Welcome to Patients at Risk a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm Dr. Rebekah Bernard and I am joined by my co host, and the co author of our book, patients at risk the rise of the nurse practitioner and physician assistant and health care. Dr. Niran Al-Agba.
Good evening.
There are almost 300,000 practicing nurse practitioners in the United States. And unlike physicians who are regulated by a state board of medicine, nurse practitioners are generally licensed and regulated by their state's Board of Nursing, who are also responsible for monitoring the care provided by 1000s of other nursing professionals in their state, including licensed products to practical nurses and registered
nurses. Recent headlines have shown that these state boards of nursing are not always up to the task, and that this improper regulation of nurse practitioners may be harming patients. Today, our guest is Dr. Amy Townsend, a family physician and a whistleblower who reported improper care being provided by a nurse practitioner in her hometown. Dr. Townsend went through incredible lengths to get the Board of Nursing to intervene, despite evidence that the nurse practitioner was
harming patients. Amy, thank you so much for joining us.
Thank you so much for having me.
Amy, I want to tell you that you are a personal hero of mine, when I heard the story of what you went through to ensure patient safety. I was just amazed. Can you share that story with our listeners?
Yes, absolutely. So, you know, my story with us begins in back in 2017. In January of 2017. I had a very close friend of mine who had a history of very run of the mill simple hypothyroidism had been on a standard dose of Synthroid for several years, but at the time was not established with a primary care physician.
And my friend asked me if he thought that it would be okay if he went to a nurse practitioner run clinic just to have his routine thyroid labs checked and to have his Synthroid refilled. You know, a little bit of background about me, I am a board certified family practice physician. I worked shortly as an outpatient physician for brief periods shortly out of residency, but then went into hospital medicine, and had been practicing in hospital medicine
for several years. So anyway, my friend asked if it was appropriate for him to go to this nurse practitioner run clinic just to have routine lab work done. And, you know, my experience with nurse practitioners at the time had been mostly working with them on an inpatient basis and I had had very good experiences working with nurse practitioners in the hospital, you know, they helped me see patients I saw every patient that they saw we work together very well as a team. They were very bright
individuals. And so you know, at that point, I had had a really good experience with nurse practitioners. So I thought that it was completely appropriate to do you know, run of the mill thyroid test and have thyroid replacement medications refilled by this nurse practitioner. Well, my friend proceeded to call and make an appointment
with this clinic. And even prior to being seen, the nurse practitioner ordered a whole slew of lab work, what turned out to be 63 different lab tests before ever seeing the patient. work was done several days later, my friend goes to the clinic and sees the nurse practitioner. in that lab they had also run testosterone levels in his level was most certainly within the normal range for a man in his 40s was actually the level was 696. So almost 700 for
testosterone level. And then the thyroid functions were also completely within the normal range. After seeing the nurse practitioner and then going over the labs, my friend left the clinic with a prescription for IM injections of testosterone
and his thyroid medication. This Synthroid he had been on for years and years, the nurse practitioner replaced with a very high dose of nature thyroid, which includes both t three and T four, and is not routinely recommended by the endocrine society for hormone
replacement. And so, you know, he brought me before, you know, actually getting the medications refilled, he brought me the lab work and asked my opinion, you know, to look over the labs that were there, and to see if the prescriptions were appropriate. Of course, they they weren't, you know, with nearly 700, testosterone starting intramuscular injections of testosterone is completely
inappropriate. I was very upset with the treatment, you know, testosterone and thyroid hormones or not benign medications, they do come with a very significant risks of, you know, cardiovascular disease, risk of stroke risk of things like polycythemia, that were never discussed with the
patient. And so I actually called this nurse practitioner and and, you know, tried to discuss with him, you know, what his treatment plan, and I was very disappointed in his response, you know, at this point, I had been practicing medicine for 10 years, and was at that point, was also the Vice President of medical affairs for a Regional Hospital system. So clinically, I was working as a hospitalist, but also had, you know, relatively extensive, you know, background in hospital
administration as well. And his response was, you know, almost overwhelming to me that he, as a nurse practitioner, he would he, he essentially claimed that I did not know what I was talking about, and that I just didn't understand hormone replacement.
Wow. So basically, he was totally condescending to you, when you reached out to him with your concerns, you knew that this was inappropriate treatment, that it could harm your friend. And his response was, 'well, you just don't know what you're talking about.'
Yes. And so I next asked, you know, of course, in the state of Texas, every non physician is required to have a supervising physician, so I asked for the name of his supervising physician. And then, to my surprise, when I actually contacted her, she was not an endocrinologist, not even a family medicine physician, but she was a general surgeon, that was actually located 140 miles away from this clinic.
So pretty hard to actually be performing supervision when you're not in the same specialty, and you're not in the same locality.
Yes, yes. And so, after speaking with her, I expressed my disappointment and essentially told her, either you can withdraw that supervision, or, you know, I would was going to consider reporting her to the Texas Medical Board for not properly supervising what was going on in the clinic,
I want to tell you, I want to stop for a second, because I'm really proud of you. Because like, I have a situation right now, where I'm really concerned about a physician in my community of specialists, just letting his PA see patients. And I realized that I need to have a direct conversation with him. And I'm not excited about it. I mean, that must have been really hard for you to call up another physician and actually just kind of call her out on what she was doing. I mean, do you have any
advice for how I can do that? Or the rest of us can do that?
I think what what partially was the driving factor for me is this was a physician that was not even part of our community that really had no investments in the community itself, and really had no concerns about the consequences of you know, what was going on and who was who was being harmed in my community.
I think this is something that I personally want to learn from you, and get that bravery. And I think we all need to speak out when we see things like this, because otherwise, it's just going to continue. So you basically let that supervising physician know that you are going to be intervening if she didn't do something. And so what happened next?
So she essentially she withdrew her supervision that same day, she retracted her prescriptive authority agreement that day, and I thought, well, whoa, great, you know, at least we've kind of put a stop to this. But unfortunately, within a week or two, they were able to find yet another supervising physician.
Can I just ask you - on the phone was was the surgeon have any explanation, did she?
Yes. One of her comments that I think rubbed me the wrong way the most was she essentially said that she really had no responsibility for what the nurse practitioner was actually doing in that clinic. I mean, she did not feel any obligation to be controlling, you know, what, what they were doing, or really providing any supervision of the prescriptions that were coming out of the clinic.
Wow. Wow, I just, that's to me amazing.
And these are, this is the kind of thing that nurse practitioners sometimes complain about that physicians are, they're paying them for collaboration or supervision, and they're just nowhere to be seen. They're just cashing a check. I think in this case, the nurse practitioner was okay with minimal supervision, because they really weren't looking for a lot of advice from a doctor
And that's something that is we do need to talk about, and we do need to absolutely
And that's why to me calling that that physician out, it was was so inspiring, and something that we really need to be doing.
Well, much to my dismay, I thought, Well, okay, this is going to solve the problem. But again, within a week or so they were able to find another supervising physician, again, this was not a physician within our community. This was an obstetrician, an OB GYN, who was over 200 miles away from the from the from the
clinic this time. So you know, there there weren't, there wasn't much of a barrier there for, you know, proper supervision, or even trying to stop practices that were obviously dangerous to the community.
So here you are, you already have red flags, you are really concerned about this. And then the next thing that happens is you hear about a bad outcome for a completely different patient.
So all of that transpired in January of 2017. And then in February towards the end of February of 2017. And I'd kind of let it go at this point, I, you know, I thought that I had mostly kind of addressed the
problem. But in February of 2017, I actually learned that a gentleman in his 40s had actually passed away, and was being seen at the clinic, and then having a conversation, you know, in doctors dining within the hospital, and within, you know, our medical colleagues actually learned of not just the one but a second death. So Brad Gilbeaux, at 47, passed away on February 23. And then on February 25, another gentleman named Jeffery Childs, at the
age of 44, also passed away. And so at this point, you know, there was there was discussion that both of these gentlemen had been seen at this same clinic. And the kind of circumstances around their death really pointed towards, you know, issues with testosterone overdose. And so at that point, I did not feel like it was something that I could, you know, sit back and do nothing.
So that was the point that I decided to actually follow a true complaint with the nursing board, and send in a formal complaint, not only with the details of, you know, my friend's situation where the prescription for testosterone was completely inappropriate, but then also told them of these two deaths of these, you know, gentlemen, both again, and they're in their mid 40s, that had died, and we're being seen at this clinic.
So you made a formal report to in Texas nurse practitioners are supervised by the Board of Nursing as they are in most states. And did you get any response from the Board of Nursing about your concerns?
So, you know, initially, I got the standard response, you know, they received the complaint and that they were going to, you know, investigate things. You know, again, in my position, though, working as a hospitalist. And also in hospital administration, I began to hear about additional adverse events, they weren't necessarily deaths, but additional adverse events that were showing up in the emergency room that were patients that were also connected to this to
this clinic. And so I would say nearly a monthly or, you know, at least every couple of weeks, I was reaching out to the nursing board trying to get them to understand how severe you know, the situation was and that that were there were patients that were actively still being harmed, because they had not taken action yet.
So like, two patients have already died that you know of that you're concerned about. And you're scared, like, hey, how many more people have to die before something's gonna happen? So you actually drove to the capital of Texas to Austin? How many miles is that from where you live?
It's about a five hour drive from where I'm located.
So you are getting to run around so much that you just had enough. You got in your car, you drove five hours from your town to Austin, Texas. And did you have an appointment, or you just showed up what happened?
I had actually called ahead of time and set up appointment with the executive director and the investigators at that point. But even prior to that happening, the local news stations had caught wind of this clinic, they had several people that had had adverse events and had gone to a local law firm and had filed complaints with this law firm. And the local news station got involved. And the nurse practitioners that were working at the clinic had heard that there was going to be a
story on the local news. So they actually went to the competing news station, and provided them with a letter from the nursing board. It looked very formal, that basically said yes, complaints had been lodged against them, but no wrongdoing had been found. Well, it turns out that they had actually altered that document that they added the sentence that said no wrongdoing had been found. And the nursing board at that point had discovered that he had presented this to the public as
a nursing board document. And so the nursing board finally took action and filed formal charges, and cited not only the three cases that I had presented them with, but another 10 cases that had been filed six months before I'd actually filed my complaints. So there were 13 cases of mismanagement, that the nursing board did not take action until he not because these these cases were there. But because he had presented a falsified document from the nursing board.
Wow. And it actually ended up taking something like was it about a year from where this case was first reported to the Board of Nursing before they actually finally made formal charges?
Yes. So after they made the formal charges is when I decided, I just couldn't understand how could you cite that there were two deaths that were involved with this clinic. And, you know, even though they had filed these charges, and made these complaints, they did not prevent the nurse practitioners from continuing to practice that the clinic was still going in, in full force, there were still people that I was hearing about, you know, showing up in the ER with
adverse events. So that's when I decided to go down to the nursing board and have a di ect conversation with them. And his is probably the most shock ng thing of this whole situa ion. So as I'm talking to the ursing board, and the executive irector, you know, I sai , I just don't understand, I on't understand how you can sa that they are at least partial y responsible for these two
deaths. And yet, you're s ill allowing them to practice And they looked at me dead in the eyes, and said, you know, Dr. Townsend, doctors are jus busy. And we have not been able to find an expert witness to actually review the cases and move this forward. And I ust sat there in complete sho k. How can a regulatory board no have the basic steps in place o actually remove people wh n they are harming the community That that's just something tha is completely unacceptable?
nd something that really ope ed my eyes to the entire situat on.
Well, you know, you said something that I quoted you in the book because I thought this was such a brilliant statement, you said, 'the Texas Board of Nursing seem incapable of dealing with nurse practicing medicine. They don' have a basic foolproof proces to deal with nurse practitioner who are dangerous.' And I thi k that what you describe is exactly right. This is a per on that had already been san tioned or had been charged
ith harming patients. And yet, he continued to practice what I would consider as nursi g would exert medicine. They cal it advanced nursing, but it's really prescribing very high ris and dangerous medicati ns. And no one was stopping him from doing this and patients didn't know better and patients were being harmed.
And actually, I would go even further, he wasn't he was not only practicing medicine, he was practicing endocrinology. So so my dad was an endocrinologist. So this always kind of gets to me because it's one of those specialties. Were you do you do a lot of retesting, I still remember my dad saying, Oh, well that TSH is off, you know, with labs we're taught and endocrine, we just we double check that one lab again, or whatever it is. And it's it's a careful
specialty. And, you know, you're deliberate in your decision making. And what I find fascinating is you have a nurse practitioner. And I don't know if he was a family nurse practitioner, or not, yes. Okay. So your family nurse practitioner, practicing endocrinology, I'll be honest ith you. What I also - with th second half of this is we ha endocrinologist and famil physicians who were using growt hormone for sort of feelings o vitality and some of tha prescribing it to patients, no
a single patient was harmed. An those physicians in Washingto State lost their licenses.
That's ome of the hypocrisy.
And so that is the hypocrisy and all this, you know, here, you've got a board of medicine that saying, Wow, that's outside of the scope of your practice, in medicine. So we're going to just take your license, and you're going to need to go to classes and have this sort of stepwise thing and, and the thing is, we've got someone who's not trained, doing now endocrinology, and actually people are dying, and we're not d
They're not nly not trained, but they adv rtise themselves as hormone spec alists, there are actually doc mented, you know, photos from heir Facebook page, that they ad ertise themselves as hormone s ecialists.
And meanwhile, this is a nurse prac itioner who not only family, b t also he attended online nurse practitioner training. And he w s, I think, maybe a year or o out of training whe he was doing the this type o prescribing. So there's a lot o red flags. And you know, y u point out that the d fferences between the way the bo rd of medicine, sanctions do tors and the Board of Nursing, y u know, a lot of times we hea it said, Well, you know, ther are bad doctors too, and that
s true. But there are definite y more interventions that are oc urring more aggressively towards physicians. And I think one of he reasons is the structure o the boards. So I'll us as an example, Texas, since tha 's the state where this happen There are 452,000 nurses in Te as, there's 26,000 of them are nurse practitioners, 320, 00 are registered nurses, an 106,000 are licensed practical urses. On the nursing bo rd. There are 13 people th t are in charge of those 452,0
0 nursing professionals. But t e Texas Board of medicine has m re members, they have 19 member and they supervise 7 ,000 physicians, just a frac ion. So how in the world c n aboard be expected to be re ponsible for this number f professionals and do a good j b? And obviously they can't.
Obviously, th y can't. I mean, ultimately, I ended up finding them an endoc inologist to review these ases, it fell on me to actuall provide them with a physician a d expert physician to review the e cases.
Basically, you're like a good samaritan that came in there and did this job, unpaid, uncompensated, simply because you were worried about patient safety, and you're doing the job that should have been done by the Board of Nursing, if they're going to allow nurses, nurse practitioners to prescribe especially these potentially and in this case, deadly medications?
Well, you know, I think there's an element though, that we should talk about, because this is such a great example of, you know, the physicians who were complicit in this. And and so often, you know, when we're doing this, even even in our book, we talk about, you know, Dr. Brent Wilson and Jeffrey Reims who are complicit in this process of hiring someone not trained to be
working in a position. And so what I what I find so interesting is these other physicians involved that would just sign off on a clinic, they've never been there. They're not, you know, working face to face with a non
physician. And that's not being against In my opinion, we are not against this this profession of nurse practitioner or physician assistant, but I think we owe a duty of care to patients, that if our name is going to be signed on as a supervising physician, that then we take that care seriously.
That was one of the other things that was a complete eye opener to me was that, you know, that there were physicians out there that were willing to, you know, to compromise the quality of care, and some of them are doing it just for financial benefit. And we do we as physicians need to continue to speak out against that and hold our own accountable.
Absolutely.
I will say that turns any backlash at all Amy from kind of doing this and standing up I mean, I'm so proud of you. I'm so impressed by your bravery.
I was so f ustrated with the whole situat on that there was no way tha I was going to you back down a d continue to see people in he community that were hurt. I on't I mean, I just, you know, i was something that that wa n't even an option to quit. Um, ou know, but as far as backlas from the physicians, No, I did not get any backlash from the physicians, I did get a lo of backlash from staff that wor ed at the clinic. And surprisin ly, this nurse practition r was very involved in i
a church. And the, the the co gregation and the church members actually gave me a lot of b cklash and very unpleasant exp rience and, and attempts to att ck my character.
We know, Niran and I have talked, we talked in the book about how so many times patients don't really see the dangerous side, the safety side, they see that somebody cares about them, someone is being nice to them, trying to make them feel better. And I think in this case, Kevin Morgan wanted his patients to feel more of a sense of vitality, and healthfulness. A d indeed, the patient's must ha e felt better, because th y followed up and they kept goi
g back. And, you know, patien s often don't know that they' e being mistreated or receivi g the wrong care, and that it c n harm them, they often just s e the side of it that this is a nice person, a caring pers n and, and you hate to be the b d guy. But patients aren't don t have the privilege of knowi g that this could potentially ki l them. And unfortunately, that s where sometimes we have to e the bad guys and tell them t e hard truths that they don t always want to hear. That'
, that's tough. Yeah, absolutel . Well, I want to just make a f w points about some other stat s because we've talked a lot abo t Texas. But Texas is not the on y state where this problem h s happened. Recently, Californ a Board of Nursing made headlin s because in 2016, they had such a significant backlog f complaints that the syst m allowed a nurse who was accus d of contributing to the death f a child to continue to practi
e for over three years. And ju t this year, the board was accus d of falsifying documents to ma e it appear as if complain s against nurses were bei g investigated in a timely fashi n when indeed they were not. n Tennessee, the Board of Nursi g allowed a nurse practitioner o practice even after sta e attorneys recommended that h r license be revoked. She was o e of Tennessee's top opio d prescribers, accused f prescribing massive amounts
f controlled substances. s e defended herself to the nursi g board by pleading ignorance a d saying she was simply refilli g prescriptions. And she ju t later learned that the dos
s were too high. And then in N w York, a nurse who was attendi g a nurse practitioner schoo , reported her online school o the Board of Nursing in New Yo k for failing to follow t e recommended that t e requirements in New York for t e educational preceptorship a d just the educational lesson , and she basically got nowhe e and the Board of Nursing clos d the case. So I just bring the e up as just some examples of t e fact that boards of nursi g across the country a
e struggling. And as we contin e to allow independent practic , there are a lot of concer s about whether they're capable f actually making sure th t improper nurse practitioners a e not practicing and potential y harming patient
Amy, what advice would you have for any physician who's listening to this podcast about what to do if they find themselves in a similar situation?
You know, I think the biggest struggle for me was the feeling of, of being alone, and not having a lot of support, you know, even discussing the situation with a lot of my physician colleagues in the community, they all knew that this was going on. But no one was willing, I think, to step up to the plate and actually do something about it.
And we need to reach out to each other, I think and support each other, in holding people accountable, and upholding, you know, the medical standard of care in each of our communities.
I think that coming together is so important and having the solidarity, I'll point out that Amy and I are both board members of physicians for patient protection. And one of the things that's so important about this group is that it does provide a place for us to talk to each other to provide support for each other. I think Amy that might have been one of the ways you were able to find an endocrinologist to help testify was through that group.
So if you're a physician out there listening, I really want to encourage you to join our group officially and you can find out more about us at our website physicians for patient protection.org so Please join us there. And we also encourage you if to learn more about this important issue to get our book it is called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available in print at Barnes and Noble and in Kindle at Amazon.
Thank you so much. We're going to invite Dr. Amy back to talk again with us at an upcoming podcast. Please subscribe anywhere that you listen to your podcast and also at our YouTube channel patients at risk