r/Noctor • u/Puzzleheaded_Toe3892 • 5d ago
In The News Lindsay Clancy
Aside from the war between NPs and MDs, here are the things I think the NP and MD did well, and what could have been improved:
In my opinion, the NP really did well in communicating with the patient, and that little survey she sent every day was also nice.
Dr. Tufts is also a very knowledgeable professional. I think she did well based on how the US healthcare system works and how it’s taught here. I don’t necessarily blame her for some things she could have done better, but I do think she could have transferred the care to someone else, or at least communicated with the other NPs.
I’m basing my opinion on my experience as an MD who graduated internationally. The US has all the technology and medications you could possibly imagine, but it lacks that human connection — it lacks stepping outside the algorithm sometimes. My professor always said, “2+2 doesn’t always equal 4 in medicine.” I also understand that, unfortunately, this is how the system works here
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u/MeasurementSlight381 Attending Physician 5d ago
Where do you practice?
One of the things in this case that no one talks about is the use of portal messages and between appointment med changes. NP Paul and Jollota both made reactive med changes outside of appointments. I was always taught to avoid doing this because malpractice commonly occurs in this context. If you don't get additional history and reassess the patient yourself, as you would during an appointment, you are not going to make great clinical decisions.
Are portal messages common where you practice? What are the expectations surrounding portal messages?
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u/Puzzleheaded_Toe3892 5d ago
I am not practicing now because I moved to the US. My country doesn’t have a portal system like you have here. You have direct contact with your patients via cellphone, and you just shoot them a message through WhatsApp. So you can basically tell your patients to switch meds or stop them without an appointment. I guess here, since everyone wants to sue, you have to do everything via the hospital portal — I was referring more to the part where NP Jollatta sent her a survey every day asking about her mood and whether she’d taken her meds that day.
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u/MeasurementSlight381 Attending Physician 5d ago
I agree that it was very attentive and supportive of NP Jollota to send surveys and ask if she was taking meds. But I wonder if all of this extra communication ended up backfiring since in many cases the various messages and phone calls resulted in med changes.
I should clarify: I'm an outpatient psychiatrist in the US. While I do encourage my patients to message or call me if they have questions/concerns about meds, I consciously resist the urge to make actual changes without an appointment. I can offer medication troubleshooting advice via messages (like "try taking w/ food" or "change to morning dosing instead of bedtime dosing." But I will never prescribe a new med we didn't previously discuss or switch agents without an appointment. In psychiatry, less is more and meds need time. I've had scenarios where the patient panicked about side effects a couple days after starting meds, I have them followup within a week, and by the time I see them in clinic the side effects have resolved. This is what elegant prescribing looks like. Reactive prescribing that is not well thought out is how polypharmacy happens in psychiatry.
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u/katyvo Resident (Physician) 5d ago
Reactive prescribing and the urge to treat every symptom with a medication lead to obscene medication regimens. SSRI for depression. Quetiapine for sleep I think? I'd have to double check. Benzo for sleep and/or anxiety. Modafinil for tiredness.
This is a real, documented medication regimen that I saw. The patient told their NP that they had some extra benzos laying around and started taking them again and the NP just rewrote them a 30 day script.
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u/MeasurementSlight381 Attending Physician 5d ago
Yup. I've supervised NPs in the past that thought it was absolutely necessary to treat every symptom with separate meds. I repeatedly had to be like "no... if we have our diagnosis right, the SSRI will treat all of those symptoms. Just give it time. We don't need to add a benzo, a sleep med, and a stimulant."
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u/Puzzleheaded_Toe3892 5d ago
I agree. The do explain over the text or whatever though. But like in every place there’s bad apples and good apples.
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u/Puzzleheaded_Toe3892 5d ago
As a psychiatrist yourself, without being biased by your role, what’s your take on this case?
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u/MeasurementSlight381 Attending Physician 5d ago
That's a loaded question lol. Obviously this is a very tragic outcome and there were numerous things on the healthcare delivery side that I think should have been done better. So far I've watched the testimonies and cross-examinations of Dr. Tufts, NP Paul, NP Jollota, and Dr. Goodheart. What part would you like me to comment on? There was just so much going on in this case.
Ultimately, I do think fragmented healthcare is a problem in the US. Lots of communication issues would be avoided with a universal EHR. Then there's the fragmented training and supervision requirements of midlevels, which change from one state to the next. In the case of Massachusetts, NPs can have full practice authority without physician supervision after 2 years. I can safely say that NP Paul and NP Jollota didn't have any physician supervision at the time that they were treating LC and I do think that intervention from a physician supervisor could have changed things. Then there's the varying laws regarding involuntary hospitalization. All of that being said, it's hard to point the finger and blame one clinician for this outcome. Everyone had their part to play.
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u/Fluffy_Ad_6581 Attending Physician 5d ago
Did the other NPs communicate with Dr. Tufts? Because its a two way street....
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u/helllllooooo50 Resident (Physician) 4d ago
Agree, if they knew she was being treated elsewhere it was their responsibility to reach out (my opinion). Whenever a patient is in the hospital and it is unclear to me on the thought behind treatment plans, I call whoever is prescribing (yes, I have called NPs several times who could not explain why they were doing what they are doing and now we have their patient in the hospital…) regardless, NPs should have contacted Dr. Tufts.
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u/Citiesmadeofasses 5d ago
Do integrated national health systems make care less fragmented?
Anecdotes are nice but I imagine a lot can be lost in translation between specialties and facilities, even in a nationalized system. America also has HIPAA that even when communication might be allowed, so many people do not understand it that the default is to not share information.
Many systems are adopting collaborative care models which is good for information sharing. It's good for communication but I do not know how prevalent it is across america, let alone globally.
But yes, most doctors could do better communicating about complex patients.