Many of our critics accuse us of exaggerating the risks that patients face when physicians are replaced by lesser trained members of the healthcare team. We are often told that we are engaging in a ‘turf war’ with nurse practitioners and physician assistants and that we should support these nonphysicians practicing ‘to the full extent of their license and training. ’ Today we are going to explain exactly why we take such a hardline stance against the independent practice by nonphysicians. It’s not because of a turf war - it’s because of patients like seven-year of Betty Wattenbarger, who died after a pediatric nurse practitioner failed to diagnose her with pneumonia and sepsis, an overwhelming blood infection. Betty’s father, Jeremy, is on a crusade to ensure that other parents do not lose their children because of a lack of access to care by a properly trained physician.
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COMPLETE TRANSCRIPT
Rebekah Bernard MD 0:07
Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book 'Patients at risk, the rise of the nurse practitioner and physician assistant and health care,' Dr. Rebekah Bernard. And today I have a special guest host joining me, Dr. Amy Townsend. She is a fellow board member with Physicians for Patient Protection.
Many critics of our organization accuse us of exaggerating the risks that patients face when physicians are replaced by lesser trained practitioners of the health care team. We're often told that we're engaging in a turf war with nurse practitioners and physician assistants, and that we should support these non physicians practicing to the quote full extent of their licensure and training. Today we're going to explain why we take such a hardline stance against the independent practice by non physician practitioners. It's not because of a turf war. It's because of patients like seven year old Betty Wattenbarger. She died when a nurse practitioner failed to diagnose her properly with pneumonia and sepsis. Betty's father, Jeremy is gracious enough to join us today to make sure that other parents don't lose their child because a physician was replaced by a non physician practitioner. Jeremy, thank you so much for joining us. And I'm so sorry for your loss.
Jeremy Wattenbarger 2:12
Thank you
Rebekah Bernard MD 2:13
Jeremy, I've seen a lot of photographs and videos of Betty and she just looked to be so full of life and vitality. Can you tell us about her?
Jeremy Wattenbarger 2:21
Yeah, Betty, the reason I'm wearing my shirt today, my Wonder Woman shirt is because we used to call her 'Wonder Betty' because it was she was making amazing progress and strides. Even though she was autistic she was starting to become verbal. And we were starting to see things in her that we were told were never to be expected. You know, she started riding her bicycle. And she started running and she started interacting with other children. And she was learning how to read and she was doing all those things before her life was cut short. So, Betty was was life and she was happiness. That's why I'm actually in her room right now you can see behind me there's bright colors. That's because that's who Betty was - that her favorite thing was greens and reds. And her whole room is painted in greens, reds, because she was vibrant and full of life and energy. And you know that that was Betty. And in a nutshell, she didn't have a lot of those, you know, break down moments, she really had that comprehension. She was, you know, hey, I'm easy going, you know, whatever. And that's kind of the way she was. And that's the way she approached life. And I think all of us need to have a little Betty in us at some point.
Rebekah Bernard MD 3:29
I think so. And really just from that little bit that I could see in the photos and the videos, you could just see that she just glowed with life. And really, other than, you know, she did have her challenges with health as far as the autism, but she wasn't an unhealthy child, I don't think, right?
Jeremy Wattenbarger 3:45
No, we even had a $10,000 donation given to us to have a genetic testing ran on her DNA after she passed away. And there was no genetic conditions or anything like that identified within that genetic testing.
Rebekah Bernard MD 4:01
So she was in generally good health until one Sunday when she developed a fever. And first she was getting better but then she quickly took a turn for the worst. So you guys decided to take her over to a local urgent care. And can you tell us a little bit about what happened then?
Jeremy Wattenbarger 4:19
Yeah, we had contacted her pediatrician first and he didn't take appointments on Wednesday, suggested we went to a pediatric urgent care. And we took her into the pediatric Urgent Care thinking, like most people do in the state of Texas, that a pediatric urgent care is going to be similar to an ER - it's going to have the same capabilities. And this one, in fact actually did advertise that they did have the same capabilities as an emergency room and had all the facilities and everything capable of diagnosing and taking care of her. So we were under the impression when we went there we were seeing someone who was number one a doctor or on that level and someone who would actually be able to treat, diagnose and give us a proper assessment of Betty and what's going on. Because when you are talking about a child that is autistic and non verbal, you take a special level of care whenever you're dealing with that patient.
Rebekah Bernard MD 5:17
Jeremy thought that he was seeing a physician. He actually wasn't -it was a nurse practitioner that was giving the care to Betty. And that wasn't something you were aware of right, Jeremy?
Jeremy Wattenbarger 5:27
No, it wasn't something we were aware of.
In this case, the the APN did not identify herself as an APN. She did not wear a name tag or a badge or any other type of identification, you're assuming at that point, having no medical background or experience, I've never been in this situation before, that you're going to be seeing a doctor because you're at an urgent care situation. Urgent Care is always painted as the next step before an ER or similar to an ER. So you're thinking you're seeing at least a doctor at that point.
Rebekah Bernard MD 5:55
Right. And then just to kind of fill in the rest of the story. You took Betty and she gets evaluated by a pediatric nurse practitioner, the nurse practitioner evaluates her says she just seems like she has maybe a viral infection recommends that she takes some Motrin and send her home. no x rays, no blood tests, no real evaluation. And so you guys take her home, because this is what the quote 'doctor' told you to do. And then she didn't seem very well. And then the next the next morning, she took a serious turn for the worse is that? Is that correct?
Jeremy Wattenbarger 6:36
Well, that night, what really threw us off was that Betty was going through the the last times of her life. And she seemed to be improving overnight, and then rapidly took a very sharp decline. The next morning, and we're like, the the nurse has just told us that you know, she just had flu, her lungs were clear, everything was fine. And with the flu, you do have exhaustion, sometimes diarrhea from taking in a lot of liquid, things like that. So we thought at that point, you know, hey, you know, we've already seen a doctor, she's already made an assessment. And we know what's going on with her. And we had no reason to be concerned at that point.
Rebekah Bernard MD 7:10
But then unfortunately, the next morning, you found her unresponsive - blood was coming from her mouth. You rushed her to the emergency room, but it was too late. She passed away shortly after.
Jeremy Wattenbarger 7:22
Yeah, that's correct.
Rebekah Bernard MD 7:23
Now you reached out to Amy Townsend. How did you find out about Amy, you just saw some reports about what we were doing to advocate for patients?
Jeremy Wattenbarger 7:32
Yeah, I did that. And I also did some additional research, trying to get some additional help here in the state of Texas, the state of Texas itself has has not been very cooperative into looking into this. And we've had a lot of struggles with it. So I was trying to find as many resources as possible to be able to kind of push back and actually get this taken seriously in the state of Texas.
Amy Townsend MD 7:57
So I don't know if Jeremy, I don't know if you remember this. But it was almost exactly a year ago today that you actually contacted me. And it he reached out to me through LinkedIn. And so what I remember of that situation was that he had actually read a story, Rebekah, that you had posted or published in MedPage Today about my struggles with a nurse practitioner here in my area and trying to get the Texas nursing board to pay attention on this nurse practitioner that was actually causing significant harm in in, you know, my area.
Rebekah Bernard MD 8:33
Now one of the things that's really interesting and Amy, I'd like your perspective on this is that Betty's mom took a photograph of Betty while she was actually there in the urgent care of me Tell us what you see in that photograph of Betty and what you as a physician may have been worried about if you weren't had been evaluating a child like this.
Amy Townsend MD 8:48
Yeah. So, you know, the first time that I actually saw that that photograph was when Jeremy had reached out to me for the very first time again through LinkedIn, and he had actually already, you know, published some of the information on a website called the Sepsis Alliance. And so he was able to forward me that story and it included the picture that they, you know, took at the urgent care. And you know, in that picture, you know, her lips are a very dusky color. She looks her cheeks look and eyes look very sucked in she she looked like she was probably somewhat dehydrated. And then Jeremy also after I spoke with him, after, you know, communicating with him on LinkedIn, he actually was able to send me some of her medical records from the the clinic itself at the time that she was she was seen. And the one thing in those records that really stuck out to me were her vital signs, her vital signs, it was very apparent that you know, the child was unstable. You know, she had a heart rate so I think it was in the 160s or 170s. Yeah, and you know that...
...[with] those sets of vital signs in combination with that picture. I don't see how any practitioner could have not recognized how ill Betty actually was, and the appropriate thing would have been to send her directly to the to the emergency room.
Rebekah Bernard MD 10:10
I mean, it's okay as a nurse practitioner or a primary care physician to maybe not know necessarily what is causing a person to not look well. But what we're all supposed to know how to do at a minimum is to recognize when someone is severely ill and needs a higher level of care. In fact, that's what we hear all the time about nurse practitioners, they know when to refer to another level and that we're supposed to trust them because they know their scope. But this is an example where certainly she did not recognize and Jeremy I think I saw in the records that you or her mom actually asked the nurse practitioner or someone there, 'Well, don't you think she looks unwell? Why is she breathing so fast?'
Jeremy Wattenbarger 10:52
Right. And just to add to what Amy was saying, also, actually, we discovered later on that there actually is an internal policy for vital signs with inside of that clinic, which was not followed. So it clearly states that a first set of vital signs for vital signs, including respiratory rate, which was not taken, needed to be taken, if those signs were outside the norm, you know, like she was tachycardic, then they should have taken a second set of vitals, which they did not do. So there's a second violation on that policy. And then the third violation on the policy says that, if the patient is vital signs, I've got it here in front of me, the patient's vital signs are not where they're supposed to be at abnormal vital signs will be documented medical record and reported to physician and medical provider in a timely manner. intervention should be administered and documented reassessment of the abnormal vital signs a patient is not to be discharged from the facility with abnormal vital signs unless approved by a physician or medical provider, she clearly violated their own internal policies not once, not twice, but three times if she had followed the vital science policy accordingly, and done the assessments accordingly we might not be in the situation right now,
Rebekah Bernard MD 12:05
Amy, talk a little bit about that, about why we have policies and procedures and especially when it comes to non physician practitioners, and how important it is that we follow those?
Amy Townsend MD 12:15
Yeah, absolutely. I mean, because there are limitations on the scope of training for non physician practitioners, you know, their, their training is much shorter than then a physician, and they can be very helpful to help physicians to extend the reach of the care that we can provide. But because of their limited training, protocols are often put into place like this to make sure that sick patients are and most certainly sick children are recognized, and the appropriate interventions or are implemented.
Rebekah Bernard MD 12:49
You know, I'm a family physician, so is Amy, we do take care of children. We're not pediatricians, but we are trained to take care of children. And one thing in my training was a very healthy respect for how quickly children can decline. Now in the case of Betty, she passed away about 15 hours after that Urgent Care evaluation, which is so fast. And from looking at the photographs and from hearing some of the history and the vital signs. It sounded like she was very unstable.
But Jeremy, you as a parent, but there's you have no way of knowing that you did everything right. You took her to a not only an urgent care, but a pediatric urgent care where you expected that someone would be there that would know what they were doing. And in Texas, nurse practitioners are required to be supervised by a physician. However, it didn't seem like there was any physician there what there was no physician available at the time that Betty was evaluated. And in fact, we don't even see any evidence that the nurse practitioner asked any advice or reached out for help in this case?
Jeremy Wattenbarger 13:49
That's correct. The the physician was in Cambodia at the time, he stated that he assigned a proxy, one Dr. Sherry Burke, and when I investigated Dr. Sherry Burke, Dr. Sherry Burke who was in a delinquent non payment status on her medical license, she was not eligible to be supervising anyone at the time. So if that was the proxy, and that was the case, then the nurse practitioner should not even been on that site because she was practicing medicine without a license. And so is Dr. Sherry Burke, who is now under investigation from the Texas Medical Board.
Amy Townsend MD 14:21
Did they say, was the substitute supervising physician, was she even aware that she was responsible at the time?
Jeremy Wattenbarger 14:29
So the medical board, whenever I talked to them about Dr. Cowan, they believe that Dr. Cowan was doing the right thing and and assign an appropriate proxy, but they did not do any further investigation into that proxy. I had to go do that piece myself. And so the Texas Medical Board now is kind of in a situation where, you know, do you call the the doctor who was in Cambodia a liar? Or do you take his word that Sherry Burke was his proxy at the time So, if you look at Sherry Burke's current licensure, it's still Active but she has no address she has no, there's no demographic. There's no information whatsoever on her license. It's just completely blank. It says N/A everything, no practice, no nothing. So I don't even know what she's doing right now.
Amy Townsend MD 15:12
So regardless, there should have been a supervising physician. There's no indication though that the nurse practitioner even made an attempt to reach out to anyone with any concerns or questions or following the protocol that you mentioned.
Jeremy Wattenbarger 15:28
No, there's there's no signs of that. She seemed like she was doing her own thing that day, even to go further, there's actually a procedure for documenting medical records, she violated that procedure also, that policy on on site also. And that was one of the things the initial Board of Nursing investigation hit her on is that for charting could have caused patient harm. So they even identified at the nursing board in the first investigation, that she was acting reckless by not charging properly. So I mean, it's been shown over and over, she clearly violated policies, procedures, she was doing her own thing that day, she was in charge, and that was all there was to it, she wasn't going to reach out to anyone.
Rebekah Bernard MD 16:06
Well, you know
Part of the problem with this remote supervision that we have is that we have to trust the person that's being supervised, that they're going to know that something's outside of their scope, or they're going to recognize that something is wrong and reach out for help. And I think this is one of the fatal flaws that we have for supervision.
Amy, you are a Texas physician, you of course, broke the big story about Kevin Morgan and his inappropriate testosterone clinics, and went through a tremendous amount of effort to get him to stop that behavior. What are your thoughts on when it comes to Texas and supervision of non physician practitioners?
Amy Townsend MD 16:43
So this is one of the most frustrating things is that over the last couple of decades, we have had this gradual deterioration of the definition in in the laws that are there about what actually, you know, physician supervision means. And so, you know,
As nurse practitioners have pushed for legislation to gain more and more independence, what has happened is medicine and physicians have ultimately conceded little by little to where now that, you know, what we have is a definition for physician supervision is very lax. And unfortunately, when we get to situations like this, it's very hard to hold anyone accountable, just due to the vagueness of what physician supervision actually is.
And I think that Jeremy has, you know, run into that as he's tried to get some accountability for this case.
Rebekah Bernard MD 17:37
Yeah, that is such an important element of this. I mean, of course, we have this terrible tragedy, that should never have happened. And now we have a grieving parent, that saying, like, wait a minute, this should never have happened. And this should never happen again to another parent. So Jeremy, you really single handedly are just starting to rattle cages and shake these legislators, these politicians, these people that are supposedly making sure that patients are being kept safe. And it seems to me like you're just hitting challenge after challenge after challenge. And I just want to thank you for what you're doing. Can you tell us a little bit about you know, first of all, did you were you aware right away, of course, you were aware something went wrong? Because you lost your daughter, but were you aware of all of the the issues with nurse practitioners and that sort of thing when this happened?
Jeremy Wattenbarger 18:29
No, I wasn't aware of it at all. It never came to my mind that you know, there was you would have a nurse in charge of a of an urgent care or anything like that. I mean, she's the owner of the urgent care. So she does have some responsibility in determining who actually is supervising her and who has licensure there.
Rebekah Bernard MD 18:46
Oh, wait, you're saying that the nurse practitioner owns this pediatric urgent care?
Jeremy Wattenbarger 18:51
Yes. Currently, she is the majority owner and the when the time when Betty was saw she was a minority owner with Dr. Cowan of this urgent care. She is now the majority owner of this urgent care with her father, Frank Shear.
Amy Townsend MD 19:04
That's part of the problem with the current laws that we have in Texas, is there is this conflict of interest there? You know, how do you essentially you know, have someone on the payroll that is responsible for also supervising your work? To me that is almost impossible for them to actually do real supervision when they're receiving, you know, a check for their salary is dependent on you know, how they supervise?
Jeremy Wattenbarger 19:31
That's been a question I've raised with legislators too is that how can you expect a doctor to delegate licensure and authority to a nurse when the nurse is the owner of the clinic?
Or at least part owner as it was in Betty's case, she was part owner the clinic over time. So she has it's almost a peer relationship when it's not really supposed to be right.
Rebekah Bernard MD 19:54
That is just amazing to me. I can't even fathom that. I don't know what the laws are - And I guess I should Know what they are in Florida. Of course, it's state to state as far as whether non physicians can own clinics. Apparently in Texas, you can, probably in a lot of other states. And I'm sure in the full practice authority states they can of course, Texas is supposed to be a supervised practice state. So you began to learn about this. And then you started talking to - Who did you go to first the nursing board?
Jeremy Wattenbarger 20:22
Yeah, actually, my first trip was to Health and Human Services here in Texas, because I didn't realize they weren't a medical facility here in the state of Texas. And I actually got involved with - I called Washington DC - called Health and Human Services there because I couldn't get anyone in the state of Texas to answer. I had an ombudsman assigned to me initially to investigate. He was shocked that it wasn't an actual licensed medical facility in the state of Texas. And they rejected my complaint as a facility complaint. They said, 'No, we can't do anything with it.' So I had to try to find the next avenue, which they said file a consumer complaint, because they're not a medical facility. So follow consumer complaint, which was then denied and told that this is a medical issue, it's not a consumer issue. And they denied it and sent it back to me, the Attorney General's Office did. And then that's when I finally you know, started going to the nursing board and saying, look, I need, I'm going to file this complaint. I filed the complaint three times, I was denied all the times every single time initially. So I got a hold of Senator Pat Fallon's office at the time. And Patricia Vojack, she got involved so that my nursing board complaint, let her know, you know that I had submitted it. And she told me how to submit it in a certain manner and way and it was like Mojo magic, all of a sudden, nursing boards doing their first investigation at that point.
Rebekah Bernard MD 21:39
That's amazing to me. So here you are a parent that's lost a child, clearly there were things done wrong. You're just trying to get an investigation really to protect other people. Because at this point, you know, this isn't really for you. It's for other families, and you got nowhere until you involved an actual political representative. That's amazing. Amy, does that sound like normal to you for what you experienced with the Texas Board of Nursing?
Amy Townsend MD 22:07
Yeah, you know, I ran into a lot of the same hurdles. Even as a physician, it was very difficult to find the right avenues of exactly where to send the complaint. And even if the complaint happened to end up in the wrong person's hands, there was no assistance in redirecting, hey, this is where you need to go. It was really just trial and error and trying over and over and over again. And again. I mean, I think that that, you know, it sounds like Jeremy ran into a lot of the same issues. You know, one of the things that I was so incredibly impressed that by the time Jeremy reached out to me, you know, he had already gone through a lot of these things, and had already already talked to Governor Abbott's office and to, you know, other representatives, as well as his state senator. And so I was really impressed that someone who did not have any medical background was able to accomplish as much as he did in that period of time.
Rebekah Bernard MD 23:02
It just amazes me that anyone would have to go through these kind of lengths just to report a concern. And that's just shocking to me. First of all, I know it's probably not for Amy because she's gone through these lengths to try to stop a different nurse practitioner who was doing things wrong over and over again. But what's also really interesting about this is when the Board of Nursing finally did agree to review it, they found really, their only complaint was just that the nurse practitioner did not adequately take vital signs. So really, it sounds like they didn't have any concerns about her practice or failure to identify a seriously ill child, but just simply that she didn't know, take full vital signs. Is that right, Jeremy?
Jeremy Wattenbarger 23:44
Yeah, that was initially what they stated on their their board orders is that, you know, her improper charting could have cause patient harm, things like that. Subsequently, I filed appeal after appeal after appeal, all of them being denied until I got ahold of the governor's office. And when I got ahold of the governor's office Scott Kibby there put me in touch with Dusty Johnson, who's the general counsel at the nursing board, and then that was October of last year. And he had to agree that the nursing board investigation was not sufficient. And they reopened the nursing board investigation, and it's still ongoing at this time, and they have a criminal justice investigator now working through that at the Board of Nursing.
Rebekah Bernard MD 24:24
Amy, if a physician was found to be - or someone reported to the Board of medicine that a physician may have contributed to the death of a child, how do you think the medical board would handle it there in Texas as compared to the way the nursing board has just hypothetically?
Amy Townsend MD 24:40
Yeah. You know,
The big issue here is what is the standard of care for that profession? Essentially what we have right now are nurse practitioners are practicing medicine, yet they're responsible to the the nursing board, not the medical board, so they're not held to a medical standard of care.
What they're going to look at in these situations is did they do the nursing tasks that they were, you know that they should have done, not looking at medical judgment, or, again, what medical standard of care is in these situations. And so that's what's makes it very difficult to hold people accountable. In these situations, you have nurses that are practicing medicine, but only held accountable to nursing standards.
Rebekah Bernard MD 25:26
And patients have no idea. Jeremy had no idea parents like him, patients like him, every day receive care from non physician practitioners, assuming that they're the person on duty, and in many cases, you have to see the physician and you're told no, the NP or the PA is just as good that they can see you quicker, they're the only ones that are here, you're probably paying the exact same as you would pay for a physician. And meanwhile, potentially, you're getting the wrong diagnosis, the wrong treatment. And if something does go wrong, that there's no accountability. Does that sound right to you in your experience, Jeremy?
Jeremy Wattenbarger 26:00
Yeah, that that's correct. And, you know, that's, that's kind of been my experience, even talking to other you know, I have a 12 year old daughter, and we still run into the same issues when we go to, you know, medical facilities or anything like that even primary care, they want to send you to a nurse practitioner first. They're like, 'Well, we've got five nurse practitioners and one doctor, and that one doctor only sees...' - 'No, I still want to see the doctor.'
Rebekah Bernard MD 26:22
Yeah. And why wouldn't you? I mean, it's a clearly there's a difference. There's a difference in training. And there's, as you've now experienced, there's a difference in accountability. And it really is mind boggling. And we're going to have a second segment, we're going to come back and we're going to talk more about the additional efforts that you're making to make changes to protect patient safety, actually looking at legislative change, looking at more, rather than just waiting for the Board of Nursing to take action because clearly they're probably not going to do that or take adequate action. So we're going to get into that in our next segment.
So I'd like to tell our all of our listeners out there. If you're interested in learning more about this topic, please get our book is called Patients at risk: the rise of the nurse practitioner and physician assistant in health care. It's available at amazon.com and Barnes and Noble. Please subscribe to our podcast and our YouTube channel. It's called patients at risk. And if you're a physician, we'd love for you to join our group. It's called physicians for patient protection. Our website is physiciansforpatient protection.org. Join us back for our second episode of this important discussion with Jeremy Wattenbarger. Thanks so much for listening.
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