Reviewing MLP charts. FUN TIMES!

[RustedFox]

Reviewing my MLP charts for the last shift. Two MLPs under my "supervision"

- 63 year old with knee pain. No knee exam, whatsoever. Just an x-ray and "discharged". No MDM. No nothing.
- 23 year old with abdominal pain. Nonspecific exam, just "diffusely tender". No degree of tenderness, just "diffusely tender". No discussion about peritoneal findings. No inspection. CBC/BMP/UA and imaging all not imported into the chart; had to do that myself (Thanks, CERNER!) No repeat exam. Just "discharged". No diagnosis listed, by the way. Had to do that myself, too.
- 4 year old with head injury. Wrong PECARN (<2 years old) autotext loaded into chart. No vital signs. Physical exam? "Swelling to head".

*** Three charts, one MLP... Three nonspecific fractures (wrist, ankle, etc). Three splints applied. Number of neurovascular exams documented? Zero. ***

Attention MLPs...

Don't suck.

Also, don't clamor for "equivalence" when you're clearly not even close.

Am I mad ? You bet.

Here's the BEST part; these two MLPs have been "in the ER for 10+ years" and they want RESPECT for their profession and their dedication and their... shutthefcukup.

Attention, kids: read the MLP charts. Don't be like the other proles out there that just blindly click "sign".

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[NYEMMED]

Reviewing my MLP charts for the last shift. Two MLPs under my "supervision"

- 63 year old with knee pain. No knee exam, whatsoever. Just an x-ray and "discharged". No MDM. No nothing.
- 23 year old with abdominal pain. Nonspecific exam, just "diffusely tender". No degree of tenderness, just "diffusely tender". No discussion about peritoneal findings. No inspection. CBC/BMP/UA and imaging all not imported into the chart; had to do that myself (Thanks, CERNER!) No repeat exam. Just "discharged". No diagnosis listed, by the way. Had to do that myself, too.
- 4 year old with head injury. Wrong PECARN (<2 years old) autotext loaded into chart. No vital signs. Physical exam? "Swelling to head".

*** Three charts, one MLP... Three nonspecific fractures (wrist, ankle, etc). Three splints applied. Number of neurovascular exams documented? Zero. ***

Attention MLPs...

Don't suck.

Also, don't clamor for "equivalence" when you're clearly not even close.

Am I mad ? You bet.

Here's the BEST part; these two MLPs have been "in the ER for 10+ years" and they want RESPECT for their profession and their dedication and their... shutthefcukup.

Attention, kids: read the MLP charts. Don't be like the other proles out there that just blindly click "sign".

But what do you do when the patient is already discharged and you find crappy care based on chart review? still falls on the ED doc. Not a good situation

 

[bravotwozero]

You can make life hard for them and get them to shape up. There are ways. It’s been done.


Sent from my iPhone using Tapatalk

 

[Psai]

Jesus Christ. Even when they're working for you it's not worth it.

 

[GonnaBeADoc2222]

Of the many midlevels (Yes, midlevels. Sorry, I'm not calling you an "APP", and I'm not lumping myself in with you as a "provider") that I've worked with, three have been excellent. And guess what? They all left (CMG).

The rest fall between the range of "OK, I don't think you'll murder any patients today, but wow you're damn slow" and "OMFG how did you even graduate PA/NP school?!?!"

I spend a good amount of time correcting mistakes, adding necessary orders, deleting completely ridiculous orders, etc.

The CMGs have no interest in improving their care, they just use them to speed low acuity through the department. The "provider" in triage functions to "stop the clock" on door to "provider" time. Meanwhile, I have to tidy up their messes on the back end (no type and screen ordered on the pregnant vaginal bleeder; deleting order for troponin on 15 yo with chest pain, etc, etc.). This is basic AF medicine.

I would rather send them all home and see the entire department myself. Mostly, they just add to my workload.

 

[GonnaBeADoc2222]

Alright I'll be that guy who admits it. And perhaps I'm too jaded and cynical and whatever else. But I've completely given up on reviewing MLP charts and have just accepted the roll of the dice.

Like most of you I work at a place where MLP's essentially practice independently, and "supervision" is not taken well. (I'm not one of the lucky few in an SDG and I don't make any hiring or firing decisions). So I have two choices. The first is to spend hours upon hours (uncompensated) a week reviewing every MLP chart I get, having multiple uncomfortable conversations with MLP's and getting complained about, having to make a bunch of follow-up calls, and having to go on antihypertensives for all of it. The second is to say "serenity now" and just sign the charts and accept the roll of the dice.

I didn't make up these MLP degrees, I didn't make the decision to hire them, it's not on my head that the hospital wants to save money by employing them, and it wasn't my decision to let them practice on their own. If I'm going to get sued I'm going to get sued, and as Birdstrike has previously noted it's really just a grudge match between two attorneys over an insurance company's money. I sign all of the charts with a statement to the effect of that I was in the department but the PA/NP didn't talk to me about the case and I didn't see the patient. If I end up on the stand it will go something like this:

Q: Why didn't you order XYZ?
A: No idea, I didn't see the patient
Q: Don't you think the chart indicates that XYZ should have been done but wasn't?
A: No idea, I can't comment about care on a patient I didn't see
Q: Why didn't you see them?
A: My hospital tells me MLP's see patients on their own, and they decide whether or not to consult me
Q: Don't you think a doctor should be seeing these patients?
A: No one even told me they were there. I didn't get record they had even been there until hours after they were discharged.
Q: But don't you think you should have followed up on them?
A: No idea, I can't comment about care on a patient I didn't see.

And so on and so forth. System is what it is. I'm not working an extra minute for something that isn't my fault and isn't my problem. Chips fall where they may. Am I alone in this?

I don't think this is totally unreasonable. In terms of liability, my understanding is that it doesn't matter whether or not you sign. If you were on shift at the time of the incident, you can be held liable. My issue with signing MLP charts on patients I did not see is that I am attesting that I physically saw and evaluated the patient and that this allows the biller to bill for more than what they could than just with an MLP signature. Since this is tantamount to attesting to a lie - and therefor fraud - I do not sign MLP charts on patients that I do not see.

 

[NicMouse64]

I don't think this is totally unreasonable. In terms of liability, my understanding is that it doesn't matter whether or not you sign. If you were on shift at the time of the incident, you can be held liable. My issue with signing MLP charts on patients I did not see is that I am attesting that I physically saw and evaluated the patient and that this allows the biller to bill for more than what they could than just with an MLP signature. Since this is tantamount to attesting to a lie - and therefor fraud - I do not sign MLP charts on patients that I do not see.

Damn that's ****ed. I'm assuming if you refuse to sign, your employer gets upset at you? I liked Mr. hat's approach.........

 

[GeneralVeers]

My Texas board complaint got dismissed after my hearing, however I can say that Mr. Hat's plausible deniability defense won't hold water. They will get you on "failure to adequately supervise" an MLP, and you will be liable/responsible.

That being said, I've also given up reviewing every word of MLP charts and roll the dice.

 

[Brigade4Radiant]

Dear Dr. Rustedfox

It is come to our attention that there has been a significant delay in the signing of other provider charts. As a provider it is your responsibility to sign these charts promptly as it is good patient care and insurance companies require timely charts for reimbursement.

Failure to sign these charts at the end of the week will result in a warning being placed in your file.

 

[miacomet]

I work somewhere without MLs, and I thank my stars.

 

[GeneralVeers]

I work somewhere without MLs, and I thank my stars.

Then you are either in a SDG or have low pay. The only thing that keeps hourly rates reasonable in the places I work is being paid based on the RVUS generated by my MLPs.

 

[miacomet]

Then you are either in a SDG or have low pay. The only thing that keeps hourly rates reasonable in the places I work is being paid based on the RVUS generated by my MLPs.

I'm actually employed (with full benefits, moderate 401k match, vested pension etc), but you're right, my hourly is pretty low- less than $300 by far, always more than $200, depending on bonuses, which I'm sure does not meet Veers-level income. My guess is we will get one handpicked ML at our other site soon as we do a ton of procedures and it would be great to have someone to sew lacs etc.

I realize the pay isn't amazing, but I rarely if ever see more than 2 pph, and this weekend I saw five pts on the overnight. There are negatives (no night diff, somewhat inflexible schedule), but my hourly would have to go WAY up to compensate for presumably worse working conditions. And, yes, it's a desirable part of the country.

 

[thegenius]

But what do you do when the patient is already discharged and you find crappy care based on chart review? still falls on the ED doc. Not a good situation

You do what I do, which is demand that each patient be presented to you prior to disposition. And they do that. Even the simpliest stuff like "I'm here because I want directions to the closest Burger King." That case has to be presented to me as well!

Doesn't mean you get a good chart though.

I've been sued over a MLP chart and I never saw the patient. Patient admitted they never saw me. Now I generally trust our MLPs, but after that experience I have every single one presented to me no matter how simple or complex.

 

[thegenius]

Alright I'll be that guy who admits it. And perhaps I'm too jaded and cynical and whatever else. But I've completely given up on reviewing MLP charts and have just accepted the roll of the dice.

Like most of you I work at a place where MLP's essentially practice independently, and "supervision" is not taken well. (I'm not one of the lucky few in an SDG and I don't make any hiring or firing decisions). So I have two choices. The first is to spend hours upon hours (uncompensated) a week reviewing every MLP chart I get, having multiple uncomfortable conversations with MLP's and getting complained about, having to make a bunch of follow-up calls, and having to go on antihypertensives for all of it. The second is to say "serenity now" and just sign the charts and accept the roll of the dice.

I didn't make up these MLP degrees, I didn't make the decision to hire them, it's not on my head that the hospital wants to save money by employing them, and it wasn't my decision to let them practice on their own. If I'm going to get sued I'm going to get sued, and as Birdstrike has previously noted it's really just a grudge match between two attorneys over an insurance company's money. I sign all of the charts with a statement to the effect of that I was in the department but the PA/NP didn't talk to me about the case and I didn't see the patient. If I end up on the stand it will go something like this:

Q: Why didn't you order XYZ?
A: No idea, I didn't see the patient
Q: Don't you think the chart indicates that XYZ should have been done but wasn't?
A: No idea, I can't comment about care on a patient I didn't see
Q: Why didn't you see them?
A: My hospital tells me MLP's see patients on their own, and they decide whether or not to consult me
Q: Don't you think a doctor should be seeing these patients?
A: No one even told me they were there. I didn't get record they had even been there until hours after they were discharged.
Q: But don't you think you should have followed up on them?
A: No idea, I can't comment about care on a patient I didn't see.

And so on and so forth. System is what it is. I'm not working an extra minute for something that isn't my fault and isn't my problem. Chips fall where they may. Am I alone in this?

Basically that's what we all do, more or less, if we work in a system with MLPs.

I suppose you could demand to see all the patients and put a note in on them. Would make things inefficient. Treat them like residents.

If you come to a head with CMG admin about this, what are they going to do? Fire you?

 

[thegenius]

My Texas board complaint got dismissed after my hearing, however I can say that Mr. Hat's plausible deniability defense won't hold water. They will get you on "failure to adequately supervise" an MLP, and you will be liable/responsible.

100% true based on personal experience being sued. If you are the supervising physician you are accuontable for everything they do. End of argument!

 

[RustedFox]

100% true based on personal experience being sued. If you are the supervising physician you are accuontable for everything they do. End of argument!

Presently involved in one myself.
MLP saw patient, signed up with me as the supervising MD.
I left the shift.
MLP has "next physician" see patient.
Discharged home.
Dead patient.
I'm being sued.
Yay.

 

[Psai]

Presently involved in one myself.
MLP saw patient, signed up with me as the supervising MD.
I left the shift.
MLP has "next physician" see patient.
Discharged home.
Dead patient.
I'm being sued.
Yay.

This is why we went into medicine isn't it?

 

[miacomet]

Presently involved in one myself.
MLP saw patient, signed up with me as the supervising MD.
I left the shift.
MLP has "next physician" see patient.
Discharged home.
Dead patient.
I'm being sued.
Yay.

That. Sucks.

Aim for FI, then practice medicine as you see it. It's the only logical way.

 

[AlmostAnMD]

Presently involved in one myself.
MLP saw patient, signed up with me as the supervising MD.
I left the shift.
MLP has "next physician" see patient.
Discharged home.
Dead patient.
I'm being sued.
Yay.

Well anyone can sue anyone for anything....I'd imagine (or maybe just hope) you'd be dropped from the suit....

 

[RustedFox]

Well anyone can sue anyone for anything....I'd imagine (or maybe just hope) you'd be dropped from the suit....

Nope. Prelim reports estimate that I am "15% responsible".

I'm named.
I'm in.

 

[miacomet]

RF, I'm worried about you. Are you OK? Is this job still filling your needs? Are you having malpractice-related PTSD/acute stress disorder? Are you taking care of yourself? Burnt out? Do you have sufficient personal and professional support?

Can we help?

 

[TheComebacKid]

Here's a crazy idea.

Don't work for a place that has midlevels. If we collectively as a group of physicians refuse to be taken advantage of a system that prioritizes inferior patient care that is cheaper and provided by other less educated individuals, while simultaneously making us accountable for the garbage care they provide, we can stop being gutted the way we are.

If you continue to sign up for a job from a corporation that allures you for $300/hr and all these other ridiculous perks at the expense of what's right for patients and for our specialty, then no offense, but you should have seen this coming.

Maybe I'm the only one who is OK working for an academic group where I do not have to sign off on midlevel charts. Maybe I'll make only $200K a year and everyone on SDN will laugh at my pathetic salary, but I'm going to sleep at night not worrying or taking responsibility for a less trained individual who doesn't even think to document a basic physical exam prior to sending a patient home.

I just don't understand how some of you are OK being employed by somebody who flashes around big dollar bills in front of your face at the expense of your sanity. They literally have no sense of obligation to you if you get sued, and at the end of the day, they don't care what it means for you (or your patients).

I'm sorry, but ALL OF US collectively are to blame for this situation since we just stood by and let it happen. It sounds great, "I'll make more money" but nobody ever stopped to think how we were being used and how the system was gaming us. Meanwhile, patients are being sent home with vaginal bleeding (without a pregnancy test or beta or ultrasound) and coming in the next day with a ruptured ectopic (true story at the community site I rotate at that is heavily staffed by midlevels).

I hate to admit it, but if I'm a patient and a midlevel provider screws up my care, you can bet your ass that I'm coming for the physician who allowed someone without training to take care of my health. Patients in my opinion have every right to come after the physician who knowingly allows unexperienced providers to take care of patients under their watch.

My comments probably come off as being harsh, but I don't really care. Nobody in medicine seems to get it or seems to want to do anything about it. ACEP is hands down the worst culprit of all, a group that we pay dues to but is simultaneously backed by TeamHealth which has a major vested interest in expanding midlevel scope of practice. It's all gone to hell.

 

[Stagg737]

Alright I'll be that guy who admits it. And perhaps I'm too jaded and cynical and whatever else. But I've completely given up on reviewing MLP charts and have just accepted the roll of the dice.

Like most of you I work at a place where MLP's essentially practice independently, and "supervision" is not taken well. (I'm not one of the lucky few in an SDG and I don't make any hiring or firing decisions). So I have two choices. The first is to spend hours upon hours (uncompensated) a week reviewing every MLP chart I get, having multiple uncomfortable conversations with MLP's and getting complained about, having to make a bunch of follow-up calls, and having to go on antihypertensives for all of it. The second is to say "serenity now" and just sign the charts and accept the roll of the dice.

I didn't make up these MLP degrees, I didn't make the decision to hire them, it's not on my head that the hospital wants to save money by employing them, and it wasn't my decision to let them practice on their own. If I'm going to get sued I'm going to get sued, and as Birdstrike has previously noted it's really just a grudge match between two attorneys over an insurance company's money. I sign all of the charts with a statement to the effect of that I was in the department but the PA/NP didn't talk to me about the case and I didn't see the patient. If I end up on the stand it will go something like this:

Q: Why didn't you order XYZ?
A: No idea, I didn't see the patient
Q: Don't you think the chart indicates that XYZ should have been done but wasn't?
A: No idea, I can't comment about care on a patient I didn't see
Q: Why didn't you see them?
A: My hospital tells me MLP's see patients on their own, and they decide whether or not to consult me
Q: Don't you think a doctor should be seeing these patients?
A: No one even told me they were there. I didn't get record they had even been there until hours after they were discharged.
Q: But don't you think you should have followed up on them?
A: No idea, I can't comment about care on a patient I didn't see.

And so on and so forth. System is what it is. I'm not working an extra minute for something that isn't my fault and isn't my problem. Chips fall where they may. Am I alone in this?

Out of curiosity, do you live in a state with independent practice for midlevels? If not this might actually be worse if the case went to court.

 

[namethatsmell]

I hate to admit it, but if I'm a patient and a midlevel provider screws up my care, you can bet your ass that I'm coming for the physician who allowed someone without training to take care of my health. Patients in my opinion have every right to come after the physician who knowingly allows unexperienced providers to take care of patients under their watch.

Eh?

Have you ever worked for a CMG? CMG docs have zero say in who a midlevel sees. Put another way, CMG pit docs have no power over staffing conditions and how a midlevel acts. If you work in an area where that's your only employment option, it may be the lesser of two evils (vs travel locums or moving) depending on your life circumstance.

I appreciate your sentiment but do you really think the average pit doc for USACS/Envision/Team etc is getting some big payout from them or making a ton of money off midlevels? The answer is no. Most are not the docs who sold out to the CMGs and yes many are getting a raw deal. But the vast majority of CMG pit docs are good folks who are trying to do the right thing for their patients and their own families.

Should you ever have cause to sue a midlevel of a CMG, I'd find a lawyer who is clever enough to find a way to also sue the CMG for their shady business tactics of heavy midlevel staffing and poor quality control combined with less and less doc staffing. Not only does the CMG have waaaaay bigger pockets than the doc to give you a better payout, but it would perhaps change the landscape of how they staff EDs. If you sue the doc, how does that make the system better?

Honestly, I'm waiting for a class-action lawsuit against CMGs for their cavalier approach to midlevels use and the unsafe conditions these corporations foster to increase their profits. Yeah I know it may be a pipe dream...but I really can't think of a more pragmatic way to make them change how they operate.

 

[shookwell]

I refuse to sign midlevel charts unless the midlevel presents the patient to me before any decisions are made about testing and disposition.

If the administrators wants a doc to sign a chart of a patient only seen by a PA, than that administrator can sign the chart themselves. They saw the patient just as much as I did.

The one place that said yes but then started "assigning" PA charts to me just got 100 unsigned charts and I don't answer their phone calls any longer.

 

[LeroyJenkinsMD]

I have a dream. Every physician refuses to work with mid levels.

 

[Boatswain2PA]

Yeah, no EP has ever screwed up documentation, especially with Skynet....I mean Cerner.

Even when they're working for you it's not worth it.

Even if I'm making you another $50-$80/hour?

Yes, midlevels. Sorry, I'm not calling you an "APP", and I'm not lumping myself in with you as a "provider"

But you'll call me a midlevel...provider??

My issue with signing MLP charts on patients I did not see is that I am attesting that I physically saw and evaluated the patient and that this allows the biller to bill for more than what they could than just with an MLP signature.

Then you are committing fraud.

Midlevels (APPs, whatever) need to be supervised. In the ED that's you. If you want to see all the patients that come to the ED, then good for you. If you want to spend some time learning about, teaching, and supervising your midlevels, then you can make a LOT more money and your ED can flow a LOT faster.

 

[enalli]

I have a dream. Every physician refuses to work with mid levels.

Will never happen. For every emergency physician who complains about midlevels you have two jumping to protect the people who will wrestle their profession away from them:

"But MY midlevels are great. You just need to train them."

Good for you, but that doesn't apply to the overwhelming majority of practice sites out there.

"They make me so much money"

They make somebody so much money; probably not you

"They speed up the department"

So would another doctor

But the one that irrationally gets me the most worked up, and I know I'm in the minority in this one is:

"They see the low acuity patients and allow me to focus on the high acuity patients"

It's like these people never rotated in an ER before starting residency. Non-emergencies have been coming to the ER since the beginning of time. I don't get why so many of you consider yourselves to be above simple complaints or consider them to be some humongous burden. Just say hi and do a pregnancy test, look in their throat, listen to their lungs, or reassure them and send them home. They are honestly a nice break from the dizzy old lady, the drug seeker, and the abdominal pain NOS.

 

[enalli]

Midlevels (APPs, whatever) need to be supervised. In the ED that's you. If you want to see all the patients that come to the ED, then good for you. If you want to spend some time learning about, teaching, and supervising your midlevels, then you can make a LOT more money and your ED can flow a LOT faster.

If I remember correctly you work mostly on your own at a rural, facility, right? From your posts you seem to be competent and an asset to your department so I would be interested in hearing your opinion.

Do you think you are in the minority or majority of midlevels out there? What percentage of your peers are either unteachable or unwilling to be taught? Of those that want to be taught, how many work in situations where staffing makes it impossible to do such teaching?

If we assume that the majority of sites have midlevels that are either unwilling to be taught, incapable of being well-trained, or are in situations where they cannot be taught, is it worth salvaging midlevel practice?

This is all hypothetical, of course. We both know midlevels are going to more or less fully replace doctors in the not-too distant future. The train has too much steam both from a monetary standpoint and from a societal standpoint--the fact that "midlevel" has become a dirty word is proof of this; doctors lost the PR battle so badly that we didn't even realize there was a battle at hand.

 

[lemurcatta]

Reviewing my MLP charts for the last shift. Two MLPs under my "supervision"

- 63 year old with knee pain. No knee exam, whatsoever. Just an x-ray and "discharged". No MDM. No nothing.
- 23 year old with abdominal pain. Nonspecific exam, just "diffusely tender". No degree of tenderness, just "diffusely tender". No discussion about peritoneal findings. No inspection. CBC/BMP/UA and imaging all not imported into the chart; had to do that myself (Thanks, CERNER!) No repeat exam. Just "discharged". No diagnosis listed, by the way. Had to do that myself, too.
- 4 year old with head injury. Wrong PECARN (<2 years old) autotext loaded into chart. No vital signs. Physical exam? "Swelling to head".

*** Three charts, one MLP... Three nonspecific fractures (wrist, ankle, etc). Three splints applied. Number of neurovascular exams documented? Zero. ***

Attention MLPs...

Don't suck.

Also, don't clamor for "equivalence" when you're clearly not even close.

Am I mad ? You bet.

Here's the BEST part; these two MLPs have been "in the ER for 10+ years" and they want RESPECT for their profession and their dedication and their... shutthefcukup.

Attention, kids: read the MLP charts. Don't be like the other proles out there that just blindly click "sign".

I feel like the EMTs I used to train wouldn't even fail to document neuromuscular exam before and after splinting. Also, I doubt any of my current PA class would order a trop on a 15 year old with chest pain (saw on another post in the thread). Embarrassing. It sucks reading the this crap on these forums because I was a paramedic for years now in PA school (for a variety of good reasons not MD), and this stuff is unrecognizable to me. None of the students in my class believe in full independent practice authority for PAs or are the type of people to demand respect before earning it. And they certainly aren't stupid enough to not document a basic exam. So I wonder whats up here.

 

[enalli]

I feel like the EMTs I used to train wouldn't even fail to document neuromuscular exam before and after splinting. Also, I doubt any of my current PA class would order a trop on a 15 year old with chest pain (saw on another post in the thread). Embarrassing. It sucks reading the this crap on these forums because I was a paramedic for years now in PA school (for a variety of good reasons not MD), and now in PA school this stuff is unrecognizable to me. None of the students in my class believe in full independent practice authority for PAs or are the type of people to demand respect before earning it. And they certainly aren't stupid enough to not document a basic exam. So I wonder whats up here.

You are a PA student at a brick-and-mortar school (I assume since you refer to a class) who had significant prior clinical experience (I assume from the fact that you were training EMTs). You are by definition miles ahead of the BSN with minimal nursing experience who completed an online NP program and whose "rotations" consisted of glorified shadowing of other NPs. Yet that NP enjoys more practice privileges than you.

 

[Apollyon]

At ACEP this year, there was a case in one of the lectures about things you don't want to miss. One of them? 25 y/o with an NSTEMI.

I don't have any mid-levels. However, a troponin on a 15 year old kid is total BS - until it isn't. Low impact, low downside. And, when it comes back positive, once in a blue moon, you/the mid-level look like heroes.

 

[southerndoc]

Youngest person with a positive troponin I've seen was 12. Complained of chest pain. EKG had some flat T's, but nothing specific. i-STAT troponin was >10 (I think like 15?). Cath was negative, but he had severe myocarditis and went into florid failure the next day.

 

[Vandalia]

Speaking of a previous post, I was at the barber shop last week. The barber was proudly telling me about his granddaughter. She had completed her "online" Nurse Practitioner program and was ready to start her "clinical work." She would be working at the same practice as her sister, "but she had to be supervised by the other NP there, because her sister had to be a NP for a year before she could supervise someone."

PS: Everyone seems to be here and posting at the same time. 4 posts in under a minute.

 

[Boatswain2PA]

If I remember correctly you work mostly on your own at a rural, facility, right?

Mostly rural/suburban locums, but I do part time at a busy shop alongside EPs. I do this just so I can learn from the "big dawgs", and it is a really great team of people to work with (Docs, APPs, nurses, etc).

Do you think you are in the minority or majority of midlevels out there? What percentage of your peers are either unteachable or unwilling to be taught? Of those that want to be taught, how many work in situations where staffing makes it impossible to do such teaching?

Peer groups, majority/minority, etc...all terms that fall apart when you dissect attributes. No, I'm not a "typical" PA, who seems to be a 28 year old brilliant young woman. I am far from that. Yes, I think I'm better at EM than most MLPs, however I have worked with a few PAs (and a couple of NPs) who I think ran circles around me in the ED. Take me out of the ED and I'm a fish in a desert.

If in my busy shop I would find a PA (or NP) who is "unteachable or unwilling to be taught" I would fix that in a heartbeat. 20 years of military operations has given me the general ability to quickly set someone straight.

Regarding staffing making it impossible to teach: I can certainly see this being an issue, but when you're building/leading a team (and as the EP, you ARE the leader in the ED) the more time you spend today teaching/guiding/mentoring your APPs, the less work/stress you're going to have in the future.

If we assume that the majority of sites have midlevels that are either unwilling to be taught, incapable of being well-trained, or are in situations where they cannot be taught, is it worth salvaging midlevel practice?

I disagree with your assumption. Maybe the majority of >200K visit/year sites fit this assumption, but I have never worked at such a site. Even if the majority of these sites meet this assumption, the MLP isn't going away because it works when done right....which calls for effective supervision.

This is all hypothetical, of course. We both know midlevels are going to more or less fully replace doctors in the not-too distant future. The train has too much steam both from a monetary standpoint and from a societal standpoint--the fact that "midlevel" has become a dirty word is proof of this; doctors lost the PR battle so badly that we didn't even realize there was a battle at hand.

I disagree we are going to "replace" doctors, likewise disagree that "midlevel" has become a dirty word (and I think those two comments are generally incompatible with each other).

I COMPLETELY agree that the Docs are losing not only the PR battle, but the battle for medicine. Y'all are terrible managing things (see the complaining about MLPs instead of fixing what's wrong in YOUR department), so we now have a bunch of overpaid bureaucrats taking over hospital management and pushing down policies PG scores, poor MLP supervision, etc. Worse yet, y'all have done nothing to fight back against the encroachment into medicine by the NPs who now have independent practice "rights" in most states.

I feel like the EMTs I used to train wouldn't even fail to document neuromuscular exam before and after splinting. Also, I doubt any of my current PA class would order a trop on a 15 year old with chest pain (saw on another post in the thread).

EMTs generally take care of one patient at a time, and don't use a EMR that is completely counter-intuitive to a human being. I'm guessing everyone here, even those complaining about how stupid MLPs can't even document something right, or those with scribes paid to follow them around capturing and double-checking their documentation, has screwed up on a chart or two. I certainly know I have....we're human.

Regarding the Trop on a 15 yo with CP....maybe nobody in your current PA class would, but that's because they are not out in the real-world yet taking care of their own patients. Trop on a 15 yo with CP? Yep, I'll order that all day long.

Unfortunately, as a PA, you may work with Rusted one day who will bitch about you getting that Trop, and the next day you'll work with SouthernDoc who will bitch at you for NOT getting that Trop!

 

[Boatswain2PA]

She had completed her "online" Nurse Practitioner program and was ready to start her "clinical work." She would be working at the same practice as her sister, "but she had to be supervised by the other NP there, because her sister had to be a NP for a year before she could supervise someone."

Please, everyone posting/lurking here, please please PLEASE understand the VAST differences between NP education and PA education.

 

[miacomet]

Please, everyone posting/lurking here, please please PLEASE understand the VAST differences between NP education and PA education.

I would have agreed five years ago, but in our area three new PA schools have cropped up. We used to just get students from the local university, who were fabulous, but now we have students from these for-profit monsters, and the quality has dropped drastically. On an EM rotation and unable to take a basic history. I'm sure online schools are soon to follow, and frankly these aren't any better.

Let all "APPs" practice independently, and don't involve me. Sink or swim on your own terms.

 

[Boatswain2PA]

I would have agreed five years ago, but in our area three new PA schools have cropped up. We used to just get students from the local university, who were fabulous, but now we have students from these for-profit monsters, and the quality has dropped drastically. On an EM rotation and unable to take a basic history. I'm sure online schools are soon to follow, and frankly these aren't any better.

Let all "APPs" practice independently, and don't involve me. Sink or swim on your own terms.

Agree with your premise that PA schooling is devolving, but still much better than NP.

More later...

 

[NicMouse64]

If all of my friends who were going to PA school were like you I think the bashing would be a lot less. I have some family friends who are in PA school who went straight from undergrad and in their terms "want to become doctors quicker", and "PA school is more competitive than medical school, therefore we need less schooling because we are smarter", and "it's ok to not have doctors see patients in the family practice or ER setting because it's simple and its all an algorithm". From what I can tell, no one here is bashing you boatswain2PA

Agree with your premise that PA schooling is devolving, but still much better than NP.

More later...

 

[RustedFox]

Unfortunately, as a PA, you may work with Rusted one day who will bitch about you getting that Trop, and the next day you'll work with SouthernDoc who will bitch at you for NOT getting that Trop!

I'll bitch at you as long as I have to sign your charts if you give me any flak.
If you're listing me as your "supervising physician", then you do as I tell you, and the answer is "yes, sir."

15 year old with trops? I've caught 'em, too. They're sick, not well.
Difference is, I have nobody to "escalate" responsibility to.

 

[RustedFox]

RF, I'm worried about you. Are you OK? Is this job still filling your needs? Are you having malpractice-related PTSD/acute stress disorder? Are you taking care of yourself? Burnt out? Do you have sufficient personal and professional support?

Can we help?

Wow. I'm okay. I just got back from a vacation, and have another one planned in two weeks to go see the foliage.
I bitch a lot on here because when things aren't right, they're wrong.
Maybe we can exact some change from this virtual space.

 

[MechEDoc]

15 year old with trops? I've caught 'em, too. They're sick, not well.
Difference is, I have nobody to "escalate" responsibility to.

Exactly this. Mine was a 17 year old, taking NSAIDs, epigastric pain completely relieved with GI cocktail. Normal EKG (confirmed by pediatric cardiology). First Troponin (asymptomatic) 2, one hour later, it was 3. Cardiac MRI confirmed myocarditis.

How do you think I would like being served a lawsuit for a sudden cardiac death in a young athlete due to non-perfusing arrhythmia in the setting on myocarditis while exercising? Or heart failure with a LVAD and pending transplant because a zero to hero practicing two weeks post NP/PA graduation didn't do a good workup and sent the kid home to a bad outcome?

They're not practicing under my license. I didn't hire them, I can't supervise them (not enough time on shift and aggressive push back if I do with me being bounced off the schedule for not being a "team player"), and they only sent me the chart 2-3 days after the patient encounter.

 

[miacomet]

Exactly this. Mine was a 17 year old, taking NSAIDs, epigastric pain completely relieved with GI cocktail. Normal EKG (confirmed by pediatric cardiology). First Troponin (asymptomatic) 2, one hour later, it was 3. Cardiac MRI confirmed myocarditis.

How do you think I would like being served a lawsuit for a sudden cardiac death in a young athlete due to non-perfusing arrhythmia in the setting on myocarditis while exercising? Or heart failure with a LVAD and pending transplant because a zero to hero practicing two weeks post NP/PA graduation didn't do a good workup and sent the kid home to a bad outcome?

They're not practicing under my license. I didn't hire them, I can't supervise them (not enough time on shift and aggressive push back if I do with me being bounced off the schedule for not being a "team player"), and they only sent me the chart 2-3 days after the patient encounter.

Can you request the PAs call the patients back if you are dissatisfied with their crap care?

 

[GonnaBeADoc2222]

Yeah, no EP has ever screwed up documentation, especially with Skynet....I mean Cerner.

Then you are committing fraud.

Midlevels (APPs, whatever) need to be supervised. In the ED that's you. If you want to see all the patients that come to the ED, then good for you. If you want to spend some time learning about, teaching, and supervising your midlevels, then you can make a LOT more money and your ED can flow a LOT faster.

Exactly right. Which is why I don't sign the charts.

100% agree with need for mentorship of new midlevels. The problem surfaces when you declare yourself as a new grad who has nothing else to learn and are totally unteachable. It is absolutely my responsibility to provide supervision and teaching on a patient-by-patient basis. It is absolutely NOT my responsibility to build you up from scratch - that's why you went to school - and if you don't feel comfortable in the ED setting after graduation there are PA/NP EM residencies that you should attend to make sure you are qualified to be in an ED.

Please, everyone posting/lurking here, please please PLEASE understand the VAST differences between NP education and PA education.

PA-C, NP, LMNOP....I honestly don't care what letters there are after your name so long as you take direction from the attending, work hard, care, and are teachable.

There is only one way in 2018 to safely operate independently in the ED and that is to go to medical school and complete an EM residency.

 

[MechEDoc]

Can you request the PAs call the patients back if you are dissatisfied with their crap care?

Yes. But there will likely be an extended delay in callback (1+ days -> chart -> 1+ days -> my review -> "call back!" -> 1+ more days). The PA/NP will pissed off, let alone the majority of patients that will have negative workups even after a callback. I'll then be told I'm not a team player, and if I keep it up, I'll be off the schedule.

 

[Vandalia]

Please, everyone posting/lurking here, please please PLEASE understand the VAST differences between NP education and PA education.

I do. I think most here do. That is why I posted that specific anecdote and specifically said "nurse practitioner."

 

[miacomet]

Yes. But there will likely be an extended delay in callback (1+ days -> chart -> 1+ days -> my review -> "call back!" -> 1+ more days). The PA/NP will pissed off, let alone the majority of patients that will have negative workups even after a callback. I'll then be told I'm not a team player, and if I keep it up, I'll be off the schedule.

Time for a new job. Worries about being off the schedule are what keep us enslaved.

 

[lemurcatta]

EMTs generally take care of one patient at a time, and don't use a EMR that is completely counter-intuitive to a human being. I'm guessing everyone here, even those complaining about how stupid MLPs can't even document something right, or those with scribes paid to follow them around capturing and double-checking their documentation, has screwed up on a chart or two. I certainly know I have....we're human.

Regarding the Trop on a 15 yo with CP....maybe nobody in your current PA class would, but that's because they are not out in the real-world yet taking care of their own patients. Trop on a 15 yo with CP? Yep, I'll order that all day long.

Unfortunately, as a PA, you may work with Rusted one day who will bitch about you getting that Trop, and the next day you'll work with SouthernDoc who will bitch at you for NOT getting that Trop!

I am not sure if you have been in the field recently, but we have unfortunately moved to a bunch of counter-intuitive and slow electronic patient care report systems. They are really, really bad... this is neither here nor there but I thought I would point out that this crap is everywhere now. Check out ELITE field PCR online sometime. Horrible.

And to clarify on the troponin- I don't think I would reflexively order trop on 15 year old, before you know like checking if there is a bruise on the chest or costochondral tenderness.

But yea sucks that clinically poor PAs and NPs are making us look bad, and that NPs have independent practice authority which just isn't appropriate.

 

[Groove]

Reviewing my MLP charts for the last shift. Two MLPs under my "supervision"

- 63 year old with knee pain. No knee exam, whatsoever. Just an x-ray and "discharged". No MDM. No nothing.
- 23 year old with abdominal pain. Nonspecific exam, just "diffusely tender". No degree of tenderness, just "diffusely tender". No discussion about peritoneal findings. No inspection. CBC/BMP/UA and imaging all not imported into the chart; had to do that myself (Thanks, CERNER!) No repeat exam. Just "discharged". No diagnosis listed, by the way. Had to do that myself, too.
- 4 year old with head injury. Wrong PECARN (<2 years old) autotext loaded into chart. No vital signs. Physical exam? "Swelling to head".

*** Three charts, one MLP... Three nonspecific fractures (wrist, ankle, etc). Three splints applied. Number of neurovascular exams documented? Zero. ***

Attention MLPs...

Don't suck.

Also, don't clamor for "equivalence" when you're clearly not even close.

Am I mad ? You bet.

Here's the BEST part; these two MLPs have been "in the ER for 10+ years" and they want RESPECT for their profession and their dedication and their... shutthefcukup.

Attention, kids: read the MLP charts. Don't be like the other proles out there that just blindly click "sign".

Attestations are your friend. Here's the one I use on those types of charts:

"I was available for consult in real time but was not asked to participate in the care of this patient nor was I asked to assist in management. The APC functioned independently in this pt's care. I am unable to determine appropriateness of management without obtaining a personal history and exam."

I just sign all the rest.

 

[RoyBasch]

At ACEP this year, there was a case in one of the lectures about things you don't want to miss. One of them? 25 y/o with an NSTEMI.

I don't have any mid-levels. However, a troponin on a 15 year old kid is total BS - until it isn't. Low impact, low downside. And, when it comes back positive, once in a blue moon, you/the mid-level look like heroes.

I'm glad I'm not the only one who thought a troponin on a young person isn't completely unreasonable. I've seed STEMI/NSTEMIs in teenagers/young 20s (one later found to have ALCAPA, another with hypercholesterolemia, likely familial [other family members with MIs at very young ages]). Also myocarditis.