Are midlevels permitted to supervise IM residents

[true2life]

I have seen threads about this but no definitive answer with a source.

Without getting sucked in to the rabbit trail of the politics surrounding this issue, whether a midlevel who has been practicing in the ICU for years and years has more experience and is better from a patient safety perspective to be supervising residents... I don't want to discuss that. There are plenty of threads discussing that and falling into that rabbit hole won't answer the question. What I want to know is whether this is permitted by ACGME regulations and if so, I would like to see a source. Can midlevels formally supervise IM resident physicians? I have looked and cannot find anything that answers this question explicitly.

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[CCM-MD]

Gray area but my interpretation is NO, unless they are individuals specifically approved by the program director. See attached. Taken from the ACGME common program requirements for internal medicine: LINK

Another important consideration is whether a residents malpractice insurance policy will cover care provided by a resident that is not supervised by a licensed physician and rather under the supervision of a midlevel.

 

[deleted547339]

I wouldn’t let it happen in our icu.

 

[MD46]

Never saw it happen, nor do I want it to ever happen.

 

[throwaway1000000]

Eek. if this were to ever happen, that is the final pinnacle.

 

[wjs010]

Hell no. They have to have all their patients staffed with an attending just like we do.


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[Señor S]

Gray area but my interpretation is NO, unless they are individuals specifically approved by the program director. See attached. Taken from the ACGME common program requirements for internal medicine: LINK

Another important consideration is whether a residents malpractice insurance policy will cover care provided by a resident that is not supervised by a licensed physician and rather under the supervision of a midlevel.

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Seems like another toothless ACGME "regulation." It's OK if the PD says it's OK? Meaningless.

OP, my vote is that it's de-facto allowed and the ACGME won't care (barring some extreme situation where >50% of preceptors are midlevels). Yes it's demoralizing. Yes, it's a sign that you (and I) probably wasted a huge amount of time and money on the now-collapsing pyramid scheme known as medical school. But there's nothing you can do about it, nothing to be gained by being a crusader. Just suck it up, do your time and get out.

 

[Raryn]

The only circumstance I would find this acceptable is for a very limited period of time for something very specific. For example, a midlevel with significant experience doing a specific procedure (say, the PA in the ICU who has done of art lines) supervising a resident for purposes of that procedure. It would be perfectly reasonable if that resident wasn't yet signed off to do them independently.

For actual primary patient care purposes though? Lol. No.

 

[deleted941485]

This is happening at a certain peds program in a big city.

 

[deleted480308]

When I was in med school on an outpatient rotation and the attending didn’t show up (leaving only a pa and np in clinic) the resident walked out. It was glorious

 

[NotAProgDirector]

We have a few specific rotations where residents are supervised by non-physicians. We have an inpatient diabetes team run by NPs who have been doing this for 30 years. We have a wound consult team run by wound nurses. We have a nutrition consult elective run by a pharmacist who formulates all the TPN for the hospital. In all cases, the non-physician is a content expert in the area, they are all electives. Usually it's for a short 1 or 2 week elective. The residents have a great experience. So, in the right scenario, it's fine. Inpatient management of ICU patients? No.

Even in the COVID crisis, I'd say no. Although lots of rules/process are out the window, we still stand behind several "musts" for our residents: 1) workhours need to be reasonable and we need to avoid burnout; 2) supervision needs to be adequate; 3) PPE needs to be acceptable.

 

[TwistedTea]

Sounds ok for very niche electives as stated above otherwise no.

 

[gutonc]

Sounds ok for very niche electives as stated above otherwise no.

But of course, the OP (who identifies as pre-med) threw this bomb and then ghosted. So we have no idea what the supervision is for. Or if it's a real life question.

NP/PA who does half a dozen art lines a day supervising a new intern on it? OK
Rounding and presenting to NP/PA in the ICU (or anywhere honestly)? Absolutely not.

Can we move on now?

 

[Instatewaiter]

But of course, the OP (who identifies as pre-med) threw this bomb and then ghosted. So we have no idea what the supervision is for. Or if it's a real life question.

NP/PA who does half a dozen art lines a day supervising a new intern on it? OK
Rounding and presenting to NP/PA in the ICU (or anywhere honestly)? Absolutely not.

Can we move on now?

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

 

[Señor S]

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

Medicine in 2020 kids: 4 years of med school, Steps, thousands of dollars on interviews just so you can be have some 25 year old PA named Lauren “overseeing” you on your ICU rotations. Only a matter of time before they start “overseeing” the fellows as well; they can be “variable” too, after all.

 

[CCM-MD]

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

That sets a terrible precedent. Why can't the attending over see the residents after rounds?

You know what might be a good way to improve “variable quality residents”? Maybe consider having them supervised and educated by properly trained attending physicians in the setting of a residency program, and not midlevels.

 

[throwaway1000000]

Medicine in 2020 kids: 4 years of med school, Steps, thousands of dollars on interviews just so you can be have some 25 year old PA named Lauren “overseeing” you on your ICU rotations. Only a matter of time before they start “overseeing” the fellows as well; they can be “variable” too, after all.

If any program indulges in this kind of BS, they have no job training residents.
Fellows or senior residents should be supervising the junior members of the team.

 

[ortnakas]

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

Keeping the team on task is the job of the senior resident.

 

[MedicineZ0Z]

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

yeah how about hellno

 

[Lexdiamondz]

so PA is an NP's need to be overseen by an attending and the ICU.

That said I don't see any problem with the NP or PA overseeing the residents after rounds to make sure things get done. Big decisions still need to go through the attending and the attending is still the head of the team but using a mid-level to keep the team on task isn't a bad option. This would be especially useful if you have a residency with variable quality residents.

I'm sorry but there's no way in hell Jenny, NP ABCDEF is "keeping me on task" with ⅓ my education. Get outta here with that foolishness.

I'm a resident physician. My job is to learn from an attending physician how to be an attending physician. My job is not to learn from a midlevel how to follow an algorithm and complete mindless busywork.

 

[throwaway1000000]

I'm sorry but there's no way in hell Jenny, NP ABCDEF is "keeping me on task" with ⅓ my education. Get outta here with that foolishness.

I'm a resident physician. My job is to learn from an attending physician how to be an attending physician. My job is not to learn from a midlevel how to follow an algorithm and complete mindless busywork.

100% this. I get mid-levels helping with tasks etc etc but if attendings or senior residents or fellows on the service can't take time to supervise the residents and train them to play those roles in the future, close your residency program.

 

[true2life]

But of course, the OP (who identifies as pre-med) threw this bomb and then ghosted. So we have no idea what the supervision is for. Or if it's a real life question.

NP/PA who does half a dozen art lines a day supervising a new intern on it? OK
Rounding and presenting to NP/PA in the ICU (or anywhere honestly)? Absolutely not.

Can we move on now?

Actually, I have better things to do than hang around an internet forum.

I'm a pgy2 IM resident. My OP has more information in it but I redacted it after getting some answers. Would rather not be identified. My program had nps supervise icu residents and cosign their notes. They justified doing this because of Covid fear, despite still only operating at around 60% capacity. We were in the 50s when the supervision issue came up.

 

[PTFoolUS]

Actually, I have better things to do than hang around an internet forum.

I'm a pgy2 IM resident. My OP has more information in it but I redacted it after getting some answers. Would rather not be identified. My program had nps supervise icu residents and cosign their notes. They justified doing this because of Covid fear, despite still only operating at around 60% capacity. We were in the 50s when the supervision issue came up.

what was the general consensus from the housestaff?

 

[throwaway1000000]

Actually, I have better things to do than hang around an internet forum.

I'm a pgy2 IM resident. My OP has more information in it but I redacted it after getting some answers. Would rather not be identified. My program had nps supervise icu residents and cosign their notes. They justified doing this because of Covid fear, despite still only operating at around 60% capacity. We were in the 50s when the supervision issue came up.

Crazy

 

[true2life]

what was the general consensus from the housestaff?

There was somewhat of an uproar but not nearly sufficient for what they did. I threatened to contact the acgme over it. A few days later suddenly and quietly they reversed course. They reorganized teams and just took residents off midlevel teams (but still allowed midlevels to retain the title bedside physician).

The fact that the icu constructed a schedule like that and gme went along with it shows what they really think about the residents. I'll be a pgy3 soon and have put in at least 30 ijs. I can't put what on without direct supervision... None of the IM residents can. Surgery and EM residents can. Midlevels can. But not IM residents. We are afforded extremely limited practice independence and it is ultimately towards our detriment professionally. When they said midlevels were gonna supervise us, that was the last straw for me. I can't wait to get out of this place.

 

[tantacles]

There was somewhat of an uproar but not nearly sufficient for what they did. I threatened to contact the acgme over it. A few days later suddenly and quietly they reversed course. They reorganized teams and just took residents off midlevel teams (but still allowed midlevels to retain the title bedside physician).

The fact that the icu constructed a schedule like that and gme went along with it shows what they really think about the residents. I'll be a pgy3 soon and have put in at least 30 ijs. I can't put what on without direct supervision... None of the IM residents can. Surgery and EM residents can. Midlevels can. But not IM residents. We are afforded extremely limited practice independence and it is ultimately towards our detriment professionally. When they said midlevels were gonna supervise us, that was the last straw for me. I can't wait to get out of this place.

That sounds like bedside bull****.

 

[Chemist0157]

There was somewhat of an uproar but not nearly sufficient for what they did. I threatened to contact the acgme over it. A few days later suddenly and quietly they reversed course. They reorganized teams and just took residents off midlevel teams (but still allowed midlevels to retain the title bedside physician).

The fact that the icu constructed a schedule like that and gme went along with it shows what they really think about the residents. I'll be a pgy3 soon and have put in at least 30 ijs. I can't put what on without direct supervision... None of the IM residents can. Surgery and EM residents can. Midlevels can. But not IM residents. We are afforded extremely limited practice independence and it is ultimately towards our detriment professionally. When they said midlevels were gonna supervise us, that was the last straw for me. I can't wait to get out of this place.

Huh. I think we could supervise/do "independently" (fellow/upper level being in the general area) after...5? at my program. It might have been 10. I can't remember. I never had an NP/PA have to supervise me for anything. Does that mean the NP/PA is liable for an issue? I doubt that, but I also doubt the attending was cosigning their cosign. So weird.

 

[tantacles]

Huh. I think we could supervise/do "independently" (fellow/upper level being in the general area) after...5? at my program. It might have been 10. I can't remember. I never had an NP/PA have to supervise me for anything. Does that mean the NP/PA is liable for an issue? I doubt that, but I also doubt the attending was cosigning their cosign. So weird.

We could do the lines independently, but the fellow still had to be there for the most critical part of the procedure. For a line, that meant they had to come in the room right before we dilated to verify the guidewire was in the vein. The fellows also had to supervise any NP's/PA's that were putting in lines. Exactly as it should be.

 

[rokshana]

Huh. I think we could supervise/do "independently" (fellow/upper level being in the general area) after...5? at my program. It might have been 10. I can't remember. I never had an NP/PA have to supervise me for anything. Does that mean the NP/PA is liable for an issue? I doubt that, but I also doubt the attending was cosigning their cosign. So weird.

Ours was 5 as well for no need for supervision

 

[Raryn]

Huh. I think we could supervise/do "independently" (fellow/upper level being in the general area) after...5? at my program. It might have been 10. I can't remember. I never had an NP/PA have to supervise me for anything. Does that mean the NP/PA is liable for an issue? I doubt that, but I also doubt the attending was cosigning their cosign. So weird.

Yeah, I could independently put them in after 10. The fellows were nowhere to be found from 5pm to 6am unless you called one in from home, and good luck doing that for anything except an emergent bronchoscopy.

 

[true2life]

Huh. I think we could supervise/do "independently" (fellow/upper level being in the general area) after...5? at my program. It might have been 10. I can't remember. I never had an NP/PA have to supervise me for anything. Does that mean the NP/PA is liable for an issue? I doubt that, but I also doubt the attending was cosigning their cosign. So weird.

It's either 8 or 10 at my program, I can't remember. I'm theoretically credentialed for independent practice in almost all invasive procedures. But the reason why I can't remember is that it doesn't matter. I've gotten taken to task for being the first one to a code and starting to tube someone... Because I was doing an invasive procedure I without supervision. I have heard midlevels laugh on the way to codes they try to get their first to take the procedures from residents. My philosophy anymore is to just do what needs to be done because you'll get yelled at either way, for taking action or not. Might as well do what's right for the patient.

 

[throwaway1000000]

It's either 8 or 10 at my program, I can't remember. I'm theoretically credentialed for independent practice in almost all invasive procedures. But the reason why I can't remember is that it doesn't matter. I've gotten taken to task for being the first one to a code and starting to tube someone... Because I was doing an invasive procedure I without supervision. I have heard midlevels laugh on the way to codes they try to get their first to take the procedures from residents. My philosophy anymore is to just do what needs to be done because you'll get yelled at either way, for taking action or not. Might as well do what's right for the patient.

That's pitiful.
Probably happens the most in the ICU. They want to train their midlevels for their business/convenience. Residents leave in 3 years, mid-levels stay.
But that kind of reasoning is absolutely horrible and those programs should seriously be named and shamed so everyone going there knows