liability shifting via midlevel attestation statements

[salud23]

Greetings,

I have a question about how different people might address attempts of contract groups to shift a disproportionate amount of liability onto the physician by means of the attestation statements that the physician is required to use when signing charts of patients seen by PAs or NPs. I've seen this with more than one entity. Usually the game is played as follows.

The chart is electronic. I don't get to handwrite anything. To sign the chart, I have to click a box that has some sort of language to the effect that I was available to the midlevel (true), saw the patient myself (often not true), and am in full agreement with all aspects of history, physical, medical decision making, and management as documented by the midlevel (the "all" portion of this statement is particularly galling to me). I might not agree with all aspects of patient management as done by another physician, and I definitely might not agree with all aspects of patient management by a midlevel. The chart is designed to give me the sole option of clicking the x in the box with no ability to alter the language beside the box in the process of signing the chart. There is no option to sign the chart without clicking the x beside the unacceptable language. How have others who have been in this situation approached this situation (apart from locating alternative employment, which is an option but which takes months)?

Thanks for your input and wisdom.

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[shopsteward]

What sort of place are you working at? In the remote chance that there is union representation, join, as the chances of you as an individual getting anywhere with a request to management to change their charting system for your benefit are slim. Otherwise -

1. Talk to the other doctors at your level in the organisation - are they concerned, what do they do?
2. Is there a space in the electronic chart for you to add something along the lines of "This patient was seen by midlevel X and this chart is completed relying on the truth and accuracy of midlevel X's statements and on midlevel X's having acted to an appropriate professional standard"?
3. Check your malpractice insurance. Are you covered for any liability arising from this situation? Could your insurer can talk to your place of work about what is and is not appropriate wording? It seems to me that there is a wider issue for malpractice insurers here, which insurers could take up as a matter of their own group interest.
4. Find another job. Make sure that your potential responsibility for the actions of others is clear to you before you accept the offer.

 

[docB]

My group does this. Several things are important. If you are not seeing the patients you should NOT be attesting that you did. Attesting that a patient was seen by a physician can justify higher billing. If you sign that they were seen by a doc when they weren't it's fraud. You must either get this wording changed or see every patient who you say you saw.

It is appropriate to document that you were available if you were. Ultimately for any MLP patient you or one of your partners will be responsible. If someone is suing over a MLP case this doesn't really increase or decrease your liability other than clearly identifying that you were the physician.

If you are supervising MLPs and you disagree with a lot of what they're doing that's a different problem.

Since supervising these MLPs is a requirement of your job I would be very surprised if your malpractice does not cover you for any claims resulting front this.

Physician unions are really rare. You can check but I would not expect any help from a union.

 

[salud23]

What sort of place are you working at? In the remote chance that there is union representation, join, as the chances of you as an individual getting anywhere with a request to management to change their charting system for your benefit are slim. Otherwise -

1. Talk to the other doctors at your level in the organisation - are they concerned, what do they do?
2. Is there a space in the electronic chart for you to add something along the lines of "This patient was seen by midlevel X and this chart is completed relying on the truth and accuracy of midlevel X's statements and on midlevel X's having acted to an appropriate professional standard"?
3. Check your malpractice insurance. Are you covered for any liability arising from this situation? Could your insurer can talk to your place of work about what is and is not appropriate wording? It seems to me that there is a wider issue for malpractice insurers here, which insurers could take up as a matter of their own group interest.
4. Find another job. Make sure that your potential responsibility for the actions of others is clear to you before you accept the offer.

Thanks, Shopsteward. The place is a community hospital. There is no physician union. It certainly is fraud to make it look like I saw the patient when I didn't. I expected to sign midlevel charts prior to accepting the offer but never thought to ask if I'd be required to say I saw ALL their patients even if I didn't. That kind of thing seems so unethical I wouldn't have expected it to ever be an issue. Don't people have a sense of right and wrong any more?????

I didn't get to see the electronic chart prior to accepting the offer, so I didn't know this would be a problem until after I signed on. I understand the economics of it - the chowderheads at the top make more money if the chart says I saw all midlevel patients but can only bill at 85% if I didn't see the midlevel's patients. So they want me to say I saw them all, which is probably why they designed the attestation statement to say I saw them all and then provided no way for me to alter the statement if it wasn't true. I love your wording in your comment which makes it clear that the midlevel (not me) saw the patient. I will probably be using some version of it. I've not yet had a shift where I had to sign a midlevel chart here but that will all be changing really soon (please don't ask why because I wish to retain at least some degree of anonymity). I think there is a way for me to add an addendum even after the midlevel has signed their part of the chart, and I'm trying to figure out how to word things in a way that is accurate and does not leave me with a disproportionate amount of liability. I'm in the process of applying elsewhere, but have found that several large management groups out there do the same thing. I worked too hard for this license to risk it by (1) committing fraud or (2) claiming to agree with everything another person did, especially a person whose body of knowledge might not be enough to allow them to render adequate care in certain situations.

 

[Birdstrike]

DocB nailed it. Not seeing a patient does not absolve you of any liability whatsoever. If you are the supervising doc, you are 100% responsible for the MLP patients. The extent to which you distrust them, is the extent to which you need to repeat their work. If you can't trust a specific MLP on simple cases, that person serves no purpose, and should be terminated. A MLP is a physician "extender" not a "physician." You're liable. Period.

A midlevel always increases your liability, even the best of midlevels, simply by increasing your exposure to more patients and therefore more liability, just as you seeing more patients does. The midlevel should allow you to move more patients through the department than you would have normally, and as a result generate enough revenue to cover their salary and cost to your group. Any excess revenue above that is your group's, and therefore yours, to keep. In that scenario it is a win, win. If that excess revenue generated by the midlevel is kept by someone else at your expense in added liability (hospital or mega-group) without sharing the revenue with you, then this is in fact a losing proposition.

As docB says, the check box is strictly for billing. If you didn't see the patient they can only bill 80% of the full charges. Your billing company wants to bill the full 100% on every chart. They are counting on you to see every patient, even if it means you walk in the room, shake hands and leave. It's not necessary to redo every single portion of the history and exam. You just have to "see" the patient.

A doctor here by me recently got nailed by CMS for billing the full 100% on MLP patients he wasn't seeing. He's a doc with multiple urgent care locations and a disgruntled employee blew the whistle on him and got a sizable percentage of the recovered charges as a whistleblower fee. It was an open and shut case, since he was billing this way at multiple locations on the same day when there was no way he could be at all the sites at one time. He settled for a big 6 figure fine. It could have been much worse, as in jail time.

 

[salud23]

My group does this. Several things are important. If you are not seeing the patients you should NOT be attesting that you did. Attesting that a patient was seen by a physician can justify higher billing. If you sign that they were seen by a doc when they weren't it's fraud. You must either get this wording changed or see every patient who you say you saw.

It is appropriate to document that you were available if you were. Ultimately for any MLP patient you or one of your partners will be responsible. If someone is suing over a MLP case this doesn't really increase or decrease your liability other than clearly identifying that you were the physician.

If you are supervising MLPs and you disagree with a lot of what they're doing that's a different problem.

Since supervising these MLPs is a requirement of your job I would be very surprised if your malpractice does not cover you for any claims resulting front this.

Physician unions are really rare. You can check but I would not expect any help from a union.

So you have to claim to agree with ALL aspects of management by the midlevel, not just sign the chart? I'm not used to that, and it seems to be too broad of a statement to me. How do you feel about it?

Lots of the docs here have been here for 15-20+ years. They predate by many years the contract management group that the hospital has allowed to staff and manage the ED docs and midlevels. Age discrimination is still a reality, even in our field. So they don't want to leave, which leads them to accept certain undesirable things on order to be able to keep working . Also, many of them are not EM residency trained and boarded. This limits their job opportunities else. While they don't like the language of that attestation statement, they don't challenge it because they need their jobs. They sign that statement for PA charts without including an addendum and hope that nothing bad happens. The hospital is in a convenient location for me, which counts for something, so it would be nice to stay. However, I do not wish to have my career permanently affected in a negative way by that broad brush “agree with all aspects” statement. I would not say that, in the past, I've always disagreed with large portions of PA and NP charts. But I can say that in certain key circumstances, I've disagreed based on having a body of knowledge that a PA or NP does not have. And in many of those circumstances, it has made a major difference. I recall one case where an elderly patient with back pain that I saw as a bounceback had initially been diagnosed with UTI and muscle strain. A midlevel often looks at back pain through a different lens. They see it as a fast track issue, and treat it as musculoskeletal in origin since that's really what it is in most patients. The prior visit's chart didn't contain anything to suggest that anyone ever asked this elderly patient about things like history of high cholesterol, history of falls, history of osteoporosis, personal/family history of AAA or Marfan's, history of hyeprtension – basic stuff. Even in younger patients, I will ask about these things- while I can still miss something, at least with a decent history and physical, I can show that I tried to be reasonably thorough. I asked the patient certain things that they had not previously been asked, did a few studies, and learned that not only did the patient have compression fractures, they also had a supersized AAA that the surgeon quickly admitted for repair. Even if the patient hadn't had anything but back strain, I'd not want to claim to agree with all aspects of history and mangement of an elderly patient with back pain who wasn't even initially asked basic questions to look for any high risk historical clues (and when asked, this patient had several). I don't want to claim to agree with a history and/or exam that is sketchy and incomplete, even if nothing (that we know of) happens to the patient because anyone reading that chart might think I'm way too cursory. Sometimes the midlevels simply don't have enough of a knowledge base to realize that back pain in elderly people can be be high risk, and I think this is what happened with this patient.

 

[salud23]

DocB nailed it. Not seeing a patient does not absolve you of any liability whatsoever. If you are the supervising doc, you are responsible for the MLP patients. The extent to which you distrust them, is the extent to which you need to repeat their work. If you can't trust a specific MLP on simple cases, that person serves no purpose, and should be terminated. A MLP is a physician "extender" not a "physician." You're liable. Period.

As docB says, the check box is strictly for billing. If you didn't see the patient they can only bill 80% of the full charges. Your billing company wants to bill the full 100% on every chart. They are counting on you to see every patient, even if it means you walk in the room, shake hands and leave. It's not necessary to redo every single portion of the history and exam. You just have to "see" the patient.

A doctor here by me recently got nailed by CMS for billing the full 100% on MLP patients he wasn't seeing. He's a doc with multiple urgent care locations and a disgruntled employee blew the whistle on him and got a sizable percentage of the recovered charges as a whistleblower fee. It was an open and shut case, since he was billing this way at multiple locations on the same day when there was no way he could be at all the sites at one time. He settled for a big 6 figure fine. It could have been much worse, as in jail time.

I'm not of the opinion that if I didn't see the patient, I have no liability. I'm of the opinion that signing a statement which says I agree with ALL aspects of history, physical, and management creates extra liability and could make me look really incompetent.

 

[salud23]

DocB nailed it. Not seeing a patient does not absolve you of any liability whatsoever. If you are the supervising doc, you are responsible for the MLP patients. The extent to which you distrust them, is the extent to which you need to repeat their work. If you can't trust a specific MLP on simple cases, that person serves no purpose, and should be terminated. A MLP is a physician "extender" not a "physician." You're liable. Period.

As docB says, the check box is strictly for billing. If you didn't see the patient they can only bill 80% of the full charges. Your billing company wants to bill the full 100% on every chart. They are counting on you to see every patient, even if it means you walk in the room, shake hands and leave. It's not necessary to redo every single portion of the history and exam. You just have to "see" the patient.

A doctor here by me recently got nailed by CMS for billing the full 100% on MLP patients he wasn't seeing. He's a doc with multiple urgent care locations and a disgruntled employee blew the whistle on him and got a sizable percentage of the recovered charges as a whistleblower fee. It was an open and shut case, since he was billing this way at multiple locations on the same day when there was no way he could be at all the sites at one time. He settled for a big 6 figure fine. It could have been much worse, as in jail time.

I'm also not okay with clicking a box to sign the chart which says I saw the patient when I, in fact, did not see the patient. It makes more money for the people at the top but to me it's just fraudulent. Since the corporate entity who is managing the department designed the chart to say this and fixed things on the chart so that I can't modify the statement, it makes me not think that much about them as people and it says something to me about their desire to make money at any cost. In my region it seems to take a few months or more to credential, so I have to find a way to deal with this for the time being.

 

[Birdstrike]

I'm also not okay with clicking a box to sign the chart which says I saw the patient when I, in fact, did not see the patient. It makes more money for the people at the top but to me it's just fraudulent. Since the corporate entity who is managing the department designed the chart to say this and fixed things on the chart so that I can't modify the statement, it makes me not think that much about them as people and it says something to me about their desire to make money at any cost. In my region it seems to take a few months or more to credential, so I have to find a way to deal with this for the time being.

This is one of many ethical dilemmas we face at the interface of medicine and business. I'm not okay with it either, as I've said in many of my tome-like posts on the subject. I've ranted about this stuff more than anyone on this board. There is a solution, though. See all of the midlevel patients, or don't check the box.

Don't be surprised if most groups with midlevel programs you look at do exactly this or some version of it. Does knowing that make me do it, or agree with it? No.

Just because one understands "the system" and it's ugly inner workings, doesn't mean one has to like it, or be corrupted by it.

 

[docB]

So you have to claim to agree with ALL aspects of management by the midlevel, not just sign the chart? I'm not used to that, and it seems to be too broad of a statement to me. How do you feel about it?

Lots of the docs here have been here for 15-20+ years. They predate by many years the contract management group that the hospital has allowed to staff and manage the ED docs and midlevels. Age discrimination is still a reality, even in our field. So they don't want to leave, which leads them to accept certain undesirable things on order to be able to keep working . Also, many of them are not EM residency trained and boarded. This limits their job opportunities else. While they don't like the language of that attestation statement, they don't challenge it because they need their jobs. They sign that statement for PA charts without including an addendum and hope that nothing bad happens. The hospital is in a convenient location for me, which counts for something, so it would be nice to stay. However, I do not wish to have my career permanently affected in a negative way by that broad brush “agree with all aspects” statement. I would not say that, in the past, I've always disagreed with large portions of PA and NP charts. But I can say that in certain key circumstances, I've disagreed based on having a body of knowledge that a PA or NP does not have. And in many of those circumstances, it has made a major difference. I recall one case where an elderly patient with back pain that I saw as a bounceback had initially been diagnosed with UTI and muscle strain. A midlevel often looks at back pain through a different lens. They see it as a fast track issue, and treat it as musculoskeletal in origin since that's really what it is in most patients. The prior visit's chart didn't contain anything to suggest that anyone ever asked this elderly patient about things like history of high cholesterol, history of falls, history of osteoporosis, personal/family history of AAA or Marfan's, history of hyeprtension – basic stuff. Even in younger patients, I will ask about these things- while I can still miss something, at least with a decent history and physical, I can show that I tried to be reasonably thorough. I asked the patient certain things that they had not previously been asked, did a few studies, and learned that not only did the patient have compression fractures, they also had a supersized AAA that the surgeon quickly admitted for repair. Even if the patient hadn't had anything but back strain, I'd not want to claim to agree with all aspects of history and mangement of an elderly patient with back pain who wasn't even initially asked basic questions to look for any high risk historical clues (and when asked, this patient had several). I don't want to claim to agree with a history and/or exam that is sketchy and incomplete, even if nothing (that we know of) happens to the patient because anyone reading that chart might think I'm way too cursory. Sometimes the midlevels simply don't have enough of a knowledge base to realize that back pain in elderly people can be be high risk, and I think this is what happened with this patient.

Remember that a chart is absolutely not the place to have the "Who's better - doctors vs. PAs" debate. You'll just wind up getting everyone screwed. From a certain perspective you should agree with all aspects of the chart if you were there in the ED because if you didn't you presumably would have changed things or taken the case over. That is how a lawyer would present it (That doesn't apply to the groups who do monthly chart review instead of real time supervision). If you're looking for a way to say "This was my case. I don't necessarily agree with what was done but I'm signing off on it anyway." I think you're ultimately going to create a worse liability situation than what's there now.

Since your main issue seems to be the "agree with all aspects" verbiage you may want to see if you can change that specific piece. I'm lucky in that I can alter our attestation to say whatever I want. I even have different ones to cover patients I personally saw, didn't see, eloped after the PA veal but before I saw them, etc. I like that I can change the attestations to suit me. But I have risk in that my attestations have not been evaluated by our lawyers like the canned ones have. So they actually could be riskier or less billable than I think.

I'm also not okay with clicking a box to sign the chart which says I saw the patient when I, in fact, did not see the patient. It makes more money for the people at the top but to me it's just fraudulent. Since the corporate entity who is managing the department designed the chart to say this and fixed things on the chart so that I can't modify the statement, it makes me not think that much about them as people and it says something to me about their desire to make money at any cost. In my region it seems to take a few months or more to credential, so I have to find a way to deal with this for the time being.

As I mentioned you can never say you did something you didn't. But I sense you don't feel very much connection between the amount of money you bill for and your personal pay. If your job really pays you with no regard to your productivity then sure I can see why you feel you have no obligation to "make more for those at the top." For me if I chart and bill more appropriately it means more money for me (even if it doesn't directly result in additional RVUs like in this case).

So if your job gives you no input or control over the attestations you have to sign and you don't share in any of the financial incentives to bill optimally I'd say the problem is with your job much more than with the concept of midlevel attestations.

 

[spyderdoc]

Our NPs see patients both "with us", like an intern, and independently, so we have 2 different attending notes....

1: This is our NP attending note when the NPs are functioning in a more "intern" role. They will see the patient, present to us, order stuff, etc. I will go see patient as well.....

"I have personally seen and examined this patient. I have fully participated in the care of this patient. I have reviewed all pertinent clinical information, including history, physical exam and plan".

2: This is our note for when they see the patients independently and discharge them without us seeing them.....

"This patient was seen, evaluated, treated, and discharged by the nurse practitioner. I reviewed the chart and care seems appropriate. I was available to the NP for questions and consultation at the time patient was being evaluated in the emergency department."

Thoughts?

 

[salud23]

Thanks, spyderdoc. I was looking for guidance about how to word alternative statements, and this really helps. While I can't alter the text beside the signature box, I can certainly insert these statements elsewhere on the chart and specify that they are to be used as my attestation statement.

 

[Birdstrike]

Thanks, spyderdoc. I was looking for guidance about how to word alternative statements, and this really helps. While I can't alter the text beside the signature box, I can certainly insert these statements elsewhere on the chart and specify that they are to be used as my attestation statement.

You can insert such a statement saying you didn't see the patient, but make sure your group knows you are doing this. If they are relying on being able to bill the full physician fee with the PA patients, putting a statement in the chart saying you didn't see the patient could open up them (and you) to a fraudulent billing charge, if the billing department is on autopilot billing the full 100%, and not the 20% discounted amount. Everybody needs to be on the same page. Most groups want to be able to bill the full amount.

 

[nsd2015]

To revive this thread on a similar vein:

What do you all do if you straight up disagree with the MLPs care, and you were available but not contacted? For example I had an MLP see a young kid with an "ant bite," no indication during the shift that made me think I should have to see this very straightforward patient (I had a pediatric GSW to the face during the 15min this other patient was in and out). I get the chart in my inbox 2 days later and see that PO linezolid was prescribed.

What do you guys do in this case? "I reviewed the chart and in no way agree with the management as rendered."?

This is especially annoying working in places where I am seeing 2-3pph (comfortable) and the MLP usually sees 1-2 low-acuity PPH. While my 2-3 PPH is reasonable, 4-5 PPH when seeing the midlevels' patients is not and I legitimately don't see how this is viable. I could quit, but at every other place nearby this also seems to be the case. As a side note, 50% of the MLPs are excellent, with whom this is NOT a problem.

I think having MLPs you trust is the solution, but shouldn't the ability to fire MLPs come with that responsibility? I can neither fire nor refuse to see charts of MLPs at any place within 40 miles of me. Gah.

 

[Birdstrike]

(error, wrong thread)

 

[goodoldalky]

To revive this thread on a similar vein:

What do you all do if you straight up disagree with the MLPs care, and you were available but not contacted? For example I had an MLP see a young kid with an "ant bite," no indication during the shift that made me think I should have to see this very straightforward patient (I had a pediatric GSW to the face during the 15min this other patient was in and out). I get the chart in my inbox 2 days later and see that PO linezolid was prescribed.

What do you guys do in this case?

Remediate or fire that APP. This type of case should be referred through your departmental PEER or quality channel/

We have a bunch of different attestations reflecting different levels of involvement. The lowest level being:

“I was available in the emergency department for consultation regarding the care of this patient.”

 

[Groove]

I'm pretty sure my CMG hates me for putting these in certain APC charts but here is what I say sometimes when I feel the need:

"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."

 

[Mad Jack]

OP's case could net a pretty hefty whistleblower sum per Medicare rules, or a prison sentence if they kept going along with it and someone caught wind. Wonder how it all turned out...

 

[gro2001]

Can you write something along the lines of:

"Chart reviewed. Called patient to follow up. Instructed to discontinue linezolid. Otherwise agree with plan."

 

[TooMuchResearch]

We don't sign charts on patients we don't see. SDG FTW.

Sent from my Moto G (5) Plus using SDN mobile

 

[Birdstrike]

To revive this thread on a similar vein:

What do you all do if you straight up disagree with the MLPs care, and you were available but not contacted? For example I had an MLP see a young kid with an "ant bite," no indication during the shift that made me think I should have to see this very straightforward patient (I had a pediatric GSW to the face during the 15min this other patient was in and out). I get the chart in my inbox 2 days later and see that PO linezolid was prescribed.

What do you guys do in this case? "I reviewed the chart and in no way agree with the management as rendered."?

This is especially annoying working in places where I am seeing 2-3pph (comfortable) and the MLP usually sees 1-2 low-acuity PPH. While my 2-3 PPH is reasonable, 4-5 PPH when seeing the midlevels' patients is not and I legitimately don't see how this is viable. I could quit, but at every other place nearby this also seems to be the case. As a side note, 50% of the MLPs are excellent, with whom this is NOT a problem.

I think having MLPs you trust is the solution, but shouldn't the ability to fire MLPs come with that responsibility? I can neither fire nor refuse to see charts of MLPs at any place within 40 miles of me. Gah.

I think you just document what happened. You stick to the facts.

“Chart reviewed at ____(time)__. Patient called and advised to ____and _____. “

You have to be careful about the PAs you work with. If they’re good, you may not have to see many of their patients. However, I’ve had PAs where at the start of my shift, I told them, “Do not discharge a patient without talking to me.” I would basically throw out everything he said, and I’d go see the patient and start over.

One patient was presented to me as “Leg pain, rule out DVT. Ultrasound is negative. About to send home.” I went to see the patient, the leg was cold with no pulse.

Another one, same PA, was presented to me as, “20 year old guy with sore knee. Swells up from time to time. X-ray is negative. Can I click the discharge button?” Went to see him. Knee was hot, red, swollen, throbbing like Rudolph’s nose. I tapped it and it was full of puss that looked & smelled like white lava from Satan’s moat. Turned out to be MRSA.

We ended up firing this person, not soon enough, though. Other PAs I’ve worked with, I’d trust seeing my own family unsupervised.

Being medico-legally responsible for providers you have no authority to hire or fire, is problematic, to say the least.

 

[surely]

We don't sign charts on patients we don't see. SDG FTW.

Sent from my Moto G (5) Plus using SDN mobile

Can I come work for you in 3.5 years? Please? You should post a list of the residencies you'll hire straight out of.

 

[Status Sciaticus]

Can I come work for you in 3.5 years? Please? You should post a list of the residencies you'll hire straight out of.

Seconded.

 

[goodoldalky]

We don't sign charts on patients we don't see. SDG FTW.

Sent from my Moto G (5) Plus using SDN mobile

This is the slippery slope that has midlevel practitioners practicing independently and without supervision in some locales and circumstances.

I don’t want to hear you complaining when CMS allows staffing of EDs with MLPs and then your salary drops by 50% within 5 years. Because that’s what will happen.

Although your SDG does this to maximize profit, I don’t think that allowing MLPs this type of latitude is best for patient care, nor is it the correct answer to challenges in supervision.

 

[gro2001]

This is the slippery slope that has midlevel practitioners practicing independently and without supervision in some locales and circumstances.

I don’t want to hear you complaining when CMS allows staffing of EDs with MLPs and then your salary drops by 50% within 5 years. Because that’s what will happen.

Although your SDG does this to maximize profit, I don’t think that allowing MLPs this type of latitude is best for patient care, nor is it the correct answer to challenges in supervision.

Funny, I read that as the opposite. I thought TMR meant all their patients are seen by an MD.

 

[Status Sciaticus]

This is the slippery slope that has midlevel practitioners practicing independently and without supervision in some locales and circumstances.

I don’t want to hear you complaining when CMS allows staffing of EDs with MLPs and then your salary drops by 50% within 5 years. Because that’s what will happen.

Although your SDG does this to maximize profit, I don’t think that allowing MLPs this type of latitude is best for patient care, nor is it the correct answer to challenges in supervision.

I highly doubt this will happen. All it takes is a couple of MLPs to make bad calls for the cost differential to shift them into a liability instead of an asset. Second, MLPs have the ability to move horizontally into different specialties, and they will. The issue concerning MLP practice is more applicable to primary care shortages, not ED staffing.

 

[RustedFox]

I think you just document what happened. You stick to the facts.

“Chart reviewed at ____(time)__. Patient called and advised to ____and _____. “

You have to be careful about the PAs you work with. If they’re good, you may not have to see many of their patients. However, I’ve had PAs where at the start of my shift, I told them, “Do not discharge a patient without talking to me.” I would basically throw out everything he said, and I’d go see the patient and start over.

One patient was presented to me as “Leg pain, rule out DVT. Ultrasound is negative. About to send home.” I went to see the patient, the leg was cold with no pulse.

Another one, same PA, was presented to me as, “20 year old guy with sore knee. Swells up from time to time. X-ray is negative. Can I click the discharge button?” Went to see him. Knee was hot, red, swollen, throbbing like Rudolph’s nose. I tapped it and it was full of puss that looked & smelled like white lava from Satan’s moat. Turned out to be MRSA.

We ended up firing this person, not soon enough, though. Other PAs I’ve worked with, I’d trust seeing my own family unsupervised.

Being medico-legally responsible for providers you have no authority to hire or fire, is problematic, to say the least.

At my one job site; there have seriously been 1 or 2 occasions where I can tell upon review of the chart that the patient was not actually seen at all by the MLP; just had "CT head" ordered and the discharge button pushed when it was negative (for example). I found this out when the nurse came to me to ask "who was going to staple the giant scalp laceration?"

Not even seen. MLP simply saw "head injury in 70 year old male"... ordered CT.... saw result.... discharge button pushed.

 

[TooMuchResearch]

This is the slippery slope that has midlevel practitioners practicing independently and without supervision in some locales and circumstances.

I don’t want to hear you complaining when CMS allows staffing of EDs with MLPs and then your salary drops by 50% within 5 years. Because that’s what will happen.

Although your SDG does this to maximize profit, I don’t think that allowing MLPs this type of latitude is best for patient care, nor is it the correct answer to challenges in supervision.

The only PAs I know practicing solo (with either an on call FP at home or telehealth consult available with BE/BC EM) are very rural, doing 36-48 hour shifts. Those places can't afford to have BE/BC EM.

Sent from my Moto G (5) Plus using SDN mobile

 

[The White Coat Investor]

At my one job site; there have seriously been 1 or 2 occasions where I can tell upon review of the chart that the patient was not actually seen at all by the MLP; just had "CT head" ordered and the discharge button pushed when it was negative (for example). I found this out when the nurse came to me to ask "who was going to staple the giant scalp laceration?"

Not even seen. MLP simply saw "head injury in 70 year old male"... ordered CT.... saw result.... discharge button pushed.

I'm not sure this is an APP problem so much as it is the staffing problem that led to APPs being used in the first place. I mean, how screwed up does your work environment have to get before you can justify that sort of behavior somewhere in your mind?

 

[Arcan57]

I'm not sure this is an APP problem so much as it is the staffing problem that led to APPs being used in the first place. I mean, how screwed up does your work environment have to get before you can justify that sort of behavior somewhere in your mind?

It's actually pretty easy to create the conditions that lead to that behavior. Board in the ED so there aren't rooms in which to evaluate new patients, give no credit to ED nurses for the care they provide boarding patients so they don't have the budget to have a team in triage, create metrics that are impossible to meet without having a provider in triage (LWBS, door-2-doc), then put a significant portion of the provider's pay at risk for not meeting those metrics. Couple that with:
1)a work rate that guarantees that the provider is unable to effectively chart
2) a culture where LOS is king, prompting a nurse to demand disposition immediately on return of all ordered studies
3) a diffusion of responsibility where the person making the decision has no significant liability for the outcome
and I can see it happening. Our job has a lot of fail-safes built in, but those fail-safes are gradually being removed in the name of efficiency and "lean-ness". And in most shops, nobody has enough experience to realize that this isn't how things should be.

 

[RustedFox]

I'm not sure this is an APP problem so much as it is the staffing problem that led to APPs being used in the first place. I mean, how screwed up does your work environment have to get before you can justify that sort of behavior somewhere in your mind?

Yeah, I don't follow what you're saying exactly. No disrespect meant.

I was trying to imply in my statement that the behavior of "just not seeing that patient" is never okay, and would generally be perpetrated by a MLP with zero ultimate responsibility because someone else is signing the chart.

 

[The White Coat Investor]

Yeah, I don't follow what you're saying exactly. No disrespect meant.

I was trying to imply in my statement that the behavior of "just not seeing that patient" is never okay, and would generally be perpetrated by a MLP with zero ultimate responsibility because someone else is signing the chart.

Not sure you understand how APP liability works. Just because you get sued too when they screw up doesn't mean they don't. They also have malpractice coverage and liability.

I agree that not seeing the patient is never okay. I don't see why it would be an APP thing. I do see why it would be a thing in a broken system. Even good people do the wrong thing if they are placed in terrible situations.

Is there some reason I'm missing why an APP would somehow be more likely than a physician to make such a terrible decision?

 

[RustedFox]

Not sure you understand how APP liability works. Just because you get sued too when they screw up doesn't mean they don't. They also have malpractice coverage and liability.

I agree that not seeing the patient is never okay. I don't see why it would be an APP thing. I do see why it would be a thing in a broken system. Even good people do the wrong thing if they are placed in terrible situations.

Is there some reason I'm missing why an APP would somehow be more likely than a physician to make such a terrible decision?

I fully understand how MLP liability works.

I think you underestimate how ignorant (willfully or other) many of the MLPs that I have run across are with respect to their own liability. They truly DGAF because "its the doc that has to sign the chart".

I think its easy to see a correlation between that attitude and poor decision-making.

 

[The White Coat Investor]

I guess they'll GAF when they get to go to court. How can that visit not generate a complaint? I mean, how many of those can you get and still have a job?

 

[shookwell]

One place I worked at tried to make me do this. I used to add an addendum to all the PA charts saying I did not examine this patient and that the PA did not discuss the patient with me and that I was doing a chart review only, and add details of how I disagreed with the PA's management. They stopped asking me to sign PA charts after a while.