Compensation for supervising mid levels?

[VA Hopeful Dr]

If admin workload and paperwork decreased, doctors could also see a greater number of patients. Not to mention staff physicians at any setting with a residency. The attendings could work harder and take on more patients on their own. Many ways to avoid midlevels seeing patients..

For most of us I don't know if that's true. The majority of us are already doing 10-15 minute appointments. Doing less than that and you're short changing the patients and asking to miss things.

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[bronx43]

For most of us I don't know if that's true. The majority of us are already doing 10-15 minute appointments. Doing less than that and you're short changing the patients and asking to miss things.

I would argue that 10-15 minute appointments are already cutting it too close if the patient is medically complex at all. Therefore, I would construct the argument in a different way; if administrative and paperwork burdens were decreased, then it would decrease clinic overhead in the number of staff needed to push paper, which then allows you to spend more time with each patient without taking a hit on your own compensation.

 

[Bacchus]

Sorta like supervising midlevels...?

And don't think for a minute that your midlevels won't document that they consulted with you in their notes. They've probably been told to do it, in fact.

Curbside Consults: An Attorney's Take

So would you not make any mention of asking a specialty? I sometimes will document will discuss with heme or GS or GI and then document what I told the patient afterwards. No names used. I guess under oath I’d have to reveal the name.

 

[deleted87716]

So would you not make any mention of asking a specialty? I sometimes will document will discuss with heme or GS or GI and then document what I told the patient afterwards. No names used. I guess under oath I’d have to reveal the name.

The only time I’ll document a curbside consult is if the patient is already established with the specialist, or if I am referring them at the time of the visit.

 

[Ironheme]

You're giving them liability without compensation.

Ah fair enough. Always thought I was doing due diligence by saying the consultant agrees with me essentially. I hadn't thought of it from the legal standpoint. Thanks for the answer. I'll change my practice.

 

[wholeheartedly]

I’m so tired of the argument, “well without mid levels we wouldn’t have enough providers to see all of the patients.”

Without mid levels, maybe the public would feel the burn of increased wait times and vote to expand residency positions. Physicians are justifying their abuse by administration by telling themselves “it’s good for the patients.” If only patients cared about physicians...

The good news is patients don’t have to care about physicians. They will vote based on their needs, and they NEED physicians. We need to quit dressing up nurses as doctors so that patients can recognize their need for us.

It doesn't matter if the public feels the burn where I live. Voting isn't going to change that. There is literally 1 physician living in the whole county here and it's a large county. We staff the ED with rotating locums docs but it's incredibly expensive.

I'm not pro midlevel at all, but your statement is incredibly overly simplistic.

 

[Reboa]

It doesn't matter if the public feels the burn where I live. Voting isn't going to change that. There is literally 1 physician living in the whole county here and it's a large county. We staff the ED with rotating locums docs but it's incredibly expensive.

I'm not pro midlevel at all, but your statement is incredibly overly simplistic.

Just wondering but what's the average and median salary for this county? Is it far from the national average for family practitioners?

 

[wholeheartedly]

Just wondering but what's the average and median salary for this county? Is it far from the national average for family practitioners?

I don't know and with an n of 1 I'm not sure what that "average" would tell you, but rural critical access hospitals are usually barely keeping afloat most places.

Even with higher compensation it's still incredibly challenging to get people to move here.

 

[LeroyJenkinsMD]

It doesn't matter if the public feels the burn where I live. Voting isn't going to change that. There is literally 1 physician living in the whole county here and it's a large county. We staff the ED with rotating locums docs but it's incredibly expensive.

I'm not pro midlevel at all, but your statement is incredibly overly simplistic.

That’s a fair point, but at some point society needs to pay for things. If the county’s ten residents want to float the cost of a physician in order to avoid the inconvenience of commuting for their healthcare, they are welcome to. Otherwise they need to accept the disadvantage of residing in the rural area they chose to reside in. I’m not moving to rural Alaska and asking the federal government to build a hospital next to me and neither should anyone else. There are plenty of places near civilization where people can live and if that doesn’t work for them... consequences. Can’t have it all.

 

[wholeheartedly]

That’s a fair point, but at some point society needs to pay for things. If the county’s ten residents want to float the cost of a physician in order to avoid the inconvenience of commuting for their healthcare, they are welcome to. Otherwise they need to accept the disadvantage of residing in the rural area they chose to reside in. I’m not moving to rural Alaska and asking the federal government to build a hospital next to me and neither should anyone else. There are plenty of places near civilization where people can live and if that doesn’t work for them... consequences. Can’t have it all.

Again with the overly simplistic assumptions. It’s 15,000 residents, plus quite a few more temp. workers. Convince them they don’t deserve healthcare access because they came where the jobs were when jobs were scarce.

 

[SXMMD]

Again with the overly simplistic assumptions. It’s 15,000 residents, plus quite a few more temp. workers. Convince them they don’t deserve healthcare access because they came where the jobs were when jobs were scarce.

Tough situation for sure. Training in such an area. Still, it's crazy to me we make policy decisions based on the circumstances of the extreme ends of the bell curve rather than carving out niche solutions for them. Surely PA/NP training/independence as we see it now is going to do little to improve the lot of people in these areas in the short or long term- why would NP/PA stick around there? Majority will leave for the same reasons anyone else would. The ones who stay generally stay for the same reason the docs do... it's home, and that's family.

 

[wholeheartedly]

Tough situation for sure. Training in such an area. Still, it's crazy to me we make policy decisions based on the circumstances of the extreme ends of the bell curve rather than carving out niche solutions for them. Surely PA/NP training/independence as we see it now is going to do little to improve the lot of people in these areas in the short or long term- why would NP/PA stick around there? Majority will leave for the same reasons anyone else would. The ones who stay generally stay for the same reason the docs do... it's home, and that's family.

Agree. Plus we have a nursing shortage too and at least two of our RNs are training to be NPs now. I'm not in favor of midlevel independence at all, but I wanted to point out to a few that it's not so easy as saying just get rid of them or add more residency spots.

 

[deleted480308]

Again with the overly simplistic assumptions. It’s 15,000 residents, plus quite a few more temp. workers. Convince them they don’t deserve healthcare access because they came where the jobs were when jobs were scarce.

They don’t deserve access they aren’t paying for and there is a critical mass required to pay for a doc

 

[LeroyJenkinsMD]

Again with the overly simplistic assumptions. It’s 15,000 residents, plus quite a few more temp. workers. Convince them they don’t deserve healthcare access because they came where the jobs were when jobs were scarce.

Here’s another simplistic assumption. That town brings in hundreds of millions per year. It can pay for things it wants. You could also argue, a PA/NP is not access to appropriate healthcare and that people don’t deserve anything, especially not convenience. I’m sure they have cars.

 

[SLC]

I think that after thinking about it long and hard, I’ve decided not to sign my mid level supervision contract.

We shall see how this affects my standing at the hospital, but I’ve seen one PA make a huge mistake recently and there are talks of a lawsuit; I want no part of that.

 

[raptor5]

I think that after thinking about it long and hard, I’ve decided not to sign my mid level supervision contract.

We shall see how this affects my standing at the hospital, but I’ve seen one PA make a huge mistake recently and there are talks of a lawsuit; I want no part of that.

Any blowback or repurcussions?

 

[SLC]

Any blowback or repurcussions?

Nope, none. They were totally fine with it. The response was something along the lines of “we don’t want you to think we need you doing anything you’re not 100% comfortable with”.

 

[deleted87716]

Nope, none. They were totally fine with it. The response was something along the lines of “we don’t want you to think we need you doing anything you’re not 100% comfortable with”.

 

[SLC]

So I've continued to hold fast to my refusal to supervise. However, something's come up and I'm wondering how others here would handle it.

I've now learned that there are two separate "contracts" for mid-level supervision here, and in my mind they're totally backwards. Pay for supervising the outpatient midlevels is almost 6x more than it is for supervising midlevels who work primarily in the hospital (inpatient medicine and ED).

So the thing is, we have a PA that sees patients 2 days per week in our clinic, otherwise it's me, another new guy, and a part-timer. The other new guy signed his PA supervision contract and has been given an ED only PA; which means $400/month basically in compensation, while bearing full liability for anything that happens while that PA is practicing alone in the ED for 24hrs at a time.

My partner has tried to ask if he can supervise the PA that works in our clinic instead, but she's been assigned to another doc in a clinic about 40 mins north of here, that clinic is in the hospital where our PA's cover the ED. I'm guessing that doc is making $20k a year for it. That doctor won't agree to trading for the PA he can be present for, and I'm guessing it's because of money.

The rub is that this PA is very green, and I'm being asked (by her) to "curbside" on probably 60% of the patients she sees here.

I'm tempted to start refusing to help, and telling her she needs to call her "supervising doc" with her questions instead. I don't want to make any waves, but it seems that if this other doc is assigned to be the supervisor, and getting paid 6x more than what they offered us to supervise, then he should have to work for it.

What does the group say?

 

[Ironheme]

Occasional curbside? Sure. 60%? I wouldn't, especially if someone else is getting paid to 'supervise' this PA. I don't blame the PA with this weird contract thing going.

I'd talk to the contract person and say hey I really enjoy working with so and so PA and I'm happy being a part of the team, but it seems I'm constantly being asked to supervise, when they already have an off-site supervisor. I'm thinking about solutions - what if I take over the contract and supervise so and so? If Dr. offsite still prefers to supervise PA x, then that's okay too but I'll likely redirect the PA to contact the supervisor when they have a lot of questions.

 

[deleted87716]

So I've continued to hold fast to my refusal to supervise. However, something's come up and I'm wondering how others here would handle it.

I've now learned that there are two separate "contracts" for mid-level supervision here, and in my mind they're totally backwards. Pay for supervising the outpatient midlevels is almost 6x more than it is for supervising midlevels who work primarily in the hospital (inpatient medicine and ED).

So the thing is, we have a PA that sees patients 2 days per week in our clinic, otherwise it's me, another new guy, and a part-timer. The other new guy signed his PA supervision contract and has been given an ED only PA; which means $400/month basically in compensation, while bearing full liability for anything that happens while that PA is practicing alone in the ED for 24hrs at a time.

My partner has tried to ask if he can supervise the PA that works in our clinic instead, but she's been assigned to another doc in a clinic about 40 mins north of here, that clinic is in the hospital where our PA's cover the ED. I'm guessing that doc is making $20k a year for it. That doctor won't agree to trading for the PA he can be present for, and I'm guessing it's because of money.

The rub is that this PA is very green, and I'm being asked (by her) to "curbside" on probably 60% of the patients she sees here.

I'm tempted to start refusing to help, and telling her she needs to call her "supervising doc" with her questions instead. I don't want to make any waves, but it seems that if this other doc is assigned to be the supervisor, and getting paid 6x more than what they offered us to supervise, then he should have to work for it.

What does the group say?

A "green" PA should never have an off-site SP.

By letting the PA curbside you, you're assuming all of the liability with none of the reward (e.g., extra compensation for being their SP).

Personally, I'd refuse and tell them they need to contact their off-site SP. If that isn't working out, dump it back on admin. It's not your problem, frankly.

 

[Dr. Wexler]

What does the group say?

Not OK of the PA to do that.

I have found some midlevels are quick to write "discussed with Dr. Wexler" when I'm not their supervisor/don't know their work product/am unable to issue corrective action. I'd be curious if this PA is doing the same to you.

I'm moving toward telling them "Please have them make an appointment with me and I can give recommendations". As is stands now, more often than not they've made a mess by shotgunning tests or doing irrational treatment plans that aren't working. And then want me to fix it.

 

[deleted87716]

I have found some midlevels are quick to write "discussed with Dr. Wexler" when I'm not their supervisor/don't know their work product/am unable to issue corrective action. I'd be curious if this PA is doing the same to you.

I imagine they're taught to do that.

And, don't think for a minute that their actual SP won't throw you under the bus if something goes sideways. "I was never consulted. My PA just did what Dr. SLC recommended."

 

[Keona]

So I've continued to hold fast to my refusal to supervise. However, something's come up and I'm wondering how others here would handle it.

I've now learned that there are two separate "contracts" for mid-level supervision here, and in my mind they're totally backwards. Pay for supervising the outpatient midlevels is almost 6x more than it is for supervising midlevels who work primarily in the hospital (inpatient medicine and ED).

So the thing is, we have a PA that sees patients 2 days per week in our clinic, otherwise it's me, another new guy, and a part-timer. The other new guy signed his PA supervision contract and has been given an ED only PA; which means $400/month basically in compensation, while bearing full liability for anything that happens while that PA is practicing alone in the ED for 24hrs at a time.

My partner has tried to ask if he can supervise the PA that works in our clinic instead, but she's been assigned to another doc in a clinic about 40 mins north of here, that clinic is in the hospital where our PA's cover the ED. I'm guessing that doc is making $20k a year for it. That doctor won't agree to trading for the PA he can be present for, and I'm guessing it's because of money.

The rub is that this PA is very green, and I'm being asked (by her) to "curbside" on probably 60% of the patients she sees here.

I'm tempted to start refusing to help, and telling her she needs to call her "supervising doc" with her questions instead. I don't want to make any waves, but it seems that if this other doc is assigned to be the supervisor, and getting paid 6x more than what they offered us to supervise, then he should have to work for it.

What does the group say?

If I’m not having a busy day and I’m not the on call md I’ll often help out. This is in the same clinic and the others pitch in if I’m slammed. The MD on call is supposed to have a lighter schedule to deal with questions and the general insanity we get. If I’m busy I’ll tell them I’m sorry you’re going to need to speak to the on call physician. There is no way I’d do this if I wasn’t getting compensated for it. Your time is worth something and you should refuse. Someone else is getting paid for this. They should be the ones answering every question. I also don’t see how you can supervise someone or help them with physical exams, etc if you’re not actually present.

 

[SLC]

If I’m not having a busy day and I’m not the on call md I’ll often help out. This is in the same clinic and the others pitch in if I’m slammed. The MD on call is supposed to have a lighter schedule to deal with questions and the general insanity we get. If I’m busy I’ll tell them I’m sorry you’re going to need to speak to the on call physician. There is no way I’d do this if I wasn’t getting compensated for it. Your time is worth something and you should refuse. Someone else is getting paid for this. They should be the ones answering every question. I also don’t see how you can supervise someone or help them with physical exams, etc if you’re not actually present.

I agree, it’s insane how this system here is set up. I’m hoping that shunting the 10-15 curbsides I get per day back to the SP will help him realize the situation is untenable.

 

[SLC]

A "green" PA should never have an off-site SP.

By letting the PA curbside you, you're assuming all of the liability with none of the reward (e.g., extra compensation for being their SP).

Personally, I'd refuse and tell them they need to contact their off-site SP. If that isn't working out, dump it back on admin. It's not your problem, frankly.

Yep and the compensation offered is frankly crap, which played a role in why I refused to do it. I can make more answering online surveys for docs if that gives you any idea. Plus they don’t pay extra to take on more PA’s, they just give them and pay the same amount as if you only have one to be responsible for.

It’s a shame because the company has been very good in every other way.

 

[Doctorsoon2011]

As a PGY 1 who already has a contract, the market is hot for FM. I get job offers weekly through Linkedin. Try it. Call a random hospital, ask to talk to the CEO, tell them your not close to signing but are interested and want to know if they are hiring FMs. The answer will be yes and they will prob fly you out, feed you, tour you, gift basket you, thank you card you, and then "check back" with you every 3-4 months from then on. Then come tell us how crazy hot the market is.

 

[deleted87716]

As a PGY 1 who already has a contract, the market is hot for FM. I get job offers weekly through Linkedin. Try it. Call a random hospital, ask to talk to the CEO, tell them your not close to signing but are interested and want to know if they are hiring FMs. The answer will be yes and they will prob fly you out, feed you, tour you, gift basket you, thank you card you, and then "check back" with you every 3-4 months from then on. Then come tell us how crazy hot the market is.

So, you can totally tell them that you ain't supervising no midlevels.

 

[Doctorsoon2011]

So, you can totally tell them that you ain't supervising no midlevels.

Actually meant to add this post to one of the other threads. I guess that's what you get when you're drinking and blogging hahaha. you'll see it pop up on one of the others.

But yeah hiring a mid-level makes absolutely no sense unless you own the business yourself or you were trying to cut down on how many patients you are actually seeing, like going semi retire.

 

[deleted87716]

Actually meant to add this post to one of the other threads. I guess that's what you get when you're drinking and blogging hahaha. you'll see it pop up on one of the others.

But yeah hiring a mid-level makes absolutely no sense unless you own the business yourself or you were trying to cut down on how many patients you are actually seeing, like going semi retire.

Meh. There is no role for midlevels in my three-physician practice. IMO, this all got started 'cause some people are lazy asses. I'm not.