physician, just wrote the script. But, I do think it's a hard line for mental health issues. Those should be done with objective providers, and outside friends or family.

Meh, kinda.

My wife saw psych for several years. After she was stable on Lexapro for over 2 years I took over writing it.

Now the second she decompensates or has any issues it's straight to someone else, but in this case I had no issue with it.

 

[WisNeuro]

If it's just refilling a script for a stable issue, sure. But, I'd personally draw the line on any changes in med regimen.

 

[VA Hopeful Dr]

If it's just refilling a script for a stable issue, sure. But, I'd personally draw the line on any changes in med regimen.

Agreed

 

[randomdoc1]

first, do no harm. prescribe what you know is safe and are comfortable prescribing.

opiates are harmful (only give if benefits > risks in acute pain states), the wrong antibiotic in the wrong situation is harmful, the list goes on.

Invanz for all, including URI. That is what they do for defensive medicine at the NY hospital I did in residency. And it was to appease nurses because they did not want to deal with multiple times a day dosing for more specific antibiotics. Next thing you know, patients are leaving in body bags due to nosocomial treatment resistant infections. Patients and families are frustrated, hospital hides the records or literally changes them...and they all act like they have no idea what is wrong for the picture. A little off topic but eh.

 

[FlowRate]

The inpatient center I work is anti-maintenance.

Why? The evidence is so good for ORT.

 

[hallowmann]

Low back pain. It wasn’t documented in the notes, but it’s what the patient told me. Two different opioids. Three benzos. If this type of patient care really isn’t substandard, then it’s pretty sad. I’m still going to report it. The state board can decide.

Are you just straight believing the patient? While it may be true, most patients that tell me their "old psychiatrist gave me two opioids and three benzos for my XYZ" are expecting me to do the same, because, to use the terminology above "its the only thing that works for me". If you can, I'd actually ask the provider or at least check a PMP to see if the same person is writing them all those scripts.

Now bad practices definitely exist. I recently had the pleasure of treating a >65yo patient that was on Adderall for their "ADHD," hefty dose Xanax TID, Valium PRN, and BuSpar for their "anxiety," Wellbutrin and Paxil for their depression, prazosin for their PTSD, and Seroquel and Risperdal for their "schizophrenia" and insomnia, along with their long-term opiates for chronic back pain. According to the medical notes and PMP, all except for the opiates were coming from the same psych PA at a local outpatient clinic. The patient came in for frequent falls and delirium vs progressing "dementia."

 

[Crayola227]

Are you just straight believing the patient? While it may be true, most patients that tell me their "old psychiatrist gave me two opioids and three benzos for my XYZ" are expecting me to do the same, because, to use the terminology above "its the only thing that works for me". If you can, I'd actually ask the provider or at least check a PMP to see if the same person is writing them all those scripts.

Now bad practices definitely exist. I recently had the pleasure of treating a >65yo patient that was on Adderall for their "ADHD," hefty dose Xanax TID, Valium PRN, and BuSpar for their "anxiety," Wellbutrin and Paxil for their depression, prazosin for their PTSD, and Seroquel and Risperdal for their "schizophrenia" and insomnia, along with their long-term opiates for chronic back pain. According to the medical notes and PMP, all except for the opiates were coming from the same psych PA at a local outpatient clinic. The patient came in for frequent falls and delirium vs progressing "dementia."

you guys post a lot of cocktail horror stories, but this one hurt me in my bones

 

[hallowmann]

you guys post a lot of cocktail horror stories, but this one hurt me in my bones

Yeah, I've seen a few bad ones, but that one has been the worst. It was on a medical floor so we peeled off meds (improving a lot of the falling and memory issues), but revealing actual psych path (in the form of primarily one condition plus maybe a personality disorder), patient then went to one of the psych units for essentially med management.