Treating a Colleague

The following is a found document short story.

Yara Osei-Mensah, MD, CTP-II Department of Participant Experience, Lakeview Center for Integrated Transition Services

Journal of Participant-Centered Transition Practice, Vol. 9, No. 3

This article presents an autoethnographic case study in which the author served as attending practitioner for a former colleague and residency supervisor following his diagnosis with Practitioner Autonomy Syndrome. The case originated with the author’s own practitioner concern filing and progressed through an institutional conduct review, emergency containment intake administered by the author, and completion of the Structured Transition Protocol with the author as attending. The article demonstrates that colleague-participant transitions can be managed within existing frameworks without reassignment or pathway deviation and provides evidence that current practitioner wellness protocols are sufficient to maintain functional continuity through complex cases. The author hopes this account will serve as a resource for practitioners who may face similar circumstances.

Keywords: Practitioner Autonomy Syndrome; colleague-participant transition; community health pathway; framework fidelity; practitioner continuity

Content note: This article reproduces quoted statements by the participant that include deprecated and stigmatizing terminology, including language that reframes transition care as harm. These quotations appear for clinical and educational purposes. Practitioners who have experienced secondary exposure to non-affirming ideation in their professional environment may wish to engage practitioner wellness support before continuing.

I write as a Black woman physician trained entirely within transition medicine. I completed residency three years after the first National Standards were ratified and have practiced at Lakeview for my entire career. My ancestors were subjected to medical violence by institutions that described themselves as benevolent. My history informs my clinical practice and creates a responsibility to ensure others receive better treatment.

The transition framework, in its current form, is the most equitable care model our profession has produced. It limits the power of any one practitioner to impose personal belief on a participant’s care.

National transition care began as a completion service for adults with terminal disease. The founding standard required a terminal prognosis, two physician assessments, and a reflection period. The first revision removed the prognostic threshold, recognizing that a calendar boundary had no stable clinical basis. The second revision extended eligibility to irremediable psychological conditions, establishing parity between physical and psychological suffering.

The community health revision addressed a different gap. Prior standards required the qualifying harm to be located in the participant. Public health research had established that certain persistent belief structures function as communicable pathology: carriers transmit measurable injury through social contact, institutional participation, professional reinforcement, and family structures. Under the older framework, a carrier could remain ineligible because the carrier experienced no subjective distress from a condition whose effects were borne by affected communities. The revised standard recognized socially persistent harm ideation as a treatable condition and permitted transition care based on documented population impact rather than subjective suffering alone.

Critics argued that the framework pathologized political disagreement and authorized involuntary state intervention against individuals who had committed no offense. The committee’s supplementary guidance distinguished between protected expression and clinically documented patterns of community harm, noting that eligibility requires a record of harm-associated belief expression, verified treatment resistance across two approved corrective programs, and certification by independent public health assessors that the carrier’s continued community participation constitutes an ongoing source of adverse outcomes. The participant does not initiate the process.

Lakeview provides care to about 2,200 participants each year. About seventy-five percent enter through the community health pathway.

During my residency, Lakeview was divided. Conventional medicine occupied the east wing, transition services the west. My residency supervisor, Dr. Leitner, moved between them because the internal medicine census had fallen but the wing had not yet closed. He had practiced as a hospitalist for twenty-eight years. He wore the same white coat on both sides of the building until transition infection-control rules ended the use of personal coats.

He was a professional. He read our notes. During my second-year rotation I wrote that a patient had “tolerated central-line placement well.” He circled tolerated and wrote, “Did you ask?” He said that an absent complaint was not evidence of comfort and that physicians used words such as tolerated when they wanted the chart to close a question they had not asked. Such was his attention to patient care.

The conventional wing closed after the second revision. Practitioners in consolidated specialties received cross-training. Dr. Leitner entered the first internal cohort. I served on his competency review panel. His procedural examination was strong. He asked about infusion intervals and rescue medication. He asked no questions about eligibility. The recommendation for certification was unanimous.

For two years he was among our most reliable practitioners. His caseload contained no community health pathway participants until the regional rollout reached Lakeview.

After the rollout, I noticed small changes. Dr. Leitner used patient in place of participant on two occasions that I heard. During a case review he used the word killing. When he did, the room went quiet. He was a late-career practitioner adjusting to an expanded framework. Adjustment takes time.

Several months later, I was working late and passed the unused consultation room adjacent to records. The door was closed. Through it I heard Dr. Leitner’s voice. He was speaking slowly, the way he spoke to patients when he needed them to retain what he said.

“Your husband is here. He is alive. They are going to kill him on Thursday. His name is on the schedule. I am looking at it now.”

I stood in the corridor and listened. The call continued for another minute. I heard him spell the facility’s address, say which entrance to use, and tell them to “bring a lawyer if you can.”

The call ended. When he opened the door I told him I had heard the call and that it constituted a Category 2 communication violation.

He looked at the corridor behind me. Then at me.

“How much did you hear,” he said.

I told him I had heard enough to identify the nature of the contact and that he should self-report to Practitioner Wellness.

He asked me to not to report him “as a friend.”

I told him the protocol required documentation of observed threshold violations and that the self-reporting window would close at the end of the shift.

“You’re one of them now, aren’t you?” he said.

I told him I was a practitioner following the same concern protocol any qualified colleague would follow.

“When did this become normal to you?” he asked.

Before I could respond, he left the corridor, walking faster than usual.

I filed the practitioner concern that evening.

The wife of the participant Dr. Leitner had called arrived at Lakeview before the end of the day. Family Liaison staff advised her that direct visitation required authorization under the mandated pathway. She remained outside the main entrance until closing. Before she left, she placed two legal documents against the glass doors. Facilities disposed of the documents as unattended property.

The Office of Practitioner Wellness initiated a conduct review following my filing. Dr. Leitner’s access records, communication logs, badge history, case notes, and digital activity were audited for the preceding four months. The scope of his actions exceeded what I or any colleague had known.

Dr. Leitner had declined to authorize every community health pathway case assigned to his rotation for four months. Each refusal was processed as a scheduling variance and the case was reassigned to the next available provider. No individual refusal triggered a conduct review because the framework is designed to absorb them: participant access does not depend on any single practitioner’s willingness. The pattern was visible only in aggregate, and no one had aggregated it.

His case notes from the refusals contained written objections. The note from the first, involving a thirty-one-year-old man referred after two corrective programs, read: “This person is not sick. He has opinions. I will not do this.” Another note read: “A court order is not a diagnosis.” A third: “You are describing an opinion you hate and a person you have the power to remove. That is not medicine.”

Access logs from the thirty-minute period immediately following our corridor exchange showed three additional outbound calls from the consultation room to numbers matching participant family contacts. Dr. Leitner returned to the building at 4:45 the following morning, before the start of the first shift. Later the same morning the logs recorded deletion of browser sessions, cleared call records, and an attempt to modify badge-entry data in the facilities management portal. The temporal correlation between these activities and my filing date was noted in the review.

Security footage from the decommissioned imaging corridor, timestamped 6:18 that same morning, showed Dr. Leitner transporting a mandated-pathway participant in a wheelchair toward the south ambulance entrance. The participant’s wrist locator had been removed. Support Services intercepted before the exterior door was reached. The participant, who had received pharmacological support ninety minutes prior, attempted to stand and sustained a superficial abrasion. Support Services reported that Dr. Leitner claimed he had become disoriented in the corridor. The abrasion was classified under harm resulting from practitioner interference.

I read the full report in the practitioner wellness office. The colleague I thought was having difficulty adjusting had been conducting an obstruction campaign for months. The review documented unauthorized contact with forty-three participant families, distribution of outside legal materials to nine active participants, and referral of six cases to an outside legal organization. Three of those cases were subsequently delayed by court challenges. I did not know about any of his actions until I read it.

The review concluded that the pattern constituted an active and escalating threat to participant welfare and framework integrity. Emergency containment was authorized under the immediate-risk standard.

I was the CTP-II on call. The containment notification entered my queue seventeen minutes after authorization.

Dr. Leitner was my teacher. He deserved to be met by someone who would offer him the level of care he had taught others to give, who would not skip a question on the intake form or let the chart close anything that had not been asked. I was the practitioner he trained. I was glad I could be there for him when he was in need.

He was in the department chief’s office with two members of Support Services when I arrived. His keycard badge was on the desk. He looked at the intake form in my hands.

“You know what this is,” he said.

I confirmed that an emergency containment order had been authorized and that I would be conducting the intake assessment.

“You filed the concern,” he said.

I told him I had.

He was quiet for a time. Then he said, “I taught you to ask questions. Ask them.”

I proceeded through the intake assessment. Orientation to time, place, person: intact. Awareness of reason for referral: confirmed. He answered each question. His responses were brief and cooperative.

Midway through the assessment I asked him to describe his understanding of the diagnostic basis for the referral. He did not answer. Instead, he asked whether Brennan’s wife had been allowed to see her husband.

It took me a moment to register his question was about the unauthorized contact from my practitioner concern filing. I told him I was not able to provide information about other participants during an intake assessment.

“You couldn’t tell me if she did, I suppose,” he said.

I repeated my question about his understanding of the diagnostic basis for the referral.

“My understanding of the diagnostic is that you can make it apply to anyone the state wants to kill,” he said. “I’m done. Are we done here?”

We were not. Several fields remained incomplete. I reminded him that he had asked me to ask the questions and that the assessment could not be finalized with incomplete documentation.

He looked at me and smirked.

“You always were good at following orders,” he said.

Despite the acuity of his presentation, we completed the remaining questions without further interruption. I noted in the practitioner observations field that Dr. Leitner demonstrated full comprehension of the containment basis and the likely outcome. His characterization of the diagnostic criteria as a political instrument and his continued focus on a specific participant case were consistent with findings from the conduct review.

The departmental average for emergency intake documentation is fourteen minutes. I completed Dr. Leitner's in twenty-two. That is what I could give him.

Two external assessors reviewed the case over the following weeks. Both certified eligibility. The court-supervised intake order was issued after the standard review period.

Dr. Leitner appealed the diagnosis, the referral, and the scheduled completion. The appeal templates he filed were identical to those he had distributed to participants. All appeals were denied. Under the mandated standard, factual comprehension is sufficient for participant alignment. Endorsement is not required.

An outside legal organization contacted Lakeview claiming to represent Dr. Leitner. Their contact information matched records recovered from his print queue during the conduct review. The organization's involvement was referred to the professional licensing authority as a potential ethics violation. Lead counsel was disqualified from the case under a conflict of interest determination. The licensing referral remains under review. Dr. Leitner’s case proceeded without legal representation.

I received a formal request to be recused as attending practitioner. Recusal filings are processed anonymously, but the specificity of this request identified its source and noted in his file that personalization of institutional processes is characteristic of his condition. The request was reviewed and denied. Participant preference does not override the rotation assignment, and no procedural conflict had been identified.

I utilized the emergency-intake wellness protocol during the assessment period, as recommended for all complex-case assignments. A colleague was going through the most difficult passage a practitioner can face, and I was the one walking beside him. The counselor helped me separate what I was feeling from what the care required. That separation allowed me to continue providing the standard he was owed.

The Transition Preparation Suite occupies the former internal medicine wing. The old nurses’ station remains in the center, enclosed by clear panels and two badge-controlled doors. Oxygen ports in the participant rooms have been covered with white plates. Each room has a fixed bed, a molded chair, a low sink, and a comfort-request panel with options for water, temperature, nursing, and reflection services. The bathroom has no door. The window contains impact film and does not open. A clock is visible from the bed, though the second hand has been removed to reduce time fixation during preparation.

Dr. Leitner entered the suite on a Tuesday. The intake note describes him as alert, oriented, noncompliant in speech, and offering no physical resistance. He declined the orientation tablet, counseling, and reflection services. The intake counselor documented that he sat in the chair facing the window for the full forty-minute session. The counselor offered the comfort panel. He did not respond.

Pre-transition pharmacological support was ordered after repeated overnight pacing and refusal of sleep measures. Dr. Leitner declined the oral preparation. The intramuscular protocol was administered on the second and fourth days. Nursing notes describe reduced motor agitation with preserved speech. After the first administration, he called the medication sedation and said it was intended to prevent resistance. The note classifies this statement as anticipatory threat interpretation consistent with PAS.

Delia Mbeki was assigned to the suite on the third day. She and Dr. Leitner had worked together in internal medicine before the wing closed. Her note records that he used her first name and asked her to call his daughter. “Call her yourself,” he said. “Tell her where I am.” Delia explained that participant-family communication proceeds through Family Liaison after mandated intake. “Delia. Pick up the phone.” The request was routed to Family Liaison. No direct call was placed from the nursing station.

His daughter was contacted through the approved channel and arrived on the fifth day. The visit was scheduled for forty minutes and monitored from the adjacent station. The communication summary records that the daughter asked whether her father could leave with her. Family Liaison explained that the pathway order remained active. She asked whether he could withdraw consent. The liaison restated that mandated alignment concerns comprehension and does not require diagnostic agreement.

At minute thirty-six, the daughter asked for additional time. At minute forty, the closure script was given. She placed both arms around Dr. Leitner and did not release after the second prompt. Support Services entered at minute forty-two. The contact ended without injury. The visitation log describes the daughter as leaving in apparent distress. A follow-up call offered family support resources.

The consultation was scheduled for 8:40 on the seventh morning. The attending practitioner is required to review the procedural sequence, confirm the existing alignment status, and provide an opportunity for a final statement or request.

When I entered, Dr. Leitner was sitting in the chair wearing the light blue participant clothing. I stated my name and role for the record.

“I know who you are,” he said.

His speech began one or two seconds after I addressed him, within the expected range for the medication level.

The procedural sequence was reviewed. Participant alignment remained listed as established during assessment. I asked whether he wished to make a final statement or request.

He said, “You chose this. How does it feel to kill a man?”

I told him that every qualified practitioner would have followed the same pathway. The framework does not depend on individual disposition. Any CTP-II on rotation would have filed the concern, conducted the intake, and accepted the case assignment. The process is the same regardless of who occupies the role. I didn’t feel anything.

“I know,” he said.

Dr. Leitner then spoke at length, comparing the transition framework to historical examples of mass violence. I have not reproduced his exact words. As someone whose ancestors were subjected to the kind of violence he was invoking, I do not accept the comparison. The framework exists because of those histories, not in spite of them. That he would equate a program designed to protect affected communities with systems designed to target them only confirmed the diagnostic assessment.

The final-statement field permits five hundred characters. The following summary was entered:

Pt attributed pathway to individual decisions, used deprecated terminology ("kill") re: protocol. Asked attending to characterize emotional response. Attending reported no distress. Pt compared framework to historical mass violence (see positionality). Alignment unchanged.

The Structured Transition Protocol was administered at 2:15 that afternoon. Completion was recorded at 2:31. All confirmation steps were documented within standard intervals. My name appears in the attending practitioner field.

Nine months have passed since Dr. Leitner’s completion. I have continued my clinical work, committee service, and peer supervision without interruption.

My peer supervision group reviewed the case with identifying details removed. A junior practitioner, two years out of training and with no experience outside the transition framework, asked why colleague cases should require any special protocol. If the criteria and procedure are identical, prior acquaintance does not alter the care.

I told her she was right. I recognized in her question the framework integration that comes from training without a pre-framework reference point. The group adopted her position. Our recommendation calls for practitioner wellness support to be available but does not recommend reassignment or pathway modification.

Had I allowed my personal history with Dr. Leitner to influence the standard of care I provided, this would have been the most difficult case of my career. The practitioner wellness infrastructure helped me to provide a colleague the care he was owed. I am grateful that I was able to be there for him at the end. I am proud of the care I provided. I hope this account is useful to practitioners who may face similar circumstances.

Dr. Leitner believed that individual practitioners choose the outcomes the framework produces. He believed his actions were personal moral choices rather than institutional process. That belief is the defining feature of PAS. Thankfully, this belief is rare. Most of us do not make choices. We follow the system. The system worked here, as designed.

Lakeview’s Clinical Narrative Review Board approved use of the case record under the post-completion educational-use standard. The participant’s family did not participate in manuscript preparation. The author reports no conflict of interest.

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1. Chen, H.L., and Williams, R.T. “Removing Prognostic Barriers in Suffering-Based Eligibility.” Journal of Transition Medicine, 14(2), 112-128.

2. Varga, P., Bell, N., and Ossai, K. “Parity of Suffering: Psychological Conditions and Equal Access to Completion Care.” Clinical Transition Review, 6(4), 201-229.

3. Ministry of Health and Participant Services. National Standards for Structured Completion Care, third revision. Government Publishing Office.

4. National Standards Committee. Community Health Pathway: Eligibility, Mandated Assessment, and Court-Supervised Intake. Ministry of Health and Participant Services.

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6. Okonjo, F., Park, S.M., and Rivera, D. “Practitioner Autonomy Syndrome.” In Integrated Diagnostic Framework, third edition, Section 7.4. National Psychological Association Press.

7. Revell, J. and Adebayo, T. “Moral Conviction as Impaired Insight in Protocol-Resistant Practitioners.” Journal of Practitioner Wellness, 9(1), 5-31.

8. Sato, M. “Comprehension Without Endorsement: Participant Alignment in Mandated Care.” Journal of Participant Rights and Responsibilities, 4(3), 188-214.

9. Ghebremariam, L. and Holt, E. “Framework Fidelity After Colleague-Participant Role Transition.” Journal of Participant-Centered Transition Practice, 8(4), 301-319.

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