Working at a Doctors Office, Ethical Issues, What Should I Do?

[kevin2400]

I'm in my gap year now, and in the summer I started working at a doctor's office where we do IV therapy treatments where I work as a receptionist and check in patients.

Our office is quite small, and one thing I noticed throughout the past couple of months is that only the medical assistant administers the IV treatments to our patients from start to finish, even though we also have a licensed nurse (much much older) who also works in our office, but she does not touch or handle IV's AT ALL.

So as long as I and this medical assistant have been here (we both were hired the same time in July), he does IV's every single day, even the days and weeks when the doctor is out of the office for vacation, etc. One day, I got a call from a patient who hasn't been in the office for a couple of months who and wanted to schedule an appointment for IV treatment while our boss (the doctor) was gone on vacation, so I let my coworker, the medical assistant know. Letting him know, I start to notice something was off. Since the patient hadn't been in the office for a while, he didn't feel comfortable doing it, and I was like...wait are you serious, why not you've been doing this for many months. Then out of nowhere the older nurse pulls me aside and whispers to me, "you know why he doesn't want to do it? it's because he's not allowed to in the first place, only certified nurses, (like RNs and LVNs) are allowed to do IVs, and the reason why my boss has the MA do it is because it's cheaper to hire an MA versus a nurse." Upon hearing this, I was obviously shocked, because here was the MA telling me all along that he was allowed to do IV's and he was certified to do it. So I decided to keep my mouth shut and do some research on my own.

After a little research on my own I found that in my state of California, Medical Assistants aren't allowed to do anything invasive (clearly stating IVs). This is literally a 21 year old guy, almost the same age as me, working as an unlicensed medical assistant doing IV's like its no big deal. He even does these treatments without doctor supervision (when the doctor is out of the office). Please correct me if I'm wrong about such regulations, but is this legal?

What should I do? Should I confront my boss about this? Does something like this happen a lot? I don't even know where to begin or who to report this to. I am currently trying to do more research on state regulations for MA's scope of practice, and the more I research I do, the more I am convicted I need to quit this job because it's just unethical. I have a feeling confronting him about it will lead him to avoid the topic (as he always does) or make up some bogus excuse about how legal it is even though my research points otherwise, keep me in the dark, or even worse, cost me my job. This is not the first time I've had issues with him, and we're not particularly on the best terms, and I'd rather not burn any bridges if possible if i'm going to leave this job. I'd rather not go to jail either, and I do have standards for quality patient care that I wish to uphold, and continuing this job would be a disservice to that commitment. I'm currently applying to medical schools right now, how would they view my situation?

The entire situation actually does not make much sense to me. Why would the doctor go through all this risk by having a medical assistant administer IVs when we have a certified nurse who is licensed to do it in the first place? Is there some secret license that MA's can get that I don't know about, and I'm just freaking out over nothing?

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[knv2u]

It sounds like an unfortunate set of events for you in potentially burning a bridge and recommendation, but ethics and safety are paramount in my opinion. I would inform the physician immediately in the event that he may be oblivious to what is occurring (don't assume the nurse is correct). If that doesn't work, seek a good reference for another medical job and leave. If the physician knows that there are activities that may endanger patient safety or that are of dubious legality, then you should contact the Medical Board of the State of California and file a formal complaint. I would recommend contacting them to verify the legality of what you're saying. If everything is accurate and if he is violating the law, he could lose his medical license and potentially be subject to criminal charges.

http://www.mbc.ca.gov


http://www.mbc.ca.gov/allied/medical_assistants.html

Medical Assistants
Medical assistants are unlicensed individuals who perform non-invasive routine technical support services under the supervision of a licensed physician and surgeon or podiatrist in a medical office or clinic setting. The supervising physician and surgeon or podiatrist must be on the premises in order for the medical assistant to perform those non-invasive techinical support services. The only exception is outlined in Business and Professions Code, Section 2069 (a) (1) and Health and Safety Code 1204(a) which applies only to licensed "community clinics" or "free clinics".

 

[dudeliness]

I'd have to agree that the best course of action would be to talk to your boss/the physician and make sure people are aware of what's going on.
I'd be interested to hear how this all goes down after the fact.

 

[Plecopotamus]

Eh. OP said the office is small, which leads me to believe that there is no way this physician does not know that the MA is starting IVs. If we take that at face value, then the physician is facilitating unlicensed practice, which is a complaint that should be directed to the medical board.

The OP is a pre-med and does not have the training or competency to investigate this or to monitor future behavior. And no nurse, pre-med, or MA should feel pressured to do a job (monitoring the boss) that if done correctly could threaten his/her own employment. Alerting the physician to concerns also gives him the opportunity to cover up his practices -- and if he is doing one illegal thing to cost-cut, we know there's high risk that he's taking some other ethically questionable measures to cost-cut/profit-boost.

Rather than resting on the OP, the onus is on the medical board to sort out where the law stands with regards to an issue or a complaint. If you contact the medical board to report "MA's are starting IVs", they will not take any action if it is actually legal for MA's to start IVs. And even if it is against the law and they decide to follow-up on the complaint, this isn't an all-or-nothing game in which licensure is instantly at stake. The board doesn't rip licenses away on the mere basis of a complaint being filed -- they investigate before they take action, and the actions they can take come in many forms far from loss of license.

If I were the OP, I would make the call and let the board do the rest of the thinking on this. I have no idea what they're infusing, but even a trained person can place an errant line, and some infiltrates/extravasated drugs have the potential to cause significant pain and even permanent injury.

 

[knv2u]

Alerting the physician to concerns also gives him the opportunity to cover up his practices -- and if he is doing one illegal thing to cost-cut, we know there's high risk that he's taking some other ethically questionable measures to cost-cut/profit-boost.

I disagree with what you're implying. In terms of covering up his practices, it strikes me that the OP's testimony would appear credible (why would he make this up in the middle of an application season when the reference would be needed?), and his testimony would be pretty damning to the physician. With regards to other practices, if found in violation of California law and medical administrative regulations, I would be shocked if his license wasn't suspended if not revoked. If he cannot practice medicine, then the other potential problems would resolve themselves. The OP should definitely talk to the physician. If he truly is oblivious, then he needs a wake up call. If not, that would seemingly be all the more damning in determining the sanctions awarded by the disciplinary board (i.e. not only negligence but knowingly and intentionally violating the law - the latter would have criminal ramifications).

 

[pietachok]

I disagree with what you're implying. In terms of covering up his practices, it strikes me that the OP's testimony would appear credible (why would he make this up in the middle of an application season when the reference would be needed?), and his testimony would be pretty damning to the physician. With regards to other practices, if found in violation of California law and medical administrative regulations, I would be shocked if his license wasn't suspended if not revoked. If he cannot practice medicine, then the other potential problems would resolve themselves. The OP should definitely talk to the physician. If he truly is oblivious, then he needs a wake up call. If not, that would seemingly be all the more damning in determining the sanctions awarded by the disciplinary board (i.e. not only negligence but knowingly and intentionally violating the law - the latter would have criminal ramifications).

Why do you think a pre-med should be administering a wake up call to a licensed physician who is breaking the law? If the pre-med noticed that the assistant was administering ivs in a "small office" why are you treating the physician as if he needs to be protected by a student? Whether he knows it's wrong or not does not change that it places patients at risk...if he's simply ignorant, who's to assume this is his only point of ignorance? The board can evaluate him comprehensively and identify any other areas of weakness in which he needs to prove improvement. That's what I'd want if I were his patient.

 

[knv2u]

Why do you think a pre-med should be administering a wake up call to a licensed physician who is breaking the law? If the pre-med noticed that the assistant was administering ivs in a "small office" why are you treating the physician as if he needs to be protected by a student? Whether he knows it's wrong or not does not change that it places patients at risk...if he's simply ignorant, who's to assume this is his only point of ignorance? The board can evaluate him comprehensively and identify any other areas of weakness in which he needs to prove improvement. That's what I'd want if I were his patient.

I realize that physicians are responsible for the conduct of their employees, but I think it is important to also consider the practical aspects of medical practice. The fact that a practice may be small in terms of the number of physicians doesn't say anything about the volume of patients, and when seeing patients, completing paperwork particularly as it relates to insurance companies, etc., I can see how a physician could honestly not be aware of misconduct in his office. Given the potential life altering consequences that suspension or revocation of license could bring (and these are realistically the type of sanctions that could be applied), I think the physician should be given the opportunity to correct things assuming that no additional patients would be put at risk. Imagine how you would feel as a physician if some stupid pre-med (the MA not the OP) did something behind your back and caused you to lose your license and ultimately your main source of income, home, etc. That would bother me personally. And while I agree that the patients' safety should be the primary consideration, what is done is done and if the problem can be addressed without a formal inquiry (and I mean in such a way that the risk to future patients would be prevented), I do not see the need to start one. Ignorance of the behavior of his subordinates doesn't suggest that there is ignorance in other areas necessarily, and the physician would presumably (if he was intelligent) hire additional staff to supervise his non-physician employees. If not, then my sympathies would be limited.

With regards to your other points, I agree that his ignorance would seemingly be irrelevant in a regulatory inquiry, but if he knows what is going on, then the State Board of Medicine may very well turn the case over to the state attorney general for prosecution under criminal statutes where different standards may apply depending on the jurisdiction (i.e. in many jurisdictions, I think aiding the unauthorized practice of medicine requires specific intent rather than being a strict liability crime).

 

[katiemaude]

You can report this violation anonymously to your state's regulatory agencies. If the practice is part of a hospital network, you can also call their safety hotline (most have one). You don't have to be the one to confront the physician. It's more important that you protect the safety of the patients above all. There are also usually rules about retaliation against those who report valid patient safety concerns.

 

[LizzyM]

Starting perepheral IVs is not "invasive". There is no federal or state regulation prohibiting a physician from employing unlicensed assistants who work in the office and start perepheral IVs. The Infusion Nurses Society objects, of course, as this is infringing on their turf. If the nurse in the office where the OP works does not handll IVs, what is she doing?

Nothing prohibits the OP from being an anonymous whistle blower but there may be no cause for action on the part of the state licensing board against the physician.

And, as an aside, "supervision" by a physician can mean operating under protocols approved by the physician and not that the physician is physically present and watching the employee.

 

[SunsFun]

I realize that physicians are responsible for the conduct of their employees, but I think it is important to also consider the practical aspects of medical practice. The fact that a practice may be small in terms of the number of physicians doesn't say anything about the volume of patients, and when seeing patients, completing paperwork particularly as it relates to insurance companies, etc., I can see how a physician could honestly not be aware of misconduct in his office. Given the potential life altering consequences that suspension or revocation of license could bring (and these are realistically the type of sanctions that could be applied), I think the physician should be given the opportunity to correct things assuming that no additional patients would be put at risk. Imagine how you would feel as a physician if some stupid pre-med (the MA not the OP) did something behind your back and caused you to lose your license and ultimately your main source of income, home, etc. That would bother me personally. And while I agree that the patients' safety should be the primary consideration, what is done is done and if the problem can be addressed without a formal inquiry (and I mean in such a way that the risk to future patients would be prevented), I do not see the need to start one. Ignorance of the behavior of his subordinates doesn't suggest that there is ignorance in other areas necessarily, and the physician would presumably (if he was intelligent) hire additional staff to supervise his non-physician employees. If not, then my sympathies would be limited.

With regards to your other points, I agree that his ignorance would seemingly be irrelevant in a regulatory inquiry, but if he knows what is going on, then the State Board of Medicine may very well turn the case over to the state attorney general for prosecution under criminal statutes where different standards may apply depending on the jurisdiction (i.e. in many jurisdictions, I think aiding the unauthorized practice of medicine requires specific intent rather than being a strict liability crime).

If he is not aware of the misconduct in his office, assuming this is illegal, it is his problem and his failure to be an effective leader and handle his responsibilities. Thinking about the volume of patients, his family, how he will feel personally when "some stupid premed rats him out" (why would you even say something like this is beyond me) is completely irrelevant.

 

[Awesome Sauceome]

Starting perepheral IVs is not "invasive". There is no federal or state regulation prohibiting a physician from employing unlicensed assistants who work in the office and start perepheral IVs. The Infusion Nurses Society object, of course, as this is infringing on their turf. If the nurse in the office where the OP works does not handel IVs, what is she doing?

Nothing prohibits the OP from being an anonymous whistle blower but there may be no cause for action on the part of the state licensing board against the physician.

And, as an aside, "supervision" by a physician can mean operating under protocols approved by the physician and not that the physician is physically present and watching the employee.

I was under this impression as well, that it is not illegal... I worked as an MA who was trained by other MA's who were trained by the physician in the office... I was under the distinct impression that physician have the right to train "in-office" techniques. I never set IV's because I ended up moving before I was there long enough to train in that stuff, but people who were in our office longer worked their way up and were doing a lot of stuff. We had MA's who were stitching and several that were even giving local anesthetics under strict guidance and training from the physician. I dont know, I mean its a different state, a different practice, and its not like anyone's words here would carry weight in court. But I do not think this is something that should be a major cause for concern. Do your job as best as you can, give the best care to the patients as you can. If something goes down its on your bosses head, not yours, it was his responsibility to allow it in the first place. If he did not feel comfortable with the risks of allowing MA's to do that sort of work with training, he would not have allowed them to do it. I seriously do not think anything illegal is going on here.

Just my two cents

 

[Goro]

You do the right thing, that's what you do.

 

[Awesome Sauceome]

If I ever meet you on the application trail, is it ok if I quote you on that hahaha 😉

 

[RogueUnicorn]

Starting perepheral IVs is not "invasive". There is no federal or state regulation prohibiting a physician from employing unlicensed assistants who work in the office and start perepheral IVs. The Infusion Nurses Society objects, of course, as this is infringing on their turf. If the nurse in the office where the OP works does not handll IVs, what is she doing?

Nothing prohibits the OP from being an anonymous whistle blower but there may be no cause for action on the part of the state licensing board against the physician.

And, as an aside, "supervision" by a physician can mean operating under protocols approved by the physician and not that the physician is physically present and watching the employee.

I've never encountered anybody clinically who doesn't consider IVs to be an invasive procedure. It's a stainless steel needle inserted into a vein, how can that not be thought to be invasive?

That being said, everybody jumping up and down on a cyber witch hunt need to calm themselves down. It's a freaking IV for god's sake, a monkey can be trained to start one. OP let it go it's not a big deal, no license magically grants you the knowledge and understanding to start IVs, a fact that'll be painfully (quite literally) obvious when you observe certain physicians

 

[knv2u]

If he is not aware of the misconduct in his office, assuming this is illegal, it is his problem and his failure to be an effective leader and handle his responsibilities. Thinking about the volume of patients, his family, how he will feel personally when "some stupid premed rats him out" (why would you even say something like this is beyond me) is completely irrelevant.

I would be very interested in hearing your comments on this thread in 10 years to see how your perspective may change (assuming that you do decide to go through with training as a physician). If future risk to patients could be avoided, what is the point of potentially ruining someone's career for what could be an easy to make (and honest) mistake that is easy to be unaware of? I'm betting you'll feel differently when you are in a similar position and could be vulnerable to the same type of thing.

Also, I didn't say the student would be stupid for alerting the State Medical Board. I was referring to person inserting IVs without proper training and/or against the law (again all taking the OP's legal assertions at face value). Reread my comment again, and you will see that the last part had nothing to do with the original poster or any other whistleblower for that matter. Even if I thought it would be better to pursue other avenues first, I would never criticize someone for doing what they felt was in the best interest of patient safety/medical ethics.

 

[knv2u]

I've never encountered anybody clinically who doesn't consider IVs to be an invasive procedure. It's a stainless steel needle inserted into a vein, how can that not be thought to be invasive?

I too am interested in how "invasive procedure" is defined legally and for medical purposes.

That being said, everybody jumping up and down on a cyber witch hunt need to calm themselves down. It's a freaking IV for god's sake, a monkey can be trained to start one. OP let it go it's not a big deal, no license magically grants you the knowledge and understanding to start IVs, a fact that'll be painfully (quite literally) obvious when you observe certain physicians

I disagree with you. The original poster references IV treatments, and we don't know what drugs are being administered. Failure to administer some drugs properly through IV can lead to severe drug reactions and severe injury. That is a big deal IMO.

 

[knv2u]

I didn't see that the State Board of Medicine actually addresses this issue clearly on its website:

Are medical assistants allowed to start or disconnect IV's or administer injections or medication into IV's?
No. Medical assistants may not place the needle or start and disconnect the infusion tube of an IV. These procedures are considered invasive, and therefore, not within the medical assistant's scope of practice. Medical assistants are not allowed to administer medications or injections into the IV line. (Title 16 CCR 1366(b)(1))

http://www.mbc.ca.gov/allied/medical_assistants_questions.html#5

 

[LizzyM]

I've never encountered anybody clinically who doesn't consider IVs to be an invasive procedure. It's a stainless steel needle inserted into a vein, how can that not be thought to be invasive?

That being said, everybody jumping up and down on a cyber witch hunt need to calm themselves down. It's a freaking IV for god's sake, a monkey can be trained to start one. OP let it go it's not a big deal, no license magically grants you the knowledge and understanding to start IVs, a fact that'll be painfully (quite literally) obvious when you observe certain physicians

Well, the New York State Department of Health does not consider a peripheral IV to be an invasive procedure

The New York State Surgical and Invasive Procedure Protocol (NYSSIPP) applies to all operative and invasive procedures including endoscopy, general surgery or interventional radiology. Other procedures that involve puncture or incision of the skin, or insertion of an instrument or foreign material into the body are within the scope of the protocol. This protocol also applies to those anesthesia procedures either prior to a surgical procedure or independent of a surgical procedure such as spinal facet blocks. Example: Certain "minor" procedures such as venipuncture, peripheral IV placement, insertion of nasogastric tube and foley catheter insertion are not within the scope of the protocol.

That said, I appreciate the information about medical assistants in California. The physician and the medical assistant may be at risk of some trouble... and the patients might be at some risk. OP might want to look for a new job to distance him/herself from this circus and might consider filing an anonymous report with the state licensure board.

 

[SunsFun]

I would be very interested in hearing your comments on this thread in 10 years to see how your perspective may change (assuming that you do decide to go through with training as a physician). If future risk to patients could be avoided, what is the point of potentially ruining someone's career for what could be an easy to make (and honest) mistake that is easy to be unaware of? I'm betting you'll feel differently when you are in a similar position and could be vulnerable to the same type of thing.

Also, I didn't say the student would be stupid for alerting the State Medical Board. I was referring to person inserting IVs without proper training and/or against the law (again all taking the OP's legal assertions at face value). Reread my comment again, and you will see that the last part had nothing to do with the original poster or any other whistleblower for that matter. Even if I thought it would be better to pursue other avenues first, I would never criticize someone for doing what they felt was in the best interest of patient safety/medical ethics.

There is a fine line between mistake, negligence, and recklessness which is something for people trained to draw it to decide rather then you, me, or the OP.

I may be mistaken about the rest of your comment but it appeared to me that you were the one saying "some stupid premed".