Boards of nursing fail to protect patients from dangerous nurse practitioners
Dr. Amy Townsend discusses the incredible lengths she went through to get the Texas Board of Nursing to act to stop a dangerous nurse practitioner after he caused 2 patient deaths.
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Rebekah Bernard MD 00:09
Welcome to Patients at Risk a discussion of the dangers that patients face when physicians are replaced with nonphysician 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.
Niran Al-Agba MD 00:29
Rebekah Bernard MD 00:30
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.
Amy Townsend MD 01:28
Thank you so much for having me.
Rebekah Bernard MD 01:31
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?
Amy Townsend MD 01:44
Yes, absolutely. So, you know, my story with us begins 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. These lab tests included things like a C peptide, insulin levels, DHEA-S, a random cortisol level, growth hormone. And so ultimately, you know, after the lab 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 T3 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 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 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, 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.
Rebekah Bernard MD 06:56
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.'
Amy Townsend MD 07:11
Yes. And so I next asked, you know, of course, in the state of Texas, every nonphysician 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.
Rebekah Bernard MD 07:42
So pretty hard to actually be performing supervision when you're not in the same specialty, and you're not in the same locality.
Amy Townsend MD 07:49
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 was going to consider reporting her to the Texas Medical Board for not properly supervising what was going on in the clinic,
Rebekah Bernard MD 08:12
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?
Amy Townsend MD 08:44
I think 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 being harmed in my community.
Rebekah Bernard MD 09:07
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?
Amy Townsend MD 09:29
So she essentially 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.
Niran Al-Agba MD 09:55
Can I just ask you - on the phone did the surgeon have any explanation, did she?
Amy Townsend MD 10:03
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.
Niran Al-Agba MD 10:33
Wow. Wow, I just, that's to me amazing.
Rebekah Bernard MD 10:37
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
Niran Al-Agba MD 10:57
And that's something that is we do need to talk about, and we do need to absolutely
Rebekah Bernard MD 11:03
And that's why to me, calling that physician out, it was so inspiring, and something that we really need to be doing.
Amy Townsend MD 11:13
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 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.
Rebekah Bernard MD 11:52
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.
Amy Townsend MD 12:04
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 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.
Rebekah Bernard MD 13:53
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?
Amy Townsend MD 14:04
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.
Rebekah Bernard MD 14:59
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?
Amy Townsend MD 15:18
It's about a five-hour drive from where I'm located.
Rebekah Bernard MD 15:22
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 did you just show up? What happened?
Amy Townsend MD 15:35
I had actually called ahead of time and set up an 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 cases were there. But because he had presented a falsified document from the nursing board.
Rebekah Bernard MD 17:19
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?
Amy Townsend MD 17:30
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 direct conversation with them. And this is probably the most shocking thing about this whole situation. So as I'm talking to the nursing board and the executive director, you know, I said, 'I just don't understand, I don't understand how you can say that they are at least partially responsible for these two deaths. And yet, you're still allowing them to practice.' And they looked at me dead in the eyes, and said, 'you know, Dr. Townsend, doctors are just busy. And we have not been able to find an expert witness to actually review the cases and move this forward.' And I just sat there in complete shock. How can a regulatory board not have the basic steps in place to actually remove people when they are harming the community? That's just something that is completely unacceptable. And something that really opened my eyes to the entire situation.
Rebekah Bernard MD 19:03
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 seems incapable of dealing with nurses practicing medicine. They don't have a basic foolproof process to deal with nurse practitioners who are dangerous.' And I think that what you describe is exactly right. This is a person that had already been sanctioned or had been charged with harming patients. And yet, he continued to practice what I would consider as nursing would exert medicine. They call it advanced nursing, but it's really prescribing very high-risk and dangerous medications. And no one was stopping him from doing this and patients didn't know better and patients were being harmed.
Niran Al-Agba MD 19:47
And actually, I would go even further, he wasn't he was not only practicing medicine, but he was also practicing endocrinology. So so my dad was an endocrinologist. So this always kind of gets to me because it's one of those specialties. Where 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 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 with you. What I also - with the second half of this is we had endocrinologists and family physicians who were using growth hormone for sort of feelings of vitality and some of that prescribing it to patients, not a single patient was harmed. And those physicians in Washington State lost their licenses.
Rebekah Bernard MD 20:46
That's some of the hypocrisy.
Niran Al-Agba MD 20:48
And so that is the hypocrisy and all this, you know, here, you've got a board of medicine that says, '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 doing anything.
Amy Townsend MD 21:10
They're not only not trained, but they advertise themselves as hormone specialists, there are actually documented, you know, photos from their Facebook page, that they advertise themselves as hormone specialists.
Rebekah Bernard MD 21:25
And meanwhile, this is a nurse practitioner who not only family, but also attended online nurse practitioner training. And he was, I think, maybe a year or so out of training when he was doing this type of prescribing. So there's a lot of red flags. And you know, you point out that the differences between the way the board of medicine, sanctions doctors and the Board of Nursing, you know, a lot of times we hear it said, Well, you know, there are bad doctors too, and that is true. But there are definitely more interventions that are occurring more aggressively towards physicians. And I think one of the reasons is the structure of the boards. So I'll use as an example, Texas since that's the state where this happens. There are 452,000 nurses in Texas, there's 26,000 of them are nurse practitioners, 320,000 are registered nurses, and 106,000 are licensed practical nurses. On the nursing board there are 13 people that are in charge of those 452,000 nursing professionals. But the Texas Board of medicine has more members, they have 19 members and they supervise 79,000 physicians, just a fraction. So how in the world can aboard be expected to be responsible for this number of professionals and do a good job? And obviously, they can't.
Amy Townsend MD 22:52
Obviously, they can't. I mean, ultimately, I ended up finding them an endocrinologist to review these cases, it fell on me to actually provide them with a physician and the expert physician to review these cases.
Rebekah Bernard MD 23:07
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?
Niran Al-Agba MD 23:28
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 so often, you know, when we're doing this, 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 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 nonphysician. And that's not being against, In my opinion, we are not against 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.
Amy Townsend MD 24:18
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.
Rebekah Bernard MD 24:43
Niran Al-Agba MD 24:44
I will say that turns any backlash at all Amy from the kind of doing this and standing up I mean, I'm so proud of you. I'm so impressed by your bravery.
Amy Townsend MD 24:53
I was so frustrated with the whole situation that there was no way that I was going to back down and continue to see people in the community that was hurt. I don't I mean, I just, you know, it was something that that wasn't even an option to quit. Um, you know, but as far as backlash from the physicians, No, I did not get any backlash from the physicians, I did get a lot of backlash from staff that worked at the clinic. And surprisingly, this nurse practitioner was very involved in a church. And the congregation and the church members actually gave me a lot of backlash and very unpleasant experience and, and attempts to attack my character.
Rebekah Bernard MD 25:50
Niran and I have 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. And indeed, the patients must have felt better, because they followed up and they kept going back. And, you know, patients often don't know that they're being mistreated or receiving the wrong care and that it can harm them, they often just see the side of it that this is a nice person, a caring person and, and you hate to be the bad guy. But patients aren't don't have the privilege of knowing that this could potentially kill them. And unfortunately, that's where sometimes we have to be the bad guys and tell them the hard truths that they don't always want to hear.
Well, I want to just make a few points about some other states because we've talked a lot about Texas. But Texas is not the only state where this problem has happened. Recently, the California Board of Nursing made headlines because in 2016, they had such a significant backlog of complaints that the system allowed a nurse who was accused of contributing to the death of a child to continue to practice for over three years. And just this year, the board was accused of falsifying documents to make it appear as if complaints against nurses were being investigated in a timely fashion when indeed they were not. In Tennessee, the Board of Nursing allowed a nurse practitioner to practice even after state attorneys recommended that her license be revoked. She was one of Tennessee's top opioid prescribers, accused of prescribing massive amounts of controlled substances. she defended herself to the nursing board by pleading ignorance and saying she was simply refilling prescriptions. And she just later learned that the doses were too high. And then in New York, a nurse who was attending a nurse practitioner school reported her online school to the Board of Nursing in New York for failing to follow the recommended that requirements in New York for the educational preceptorship and just the educational lessons, and she basically got nowhere and the Board of Nursing closed the case. So I just bring these up as just some examples of the fact that boards of nursing across the country are struggling. And as we continue to allow independent practice, there are a lot of concerns about whether they're capable of actually making sure that improper nurse practitioners are not practicing and potentially harming patients.
Niran Al-Agba MD 28:35
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?
Amy Townsend MD 28:42
You know, I think the biggest struggle for me was the feeling 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.
Rebekah Bernard MD 29:24
I think that coming together is so important and having solidarity, I'll point out that Amy and I are both board members of physicians for patient protection. And one of the things that are 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.
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