Reviewing MLP charts. FUN TIMES!

[Dr Mantis Toboggan]

Not in middle TN. Envision has every HCA hospital around Nashville.

Does that mean that they out competed Envision for HCA? Higher level of fee splitting? Even greater levels of unethical behavior? Questions, questions, questions!

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[DocEspana]

I just discovered about a week ago that one of our NPs documents about a third of his discharges as being "guarded".

after the stress induced stroke that I had was finally resolving, I explained to him that he truly had to stop doing that as he is making any bounceback a likely litigious nightmare.

I hear he hasn't changed his old habits at all and is still doing it - just not on my charts.

 

[TheSingularity]

W.t.f.

I just discovered about a week ago that one of our NPs documents about a third of his discharges as being "guarded".

after the stress induced stroke that I had was finally resolving, I explained to him that he truly had to stop doing that as he is making any bounceback a likely litigious nightmare.

I hear he hasn't changed his old habits at all and is still doing it - just not on my charts.

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[Piebaldi]

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".

Sometimes you have to fight fire with fire. Bring it to administration. Call the patient and let them know an incomplete exam was done. Or - as I will do in the future - join the legal profession in being a "witness" for midlevel malpractice.
Like they say - the enemy of your enemy is your friend.

Because at the end of the day, it's YOUR fault regardless as the "supervising" physician.

 

[Piebaldi]

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.

Love it!
I very rarely oversee midlevels on purpose, but the few times I do - can I borrow your statement above? Sounds fantastic.

 

[TheSingularity]

None of this matters. You will be sued as the supervising physician if you are present.

Love it!
I very rarely oversee midlevels on purpose, but the few times I do - can I borrow your statement above? Sounds fantastic.

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[GeneralVeers]

Sometimes you have to fight fire with fire. Bring it to administration. Call the patient and let them know an incomplete exam was done. Or - as I will do in the future - join the legal profession in being a "witness" for midlevel malpractice.
Like they say - the enemy of your enemy is your friend.

Because at the end of the day, it's YOUR fault regardless as the "supervising" physician.

All you are doing is harming the "supervising physician" who now has to put tons of time and effort into defending themselves in a case where they never saw the patient. Went through one of these in front of the Texas Board and it was super annoying.

Midlevels aren't going away. We need to harness them and control them, not fight them.

 

[Piebaldi]

All you are doing is harming the "supervising physician" who now has to put tons of time and effort into defending themselves in a case where they never saw the patient. Went through one of these in front of the Texas Board and it was super annoying.

Midlevels aren't going away. We need to harness them and control them, not fight them.

Midlevels aren't going away, but right now they are in a perfect state of chaos for physicians - they don't want "supervision" yet the physician is on the hook for their mistakes. So a decision has to be made - either practice independently, on their own license, without physician supervision, which I think would be ideal since I feel it will stop the nonsense right away when they start getting sued right and left, or be teachable and practice truly under physician supervision.

Can't have this hybrid in between state.

 

[GeneralVeers]

Midlevels aren't going away, but right now they are in a perfect state of chaos for physicians - they don't want "supervision" yet the physician is on the hook for their mistakes. So a decision has to be made - either practice independently, on their own license, without physician supervision, which I think would be ideal since I feel it will stop the nonsense right away when they start getting sued right and left, or be teachable and practice truly under physician supervision.

Can't have this hybrid in between state.

Agreed. The groups I work with though have the midlevels tightly under our control. It's a competitive market for them here (they make about $100/hr), so they don't want to piss off individual docs for fear of their jobs.

 

[Piebaldi]

Agreed. The groups I work with though have the midlevels tightly under our control. It's a competitive market for them here (they make about $100/hr), so they don't want to piss off individual docs for fear of their jobs.

I don't know midlevels making 100$/hr, that's what many physicians make - that would be close to 200k or so a year. They make in most places that I have seen about half of that, but still tends to be good money for the work.

 

[thegenius]

None of this matters. You will be sued as the supervising physician if you are present.

Sent from my Pixel 3 using SDN mobile

100% true.

None of this *really* matters.

 

[BoardingDoc]

I don't know midlevels making 100$/hr, that's what many physicians make - that would be close to 200k or so a year. They make in most places that I have seen about half of that, but still tends to be good money for the work.

I've seen the same as Veers. Not everywhere in my area by any stretch, but I've worked with PAs that are in the 150-200k / yr range.

 

[Piebaldi]

I've seen the same as Veers. Not everywhere in my area by any stretch, but I've worked with PAs that are in the 150-200k / yr range.

Then why do we bother having physicians? That's what a lot of physicians including primary care physicians make. We make physicians go through countless loops, certifications, this and that to have PA/NP make the same with a few years of education?
Whats the point?

As physicians there are too many that simply are sheep - they don't want to create trouble so nothing changes while other fields like midlevels make great strides. One of the PAs at the place where I was doing my bogus fellowship was telling me that I thunk her PA program was 2 years? Essentially she's saving herself 6 years of hell - in terms of med school, residency, etc. Why even be a doctor if doctors and PAs make the same?

 

[Listen2Savage]

Then why do we bother having physicians? That's what a lot of physicians including primary care physicians make. We make physicians go through countless loops, certifications, this and that to have PA/NP make the same with a few years of education?
Whats the point?

As physicians there are too many that simply are sheep - they don't want to create trouble so nothing changes while other fields like midlevels make great strides. One of the PAs at the place where I was doing my bogus fellowship was telling me that I thunk her PA program was 2 years? Essentially she's saving herself 6 years of hell - in terms of med school, residency, etc. Why even be a doctor if doctors and PAs make the same?

because she has "assistant" in her job title, at least until they change that

 

[Piebaldi]

because she has "assistant" in her job title, at least until they change that

My point is that - if many physicians are going to make the same as PA/NPs then we should eliminate one of the two types of positions - it makes no sense to have lower qualified people get paid the same as physicians - how is that "cost savings" - it's as if interns and attendings got paid the same. nonsense. so if physician assistant makes the same as the physician perhaps one of the two positions should go the way of the doo doo.

 

[TooMuchResearch]

BCEM docs don't work for $100/hour.

My point is that - if many physicians are going to make the same as PA/NPs then we should eliminate one of the two types of positions - it makes no sense to have lower qualified people get paid the same as physicians - how is that "cost savings" - it's as if interns and attendings got paid the same. nonsense. so if physician assistant makes the same as the physician perhaps one of the two positions should go the way of the doo doo.

 

[Piebaldi]

BCEM docs don't work for $100/hour.

Perhaps not EM, but 100/hr is about 200k. What do you think primary care docs make? Look at ads - that is an average pay for MANY physicians - IM, FM, peds, Occ/Prev med, etc etc.

 

[BoardingDoc]

Perhaps not EM, but 100/hr is about 200k. What do you think primary care docs make? Look at ads - that is an average pay for MANY physicians - IM, FM, peds, Occ/Prev med, etc etc.

We are talking about PAs working in EM. Why are you comparing them to the salary of a peds/FM/Occupational med MD? Is your argument that having an MD entitles you to more money than a PA working in any field?

 

[Listen2Savage]

We are talking about PAs working in EM. Why are you comparing them to the salary of a peds/FM/Occupational med MD? Is your argument that having an MD entitles you to more money than a PA working in any field?

I'd argue that

 

[Piebaldi]

We are talking about PAs working in EM. Why are you comparing them to the salary of a peds/FM/Occupational med MD? Is your argument that having an MD entitles you to more money than a PA working in any field?

Of course. Is that even a question? If anything, it shows that certain medical specialties are devalued. Of course an MD should ALWAYS make more money than a "physician ASSISTANT" in any field.

 

[RustedFox]

Of course. Is that even a question? If anything, it shows that certain medical specialties are devalued. Of course an MD should ALWAYS make more money than a "physician ASSISTANT" in any field.

+1.

 

[BoardingDoc]

Of course. Is that even a question? If anything, it shows that certain medical specialties are devalued. Of course an MD should ALWAYS make more money than a "physician ASSISTANT" in any field.

Interesting perspective. I'm not advocating for PAs to make more than MDs, but if you have a PA who works in derm and does first assist on MOHS all day long, I would probably expect them to get paid more than say a pediatrician if only because they are generating WAAAAY more money. One could argue that the dermatologist should get all of that money and the PA should get whatever they get, which is reasonable, but I wouldn't be shocked if it turned out the way I described.

 

[Listen2Savage]

Interesting perspective. I'm not advocating for PAs to make more than MDs, but if you have a PA who works in derm and does first assist on MOHS all day long, I would probably expect them to get paid more than say a pediatrician if only because they are generating WAAAAY more money. One could argue that the dermatologist should get all of that money and the PA should get whatever they get, which is reasonable, but I wouldn't be shocked if it turned out the way I described.

with such limited training how could PAs/NPs not be satisfied with ~100K?

I think the residency expansion/sky is falling argument in EM will come to fruition in midlevel $$$ first.

 

[Piebaldi]

Interesting perspective. I'm not advocating for PAs to make more than MDs, but if you have a PA who works in derm and does first assist on MOHS all day long, I would probably expect them to get paid more than say a pediatrician if only because they are generating WAAAAY more money. One could argue that the dermatologist should get all of that money and the PA should get whatever they get, which is reasonable, but I wouldn't be shocked if it turned out the way I described.

Reason why we have less and less people wanting to go into primary care, peds, etc. Why spend 4+ years of undergrad, 4+ years of med school, potentially grad school like some of us 3 + years of residecny, when you can just do a BA, go to PA/nursing/NP school and make more? Where is the sense in that?

I would imagine that the Dermatologist should get the money not the PA. I think we are going to continue seeing a brain drain bc no one wants to go through all that to make less than a midlevel. Pointless work and sacrifice.

 

[Piebaldi]

with such limited training how could PAs/NPs not be satisfied with ~100K?

I think the residency expansion/sky is falling argument in EM will come to fruition in midlevel $$$ first.

And generally speaking (not speaking to EM specifically) = if we are paying midlevels the same as physicians, nhow are midlevels saving any money? I will bodly say that while some (small percentage) of midlevels are good, most are rather clueless.

 

[TheSingularity]

As would I.

I'd argue that

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[jw3600]

For the record most PAs make $70-80/hr or less. This is true for EM. And I believe it’s one of the more well paid fields for midlevels. This is still damn good pay considering some are making this at age 24/25. I know there are PAs that do make close to 200k but it’s definitely an exception not the rule.
Doesn’t really change the discussion over the last page which I agree with but just trying to make sure the numbers out there are accurate.

CRNAs on the other hand....

 

[deleted941485]

Well 15 docs at elmhurst health won’t be reviewing any MLP charts

15 Docs Fired From Illinois Health System to Be Replaced With NPs

A leaked internal memo says they will be replaced with advanced practice nurses as 'patients have made it very clear that they want less costly care and convenient access for lower-acuity issues.'

www.medscape.com

 

[Piebaldi]

Well 15 docs at elmhurst health won’t be reviewing any MLP charts

15 Docs Fired From Illinois Health System to Be Replaced With NPs

A leaked internal memo says they will be replaced with advanced practice nurses as 'patients have made it very clear that they want less costly care and convenient access for lower-acuity issues.'

www.medscape.com

Was just reading that. Again - it's time to join lawyers in helping patients "get justice" from midlevel malpractice. Once again - the enemy of your enemy is your friend. This is the wild wild west ladies and gentlemen.

 

[deleted941485]

Was just reading that. Again - it's time to join lawyers in helping patients "get justice" from midlevel malpractice. Once again - the enemy of your enemy is your friend. This is the wild wild west ladies and gentlemen.

This isn’t happening in the poor rural community. This is Naperville, IL. First urgent care then to the ED.

Why this hasn’t hit the EM forum harder I can only guess that the info has not completely disseminated yet.

 

[Piebaldi]

This isn’t happening in the poor rural community. This is Naperville, IL. First urgent care then to the ED.

Why this hasn’t hit the EM forum harder I can only guess that the info has not completely disseminated yet.

ED docs apparently are "supervising" the midlevels.

 

[thegenius]

Well 15 docs at elmhurst health won’t be reviewing any MLP charts

15 Docs Fired From Illinois Health System to Be Replaced With NPs

A leaked internal memo says they will be replaced with advanced practice nurses as 'patients have made it very clear that they want less costly care and convenient access for lower-acuity issues.'

www.medscape.com

Here's the deal with all this nonsense.

If people want to spend THEIR OWN money, and want to see a less qualified person than a doctor for their medical concerns, then let them. I have no problem if people want to SPEND THEIR OWN money for this kind of stuff.

There is varying quality in all industries in our life. Lawyers, electricians, real estate agents, financial advisors, biologists, prostitutes. They all have their own price. You have the right to choose an established, high quality lawyer and pay more. You also have the choice to go with a lower priced lawyer. Your results will vary. Same for everything else. With all these cases above, you are spending your OWN MONEY, not insurance money, and you get what you get. Caveat Emptor.

This should also apply to most of medicine (surprisingly not EM in my opinion). If you want someone more educated, then you have to pay more. If you want to see an NP who gets educated online, then you get what you get. Which won't be great. However you have to use your own money. If you use insurance money (or tax money) for all this meaningless crap, then you are going to be subject to extra fees, rationed care, high bills, care not reimbursed, AND it raises the price for everybody using the insurance. That's probably the main reason why I hate this crap. All these people who want to go get medicine for their meaningless sniffles, rashes, itches, diarrhea, nose hairs, ankle pains, knee pains, work notes, zits, low back pain, migraines, etc, just increases the cost for everybody else.

If I were an insurer, armed with the knowledge that Americans are hypochondriacs, I would be raising prices too and denying reimbursements for stupid things. We have to get to the point of people paying for health care with their own money, and using insurance only for catastrophic care. Then we will see a more normal health care system.

 

[deleted941485]

ED docs apparently are "supervising" the midlevels.

Hahahahaha. Right Remotly from a desk at a computer they aren’t at that just rubber stamps it while they tend to the craziness that is the actual ED.

I’m sure they “collaborate” with them as well.

I bet the admin are making it crystal clear to their patients that if they go to Elmhurst urgent care they won’t be seeing a physician at all. Rather a DNP or whatever ridiculous diploma that allow them to use the word doctor without legal repercussions or malpractice risk.

 

[thegenius]

One way to get rid of these NP's is to now allow them to write prescriptions unless they have earned an MD or DO. Why should the government permit or license people to dispense medications without MD or DO knowledge?

 

[deleted941485]

Here's the deal with all this nonsense.

If people want to spend THEIR OWN money, and want to see a less qualified person than a doctor for their medical concerns, then let them. I have no problem if people want to SPEND THEIR OWN money for this kind of stuff.

There is varying quality in all industries in our life. Lawyers, electricians, real estate agents, financial advisors, biologists, prostitutes. They all have their own price. You have the right to choose an established, high quality lawyer and pay more. You also have the choice to go with a lower priced lawyer. Your results will vary. Same for everything else. With all these cases above, you are spending your OWN MONEY, not insurance money, and you get what you get. Caveat Emptor.

This should also apply to most of medicine (surprisingly not EM in my opinion). If you want someone more educated, then you have to pay more. If you want to see an NP who gets educated online, then you get what you get. Which won't be great. However you have to use your own money. If you use insurance money (or tax money) for all this meaningless crap, then you are going to be subject to extra fees, rationed care, high bills, care not reimbursed, AND it raises the price for everybody using the insurance. That's probably the main reason why I hate this crap. All these people who want to go get medicine for their meaningless sniffles, rashes, itches, diarrhea, nose hairs, ankle pains, knee pains, work notes, zits, low back pain, migraines, etc, just increases the cost for everybody else.

If I were an insurer, armed with the knowledge that Americans are hypochondriacs, I would be raising prices too and denying reimbursements for stupid things. We have to get to the point of people paying for health care with their own money, and using insurance only for catastrophic care. Then we will see a more normal health care system.

I think that is sensible. THe problem with all of that is that the physician could be on the hook for them and they may be lending their expertise and taking on risk for free especially if they are not. Everyone in this game wants something for nothing.

 

[Piebaldi]

Hahahahaha. Right Remotly from a desk at a computer they aren’t at that just rubber stamps it while they tend to the craziness that is the actual ED.

I’m sure they “collaborate” with them as well.

I bet the admin are making it crystal clear to their patients that if they go to Elmhurst urgent care they won’t be seeing a physician at all. Rather a DNP or whatever ridiculous diploma that allow them to use the word doctor without legal repercussions or malpractice risk.

And that's the issue - if I were an ED doc there, I'd be quitting. Can you imagine - having to supervise an NP or numerous NPs while working in the ED? And that is a busy hospital, not to mention in an affluent area - so people want high quality care and are demanding. I would be shocked if they are ok with midelvels.

 

[deleted941485]

And that's the issue - if I were an ED doc there, I'd be quitting. Can you imagine - having to supervise an NP or numerous NPs while working in the ED? And that is a busy hospital, not to mention in an affluent area - so people want high quality care and are demanding. I would be shocked if they are ok with midelvels.

Patients know one thing. I got better or I didn’t. That’s it. They aren’t good judges of quality they only see the price.

The admin of elmhurst claim to
Speak for patients...probably a dubious claim. They probably speak for the bean counters in the admin and the RN who happens to be running the place.

 

[thegenius]

One way to get rid of these NP's is to now allow them to write prescriptions unless they have earned an MD or DO. Why should the government permit or license people to dispense medications without MD or DO knowledge?

The more I think about it, governments are licensing people to dispense medicines after earning an degree ONLINE. Crazy. They are allowed to write for drugs with a narrow therapeutic index like lithium, warfarin, Dilantin. Just crazy

 

[RustedFox]

The MLP day of reckoning will come soon.
The sooner, the better.
Welcome this change, and watch as it fails.

 

[Piebaldi]

The more I think about it, governments are licensing people to dispense medicines after earning an degree ONLINE. Crazy. They are allowed to write for drugs with a narrow therapeutic index like lithium, warfarin, Dilantin. Just crazy

Essentially Univ of Phoenix type educated nurses are treating patients with no doctor supervision. How are NPs not regulated either? Do they take licensing exams? It's one of the most awful things that's happening to the healthcare in our nation.

 

[Piebaldi]

The MLP day of reckoning will come soon.
The sooner, the better.
Welcome this change, and watch as it fails.

I would agree. I think the sooner Midlevels start practicing on their own, with their OWN malpractice, when they have no clue what they are doing, then all of this will go belly up. Some big shot's family member needs to be misdiagnosed and then they will tell people how "we need more doctors" bla bla

 

[RustedFox]

I would agree. I think the sooner Midlevels start practicing on their own, with their OWN malpractice, when they have no clue what they are doing, then all of this will go belly up. Some big shot's family member needs to be misdiagnosed and then they will tell people how "we need more doctors" bla bla

This; for the win.

Mrs. Fox had her intake appointment at a new PMD office last week.
She came home, and this is what she had to say:

The PA introduced herself as "Doctor Jenny".
She didn't know several of the meds on my medication list; couldn't pronounce them.
She completely blew off my concerns about autoimmune disease, despite me telling her that "the pain gets better after steroids, and is in my large joints; it comes and goes without any warning".
I don't want to see her again. I really thought for an intake appointment, that I'd see a doctor.

 

[thegenius]

The MLP day of reckoning will come soon.
The sooner, the better.
Welcome this change, and watch as it fails.

I dunno if anyone plays Clash Royale...but the laugh I chuckled looked (and sounded) a bit like this:

If you play the game you'll know exactly how it sounds!

 

[RustedFox]

I dunno if anyone plays Clash Royale...but the laugh I chuckled looked (and sounded) a bit like this:

If you play the game you'll know exactly how it sounds!

I don't play this game.
Are you agreeing, or disagreeing?
Either is welcome.

 

[Piebaldi]

This; for the win.

Mrs. Fox had her intake appointment at a new PMD office last week.
She came home, and this is what she had to say:

The PA introduced herself as "Doctor Jenny".
She didn't know several of the meds on my medication list; couldn't pronounce them.
She completely blew off my concerns about autoimmune disease, despite me telling her that "the pain gets better after steroids, and is in my large joints; it comes and goes without any warning".
I don't want to see her again. I really thought for an intake appointment, that I'd see a doctor.

How is a PA saying she's a doctor? And what kind of doctor calls themselves by their first name?

 

[RustedFox]

How is a PA saying she's a doctor? And what kind of doctor calls themselves by their first name?

You heard it:
"Hi, I'm Doctor Jenny."

My wife knew that she was a PA because she read the website before her intake appointment.

Furthermore, the patients that come to my ER seem to have no idea that they're seeing a MLP.

Me: "Who is your family care doctor?"
Them: "I see Doctor Jenny." (always first-name only)
Me: "Where does Doctor Jenny work?"
Them: "At ABCD HealthCare"
Me: "That's not a doctor. Who is their supervising physician?"
Them: "I don't know what that means."

 

[Piebaldi]

You heard it:
"Hi, I'm Doctor Jenny."

My wife knew that she was a PA because she read the website before her intake appointment.

Furthermore, the patients that come to my ER seem to have no idea that they're seeing a MLP.

Me: "Who is your family care doctor?"
Them: "I see Doctor Jenny." (always first-name only)
Me: "Where does Doctor Jenny work?"
Them: "At ABCD HealthCare"
Me: "That's not a doctor. Who is their supervising physician?"
Them: "I don't know what that means."

My statement is - that person is a nurse or an assistant, not a doctor. Our midlevels know better than to call themselves doctor. Ugh - so what is the point of all the boards, exams, toxic environment, yet complete lack of regulation of these nurses?

 

[thegenius]

I don't play this game.
Are you agreeing, or disagreeing?
Either is welcome.

Totally agree with you! We can sit back, laugh out loud like that emote above (it's in the video) as we see PA after PA fail

I'm addicted to that game (ugh)

 

[RustedFox]

My statement is - that person is a nurse or an assistant, not a doctor. Our midlevels know better than to call themselves doctor. Ugh - so what is the point of all the boards, exams, toxic environment, yet complete lack of regulation of these nurses?

I'm with you, amigo.
These MLPs need to know their role.
Want to be called "Doctor"? Go to Doctor School.
Simple as that.
Oh, and sign your own charts; being responsible for 100% of your own decisions.

 

[thegenius]

My statement is - that person is a nurse or an assistant, not a doctor. Our midlevels know better than to call themselves doctor. Ugh - so what is the point of all the boards, exams, toxic environment, yet complete lack of regulation of these nurses?

Dude we agree. All of us. It should be a crime. You should be sentenced to JAIL for calling yourself a doctor if you are not one.