Attendings not rounding on patients

[nsap102]

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Hi Would like to get opinions from people on this forum. My friend is on a consultation service and the attending s/he is with is not rounding on the patients. The attending shows up to collect billing sheets but does not always see the patients. Conversely the attending is lazy and sometimes fails to collect billing sheets before the patient is discharged. It appears that the PD and the head of the department are aware of this but fail to take any action and the attending does whatever s/he wants. Apparently, one resident previously did complain but was chastised by the department for spreading slander. And the attending in question did his/her own retribution against this particular resident because the department let it slip that the resident was complaining about the attending not rounding. My questions are: 1. What are the legal implications? 2. Are there any implications for simply not rounding on the patient (for the patients the attending did not bill for) 3. If current resident chooses to stay silent out of concern for retribution is s/he at fault in anyway legally? 3. Are there any anonymous options? 4. How anonymous is the ACGME? Any additional input appreciated.

 

[anonperson]

Hi Would like to get opinions from people on this forum. My friend is on a consultation service and the attending s/he is with is not rounding on the patients. The attending shows up to collect billing sheets but does not always see the patients. Conversely the attending is lazy and sometimes fails to collect billing sheets before the patient is discharged. It appears that the PD and the head of the department are aware of this but fail to take any action and the attending does whatever s/he wants. Apparently, one resident previously did complain but was chastised by the department for spreading slander. And the attending in question did his/her own retribution against this particular resident because the department let it slip that the resident was complaining about the attending not rounding. My questions are: 1. What are the legal implications? 2. Are there any implications for simply not rounding on the patient (for the patients the attending did not bill for) 3. If current resident chooses to stay silent out of concern for retribution is s/he at fault in anyway legally? 3. Are there any anonymous options? 4. How anonymous is the ACGME? Any additional input appreciated.

Tough situation. Especially with the fact that your department isn't doing the right thing.

As far as implications. The attending in question is SOL if anything happens with these patients since they have only been seen by a resident. If they have any complications and choose to pursue legal action, the attending would be nailed.

In addition, if the attending is billing for these patients then that is fraud if they have not seen the patients. Not sure on the implications if they never billed for them.

As far as anonymous options, it seems like your program doesn't have your back and it is a dangerous situation for residents. I;ve heard hit and miss things about ACGME. I don't think it's all too anonymous. All whistleblowers get found out eventually unfortunately.

 

[Top Gun]

Hi Would like to get opinions from people on this forum. My friend is on a consultation service and the attending s/he is with is not rounding on the patients. The attending shows up to collect billing sheets but does not always see the patients. Conversely the attending is lazy and sometimes fails to collect billing sheets before the patient is discharged. It appears that the PD and the head of the department are aware of this but fail to take any action and the attending does whatever s/he wants. Apparently, one resident previously did complain but was chastised by the department for spreading slander. And the attending in question did his/her own retribution against this particular resident because the department let it slip that the resident was complaining about the attending not rounding. My questions are: 1. What are the legal implications? 2. Are there any implications for simply not rounding on the patient (for the patients the attending did not bill for) 3. If current resident chooses to stay silent out of concern for retribution is s/he at fault in anyway legally? 3. Are there any anonymous options? 4. How anonymous is the ACGME? Any additional input appreciated.

The legal implications could be very serious. Suppose the resident following the patient makes a serious error, and the patient develops a complication? Not only the resident and attending, but the residency program and the entire hospital could be subject to a malpractice suit. The program could also end up being put on probation for providing inadequate supervision of residents. It is completely unethical for the attending to bill for the patient without ever seeing him/her, and it is also unethical for the PD/department chair to look the other way while this is happening.

 

[mlw03]

Is this not insurance and/or Medicare fraud if there's that line in the note about the attending seeing the patient? And if not, the inability to bill as you are suggesting. I think financial is the way to pursue this. I think there are whistleblower laws for this sort of thing, so if you could somehow notify the hospital billing office of this fraudulent practice anonymously, that seems like a decent avenue to pursue.

 

[eforest]

As bad as this sounds- just ignore it. You're a resident and have absolutely no power. Ratting out an attending will only make your job harder.

 

[dannyboy1]

As bad as this sounds- just ignore it. You're a resident and have absolutely no power. Ratting out an attending will only make your job harder.

agreed. it is the attending who is ultimately responsible for the patient. If something goes wrong it is his @ss on the line. besides there are plenty of patients (Social admits, terminal patients) that really dont need to be seen every day

 

[Skinceutical]

This is actually pretty serious.

Defrauding Medicare is a federal offense...and, assuming you're not in peds and your attending is billing for these consults, he/she is inevitably committing fraud. Hospitals have been fined millions of dollars and have been threatened with loss of Medicare funding for this. In some of the more egregious cases, people have gone to jail. UT Southwestern was recently in the news for something similar.

Your department should take this pretty seriously.

 

[Skinceutical]

agreed. it is the attending who is ultimately responsible for the patient. If something goes wrong it is his @ss on the line. besides there are plenty of patients (Social admits, terminal patients) that really dont need to be seen every day

You do realize that residents get sued pretty frequently?

 

[gutonc]

You do realize that residents get sued pretty frequently?

Suits involving residents are frequent...lawyers like to name anybody and everybody whose name is in the medical record in a suit.

Suits resulting in judgements against residents however are extraordinarily rare. Not because residents don't screw up, but because, in general, the mistakes they make are honest and part of the training process and they weren't caught by their supervising attendings.

 

[dannyboy1]

This is actually pretty serious.

Defrauding Medicare is a federal offense...and, assuming you're not in peds and your attending is billing for these consults, he/she is inevitably committing fraud. Hospitals have been fined millions of dollars and have been threatened with loss of Medicare funding for this. In some of the more egregious cases, people have gone to jail. UT Southwestern was recently in the news for something similar.

Your department should take this pretty seriously.

Almost every attending will write in their note "saw and examined patient at bedside" regardless of if it happened or not, at some point in their careers. This is especially true if the team has a big list or there are things like departmental meetings or discharge rounds that they need to be at. It is actually pretty difficult to catch, being that the vast majority of patients will not scrutinize their hospital bill to report fraud and probably would not remember if a particular doc was in their room on a specific day with all the traffic of residents, interns, consults, medstudents, nurses, transport, and food service people ect. that parade in and out of their rooms on a daily basis. Never mind the sizable amount of demented, ******ed, or comatose patients that have no clue what is going on.

 

[Depakote]

Almost every attending will write in their note "saw and examined patient at bedside" regardless of if it happened or not, at some point in their careers. This is especially true if the team has a big list or there are things like departmental meetings or discharge rounds that they need to be at. It is actually pretty difficult to catch, being that the vast majority of patients will not scrutinize their hospital bill to report fraud and probably would not remember if a particular doc was in their room on a specific day with all the traffic of residents, interns, consults, medstudents, nurses, transport, and food service people ect. that parade in and out of their rooms on a daily basis. Never mind the sizable amount of demented, ******ed, or comatose patients that have no clue what is going on.

So it would be acceptable to submit a bill to that patient, their insurance, medicare, etc for an attending's care that day? After all, they might not remember they didn't get the care and the team's gotta eat.

 

[Doctor Bagel]

As bad as this sounds- just ignore it. You're a resident and have absolutely no power. Ratting out an attending will only make your job harder.

This. It's bad that this attending is doing this, and it's bad that your program doesn't care. But, you can't fix it, and it sounds like this guy can hurt you more than you can hurt him. I'd leave it for now.

 

[Law2Doc]

I agree with the three points raised in this thread, that

1. It is fraud to claim to have seen a patient you didn't, and moreso to bill for that. People lose their licenses over this, and sometimes yes they do get caught. Never take the approach that "everyone does it at some point". It is career and financial suicide.

2. as a resident you would be foolish to play whistleblower against an attending like this. It inevitably comes down to who the hospital wants to believe, and that won't be you. You are right on principle, but you basically will end two careers by doing this, one of which will be your own. For all you know, the attending circles back around and rounds on patients in the evening. You can bet he claims this even if it's not true. We have already established this person is a liar, remember.

3. Residents do get sued, but rarely resulting in a judgement against them. Unless you are acting outside of the scope of your authority, there is always going to be a supervising attending with deeper pockets. And most of the time it never gets to this point because if anyone is at fault the incentive to settle before court is huge.

 

[michaelrack]

2. Are there any implications for simply not rounding on the patient (for the patients the attending did not bill for) QUOTE]

As long as no fraud is involved, since this is a consult service, it is between the attending of the consult service and the attending of the consulting service whether the attending sees the patient or not.

If the consult resident feels he is not getting proper education or supervision on the rotation, he can take up this issue with the PD.

One thing that it would be helpful for the OP to clarify is wether the attending was seeing most of the initial consults.
When I was a consult attending, I sometimes did not see pts after the initial consult.

 

[gutonc]

As long as no fraud is involved, since this is a consult service, it is between the attending of the consult service and the attending of the consulting service whether the attending sees the patient or not.

If the consult resident feels he is not getting proper education or supervision on the rotation, he can take up this issue with the PD.

One thing that it would be helpful for the OP to clarify is wether the attending was seeing most of the initial consults.
When I was a consult attending, I sometimes did not see pts after the initial consult.

This is kind of important. If no billing is happening, then the attending doesn't technically need to see the patient. At that point it is strictly all about what the consulting attending wants. And frankly, it's not like s/he's going to sit at Mr. Jones' door and wait to see if Dr. GI actually comes to see the patient. As long as there's a note in the chart, the consulting team is usually happy.

I also agree with initial vs. follow-up visits on consults. Since they're basically only going to be able to bill the initial consult, I think it's not uncommon for consult attendings to skip bedside follow-up unless there's an active issue.

 

[dragonfly99]

The issue of INITIAL consult versus FOLLOWUP consult/rerounding on subsequent days I think is important. The attending needs to/should see the patient initially, the same day you see the patient, or at least the next morning. My understand is that otherwise they cannot bill for the consult.

I would not report it to your department. They have demonstrated that they do not care, and that they will allow or perhaps even assist in retaliation against residents who "complain" about such things. What you see as a legitimate concern they see as whining and/or disloyalty....at least if what you, the OP, have stated is true (another resident already reported this behavior and got in trouble for it).

Do not report it to the medical billing department since they are likely to take it right back to your department (see above paragraph).

In this situation, I would make sure that my note does not say, "seen and examined with the attending, who agreed with the assessment and plan". If the attending isn't going to see the patients, let him take the fall for it. Just act within your scope of practice.

If you are afraid that your consult, or your consulting service, is so important that there is going to be patient harm, you may need to pester the attending a little to at least see the more important consults...or find a different attending to staff them with. Depending on whether the attending is just kind of lazy or totally unwilling to do his job, this may or may not be possible.

Some attendings don't always see followup patients with me, particularly on weekends. I'm an upper level fellow and already board certified in IM so that's not quite the same as some attending not staffing and/or seeing consults with a PGY1 or 2 resident, who naturally has less experience. Also, I think it's totally a bad idea for an attending to refuse to see and/or make a resident feel bad about asking him to see consult patients, even followup ones. It's kind of like when you are a resident and one of the RN's from the floor calls to pester you at 3 a.m. and you really don't want to get out of bed and go see the patient...but you should because there might be something actually wrong.

I wouldn't stick your neck out over this unless you think there is imminent patient harm...in that case you have to find some way to fix it...call another attending, perhaps,if there is smarter more responsible one.

 

[nsap102]

To clarify a few queries here: I am all too familiar with is particular attending not to mention the retribution served to the first resident who complained. That resident is a black sheep in the program now and is passing time hoping that nothing else will be served up. As for the practices of the attending, s/he fails to round on initial consults and follow up consults. As a few of you have correctly inferred this attending is an established liar. Furthermore, the attending has an inpatient service and the resident there states that it is not uncommon for the attending not to round a few days a week. Beyond this, I wish to say no more as it may be too revealing. I really appreciate the advice you have given here. I will pass it onto my friend.

 

[michaelrack]

some hospitals don't require daily rounds by a physician, although I believe daily rounds would be the standard of care for inpt non-psychiatric services

 

[45408]

In this situation, I would make sure that my note does not say, "seen and examined with the attending, who agreed with the assessment and plan". If the attending isn't going to see the patients, let him take the fall for it. Just act within your scope of practice.

Agreed. I always see the patient (obviously), and if the staff hasn't seen the patient yet, I'll say at the end of my note "Pt was seen and examined (+/- with senior resident), and discussed with Dr. Attending, who agrees with my assessment and plan." If they were actually there, I'll say that the pt was seen and examined with them.

I just say what I did. What they do and how they document it is up to them.

 

[FutureInternist]

If this is an ongoing problem then I do not see how an anonymous email from a new email address or filling out ACGME survey with ONLY that information and NONE other that can link you to a comment can be traced back to you.
It is fraud, it is dangerous, illegal & immoral.....and you should try to stop it if it can be done w/o getting fired.
Whether someone gets money out of you is not the issue. Just getting sued as a resident would be bad enough. Then when you are asked what you did to stop this, you will have no answer. Saying I thought I would get in trouble will likely not be good enough since proving that will be a big issue and if it is out in the open no one will back you up.
I am a big fan of anonymous emails, making sure you register for it from a hospital computer that lots of people have access to.

Good Luck

 

[wholeheartedly]

If this is an ongoing problem then I do not see how an anonymous email from a new email address or filling out ACGME survey with ONLY that information and NONE other that can link you to a comment can be traced back to you.
It is fraud, it is dangerous, illegal & immoral.....and you should try to stop it if it can be done w/o getting fired.
Whether someone gets money out of you is not the issue. Just getting sued as a resident would be bad enough. Then when you are asked what you did to stop this, you will have no answer. Saying I thought I would get in trouble will likely not be good enough since proving that will be a big issue and if it is out in the open no one will back you up.
I am a big fan of anonymous emails, making sure you register for it from a hospital computer that lots of people have access to.

Good Luck

The department has already established they will protect the attending. In a small group of residents they will try to figure out the who the complaint came from and make assumptions that it was either someone currently/recently working with that attending or someone who has expressed concern about it. That may point to the friend in question or the poor resident who has already brought it up to the department, or somebody else having nothing to do with it. The attending is in the wrong, but the resident is the one who's butt is on the line.

I think dragonfly had the best advice. Make sure the documenting is accurate and doesn't give the attending credit for being their when s/he wasn't.

Just out of curiosity, since this is a longstanding issue and obviously puts patients at risk along with the billing issues, what do you all think about reporting it to risk management, the state board, other agency after the resident finishes the program?

 

[Law2Doc]

...

Just out of curiosity, since this is a longstanding issue and obviously puts patients at risk along with the billing issues, what do you all think about reporting it to risk management, the state board, other agency after the resident finishes the program?

you are going to need letters from your residency forever (for fellowship, jobs, future licenses). There is no time at which you can say "I'm done and so I can cut all ties now".
And it sounds like sour grapes if you are done with residency and still focused on attendants who perhaps somehow did you wrong -- don't assume that this gets spun the way you intended. And most likely you won't care as much once it's not your problem.

 

[FutureInternist]

The department has already established they will protect the attending. In a small group of residents they will try to figure out the who the complaint came from and make assumptions that it was either someone currently/recently working with that attending or someone who has expressed concern about it. That may point to the friend in question or the poor resident who has already brought it up to the department, or somebody else having nothing to do with it. The attending is in the wrong, but the resident is the one who's butt is on the line.

I think dragonfly had the best advice. Make sure the documenting is accurate and doesn't give the attending credit for being their when s/he wasn't.

Just out of curiosity, since this is a longstanding issue and obviously puts patients at risk along with the billing issues, what do you all think about reporting it to risk management, the state board, other agency after the resident finishes the program?

If its a consult service then he likely has had multiple residents work with him, maybe even a new one every month. However, if the fear is so wide-spread then I agree with waiting till after residency although at that point most people would be less likely to muddle into that s---storm again.