Doctor leaving our group and I anticipate being asked to supervise his NPs

[SpongeBob DoctorPants]

An outpatient psychiatrist in our clinic will be leaving in a couple of months for another job.

The concern I have about this is that he has been supervising a few NPs in the clinic, and I haven't supervised any. (I was once offered a supervisory role when I started, but I didn't want it, so they asked him to take on one more, which he agreed to.) We have another psychiatrist joining us this summer, but I do not yet know if this doctor would be agreeable to supervising.

Assuming we won't get rid of the NPs, I see a few possibilities: 1) Have the new psychiatrist supervise them; 2) Have me supervise them; 3) Have one or more of the medical group's inpatient psychiatrists supervise them; 4) Split up the supervising work among two or three of these.

I anticipate that in the near future I will be asked to supervise at least one or two of them. I have no idea if the new doctor joining our clinic would want to supervise, and I doubt that the inpatient doctors would want to. (One of them actually already supervises a couple of others on the inpatient unit, but has no interest in anything related to the outpatient world.) I am not very interested in it myself, and the pay increase isn't really enough to make me interested, but I'm not sure how much of a choice I'd really have in this situation. If it was a matter of having no NPs to start with, and they were thinking of adding one, I'd probably say no thank you. But in this case, we already have the NPs, and if no one is willing to supervise them, I suppose that they would suddenly become unemployed and there'd be a lot of patients without a provider.

The good news is that I have at least become familiar with these NPs through the course of my employment over the years, and I am somewhat familiar with their level of competence and treatment styles. I suppose that if I have to take on an NP or two for the sake of being a team player, at least I will already sort of know what to expect and as of right now I don't have any concerns with the way they practice.

Has anyone else been in this kind of situation before? Any suggestions for how to handle this conversation when it comes up? And if I do end up supervising, what are some good things to know about beforehand?

Thank you...

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[Sushirolls]

This is business. Check your emotions at the door. Do you want to do this yes or no? If not, then say no. What happens after that isn't your problem. You weren't the admin who made the choice to hire NP. You weren't the admin who failed to appropriately have/hire another Psychiatrist willing to supervise. Why are you going to be the rescuer to bail out the suits? This likely isn't the first, nor will it be the last operational nightmare a suit will have to solve - they get paid to solve it not you.

Where one door closes another door opens. Worse case scenario the clinic gets rid of the ARNPs and now the community has a demand for a private practice clinician. Could be you? Could be the ARNPs? Could be another psychiatrist swooping in.

 

[Stagg737]

Still a resident, but fairly educated on the aspects and ramifications of supervisory roles. If you're not comfortable in that role, make it very clear that you aren't and that you don't want to take on that responsibility. If you feel like you're going to be forced into it or your bosses suggest that and you're not willing to look for another job, then you may want to say which NP(s) you'd be willing to take on. If worse comes to worst and you're forced into it then you should definitely have some say into who you'll be supervising.

As for good things to know, anyone who you are listed as the supervising physician for is your responsibility and by extension you are liable for all of their actions. That means even if you didn't see the patient and just signed the chart, even if the NP saw a patient and didn't tell you, even if you're name doesn't actually appear in the chart, you can be held liable for any mistakes they make and repercussions of those mistakes. There are several court cases in multiple states where this precedent has been set where physicians were named in lawsuits and lost. From a liability standpoint, it's ideal to treat NPs like med students or residents and basically have them present each patient to you and then see the patient afterwards. This is not the most practical/efficient way to utilize them, but it's the safest. Some places will just have you review every X charts but sign off on every patient the NP sees. I would not work in a position like this as the liability is just not worth it to me, but to each their own.

 

[WalSlave]

Double check that you're not in a state where NPs can practice independently. This doesn't go for PAs.

 

[splik]

Double check that you're not in a state where NPs can practice independently. This doesn't go for PAs.

if he were in a state where NPs can practice independently, he wouldn't be asked to supervise them.
BTW PAs are lobbying hard for independent practice (though under different names in some cases). while most states require PAs to be supervised, in AK and IL, PAs do not need supervision and can have a "collaborative agreement". New Mexico doesn't require any physician oversight for non-specialty PAs with more than 3 yrs clinical experience....

In addition 8 states no longer have PAs licensed by the medical board. they have their own boards in those states, e.g. CA. They basically argued that physicians should not be evaluating whether they breached standard of care because they shouldn't be held to the same standard as physicians...

 

[WalSlave]

if he were in a state where NPs can practice independently, he wouldn't be asked to supervise them.
BTW PAs are lobbying hard for independent practice (though under different names in some cases). while most states require PAs to be supervised, in AK and IL, PAs do not need supervision and can have a "collaborative agreement". New Mexico doesn't require any physician oversight for non-specialty PAs with more than 3 yrs clinical experience....

In addition 8 states no longer have PAs licensed by the medical board. they have their own boards in those states, e.g. CA. They basically argued that physicians should not be evaluating whether they breached standard of care because they shouldn't be held to the same standard as physicians...

I hear you. I've known some truly incompetent office managers who I could totally see instituting some kind of "supervisory contract" on their docs and NPs even though it isn't necessary in the state. I figured I'd throw out the obvious on the off-chance it was an easy fix.

 

[TexasPhysician]

This is business. Check your emotions at the door. Do you want to do this yes or no? If not, then say no. What happens after that isn't your problem. You weren't the admin who made the choice to hire NP. You weren't the admin who failed to appropriately have/hire another Psychiatrist willing to supervise. Why are you going to be the rescuer to bail out the suits? This likely isn't the first, nor will it be the last operational nightmare a suit will have to solve - they get paid to solve it not you.

Where one door closes another door opens. Worse case scenario the clinic gets rid of the ARNPs and now the community has a demand for a private practice clinician. Could be you? Could be the ARNPs? Could be another psychiatrist swooping in.

Agreed. Administrative positions in medicine have grown exponentially which increase the cost of healthcare, but that debate is for another day. As you are stuck with admin, I would recommend that you have them do their job. It is their problem to address the needs of the clinic, not yours. Hold strong to your position as you are in the position of strength. Firing you when short psychiatrists would be stupid. They will of course attempt to convince you that supervising would be temporary, but admin research has shown that convincing a physician to do something is the hardest step. Once we’ve given in, research shows that we lack the backbone to enforce deadlines of “temporary” situations, so they won’t try hard to fix the situation or hold deadlines you give them to find a solution or replacement.

Using guilt to convince you will likely be their tactic, because you giving in will allow admin to keep making big money without trying very hard. There are many other solutions like using locum companies, adding an additional psychiatrist, etc.

Supervising each midlevel has a value of $5k/month+. If you aren’t getting at least that, admin is taking advantage of you. In New Mexico, they have allowed NP’s to practice independently, and multiple practices subsequently fired their psychiatrists. I’d refuse to supervise potential replacements that are more likely to cause harm, but that is just me.

 

[Lawpy]

Supervising each midlevel has a value of $5k/month+. If you aren’t getting at least that, admin is taking advantage of you. In New Mexico, they have allowed NP’s to practice independently, and multiple practices subsequently fired their psychiatrists. I’d refuse to supervise potential replacements that are more likely to cause harm, but that is just me.

This is extremely depressing to read. I’m hoping all physicians take note and refuse to supervise midlevels

 

[Monocles]

This is business. Check your emotions at the door.

This. A thousand times this!

Supervising each midlevel has a value of $5k/month+.

Congratulations OP. You now have a monopoly on midlevel supervisor positions, which means you can effectively set your own price. I bet if you ask for $7k per midlevel (and settle for $6k) your admin would do it. After all, it should be "temporary" so at those rates they would probably be running in circles trying to find a new psychiatrist to do it for cheaper.

At the end of the day never forget that you are just a cog in the corporate medicine machinery. The medical system knows to exploit physicians based on morals, virtues, altruism blah blah and so they will take advantage of you in a business sense.

Be ruthless in your negotiations.

 

[Sushirolls]

if he were in a state where NPs can practice independently, he wouldn't be asked to supervise them.

Medical groups, hospitals, etc can still require supervision even when there are independent practice laws in the state.

 

[NickNaylor]

Haven't been in this situation, but as others said, you have the leverage here - particularly if you're able to find another position in the event they "demand" that you supervise. If there's a price at which you would be willing to supervise, tell your administrator(s) what that price is and you would be happy to do it. They can't fault you for not wanting to supervise when you previously turned that down, which they then accommodated.

 

[Stagg737]

if he were in a state where NPs can practice independently, he wouldn't be asked to supervise them.
BTW PAs are lobbying hard for independent practice (though under different names in some cases). while most states require PAs to be supervised, in AK and IL, PAs do not need supervision and can have a "collaborative agreement". New Mexico doesn't require any physician oversight for non-specialty PAs with more than 3 yrs clinical experience....

In addition 8 states no longer have PAs licensed by the medical board. they have their own boards in those states, e.g. CA. They basically argued that physicians should not be evaluating whether they breached standard of care because they shouldn't be held to the same standard as physicians...

PAs can now practice independently without supervision in North Dakota as well. A recent bill passed that allows them to practice medicine without physician supervision if they have completed 4,000 hours of supervised work. I feel ever so slightly better about this than allowing NPs straight out of school to practice independently with as little as 500 clinical hours, but still don't like the precedents being set.

 

[notlucid]

I had to do collaboration as part of my job. Any thoughts on the case below.
MN Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs for Malpractice

4/18/2019
In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.

 

[Merely]

I had to do collaboration as part of my job. Any thoughts on the case below.
MN Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs for Malpractice

4/18/2019
In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.

WTF that’s horrible..

 

[clausewitz2]

I had to do collaboration as part of my job. Any thoughts on the case below.
MN Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs for Malpractice

4/18/2019
In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.

Not really a comparable case:

"The Supreme Court reversed the judgments of the lower courts that, as a matter of law, a hospitalist owed no duty of care to a patient seeking to be admitted because no physician-patient relationship had been established, holding that there was sufficient evidence in the record to survive a summary judgment motion.

A hospitalist denied a patient admission, and, three days later, the patient died. Plaintiff filed a professional negligence suit against the hospitalist and the hospital. The district court granted summary judgment for Defendants on the issue of duty, concluding that the relationship between the patient and the hospitalist did not create a doctor-patient relationship. The court of appeals affirmed. The Supreme Court reversed after noting that a physician-patient relationship is not a necessary element of a claim for professional negligence, holding (1) a physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician's acts and be harmed by a breach of the standard of care; and (2) it was reasonably foreseeable that the patient in this case would rely on the hospitalist's acts and be harmed by a breach of the standard of care."

Also since this was the MN Supreme Court this is only precedent for Minnesota. Honestly seems more relevant to the other thread about prescribing without seeing someone first. The two-part test articulated here is not obviously and immediately met by the situation of an adverse event happening to the patient of a mid-level one is supervising.

 

[Stagg737]

Not really a comparable case:

"The Supreme Court reversed the judgments of the lower courts that, as a matter of law, a hospitalist owed no duty of care to a patient seeking to be admitted because no physician-patient relationship had been established, holding that there was sufficient evidence in the record to survive a summary judgment motion.

A hospitalist denied a patient admission, and, three days later, the patient died. Plaintiff filed a professional negligence suit against the hospitalist and the hospital. The district court granted summary judgment for Defendants on the issue of duty, concluding that the relationship between the patient and the hospitalist did not create a doctor-patient relationship. The court of appeals affirmed. The Supreme Court reversed after noting that a physician-patient relationship is not a necessary element of a claim for professional negligence, holding (1) a physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician's acts and be harmed by a breach of the standard of care; and (2) it was reasonably foreseeable that the patient in this case would rely on the hospitalist's acts and be harmed by a breach of the standard of care."

Also since this was the MN Supreme Court this is only precedent for Minnesota. Honestly seems more relevant to the other thread about prescribing without seeing someone first. The two-part test articulated here is not obviously and immediately met by the situation of an adverse event happening to the patient of a mid-level one is supervising.

While the MN case isn't the best example, there are several other cases where physicians have successfully been sued and many more where hospitals settled when the patient was only seen by a mid level. It's a busy week for me, but I'll see if I can dig some of them up and post them here.

 

[TexasPhysician]

While the MN case isn't the best example, there are several other cases where physicians have successfully been sued and many more where hospitals settled when the patient was only seen by a mid level. It's a busy week for me, but I'll see if I can dig some of them up and post them here.

Not only that, you can lose your license based on the prescribing of your midlevel.

 

[hamstergang]

While the MN case isn't the best example, there are several other cases where physicians have successfully been sued and many more where hospitals settled when the patient was only seen by a mid level. It's a busy week for me, but I'll see if I can dig some of them up and post them here.

But when you're supervising a mid-level, you are agreeing to be responsible for all of their cases. This MN case was not about a doctor in a supervisory role.

 

[Duloxetini]

This is extremely depressing to read. I’m hoping all physicians take note and refuse to supervise midlevels

The best part is that physicians that don't go along with the schemes to do this are painted as selfish and unreasonable... And not being willing to address the care shortage.

It's like... Bitch please... Collaboration is great but your organizations are ultimately trying to push us out so why would we go against our own self interest so directly?

Physician organization is disgustingly poor. If we can't be the voice of medicine and medical, then who can? We didn't do all this 'extra' training because it's convenient. The lack of foresight by physicians who go along with things because it doesn't really affect them is the reason why medical boards have the power that they do...

Every lawmaker that votes yes on measures like this should have a clause in their insurance limiting their care to the NPs/PAs that they think their constituents are entitled to... Everything else should be out of pocket.

 

[Duloxetini]

I had to do collaboration as part of my job. Any thoughts on the case below.
MN Supreme Court Rules Physician-Patient Relationship is Not Necessary to Sue Docs for Malpractice

4/18/2019
In a case that could have wide-reaching implications for medical practice in Minnesota, the Minnesota Supreme Court issued a ruling on April 17 in the case of Warren v. Dinter holding that the existence of a physician-patient relationship is not a prerequisite for a medical malpractice action. Rather, a person may sue a physician for malpractice – even if that person was not a patient of the physician – if the harm suffered by the person was a “reasonably foreseeable consequence” of the physician’s actions.

Does transfer of care to a mid-level count? Curious if folks can require physician follow up if they don't want the additional liability.

As a student I've enjoyed working with just about everyone and know I don't really have to deal with this as a resident.... but as an attending I don't really want to have liability over people who believe they want autonomy and none of the sequelae or liability that comes with that.

With great power comes great responsibility and all.
Hat tip to ya uncle Ben!

 

[SpongeBob DoctorPants]

Not only that, you can lose your license based on the prescribing of your midlevel.

Do you know if this has actually happened to anyone before?

 

[TexasPhysician]

Do you know if this has actually happened to anyone before?

Yes, it has. A friend of mine actually.

 

[SpongeBob DoctorPants]

Yes, it has. A friend of mine actually.

Yikes. That certainly makes the potential liability issue a lot more real. I'm sorry that happened to a friend of yours.

 

[Stagg737]

But when you're supervising a mid-level, you are agreeing to be responsible for all of their cases. This MN case was not about a doctor in a supervisory role.

You're right, but the implications are actually a lot worse than that. The NP curb-sided the physician to ask whether hospitalization was warranted and the physician said he didn't think it was. NP made the decision to discharge, the patient died, and the family successfully sued both the NP and the physician who was informally consulted. It sets the precedent that as a physician you can be held liable for the actions of an NP even if you're not the supervising physician and you're just informally consulted. It potentially creates a standard where you can be sued as the treating physician without ever establishing a doctor-patient relationship, which as far as I know has not happened prior to this case.

It's a dangerous precedent and one which seems to completely ignore a fundamental requirement for proving malpractice.

 

[hamstergang]

You're right, but the implications are actually a lot worse than that. The NP curb-sided the physician to ask whether hospitalization was warranted and the physician said he didn't think it was. NP made the decision to discharge, the patient died, and the family successfully sued both the NP and the physician who was informally consulted.

The NP was in an outpatient clinic and was speaking to the hospitalist about admission. This wasn't an informal curbside, and it doesn't seem to have to do with the outpatient person being an NP.

And even if I'm wrong above, none of this is still about the OP where he's debating signing an agreement to supervise NPs and accept responsibility for their actions. This court case is irrelevant to those with signed supervisory agreements.

 

[Sushirolls]

You're right, but the implications are actually a lot worse than that. The NP curb-sided the physician to ask whether hospitalization was warranted and the physician said he didn't think it was. NP made the decision to discharge, the patient died, and the family successfully sued both the NP and the physician who was informally consulted. It sets the precedent that as a physician you can be held liable for the actions of an NP even if you're not the supervising physician and you're just informally consulted. It potentially creates a standard where you can be sued as the treating physician without ever establishing a doctor-patient relationship, which as far as I know has not happened prior to this case.

It's a dangerous precedent and one which seems to completely ignore a fundamental requirement for proving malpractice.

I predict from the Minnesota case, hospitals might reconsider the concept of the transfer/admit line where a Hospitalist fields possible cases from outpatient clinics. They'll simply just simply say, go to the nearest ED, where at least at that moment they will have had the basic lab/imaging work up to understand if a hospital-to-hospital transfer is necessary.

 

[Stagg737]

The NP was in an outpatient clinic and was speaking to the hospitalist about admission. This wasn't an informal curbside, and it doesn't seem to have to do with the outpatient person being an NP.

And even if I'm wrong above, none of this is still about the OP where he's debating signing an agreement to supervise NPs and accept responsibility for their actions. This court case is irrelevant to those with signed supervisory agreements.

They still failed to establish a doctor-patient relationship as the doc never saw the patient and never even saw their chart, so basically the equivalent of a curbside (even if it wasn't supposed to be). Regardless, the physician was still found liable for a decision that laid in the NP's hands.

You're right that this is not what OP is asking about though. Here's a Medscape article which addresses it though with a few examples where the supervising physician was held liable: Medscape: Medscape Access


Some notable quotes/examples relevant to the OP:

"a patient presented to the ED with a fracture that was misdiagnosed by the PA. "The patient never saw the physician, and he didn't even know the patient was in the hospital," said Craig P. Sanders, a malpractice defense attorney with Rainey Kizer Reviere & Bell in Jackson, Tennessee. "A 2010 decision by the Tennessee Supreme Court held that a supervising physician can be held vicariously liable for the negligence of his or her PA even if the physician never saw or treated the patient. This means that the doctor may automatically be held liable if the PA is found to have been negligent."

"some attorneys and physicians argue that midlevels don't have the same extensive training as physicians and often practice beyond their areas of expertise. "Whenever a midlevel is sued, you can be sure that the supervising physician will be sued as well," said Craig Sanders. "Courts have held that the midlevel is an agent of the physician, who can be held vicariously liable for negligence even if he never saw the patient," he said. "Physicians don't realize the extent of supervision necessary to keep the liability risk low.""

 

[Duloxetini]

Holy wow.

 

[Merely]

You're right, but the implications are actually a lot worse than that. The NP curb-sided the physician to ask whether hospitalization was warranted and the physician said he didn't think it was. NP made the decision to discharge, the patient died, and the family successfully sued both the NP and the physician who was informally consulted. It sets the precedent that as a physician you can be held liable for the actions of an NP even if you're not the supervising physician and you're just informally consulted. It potentially creates a standard where you can be sued as the treating physician without ever establishing a doctor-patient relationship, which as far as I know has not happened prior to this case.

It's a dangerous precedent and one which seems to completely ignore a fundamental requirement for proving malpractice.

I never understand why this happens. If it’s not documented then when asked “did the NP consult you?” You just say no..if it’s not documented it didn’t happen right?

 

[michaelrack]

The problem is that the np might document it

 

[Splenda88]

Why would NP need supervision when they have equal or even better outcomes than physicians?

 

[Splenda88]

This is extremely depressing to read. I’m hoping all physicians take note and refuse to supervise midlevels

Yeah, like we have the backbone to do that...


Why would someone put his medical license (or livelihood) in jeopardy for 30 or 40k/yr? Basically, you can make that working an extra 4 hrs/wk without the headache of watching over someone's else shoulder.

 

[Ironspy]

The problem is that the np might document it

And it’s worse than that. EMRs don’t let you document on a patient that’s not in the system. If the patient has never been to your hospital you couldn’t document if you wanted to. Nor can you see any records from the outside hospital and you have to rely on the NPs presentation. Sounds like a big mess. No thanks. Everyone needs an ED eval

 

[SpongeBob DoctorPants]

Why would someone put his medical license (or livelihood) in jeopardy for 30 or 40k/yr? Basically, you can make that working an extra 4 hrs/wk without the headache of watching over someone's else shoulder.

This is a very good point, and from what I've heard the pay for supervision in our group isn't even nearly that high. Fortunately I have not been asked to supervise yet; it seems that they are still honoring my preferences from when I was first hired. Perhaps they have found someone else to take on this responsibility.

 

[Merely]

This is a very good point, and from what I've heard the pay for supervision in our group isn't even nearly that high. Fortunately I have not been asked to supervise yet; it seems that they are still honoring my preferences from when I was first hired. Perhaps they have found someone else to take on this responsibility.

Supervising for less than the above number is an absolute joke..not even close to worth it