Ms D, 42, was a nurse practitioner (NP) working in a federally funded clinic in a low-income area. When she first became an NP, about 15 years prior, she had big dreams about her role in improving patients’ health. She knew right away that she wanted to work in an underserved community and began her career with great enthusiasm. Ms D had begun her current position with the clinic 10 years ago. She had been optimistic when she started, imagining that she was going to make a big difference in her patients’ lives, and sometimes she did. But after a few years, she started to feel irritable at work. She was annoyed when patients were noncompliant with their medication or did not show up for follow-up appointments. She began to feel taken advantage of — she could have taken a job in a better area or with higher pay, but she had chosen to do this.

After 10 years in her job, her heart was no longer in it. Ms D functioned as a primary care provider, treating patients for a variety of conditions. She typically saw between 15 and 20 patients per day. Although she worked under the direction of a collaborating physician, she did not find it necessary to consult with him that often.

Every day was starting to feel like the next, a series of patients, mostly uneducated, some barely speaking English, who did not listen to her recommendations, did not follow her advice, and did not heed her warnings.

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One day in the spring of 2008, a new patient came in. Mr K was a heavy-set, 28-year old, African-American man who had been referred to the clinic after a pre-employment screening revealed very high blood pressure. At the clinic, Mr K’s blood pressure was 210/170 mm Hg. Ms D gave the patient clonidine in the office, which immediately lowered his blood pressure to 200/130 mm Hg. “You need to watch what you eat,” she told him. She ordered routine lab work, noted “hypertension and obesity” in his file, and gave him some blood pressure medication to take home. She told him to come back in a week. When he did not return, Ms D was not surprised.

But two years later, Mr K showed up again. He had not taken any blood pressure medication within the last 2 years. Again, his blood pressure was flagged during a screening at work, and he returned to the clinic. Ms D quietly wrote “noncompliant” in his file. Mr K’s blood pressure was 240/150 mm Hg. Ms D gave the patient clonidine, which lowered his blood pressure to 200/110 mm Hg and wrote him a prescription for hypertension medication. She instructed the patient to return in a week, but he did not return for three weeks.Ms D saw the patient 10 times between July 2010 and October 2012. His blood pressure was consistently extremely high. The patient and clinician occasionally argued about his medication. Periodically, he would stop taking one of his medications because he thought it was not working or was causing side effects. Ms D noted in his file that his hypertension was “uncontrolled” and that he was noncompliant.

Mr K’s original lab work was done in 2008. Ms D did not order any new lab work until 2011, but she failed to look at the results, which never made it into the patient’s file. In 2012, Ms D ordered lab tests and reviewed the results a few days later. They showed extensive kidney damage. Again, Ms D never told the patient about his results. Two months later, Mr K collapsed at work and was hospitalized. He was diagnosed with stage V chronic kidney disease due to poorly controlled hypertension. For the next three years, Mr K required hemodialysis until he was able to receive a kidney transplant.