S2 EP 2: Suicide Assessment – Responsibilities And Documentation

Narrator  [00:00]  Every minute someone’s life takes a terrifying detour, not down a dark alley, but into the sterile, bright halls of healing. They walk in seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis. Now before you raise a pitchfork at every white coat you see, let’s be clear. This isn’t an indictment, it’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors. Welcome to FHEA’s Scrubs and Subpoenas, Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode, a cautionary tale of blueprint for change, a reminder that even in the darkest corners of human error, there’s a light. The light of knowledge, the light of empathy, the light of a future where healthcare becomes not a gamble, but a guarantee. So join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal not just bodies, but the very system itself.

Dr. Wendy Wright  [01:21]  Well, welcome to this next episode of Scrubs and Subpoenas. I am so excited to be joined by my colleague, Dr. Sally Miller, where we’re going to talk about another episode from the Witness Stand. And so, as you all know, if you’ve listened to Scrubs and Subpoenas before, one of the things that’s really important to me, and I know to Sally as well, is that you know that we’re not here to place one ounce of judgment, because both of us have looked at our records and looked at things we’ve done over the course of our years and said, we’re not perfect, we’ve made mistakes, and we just pray that no one gets harmed while we’re making those mistakes. And so, just know that this is a judgment-free zone and that we’re just here really to chat about some cases, and hopefully you can take away some learning points from actually other people’s cases and misery, if you will. So, without any further ado, Dr. Miller, I think you’re going to bring the case to the table today, and we’re not going to tell people which side you worked on in this case, so let’s give it a go.

Dr. Sally Miller  [02:27]  Okay, I’m going to be as objective as I can in this presentation, and I wrote down some points, because I have a tendency to forget half of what I want to say, so if I occasionally glance downward, that’s why. But I want to give you the backstory or the primary information from the complaint. For anyone who’s listening who’s maybe new to practice or doesn’t know a whole lot about how a malpractice case gets from, you know, from, you know, ground zero to the point of a settlement dismissal or a trial, it begins with a complaint. The plaintiff, the wronged person, either the patient or the patient’s family, makes a complaint. And some states have a requirement for a certification even before that, that an expert signs an affidavit that this case has some merit, but it still, it all begins with the plaintiff’s version of events. That’s typically the first thing we receive as expert witnesses. That’s one of the first things we get to look at is the complaint. And I’m emphasizing this because I’m going to give you the info from the complaint, and then later when we talk about what we can take away from this, you know, I want to talk a little bit more about the complaint and what that means. But right now, we have a story of a 21-year-old young man. And so this is a 21-year-old man who was living independently in an apartment in a city. And the first information anyone has about this circumstance is that one night he contacted his mother who lived in the Burbs, so maybe an hour away. He contacted his mother and told her that he couldn’t sleep because he was having bad thoughts and he was having nightmares and he was seeing the devil. So he just called his mom to talk to her that night. The next day, he called mom back and he asked his mother to pick him up and take him back to the family home out in the suburbs because he was having these bad thoughts and he wanted to hear some stories about his childhood. It sounded like he wanted to feel safer. So mom went and picked him up and took him back out to that family home out in the suburbs and he stayed there for the day and then he spent the night there. According to the complaint, he didn’t sleep that night, but he spent the night there. The next day, mom drove him home back to his apartment building and dropped him off. And before the mother even made it back to her house, he called her again and asked if she would come pick him up because there were people chasing him and he wanted to know if his mother would come get him. So she turned right around and she went back to his apartment building. She said she found him about a block away and when she found him, he didn’t recognize her. She tried to entice him in the car. He said, you’re not my mother, like that sort of thing. Eventually, somehow, she managed to talk him into the car and she drove him back to the family home that they just left an hour ago. You know, this all happened in the space of like we’re 36 hours in now. So she takes him back to the family home and when they arrive, the patient, the 21-year-old, says that he is fearful that the mother’s husband wants to kill him. And when they get to the home, the patient insists that his mother and the family dogs go out into the backyard because the patient is afraid that the mother’s husband, the stepfather, wants to kill everybody. At this point, the stepfather calls the police and calls for an ambulance finally. So the ambulance comes out and they pick up this young man and his mother goes along with him to a local hospital. The local hospital, they diagnose him with acute psychosis. They restrain him. They medicate him and they transfer him to a psychiatric facility, inpatient facility. He’s in the facility for seven days. He’s diagnosed with acute psychosis and no one really knows why. There’s no real background story here. It’s like we went from zero to 60 in a two-day period. But he’s diagnosed with acute psychosis. He’s put on Zyprexa, Haldol, like anti-psychotics, and he’s there for a week. And then he is discharged back with his mother. So he’s discharged to home a week later. So there isn’t a lot of information about that facility because that’s not where my part of the case happened. But we all do know that he was diagnosed and treated for a psychotic episode of unknown etiology. There’s a history of some use of mushrooms, marijuana use, occasional alcohol. No one specifically identified those as the etiology of the psychosis, but it’s noted in the history and that’s pretty much all we know. So a week later, after a week’s inpatient stay, he’s discharged to home with his mother. So mother picks him up, takes him back to her house in the burbs. And according to the complaint, the mother says that immediately his speech is pressured. He’s rambling. He’s saying things that don’t make sense. He’s talking about the devil. But mom continues to take him home, and he spends the night in the family home. During the night, he goes to his mother’s room, and he says that he wants to spend the night with her. He’s trembling, and he’s scared. I mean, that’s about all the info we have. But we know that he went to his mother in the middle of the night, and he was disturbed. So the mother spent some time with him. He fell asleep. She went back to sleep. Patient wakes her up at 7 in the morning and says he wants to go out to breakfast, which apparently is a family on the weekends. The family does this sometimes. They will go out together for breakfast. So mom agrees to take him out for breakfast. And as they’re driving, the patient asks her to go to a specific restaurant, and he directs her to this restaurant. And when they get there, after they finish breakfast, the patient tells her he has a surprise for her, that he’s just booked a ticket to San Diego. Now, I won’t give you the city where this is all happening, but it’s far away from, so it’s nowhere near the West Coast. So he has booked a ticket to San Diego, and as it happens, this restaurant is very close to the airport. So he wants to go right to the airport, and the mother says, no, you can’t go to the airport because you were just discharged from the hospital. So he runs out of the restaurant and runs out into traffic and starts walking, you know, running, walking toward the airport himself. Mom grabs her car. She goes to follow him. She tries to get him in the car, and after, I guess, some negotiation, he does get into the car in the passenger seat. Reportedly then, this is all in the complaint. He leans over, grabs the wheel, drives the car to the airport. I’m trying to figure out how exactly that happened. He drove the car to the airport, and when he got close enough, the patient jumped out and ran inside. So mom had to park the car, and then, you know, she goes in the airport, and she’s trying to get the airline to block the ticket. He’s already through security. He’s on the other side of security, heading for his plane. Mom’s texting him while she’s at the counter.

Dr. Wendy Wright  [09:25]  With no clothes, no nothing?

Dr. Sally Miller  [09:26]  No, no, no, nothing. Just an ID. Just the clothes on his back. And him. So somehow, she talks him into coming back. You know, he comes back outside from security, comes out toward the counters, strips off his shirt and his shoes because he says they’re demonized, and he throws them in the trash. He won’t let her retrieve them. So she then, she gets him to go with her back home, takes him back to the family home, then goes home and calls an ambulance, and the ambulance picks him up, takes him back to the first hospital he was transferred to, you know, nine days prior. They go through the same thing, a psychotic episode, restrain him. They transfer him to a different psychiatric facility. And that’s where we jump into the scene now. So now he’s going to a new psychiatric facility. At the new psychiatric facility, now it’s the middle of the night. So he’s seen via telehealth by a psychiatrist via telehealth for his initial intake. The initial telehealth assessment documents him as based on major depressive disorder severe without psychotic features. That was the admitting note from the psychiatrist. Note some suicidal ideation. Writes a standard. You know, in psych hospitals, there’s just a protocol for antipsychotics, you know, PRN. But it doesn’t prescribe anything consistently, just the PRN protocols, and recommends that the daytime staff contact the family for more information, and that’s it. The patient is admitted. So now that the patient is being admitted, as is very common, he’s given the opportunity to make this a voluntary admission. You can either be held involuntarily or…

Dr. Wendy Wright  [11:10]  Right. And there’s no ability to hold him involuntarily until someone can see him? If he refuses it?

Dr. Sally Miller  [11:15]  Well, if he refuses admission and they feel like he’s an immediate threat to self, they can initiate them. And there’s mechanisms for having a hold immediately. But in this case, he agreed to a voluntary admission. Okay. So he agreed to a voluntary admission. So he is now a voluntary patient. So he’s admitted to this facility. And, you know, it’s analogous to a hospital where there’s a hospitalist who will manage you. Right. You know, like in a regular hospital, the ER admits you, and then you’re [admitted] to a service, and the hospitalist follows you. Well, here, this… the on-call person did the telehealth admission. The patient’s admitted to the service, and then is seen by… is placed on the service that is managed by a nurse practitioner. So now the nurse practitioner is the hospitalist in this psychiatric facility. She’s the person who’s going to manage his…

Dr. Wendy Wright  [12:05]  And that’s fairly common now, isn’t it?

Dr. Sally Miller  [12:07]  Very common. In both mental health, I think, and even in, you know, general medicine.

Dr. Wendy Wright  [12:12]  Right. Okay.

Dr. Sally Miller  [12:15]  So just as a side note here and something else we can talk about at the end of our discussion, this is a family nurse practitioner who is in a psychiatric mental health program. But, you know, at the moment, she’s a family nurse practitioner.

Dr. Wendy Wright  [12:28]  I think we need to talk about that. We need to have scope of practice. So I think we should talk about that, okay?

Dr. Sally Miller  [12:35]  Well, and this may be a great example of why it really is a better idea to stay with your scope of practice. But again, the state permits it. Right. And when you, you know, looking at it from a standard of care perspective, when you look at the stats and the data, the objective data and the literature, there’s actually more FNP’s functioning in the role of a mental health provider than there are psych NPs. Now, that’s going to change really fast. It is going to change. Psych programs are just like blowing up.

Dr. Wendy Wright  [13:09]  And I think it’s because there was no other option for a long time. But as we start to splinter the scopes of practice, that line becomes very blurred. As to what can you do as a psych NP that I necessarily maybe shouldn’t do as a family.

Dr. Sally Miller  [13:25]  It’s a hard one. It is. If we have time at the end, I’ll give you a little very lateral, like, you know, little lateral thing that’s kind of interesting about that. But so back to this person. So now, this NP who is managing this patient, she assumes his care. And remember that the physician who admitted him via telehealth did a admission history and physical, documented the absence of hallucinations, of delusions, of psychosis, basically documented that the patient was evasive and not very talkative, not forthcoming, was severely depressed, had some passive suicidal ideation. And that was the, I mean, I’m editorializing here to try to just be relevant. But on that admitting exam, specifically, hallucinations, delusions, or any psychotic behavior were ruled out at the time of that admission. He was diagnosed with MDD, severe, without psychotic features, and put on sertraline. So this is the patient that the nurse practitioner inherits to manage during his inpatient stay. So the patient was there for seven days. He was there for another week. And through the course of those seven days, the nurse practitioner saw him daily. He was also seen at least daily by a psychotherapist. And there’s like recreational therapy. There’s dance therapy. There’s art therapy. There’s group. There’s a whole lot that goes on. There’s nursing assessments, every shift. And throughout the entire hospitalization, never is there any documented hallucinations, delusions, discussions of the devil, or any of these other psychotic, not knowing anybody. This is a depressed patient who is keeping to himself, doesn’t participate frequently, you know, refuses or declines to participate in groups. Other times, he does participate in things. He apparently seemed to really enjoy dance therapy, like a very typical depressive sort of patient to the tune of having to be admitted. There were numerous suicide assessments done. And of course, another thing we need to give a nod to here is that suicide assessment is more than negative SI. You know, we don’t just negative SI. Of course, in a psychiatric facility, they, you know, they use good tools as a framework. The ASQ questionnaire is documented here routinely. There was specific attention to, you know, protective factors, risk factors, passive ideation. And passive ideation was occasionally noted. In other days, there was no ideation. There was never active ideation. And so another interesting little side note is that during that hospitalization, one of his therapists noted that she conducted her therapy session in Spanish. And that’s the first time anybody found out that the patient was born and raised in Mexico to the age of 18. And then at the age of 18, came to the US to go to college. And so apparently, in these initial interactions, the patient was speaking English, and people were responding in English. But there may very well have been some deficit in communication because of a language barrier that wasn’t identified. Who knows? It just maybe didn’t become apparent. But she documented her interview in Spanish, and it was really instructive. She was very open. He talked a lot about feeling like his mother, that he was an unwanted pregnancy. His mother didn’t want him at birth. Apparently, the mother left Mexico very early in his life, and he was raised in the country by his father with his brothers. That there was a lot of difficult relationship with the mother. You know how it is in psychiatry. It’s always the mother. It’s always the mother’s fault. None of this came out. None of this came out until the therapist conducted the interview in Spanish. It was really a full, like, I don’t know what the word I want here is.

Dr. Wendy Wright  [17:28]  A very [inaudible] moment.

Dr. Sally Miller  [17:31]  Yeah, I mean, like, wow. And then the patient, he related to her. He opened up to her, and he told her that he understood the concerns. He felt like things were much better. He was not suicidal. He was looking forward to connecting with a therapist upon discharge. It was really an interesting and eye-opening and very positive interaction. Okay? So at the end of seven days, the patient is discharged to home with now, by now, like his father has come. From Mexico, you know, because now, like, the mother’s in touch. Time has gone by. This is a serious situation. So now the father is here, the person I think with whom he has felt most connected through his childhood. And he is discharged from the hospital with his natural father, who goes back with him to his apartment in the city. So now they’re back to the patient’s apartment in the city, and they get discharged back to home. And two days later, the patient jumps out of the window of his 21st-story apartment and kills himself. Oh, my goodness. So, so. Wow. That’s the story. So that’s, all of that’s in the complaint. All of that is what’s in the complaint. And the reason I mention that is because it is important for everybody to realize that the complaint is the plaintiff’s version of events. And I’m not, I’m not saying necessarily any of it’s not true. I’m saying it’s the plaintiff’s version of events. And you know that in the world of communication, people say things through their filter, and the listener receives it through their filter. And that’s how it gets recorded. And there’s always more that we have to explore. So that’s the complaint. The specific allegations against that nurse practitioner were, number one, failed to consider the history. She failed to consider the history. So, you know, I think we all need to think about, well, did she fail to consider the history? What history would she reasonably have been expected to have? I mean, keep in mind, she assumed the patient following the admission history and physical by the telehealth psychiatric provider. And in that history and physical, there was, there was passive suicidal ideation. There was no discussion of psychosis. In fact, I have it in front of me on the other screen. What the admitting physical described was patient was transferred from the emergency room of another facility where his mother took him there because he was depressed and expressing suicidal thoughts. Patient was recently hospitalized to a psychiatric unit in another facility for the same problem. That’s the history that the NP has in front of her with this admission.

Dr. Wendy Wright  [20:10]  I would say to you that that’s not unlike what we get, you know, whether it’s a psych facility or not. I, as a family NP, am often looking through the lens of what the patient is telling me or what the family is telling me without the benefits of always having all those records. Yeah.

Dr. Sally Miller  [20:27]  So when you hear all this business of the demons and the devil and running into traffic and coming out of security, this NP doesn’t know any of this. And of course, the plaintiff asserted that she had a much greater responsibility to dig into that history. So, you know, one of our questions is what, you know, what responsibility do you have when you have an adult with a voluntary admission and this information in front of you. She knew he was hospitalized for the same problem. One of the big bones of contention was she should have gotten those records and looked into them.

Dr. Wendy Wright  [21:03]  I think whether you have those records or don’t, here’s my opinion on this. If I were to kind of think about it, whether I had those records or not, I’m going to treat the patient that’s in front of me. Right. I mean, that is, you’re going to treat what’s in front of you because that may be very different than what it was seven days ago, regardless of whether I have those records or not. You and I often say, treat the patient, not the lab. Yeah. Right.

Dr. Sally Miller  [21:28]  And even if you wanted records, I mean, I request records from psychiatric facilities all the time, and I probably don’t get them more than I do. And another system. And they have 30 days to render those records to you.

Dr. Wendy Wright  [21:39]  By that point, the [inaudible] is already gone anyway. So, I don’t.

Dr. Sally Miller  [21:44]  I mean, I don’t. I mean, you know, we need to think about if it was if the standard of care, if the reasonable expectation is that based on what’s in front of her, there was a responsibility to chase those records or not. You know, keeping in mind, not only does she have a different history in front of her, but when she’s examining the patient for the first time on the first day, she says he felt, okay, he denied any suicidal thoughts, denied hallucinations. He admitted to depressed mood. He admitted to having anxiety. I mean, again, I’m paraphrasing, but this is what he admitted versus what he denied. They also asserted, you know, it is amazing how a plaintiff’s attorney, no, just there are some good plaintiff’s attorneys out there, and I’ve worked with them too. But there might be two or three themes, and they managed to turn it into 20 different allegations. That’s just all saying the same thing. So, again, I’m paraphrasing here, but another one was failed to contact the family to investigate the history. Now.

Dr. Wendy Wright  [22:45]  Wow. I don’t know that I’ve ever seen that in a complaint.

Dr. Sally Miller  [22:50]  Failed to contact the family to investigate history. So is it any responsibility when you have a patient in front of you who is an adult on a voluntary admission? Do you call the families? Yeah. Do you call his mother or anybody to ask more questions? So that was another assertion. Failed to investigate family history. Now, again, during his admission, history and physical, which was comprehensive, he denied any psychiatric family history. Later, in deposition testimony, the mother said that she was bipolar, and so plaintiff’s attorney argued that that bipolar history could have, you know, could put the patient at greater risk and, or, you know, it could also perhaps make the mother a little bit less objective in how she interpreted things. So, but the assertion was failed to investigate family history. Failed to follow up with the family as suggested by the admitting telehealth provider. Telehealth in the middle of the night said, you know, suggest contacting the family in the next day. Oh, okay. And so, again, is this a standard of care? If an admitting provider suggests that I do something the next day, is it a violation of standard of care if I don’t do it? Is it or isn’t it?

Dr. Wendy Wright  [24:04]  I mean, well— And this is where cases— There’s often no correct answer. Like there’s nothing in a book that says, if a physician says call the family tomorrow, that that’s standard of care. And that’s what they’re, they’re preying on the sadness of this case, you know?

Dr. Sally Miller  [24:26]  On that particular point, my, my personal thought was, if it was so important to contact the family— You call them. You call them that night. So, I mean, and maybe then he saw that note and thought about it and thought, well, I don’t need them because I am, you know, so what if so that was another particular…

Dr. Wendy Wright  [24:44]  Particularly if he’s articulate, communicative, he’s forthcoming as best as you can tell. I wouldn’t call the mom. Do we know if there was a release sign to allow anyone to speak with mom? I’m just curious about that. Yeah.

Dr. Sally Miller  [24:57]  There actually was a, he declined to have any family contacted. He signed a form that said not to contact anybody. You do it. You’re going to be sued. The plaintiff’s argument is he was a danger and therefore these things don’t apply, which in itself is not true. I mean, it’s not a blanket truth. Another one, right from the plaintiff, failed to address the patient’s intense anxiety, which is known to increase suicidal risk. I don’t even know that I put those two things together. Neither did I see intense anxiety in any of this hospital stay. But these, again, this is the plaintiff’s assertion and that’s why it’s important for all of us to recognize that that’s not always the way things were.

Dr. Wendy Wright  [25:48]  I say to patients in front of me, there’s three truths. It’s like divorce. There’s yours, there’s his, and the truth that probably falls somewhere in the middle.

Dr. Sally Miller  [25:56]  In the middle. Now, another interesting one, failed to establish necessary aftercare. The patient was discharged with an appointment for a follow-up in the clinic three days after his discharge. He was given written instructions about where the appointment was, what time it was, a contact name and a contact number, and additional resources for mental health crisis.

Dr. Wendy Wright  [26:18]  Do you think they were just throwing things… To me, this feels like they were throwing things against the wall like putty, like Play-Doh and seeing which one of those pieces are going to stick and what defense is going to just say, I’m going to make this case go away. That’s what they often anticipate that someone’s just going to settle to make it go away.

Dr. Sally Miller  [26:42]  They also asserted, improperly assessed his suicide risk as none, like quotes none, which is not the way the risk was assessed. On discharge, it was documented that he was not suicidal at the time of discharge, which is very different than no risk. You can’t keep somebody in the hospital, even for passive ideation. You only can keep somebody there when they are in imminent danger to self or others. The fact that they might have had some suicidal ideation a week ago, you can’t, I mean, if we hospitalized that. Right.

Dr. Wendy Wright  [27:23]  I have a feeling I know which side is the case you’re on, but I’m just really curious. Can you tell us, because I want us to make sure we have time to talk about this. It’s always clear.

Dr. Sally Miller  [27:34]  By the time I’m done, it’s always obvious what side of the case I’m on. I was on the defense side, although I did support the defense because based in what was in front of us, I feel like the defendant acted consistent with the standard of care. There’s perfection and then there’s standard of care. In hindsight, when we went through all the depositions and all the family members, the brother, the ex-girlfriend, in retrospect, actually, I think what we were seeing here was the first psychotic break with a diagnosis of schizophrenia.

Dr. Wendy Wright  [28:08]  I was going to ask you that.

Dr. Sally Miller  [28:10]  A very long history. Years back, like normal high school years when he started college, the withdrawal, the depressed mood, breaking up with the girlfriend, withdrawing into himself.

Dr. Wendy Wright  [28:24]  And it seems at the time, particularly a male, that we often see the declaration of some of the symptoms. Wow.

Dr. Sally Miller  [28:31]  So in retrospect, it looked like schizophrenia, but that isn’t anything based on what the NP had in front of her that she could have known. Should she have explored it more?

Dr. Wendy Wright  [28:43]  So what happened? Do we know?

Dr. Sally Miller  [28:46]  It settled. She was sued and the physician was sued and the facility was sued because again, it was a sympathetic case. Yes.

Dr. Wendy Wright  [28:53]  So they did end up paying out?

Dr. Sally Miller  [28:55]  They did end up paying out.

Dr. Wendy Wright  [28:57]  I think what we should do too is at some point talk about cases that actually just get dropped because there are cases as we move through these Scrubs and Subpoenas about how they take it so far and then just realize, listen, every expert out there is saying there’s not a case. Or how about every expert that says there is a case. I’ve done that a lot. And they’re saying, I just had one and I told my thoughts and the attorney said, you’re the third expert we’ve got. The exact same thing I said, third time’s a charm is what I’m told. You probably ought to start settling this case because you just there’s nothing much you can do. So let’s do some takeaway points from this. One thing is scope of practice. Maybe we can just talk really quickly about that. I’ll say my piece and then I want to defer to you. But as we get more and more certifications, psych mental health, women’s health, pediatrics, family, dermatology, cardiology, emergency room. Where does the line break between what I can do as a family NP that I’ve been educated womb to tomb? When does the line break that that person should go over to you? I know in my head as a psych NP, I know in my head schizophrenia, delusional, severe major depressive disorder that I just can’t treat, active suicidality. But you know what? There are a lot of NPs in rural America who are the only thing that stands between that patient and dying. Is it okay for a family NP to write an antipsychotic? This is where scope of practice and attorneys are very worried about this because NPs are one of the few professions that divides and conquers like this. So thoughts?

Dr. Sally Miller  [30:51]  It is. I know we’re running out of time so fast here. But there’s standard of care and then there’s what ethically, professionally, ideally. And for malpractice, it’s about standard of care. It’s about what typically happens. And just because of the sheer number of FNPs doing it, it’s common at this point. So there’s that. Should it be happening? Well, you know, in this case, I think one of the, perhaps one of the downsides of the fact that this was not a psych NP was that she didn’t seem to appreciate the need to explore even just depression. Where does, like, you know, in psychiatry, we all know that if somebody presents to you with a depressive episode, you have to rule out other causes of it. And bipolar disorder and schizophrenia at that age are the big two. So if I see anybody who’s presenting as depressed, I’m going to really explore that depression and the trajectory of it and the timeline. And has there been any any psychosis? If I have a young man in front of me who’s 21, who I am hearing about like the devil and running in the street and flying away. And he’s in front of me right now being depressed. I’m going to consider but an FNP might not.

Dr. Wendy Wright  [32:15]  Because maybe one thing, maybe one, I had a family physician, he should have been a psychiatrist. He knew his meds. He was so good. He just didn’t become a psychiatrist. Can you defend it educationally? Can you defend it experientially? But I’ll tell you, you’ve got just know that attorneys are using scope of practice a lot now in a lot of malpractice cases. And I asked an attorney recently, is this something you’re seeing more of? And he said, no question in my mind, we’re seeing it more with family with nurse practitioners. And the reason people want family is because we can manage all age groups. You do anything.

Dr. Sally Miller  [32:53]  Yeah, you know, in like in some states, you are restricted by your certification and Nevada is one of them. I know we’re getting time here, but I mentioned if we had a minute at the end, I’d tell you a story. So Nevada, your license is very restricted to your certification. If you’re an FNP, you cannot work as a psychiatric NP, you can’t have a job description that makes you a psych NP, except that in the state because there were no psych NPs for 100 years, most of the NPs practicing in mental health were FNPs. Well, there was a really, really good one all this NP ever did was psych, she was very good at what she did. Someone made a complaint, actually her employer made a complaint against her to protect the company. There was a patient made an assertion about violating confidentiality. That was all, you know, backside political navigating. The employer made the complaint with the board, almost as a protective mechanism to protect the business. So in investigating the complaint, it turned out that the NP, there was no concern about the confidentiality violation. But in the course of the investigation, it became apparent that she was an FNP practicing in a psych NP role. And I mean, we pulled job descriptions, there was just no, there was no wiggle room here. It was a psych NP job description, it was a psych NP role. She was an independent contractor and her own contract showed her as a psych NP. And so because that was a direct violation of our nurse practice act, she was disciplined by the board, which you know, follows you for the rest of your career, there’s no time limit on it. And she can no longer practice in mental health in that state, unless she goes back to become a psych NP. And it didn’t matter that she was really good at it. So it was really kind of, you know, so it’s state by state.

Dr. Wendy Wright  [34:42]  And that really brings up occasion really have to be cognizant of state laws, and statutes and and what your board of nursing sets as your scope. So if your employer says and I tell this, I say this all the time, you’re an adult NP, you know what that eight year old, it’s their ear and ears and ear, what’s the deal? Do not do it. Do not do it. As an adult NP shouldn’t be seeing an eight year old. Yep. And that’s where scope of practice really comes in. If you’re not sure, reach out to the board.

Dr. Sally Miller  [35:16]  Exactly.

Dr. Wendy Wright  [35:17]  I can restrict the NPs that work for me and say you’re not going to do x, y and z, but I cannot expand. Right. Right. Anything else you want to bring up before we know our time is up. I know our time… Big takeaways scope of practice is a big one. Do your best to get the best comprehensive history and physical. And she was able to have seven days in a row. How many of us don’t have access to that? I know I see a patient and send them loose and just pray that they are okay. Right. It’s just hard. It’s a hard job. It is.

Dr. Sally Miller  [35:55]  Oh, it is. We get the big bucks for it, right?

Dr. Wendy Wright  [35:57]  Yes, we do. Yes, we do. All right.

Dr. Sally Miller  [36:01]  Hopefully, those cases that are dismissed next because I have a waiting for them to drop.

Dr. Wendy Wright  [36:07]  I know me too. I’m like, this is the most stupid case you’ve ever asked me to work on. But, you know, someone’s got to do it, right? So, if you want to conclude us today and just do some takeaways.

Dr. Sally Miller  [36:20]  I mean, I think the takeaways are when, you know, what’s a realistic assessment of our of how far we go of how far we dig. I think scope of practice is a real obvious one here. And just because you are legally authorized to do a thing doesn’t mean that you should do it. Rule number one, does your state practice act permit it? Okay, it does. Then do you feel qualified to do it? Are you qualified experientially, educationally? You know, it’s a decision tree. Absolutely. And document the real takeaway. Oh, I mean, I write my notes now every note as if three, four experts are going to be looking at it with a magnifying glass three years down the line. You don’t know. My peers laugh at me. Don’t know.

Dr. Wendy Wright  [37:03]  And, and I, I live in fear. I’ve seen what it does to NPs. I don’t want to be sued. But I’m not. I’m human. And we don’t make mistakes. And in a busy practice, I just did a physical today I had 21 diagnoses to address. I mean, my notes are not huge. I don’t have time to make huge notes. So, but you know what I did with a patient today brand new who was so complex. And I said to her, I need time to think about you. You have nothing. What we what we did today, I addressed some of those pressing things. But I’m going to go home and I’m going to think and I will be back in touch with you in the next 24 hours so we can come up with a plan. There’s nothing that says you can’t do that. If you need a follow up,

Dr. Sally Miller  [37:45]  You have a follow up. You need a follow up.

Dr. Wendy Wright  [37:49]  Absolutely. Book it. And then if they don’t show up, that’s on them, not on you. So all right, we have a lot of things to talk about. But we gotta save that for Episode 53. So, so thank you all so very much. Thanks. Thank you for joining into Scrubs and Subpoenas. And please tell your friends about it. I think we’re on all of the different social media channels. So some attorney found one of these episodes. So if I can find it, you can find it. Have a great day, everyone. And thank you for joining us. Bye bye.

Dr. Sally Miller  [38:20]  Bye bye for now.

Narrator  [38:21]  Thank you for listening and learning with Scrubs and Subpoenas. Tales from the Witness Stand presented by Fitzgerald Health Education Associates. Please rate, review and subscribe to this podcast. And for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.