XXX
[your address]
Department of Consumer Affairs Physician Assistant Board
XXX,
RE: COMPLAINT AGAINST XXX
The above matter refers.
I am writing to address the complaint lodged against me and express my deep concern and surprise regarding the situation. I have been a Physician Assistant since the year XXX. Throughout my career, I have worked in esteemed institutions such as XXX Healthcare, XXX Hospital, and Scripps Healthcare, where I have gained extensive experience in various medical settings, including emergency departments, urgent cares, internal medicine departments, and trauma centres. I have been involved in the treatment of patients of all age groups and acuity levels, maintaining an impeccable record and displaying sound clinical decision-making skills. It is important to note that I have never received any complaints from any agency, including the Medical Board. Therefore, this complaint has caught me completely off guard.
Should it be necessary, I am more than willing to promptly provide multiple academic and professional references who can confidently vouch for my education, training, and clinical practice. Their testimonials will undoubtedly reinforce my competence as a healthcare professional.
I would like to bring to your attention the fact that I was not notified about this complaint in real time at my place of employment. Consequently, I have not had the opportunity to review the patient’s chart, refresh my memory regarding the case, or defend my clinical decision-making to the attending physician and clinical staff at Marque Urgent Care. This lack of communication is highly unusual and unprofessional, as it is standard protocol for clinical settings to address patient complaints internally before escalating them to external authorities. I believe that it is only fair and just and also essential to resolve such matters within the organization before involving external entities. Unfortunately, I was denied access to the patient’s chart and was unable to prepare a proper response on the day I left the clinic.
Nonetheless, allow me to summarize the patient visit to the best of my recollection, as it was the only encounter I had with the complainant:
- Initially, the patient was seen by a virtual provider, XXX, who consulted with XXX and XXX. They advised that the patient be sent to the clinic to undergo a swabbing procedure and then be transferred to the emergency room at XXX Children’s Hospital to rule out any potential abuse, infection, or other possible diagnoses.
- I was informed of this plan by the virtual provider, XXX. I suggested that, given the clinic’s limited resources and equipment for pediatric cases of this nature, it would be best to directly send the patient to the Rady Children’s ER to ensure comprehensive care. However, I was informed that the patient was already on the way to the clinic.
- According to clinic policy, every patient must be checked in and cannot be directly triaged by an advanced practice provider. Therefore, I followed the policy and saw the patient once she was in the examination room.
- During the encounter, I explained to the mother that, in pediatric cases of XXX discharge, a cursory external genital exam is typically the extent of the evaluation in our setting, considering the absence of rape kits or equipment for visualizing the genitalia. I outlined the most common differentials, which included XXX, child abuse, and urinary tract infections, among others. Unfortunately, the patient was unable to provide a clean catch urine specimen, and since we do not catheterize in the clinic, ruling out a urinary tract infection was not possible. I advised the parent to proceed to the XXX Children’s ER for a comprehensive evaluation and timely treatment.
- Despite my repeated recommendations for a higher level of care facility, the patient’s mother insisted on obtaining an external swab in order to obtain some form of diagnostic testing at our clinic. Given the limitations of our resources, I proceeded with the external swab, understanding that it may not provide a definitive diagnosis but could potentially offer some insights. I documented this discussion and the mother’s decision in the patient’s chart.
- The external swab was performed according to standard procedures, and the sample was sent to the lab for analysis. I made it clear to the patient’s mother that the results of the swab would not provide a comprehensive evaluation and that further assessment at the XXX Children’s ER was necessary.
- After completing the external swab, I reiterated the importance of the patient receiving a more comprehensive evaluation at the Rady Children’s ER, emphasizing the need for further testing, imaging, and specialized care. I provided the mother with all the necessary documentation and referrals for a smooth transition to the ER.
- It is crucial to note that I did not provide a definitive diagnosis during the encounter, as it was beyond the scope of our clinic’s capabilities. My role was to assess the patient, provide appropriate guidance, and facilitate a transfer to a higher level of care.
On Examination:
- I want to clarify that during the patient’s genital exam, as per my usual practice, a chaperone was present in the room. Unfortunately, I do not recall the specific medical assistant who served as the chaperone at that time. The patient’s mother was also present, standing at the patient’s headboard.
- To ensure patient comfort and privacy, the patient was appropriately draped with a chux before the examination. Regrettably, our clinic does not have gowns available in the patient’s size.
- Upon inspection, I did not observe any obvious signs of physical abuse on the patient’s body. However, due to the limited resources and lack of specialized pediatric equipment, I was only able to perform a cursory external genital exam. I do not recall noticing any external signs of blood, discharge, or foreign bodies during the examination.
- The vaginitis swab used for the procedure was provided by the medical assistant responsible for placing the lab order based on the patient’s insurance carrier. According to our clinic policy, I did not personally select the type of swab or place the order. I simply requested a “vaginitis swab” to perform a superficial swabbing of the external genitalia.
- I want to emphasize that the swabbing of the external genitalia was performed superficially without any form of penetration or insertion. The purpose of this swab was to gather preliminary information, and the plan was for the patient to receive a more detailed genital examination and repeat internal swabbing if necessary at the Rady Children’s ER.
- The patient tolerated the entire procedure without any visible discomfort. It is important to note that at no point during the encounter did the patient scream, turn, twist, cry, or require any form of physical restraint from the mother or the medical assistant. Both the mother and the medical assistant maintained a distance from the patient throughout my examination and swabbing. Furthermore, there were no signs of pain, bleeding, or trauma expressed by the patient during or after the exam.
- After I completed the examination and swabbing, the patient remained in the clinic for approximately ten to twenty minutes while I finished documenting the encounter and prepared the discharge and ER transfer summary. Throughout this time, the patient did not experience any bleeding. Upon leaving the clinic, the patient appeared well, ambulated without difficulty, and exhibited a cheerful and stable demeanour. Additionally, it is important to note that the patient’s mother did not express any complaints of pain, trauma, or bleeding during the entire visit until the patient was discharged from the clinic. The mother’s nodding agreement to the referral to Rady Children’s ER was an encouraging indication of her concern for her child’s well-being.
- Please understand that my recollection of the case is based on my last memory and I have not had the opportunity to review the patient’s chart since completing my note.
Final thoughts:
- It is my assertion that I followed the plan of care established by my supervising physicians, who were consulted prior to the patient’s arrival through the virtual provider. Despite my recommendation for the patient to be transferred to the ER, the parent insisted on completing the swab, and I performed the procedure in the correct and appropriate manner, without any invasive or substandard care. I want to reiterate that I did not have the necessary equipment for an internal genital examination, nor did I insert the swab anywhere within or around the patient’s genitalia or any other body orifice. The superficial swabbing would not and did not cause bleeding, visible trauma, or pain to the patient based on my recollection of the clinic course.
- I empathize with the patient and the concerned parent regarding the bleeding noted in the diaper upon arrival at the ER. However, events that transpired after the patient’s discharge from the clinic until the visit to the ER are beyond my control and cannot be attributed to my actions or the swabbing procedure.
- If given the opportunity to address this complaint while still actively employed in the clinic, I would have reached out to the mother to discuss the various potential causes of bleeding, such as vulvovaginitis, foreign body, UTI, hematuria, blood in stools, scratching, nail injury, diaper-related issues, chemicals, bubble baths, contaminated pools, falls, mechanical trauma, or the physiological fact that low estrogen levels in this age group can make the external genital tissue thin and prone to bleeding upon mild scratching. These discussions could have potentially reassured the parent and shed light on the possible reasons for the bleeding. Importantly, I promptly referred the patient to the ER for thorough evaluation and management, which was the appropriate and safe course of action.
- I believe that the assumption or misunderstanding that the swab was “inserted” and may have caused the bleeding in the ER was relayed to the ER provider by the parent. However, if an acute injury had occurred during my examination, I would vividly recall it, and the patient would not have remained calm, cheerful, and stable without expressing any complaints throughout the clinic encounter. Acute trauma typically causes immediate pain and bleeding, which was not observed during my examination. Furthermore, the patient was draped, and both the mother and the medical assistant were positioned near the patient’s head, making it challenging for them to comment on the method employed. I can confidently state that I acted in accordance with my experience and consistent safe practices.
- I want to reiterate that I did not diagnose or treat this case, and I cannot be held responsible for any events that occurred after the patient’s discharge. My clinical decision-making was sound, and no substandard care was provided at any point.
I remain committed to providing high-quality healthcare and upholding the professional standards expected of a Physician Assistant. I am fully willing to cooperate with any investigation or review process that may be undertaken regarding this matter. I trust that a fair and thorough assessment will clarify any misunderstandings or misconceptions.
Please do not hesitate to reach out to me if you require any further information or clarification. I appreciate your attention to this matter and look forward to resolving it promptly.
Sincerely,
XXX
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