Midlevel supervision

[deleted497653]

My ED this week started having the ED doc staff all midlevel patients. As docs, we don't have to see each midlevel patient but we have to listen to a brief presentation about the patient before they leave the ED (even sutures removal) and give our blessing or see the patient. Then we get those charts. The midlevels dislike this level of supervision. In the past, they would just send their charts to the medical director unless it was a level acuity 3

1. What are your views on this? Personally, I think midlevels should only see level acuity 4s and 5s. And the other concern is that this prolongs the patient's stay in the ED if I chose to see the midlevel patient after they present them to me.

2. What is done at your ED? Looking for ideas..

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[southerndoc]

We supervise the APP's. Most are chart reviews (level 4's and 5's). We get credit for them, but pay for the APP salary out of the patient's we see (based on proportion of the RVU they generate for the day).

Level 3's, 2's, etc. we must see with the APP and write a brief note stating we've seen them.

Whether its the medical director or the physician on-duty during the patient's ED visit, somebody is ultimately responsible for physician oversight of the APP. It makes sense for it to be the physician on-duty when the patient was in the ER as it allows the APP the opportunity to ask questions, get help, etc.

 

[namethatsmell]

My ED this week started having the ED doc staff all midlevel patients. As docs, we don't have to see each midlevel patient but we have to listen to a brief presentation about the patient before they leave the ED (even sutures removal) and give our blessing or see the patient. Then we get those charts. The midlevels dislike this level of supervision. In the past, they would just send their charts to the medical director unless it was a level acuity 3

1. What are your views on this? Personally, I think midlevels should only see level acuity 4s and 5s. And the other concern is that this prolongs the patient's stay in the ED if I chose to see the midlevel patient after they present them to me.

Your old way sounds way better for you and I'd fight to get that back. Your director get tired of signing all their charts and absorbing the risk?

2. What is done at your ED? Looking for ideas..

I've worked at a place where every 4/5 had to be physically seen but you were in fast track with them specifically for that purpose. It worked well.

I've worked at a place where there were rules that nobody followed and PAs/NPs were seeing 2s and not presenting them. That ended poorly and many regular docs quit and that ED is now relying on heavy locums.

One place I work now doesn't have me signing any PA/NP chart unless I physically see the patient. I like that.

 

[deleted497653]

The previous medical director retired. The new one started a few months ago and started slowly bringing in new rules. I think they are scared of the risk of singing all those charts because they can't possibly review each chart.

I've heard of some ERs where there are no midlevels working there. Honestly that would be much more preferable. An alternative, there should be a doc (maybe with a midlevel) in fast track to clear the 4s and 5s and prevent the waiting room from blowing up with people.

 

[miacomet]

Why not hire NPs instead of PAs and let them shoulder all the risk themselves?

 

[deleted497653]

we have NPs and PAs but for some reason, even NP notes have to be co-signed. But I agree with your point, NPs should be able to shoulder their own risk.

The thing with mid levels is that the skill level varies so much. There are good ones, then there are those who don't know what they are doing. I've noticed some NPs have huge knowledge gaps or do things I consider pet peeves like wrong antibiotic dose or ordering X-rays for lumbar spine in adults, and a bunch of other things that someone learns in residency and cannot be taught over the course of an ER shift. I've also found SOME midlevels are not of the mindset that they can learn from you but rather consider themselves on par as far as knowledge. I think this is why it's harder to work with a midlevel than a resident. A resident knows they haven't arrived.

I once interviewed at a hospital in South Carolina that has zero midlevels. Should have considered that position more.

Once again, not all midlevels are bad. Some do help but I've found not much in the ED other than 4s and 5s.

 

[southerndoc]

I'm lucky to work with some excellent APP's who are well trained. We (the ER docs) have taught them. They run patients by us, but generally do an excellent job on their own. Many are credentialed for chest tubes, central lines, LP's, etc. I work in a very busy comprehensive stroke, trauma, STEMI/LVAD center and we rely on our APP's extensively especially for I&D's and laceration repairs. Nothing can ruin your shift than spending an hour suturing up a facial laceration.

 

[deleted836128]

ER PA here, hoping I can provide some insight for you. Our APPs see every level except for a level 1 patient. We see nearly all the 4s and 5s, lots of 3s, and some 2s. The recent requirement is that we ask the attending if we can pick up a level 2. At this point my attendings trust me and know that I consult them heavily if needed so they never have an issue with picking up a 2 so far. Most of our APPs were hired on as new grads and were trained... we feel very fortunate (at least I do!). I have done a few central lines, paracentesis, bedside US, cardioversion and conscious sedation with supervision. I do all my laceration repairs even very complex and multilayer, incision and drainage, joint reductions, arthrocentesis, lumbar puncture. I have done two peritonsillar abscess drainages with an attending and would never do it again. :-D The docs in our ER prefer the PAs to NPs by a landslide. They feel the PA training is much more extensive. They seem to trust the PAs a lot more. I do understand the anxiety of signing off on the chart - if I were a physician I would feel uncomfortable signing off on the chart for someone unless I knew their work very, very well. I don’t deserve Independence and a lack of supervision… I didn’t go to medical school. Therefore I completely understand the need for supervision, and welcome it, because it just represents a learning experience for me and I want to be a rockstar PA!

 

[Apollyon]

ER PA here, hoping I can provide some insight for you. Our APPs see every level except for a level 1 patient. We see nearly all the 4s and 5s, lots of 3s, and some 2s. The recent requirement is that we ask the attending if we can pick up a level 2. At this point my attendings trust me and know that I consult them heavily if needed so they never have an issue with picking up a 2 so far. Most of our APPs were hired on as new grads and were trained... we feel very fortunate (at least I do!). I have done a few central lines, paracentesis, bedside US, cardioversion and conscious sedation with supervision. I do all my laceration repairs even very complex and multilayer, incision and drainage, joint reductions, arthrocentesis, lumbar puncture. I have done two peritonsillar abscess drainages with an attending and would never do it again. :-D The docs in our ER prefer the PAs to NPs by a landslide. They feel the PA training is much more extensive. They seem to trust the PAs a lot more. I do understand the anxiety of signing off on the chart - if I were a physician I would feel uncomfortable signing off on the chart for someone unless I knew their work very, very well. I don’t deserve Independence and a lack of supervision… I didn’t go to medical school. Therefore I completely understand the need for supervision, and welcome it, because it just represents a learning experience for me and I want to be a rockstar PA!

How rare...someone who knows their limit, and is not cowed by that. I appreciate that.

Knowing your property line is quite important, as you've found. The best mistake is the one you don't make.

 

[JAFERD]

I worked with midlevels at my last job. They staffed the fast track independently, but needed at least a year on the job before they could do that, and the attendings all had input before they were cleared for it. They did a good job and would come to us if they were uncomfortable with anything. It was obviously all 4’s and 5’s. In general, I think this is the best use for midlevels.
I don’t like the idea of having them discuss every patient with you. For one, it’s just not necessary, assuming they’re experienced and you’re not letting just any mid level see patients independently. In most situations, huge waste of time for all parties involved. More importantly though, I don’t like the idea of being involved in the care, but not actually seeing the patient. If I’m going to be liable for a patient, I want to see the patient. If you haven’t actually seen the patient, you have no way to know if something was missed or assure everything is being done properly.
We also had midlevels in the main ED seeing 2’s and 3’s (mostly 3’s), but we were involved with everything level 3 or sicker, regardless of experience. How much depended on the patient and the mid level. Varied from standing next to them while they saw the patient (rare), to just popping my head in and saying hi.
I do not think there are any situations where a mid level should be seeing a real level 2, or certainly level 1, without an attending closely involved. And while I fully support them doing I&D’s and suture repair, if a patient needs to be intubated or have a chest tube placed, they probably also need an attending present. And if I’m there, I’d rather do the procedure myself. Isn’t that one of the reasons we went into EM?!

 

[deleted836128]

How rare...someone who knows their limit, and is not cowed by that. I appreciate that.

Knowing your property line is quite important, as you've found. The best mistake is the one you don't make.

Thank you! I appreciate that.

I think a GOOD APP can be absolutely invaluable. Some of the senior docs I work with breathe a sigh of relief when they’re loaded with patients and yet another chest pain comes in and they know I can handle it and am going to come to them so we can review the EKG and other pertinent points so I don’t miss anything sneaky. The patient gets seen and often admitted and they spent two or three minutes max on the case with me. When they’ve got a code to run and a giant laceration to repair they know I can hand that off to me. When they get loaded wirh five patients at once they know I can take at least two of them off their hands.

The ONLY way the above situation works out to the benefit of providers and patients is if the APP is well trained, open to learning, and has a close relationship with the attending, AND If the attending is approachable, realistic about the limits of the APP, and takes some time here and there to educate.

I have seen ERs in which the APPs are micromanaged... the docs sees every patient or at least has to hear about it. It is not efficient and there’s no point in having that extra provider. On the other hand there’s another ER in my town in which the APPs (mostly NPs... yikes) just see all the patients they can and only get help when they’re lucky. Neither situation is good.

I will never forget that when I did my ER rotation in PA school, there was a ROCKSTAR PA of 20 years who had his own 12 bed section, did every procedure you could think of, caught all sorts of wacky things like a patient in thyroid storm (bet I won’t see that for a long time) ... and the docs would come to him to ask him his opinion on cases! That’s the kind of PA I want to be one day but I realize it will take a hell of a lot of time. He got there because of a lot of effort on his part obviously but because he had excellent mentors throughout the learning process. The effort those docs put into training him was well worth it - now he’s invaluable!

NPs are gaining more and more power despite having less education than PAs (seriously, the two NPs at my job went to online school and didn’t even have an ER rotation and were somehow able to work as nurses during the program... what?) Because of this I think some PAs are feeling threatened that the NPs “independence” will make them more desirable for jobs. But the reality is, we should not be entirely independent providers because WE DIDN’T GO TO MEDICAL SCHOOL! It’s sad that we PAs are feeling threatened by NPs despite all this.

 

[JAFERD]

Why not hire NPs instead of PAs and let them shoulder all the risk themselves?

Regardless of state laws, there should be no difference between an NP or PA in the ED. Possibly with the exception of the fast track, the ED is not a place where midlevel independent practice is safe or acceptable.


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[Rendar5]

If they only see 4’s and 5’s I’d be worried about them being able to pick the improperly triaged patient out of the bunch then or knowing how to handle it (whoops they fell because they got dizzy from the gi bleed they forgot to mention in triage).

Fortunately the mid levels who work at my shop are extremely experienced and know to grab us to help with a few cases a day. We sign off on their charts with an attestation. That attestation changes depending on if we saw the patient or not. If we didn’t see them, the attestation specifically says we were available for consultation if requested and that we did not see the patient and only reviewed the chart.

 

[JAFERD]

If they only see 4’s and 5’s I’d be worried about them being able to pick the improperly triaged patient out of the bunch then or knowing how to handle it (whoops they fell because they got dizzy from the gi bleed they forgot to mention in triage).

Fortunately the mid levels who work at my shop are extremely experienced and know to grab us to help with a few cases a day. We sign off on their charts with an attestation. That attestation changes depending on if we saw the patient or not. If we didn’t see them, the attestation specifically says we were available for consultation if requested and that we did not see the patient and only reviewed the chart.

I agree. As I mentioned, at my old place, they all started on the main side. They couldn’t go to fast track, where they’re essentially independent, until at least a year on the job and approval from the attendings. And almost all of them still worked shifts in the main ED, in addition to the fast track shifts.

 

[namethatsmell]

We sign off on their charts with an attestation. That attestation changes depending on if we saw the patient or not. If we didn’t see them, the attestation specifically says we were available for consultation if requested and that we did not see the patient and only reviewed the chart.

I have the same attestation for when I need it. While it makes us feel better it doesn't provide any real med-mal protection.

 

[thegenius]

My ED this week started having the ED doc staff all midlevel patients. As docs, we don't have to see each midlevel patient but we have to listen to a brief presentation about the patient before they leave the ED (even sutures removal) and give our blessing or see the patient. Then we get those charts. The midlevels dislike this level of supervision. In the past, they would just send their charts to the medical director unless it was a level acuity 3

1. What are your views on this? Personally, I think midlevels should only see level acuity 4s and 5s. And the other concern is that this prolongs the patient's stay in the ED if I chose to see the midlevel patient after they present them to me.

2. What is done at your ED? Looking for ideas..

I think this boils down to (medico)legal issues. I work in CA, and CA state law says we are responsible for every action a PA does. Even if they perforate an eardrum while looking at it with an otoscope, you are responsible.

I am particular about this issue because I was named in a PA lawsuit when I never saw the patient, and the patient admitted they never saw me. Still got named, sued, and the case was settled out of court. So now, I have all cases presented to me. Sometimes it takes 5 seconds, like an ankle sprain, but our PA's are allowed to see some complicated patients too.

We are considering changing our policy to make PA's see only very low acuity patients.

Overall, even though I like our PAs in general, I would rather not work with PAs. I don't like the liability.

 

[thegenius]

One place I work now doesn't have me signing any PA/NP chart unless I physically see the patient. I like that.

Who is the supervising physician on those charts that are not signed by you? I presume you are on shift for some of these charts.

 

[miacomet]

We don't currently have midlevels (thank goodness), although I sometimes wish we had people to help us with procedures. We do a ton of sedations/reductions, lacs etc and it really bogs us down. I still don't understand why anyone should or even could sign an NP's chart in states where they practice under their own license. Definitely a minefield, and I see EM more and more going towards one doc supervising a bunch of midlevels, which is a medmal disaster.

 

[thegenius]

Getting sued is a low probability event, it's something like 1/20,000 cases nationwide (from what TeamHealth says. They brag saying their providers are sued 1/40,000 cases seen).

Liability boys and girls. If you are the supervising physician, doesn't matter if you sign the chart or not. Doesn't matter if you see or don't see the patient. If you are deemed the supervising physician (and the plantiff lawyers will pry that information from the group and force the director to name a supervising physician, or they will sue everybody) then you are responsible.

 

[Rendar5]

I have the same attestation for when I need it. While it makes us feel better it doesn't provide any real med-mal protection.

It lets me sleep at night and if I’m named in a suit, it lets me take it a lot less personally. Let my malpractice insurance take care of it.

 

[TheComebacKid]

I will never work in an ED that forces the physician to sign off on an NP or PA chart. The idea of that is so horrendous to me that it makes me physically ill. Essentially, what your group is telling you is that "We want to bill higher for physician level of care, but we want to see as many patients as possible. You are here to help us bill for more money, even if it means that you assume higher risk for yourself by signing off on a chart from a provider who has less than half the amount of training that you do".

It's an absolute joke.

Physicians are hands down to blame for unproliferated midlevel expansion without any regulation or oversight. Everyone wants the big bucks, but we are ultimately selling out our own careers and the future of our specialty by partaking in this nonsense. EM is going down the road of anesthesia with the CRNAs. Everyone is sitting on cloud nine right now since our specialty is booming, but in 20 years time, EM residency slots will go unfilled (like anesthesia) given the lack of demand for our specialty and the unregulated growth of midlevel providers. And that's only secondary to the fact that we are providing care to patients by people who have less training. It's bad patient care, period.

Are some midlevels "good"? Sure. They can put together a laceration, reduce a fracture and splint etc. But why you would trust someone who has a fraction of your training, sign off their chart, and assume medical responsibility for someone's health is beyond me. Forget the fact that you open yourself up to medicolegal nightmares, but you are ultimately allowing someone with less experience than you to take care of an actual patient's health and make a mistake.

This is not because they are "dumb" or "stupid", it's because their training simply does not prepare them for managing patients with serious medical issues when they present to the ED. This is not to sleight them in any way. It's the same reason why I'm not adequately trained to operate on a femur. Sure, I could spend the next several months, do an orthopedic rotation and see some surgeons hammer pins and nails into a bone, but does that mean that I am qualified to do this on my own? Absolutely not.

You don't know what you don't know. The false equivalency of PA/NP training to MD/DO training needs to stop, and EM physicians need to get vocal about it instead of sitting happy with their huge paychecks they are getting right now, not thinking about the future of the specialty.

 

[southerndoc]

I cannot say this enough: whether you sign the chart or not, your presence in the ED with an APP patient means you are ultimately responsible for their care. This has been successfully litigated numerous times. If you do not think you have liability, then you are fooling yourself.

Cosigning a chart does not allow a higher charge unless you specifically document that you saw the patient.

 

[InternistDO]

I cannot say this enough: whether you sign the chart or not, your presence in the ED with an APP patient means you are ultimately responsible for their care. This has been successfully litigated numerous times. If you do not think you have liability, then you are fooling yourself.

Cosigning a chart does not allow a higher charge unless you specifically document that you saw the patient.

What about in states with independent NP practice?

 

[southerndoc]

What about in states with independent NP practice?

I reviewed such a case in an independent practice state. The ER attending on record for that day was successfully sued for a decent amount of money.

 

[miacomet]

I reviewed such a case in an independent practice state. The ER attending on record for that day was successfully sued for a decent amount of money.

That's insane.

 

[deleted497653]

@ southerndoc

How does the legal system justify punishing a doc who didn’t see the patient? In the case where they were available to be consulted and were not consulted by the mid level but were sent the chart?

Just wanting to understand.

Asked the director about having a separate fast track but with the increase in urgent cares in the area, we don’t have enough fast track patients to do that.

Like many are saying, this is a new problem as far as how to manage risk and keep patients safe while still operating a financially sound ER. As someone else said, we should regulate this beast before it’s too late.

 

[miacomet]

Because nurses are perfect humans who are never responsible for anything.

 

[Arcan57]

@ southerndoc

How does the legal system justify punishing a doc who didn’t see the patient? In the case where they were available to be consulted and were not consulted by the mid level but were sent the chart?

Just wanting to understand.

Just because you delegated your license to someone else don't mean you don't bear responsibility for what happens under it. I imagine even in independent practice states that hospital by-laws are going to require some level of supervision and I could see making a case against the doc on that basis. If it's not convenient or "takes too much effort" to appropriately supervise your mid-levels, realize that the law considers that a choice you made and for which you are accountable. You could turn around and try and go after the CMG to recoup damages, but if you read your contract that's going to be the legal equivalent of free-climbing a 900ft sheer cliff.

The system was never meant to deal with 40-50% of patient volume being seen by mid-levels. Due to the ease of hiring midlevels vs. EM docs when volume expands, many shops are going to still be operating under regulations drafted when there was a 2-3: 1 doc to MLP vs. a 1:1 or 1:2 commonly seen today. Hospitals recognize the risk and frequently require on-line direction on every patient and will carve out a subset of patients that also require direct doc at bedside involvement (peds, Level 1 or 2's, admits, etc). And if there's one type of organization that doesn't GAF about creating rules that are impossible to comply with while still performing your original job, it's hospitals.

 

[GeneralVeers]

I am responsible for all PA patients and the charts as I have found out. This month I have to go before the Texas Board to respond to a patient complaint. The short version of the story is that a lady came in with abdominal pain was seen by the PA, she got a RUQ ultrasound which showed gallstones. Apparently her pain was controlled, she was tolerating PO fluids, and was discharged home. Straightforward right? I thought so too so I signed the chart. Little did I know the lipase was elevated as well and the PA never saw it. The patient made a complaint to the board about not admitting pancreatitis to the hospital. So now I'm stuck going to a hearing, paying my own travel and wasting my time for a patient I never saw, treated, or even was aware of until well after discharge. Oh and the best part is, I got a letter from them declaring that they have made a summary declaration of wrongdoing against me, before going to the hearing.

 

[miacomet]

I am responsible for all PA patients and the charts as I have found out. This month I have to go before the Texas Board to respond to a patient complaint. The short version of the story is that a lady came in with abdominal pain was seen by the PA, she got a RUQ ultrasound which showed gallstones. Apparently her pain was controlled, she was tolerating PO fluids, and was discharged home. Straightforward right? I thought so too so I signed the chart. Little did I know the lipase was elevated as well and the PA never saw it. The patient made a complaint to the board about not admitting pancreatitis to the hospital. So now I'm stuck going to a hearing, paying my own travel and wasting my time for a patient I never saw, treated, or even was aware of until well after discharge. Oh and the best part is, I got a letter from them declaring that they have made a summary declaration of wrongdoing against me, before going to the hearing.

Missing Canada now? That's horrible, BTW. And PAs should not be seeing abdominal pain. I fail to see how midlevels save the system any money. But admin and the government love them. Love.

 

[GeneralVeers]

Missing Canada now? That's horrible, BTW. And PAs should not be seeing abdominal pain. I fail to see how midlevels save the system any money. But admin and the government love them. Love.

I will never miss the snow! Fortunately it's been a one-off, and in 10 years, signing thousands of PA charts it has been the only issue. I strongly disagree with you about PAs not seeing abdominal pain. I think the vast majority of abdominal pain is low-acuity and can easily be seen by a PA/NP. It should be required that they review all these patients with the attending, and give him/her the option of seeing these patients prior to discharge. Some places I work at, young females with abdominal pain make up 20-25% of all the presenting patients. It would be impossible to staff with enough physicians to see all these.

I also get annoyed at places that require physicians to see "every level 3 patient". Some triage nurses will make everything a 3, thereby making it impossible. I had a 50 year old lady come in this week with "Right arm pain after picking up a baby". Guess what? Level 3!

 

[TheComebacKid]

I cannot say this enough: whether you sign the chart or not, your presence in the ED with an APP patient means you are ultimately responsible for their care. This has been successfully litigated numerous times. If you do not think you have liability, then you are fooling yourself.

Cosigning a chart does not allow a higher charge unless you specifically document that you saw the patient.

I would venture a guess that the many docs will stand outside the room poke their head through the curtain and wave and document that they "saw" the patient and bill for higher charges. Not only is this unethical and bad patient care, you open yourself up to the liability.

In residency, an attending goes and sees every single patient the resident staffs with them. They physically examine the patient. Is this the most efficient method? Absolutely not, but it's the right way to do things. I would argue you don't utilize midlevels at all, but if you are willing to, you treat them like residents. This idea of allowing them to practice independently is insanity.

Just because you delegated your license to someone else don't mean you don't bear responsibility for what happens under it. I imagine even in independent practice states that hospital by-laws are going to require some level of supervision and I could see making a case against the doc on that basis. If it's not convenient or "takes too much effort" to appropriately supervise your mid-levels, realize that the law considers that a choice you made and for which you are accountable. You could turn around and try and go after the CMG to recoup damages, but if you read your contract that's going to be the legal equivalent of free-climbing a 900ft sheer cliff.

Again, this emphasizes that physicians are to blame here. We have allowed this to happen. While I feel the frustration of physicians being sued for the care provided by someone who is not as qualified, if you are willing to work at a place that has this set up, you knew what you were getting yourself into.

The system was never meant to deal with 40-50% of patient volume being seen by mid-levels. Due to the ease of hiring midlevels vs. EM docs when volume expands, many shops are going to still be operating under regulations drafted when there was a 2-3: 1 doc to MLP vs. a 1:1 or 1:2 commonly seen today. Hospitals recognize the risk and frequently require on-line direction on every patient and will carve out a subset of patients that also require direct doc at bedside involvement (peds, Level 1 or 2's, admits, etc). And if there's one type of organization that doesn't GAF about creating rules that are impossible to comply with while still performing your original job, it's hospitals.

Physicians are one of the most important part of the healthcare system, period. We bring in more money for the hospital than any other individual as it's related to patient care. Why we don't leverage our roles and allow this to happen is beyond me.

 

[RustedFox]

I am responsible for all PA patients and the charts as I have found out. This month I have to go before the Texas Board to respond to a patient complaint. The short version of the story is that a lady came in with abdominal pain was seen by the PA, she got a RUQ ultrasound which showed gallstones. Apparently her pain was controlled, she was tolerating PO fluids, and was discharged home. Straightforward right? I thought so too so I signed the chart. Little did I know the lipase was elevated as well and the PA never saw it. The patient made a complaint to the board about not admitting pancreatitis to the hospital. So now I'm stuck going to a hearing, paying my own travel and wasting my time for a patient I never saw, treated, or even was aware of until well after discharge. Oh and the best part is, I got a letter from them declaring that they have made a summary declaration of wrongdoing against me, before going to the hearing.

?!

I don't admit all of my pancreatitis cases reflexively. How are you *summarily* in the wrong?

 

[GeneralVeers]

?!

I don't admit all of my pancreatitis cases reflexively. How are you *summarily* in the wrong?

Me neither, but I guess these geniuses, made up of FM and EM think they know more about my specialty than I do. I had to hire an expert witness ($350) to rebuff their claims. His letter is rather scathing, and does a good job of defending the rationale for sending a patient home. There is still a chance after the interview that they could reverse their finding. This is the problem with these out-of-control boards. They need to justify their existence, so investigate every claim no matter how bogus. While patients may not be able to sue in most cases, a disgruntled patient can cause significant trouble by just making a board complaint, which costs the physician time and money.

 

[Apollyon]

Me neither, but I guess these geniuses, made up of FM and EM think they know more about my specialty than I do. I had to hire an expert witness ($350) to rebuff their claims. His letter is rather scathing, and does a good job of defending the rationale for sending a patient home. There is still a chance after the interview that they could reverse their finding. This is the problem with these out-of-control boards. They need to justify their existence, so investigate every claim no matter how bogus. While patients may not be able to sue in most cases, a disgruntled patient can cause significant trouble by just making a board complaint, which costs the physician time and money.

The lawyers have a saying: "If you can't argue the law, argue the facts. If you can't argue the facts, argue the law. If you can't argue the facts or the law, pound the table and yell."

I don't advise that. What are criteria to go home with pancreatitis? Pain control, taking PO. I think you're in the right. "Although I did not see this patient, and knew nothing of them until well after the fact, I was the attending physician that day. I am emergency medicine residency trained, and board certified. On retrospective review, I concur with the management rendered."

 

[VA Hopeful Dr]

?!

I don't admit all of my pancreatitis cases reflexively. How are you *summarily* in the wrong?

Isn't the Texas board known for being hard on doctors?

 

[deleted497653]

Was it gallstone pancreatitis?

 

[bravotwozero]

I reviewed such a case in an independent practice state. The ER attending on record for that day was successfully sued for a decent amount of money.

That is so crazy. "Independent" practice cannot possibly be independent in reality, if the liability is not independent, by definition...

 

[southerndoc]

There have been docs sued for APP's operating under their license and the doc not be physically on the property when the patient was seen (e.g., urgent care centers).

There have been docs sued successfully for patients that presented to the ER, were triaged, then something happened (patient left AMA, eloped, etc due to long wait). The doc had absolutely no knowledge of the patient even being on the premises, but either was sued or had an EMTALA violation (can't remember which). I haven't been involved with litigation in one of these cases. It was documented in an issue of ED Legal Letter not too long ago.

 

[deleted859535]

There have been docs sued successfully for patients that presented to the ER, were triaged, then something happened (patient left AMA, eloped, etc due to long wait). The doc had absolutely no knowledge of the patient even being on the premises, but either was sued or had an EMTALA violation (can't remember which). I haven't been involved with litigation in one of these cases. It was documented in an issue of ED Legal Letter not too long ago.

What in the hell? What state was this / any particular circumstances you recall?

 

[thegenius]

@ southerndoc

How does the legal system justify punishing a doc who didn’t see the patient? In the case where they were available to be consulted and were not consulted by the mid level but were sent the chart?

Just wanting to understand.

It is very clear in California Law that a PA / NP (or whatever you want to call them) works under a supervising physician, and that supervising physician is responsible for ***everything*** that they do. I was involved in a PA court case and I never saw the patient. I was sued. The patient even said, under oath, that they never saw me.

 

[thegenius]

?!

I don't admit all of my pancreatitis cases reflexively. How are you *summarily* in the wrong?

This doesn't sound like a legal case, like negligence. Proving there was harm done from negligence, or gross negligence, is different than a state board saying you didn't properly oversee your PA's.

I don't admit all my pancreatitises either.

 

[deleted497653]

Out of curiosity, did both you and the PA continue working together after that? I understand life must go on but that would be kinda...next to impossible to keep working with that PA (for me)...not saying they should or should not have been sued.

 

[thegenius]

There have been docs sued for APP's operating under their license and the doc not be physically on the property when the patient was seen (e.g., urgent care centers).

There have been docs sued successfully for patients that presented to the ER, were triaged, then something happened (patient left AMA, eloped, etc due to long wait). The doc had absolutely no knowledge of the patient even being on the premises, but either was sued or had an EMTALA violation (can't remember which). I haven't been involved with litigation in one of these cases. It was documented in an issue of ED Legal Letter not too long ago.

I do recall that "triage" is not a MSE. Just imaging that LA County Hospital, or Cook County Hospital in Chicago probably violate EMTALA every day with waits that are 5-10 hours long. But they are not getting regular EMTALA violations.

 

[deleted497653]

Medical boards have to investigate every complaint they get, no matter how frivolous. I had a patient who got kicked out for being abusive to staff complain to the medical board that I had "failure to communicate". She came in with abdomen pain and an IV infiltrated. she got tired of waiting for her results and acted up when she was told I was seeing someone else and would come see her after. I submitted all the requested info and the finding was that there was no case. It took 6 months. I didn't hire lawyer or expert witness just submitted what they asked for.

So obviously try to not get a complaint and always document well...also helps to ask the nurses to document when a patient is being abusive or bizarre ...and most importantly...don't be caught slipping. Your care should be top of the line, no short cuts because this kind of stuff is no bueno if they can show you were on the wrong.

 

[thegenius]

Out of curiosity, did both you and the PA continue working together after that? I understand life must go on but that would be kinda...next to impossible to keep working with that PA (for me)...not saying they should or should not have been sued.

I think you are referring to me?

I make life very hard on that PA. I force him to tell me everything, I personally see about 10-15% of his patients. We do not get along at all. I told him, in front of my boss, that I don't trust anything he does. I tend to avoid detailed oversight on things like ankle sprains, dental pain because they are extremely low risk. I even asked the scheduler to minimize shifts I get with him.

But overall, I ask all PAs to present all patients to me prior to dispo. I'm probably the only doc that does that in our group.

At the end of the day, most of us develop a good working relationship with the PAs. You know what they know, what they don't know. There are red flags in patients and you help them out. Sometimes you see the patients. Neurologic, Ophthalmic, and Rheumatologic patients get more of my scrutiny. Largely because we don't have readily available consults for them. Cardiac, General Surgery, OB, Nephrology, and Heme/Onc I don't mind as much because if they are in a sticky wicket, they can consult them and they are good at my hospital. Some PAs come to me and say "this patient is too complicated can you help me." And I'm more than happy to.

 

[southerndoc]

I do recall that "triage" is not a MSE. Just imaging that LA County Hospital, or Cook County Hospital in Chicago probably violate EMTALA every day with waits that are 5-10 hours long. But they are not getting regular EMTALA violations.

CMS may determine that a medical screening exam is not just an assessment. An MSE may require labs, x-rays, or obtaining a CT to exclude serious pathology. See the other thread regarding the appendicitis case.

 

[southerndoc]

Medical boards have to investigate every complaint they get, no matter how frivolous. I had a patient who got kicked out for being abusive to staff complain to the medical board that I had "failure to communicate". She came in with abdomen pain and an IV infiltrated. she got tired of waiting for her results and acted up when she was told I was seeing someone else and would come see her after. I submitted all the requested info and the finding was that there was no case. It took 6 months. I didn't hire lawyer or expert witness just submitted what they asked for.

So obviously try to not get a complaint and always document well...also helps to ask the nurses to document when a patient is being abusive or bizarre ...and most importantly...don't be caught slipping. Your care should be top of the line, no short cuts because this kind of stuff is no bueno if they can show you were on the wrong.

That is true. You'd be surprised at some of the egregious stuff that occurs (i.e., sending a chest pain home before troponin is resulted and not calling the patient back when the troponin results is 2, not ordering a CT on a car crash victim with positive LOC who is 80 years old on Pradaxa, etc.). You can't make up some of the stupid stuff people do.

 

[RustedFox]

It is very clear in California Law that a PA / NP (or whatever you want to call them) works under a supervising physician, and that supervising physician is responsible for ***everything*** that they do. I was involved in a PA court case and I never saw the patient. I was sued. The patient even said, under oath, that they never saw me.

Yep. Presently being sued for a PA patient that I never saw or could even review the chart on until long after I went home for that shift.

I'm rather anti MLP in general.

 

[namethatsmell]

Yep. Presently being sued for a PA patient that I never saw or could even review the chart on until long after I went home for that shift.

I'm rather anti MLP in general.

Ugh I'm so sorry you're going through this. I hope it goes in your favor.

The idea that we're responsible for all PA and NP care when most of us have absolutely no power to provide said oversight over them is insane (SDGs being an exception). The likelihood of us being roped into a PA/NP lawsuit will only become more common as PA/NPs see more and more patients to make our corporate overloads fatter.

Anybody have ideas to meaningfully shift the risk from a doc up the chain to the CMG or hospital or whoever employs the PA/NP? A lawsuit from a doc roped into a PA case that loses? Something else? Yeah I know I'm probably dreaming.