Mid Level Attestation

Discussion in 'Emergency Medicine' started by CreoleDoc, Feb 10, 2019.

  1. CreoleDoc

    CreoleDoc Gettin close
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    All,


    I've been an attending for <1yr and work at quite a few hospitals. Each one obviously has different staffing models but there are a couple that allow mid levels to run a "fast track" area where patients are seen completely independently without discussing the case with me. MOST of the time things are good but occasionally i'll review a chart with questionable management (at least per what is dictated in the chart).

    I have taken time to discuss these individual cases with said mid level but I wonder going forward if I am protected in anyway from these cases where I was "available but not consulted with" and am only review the chart on the back end. Thanks
     
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  2. migm

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    Your name is on the chart. It doesn't matter what you put in there. If that person is getting sued, so are you.
     
  3. namethatsmell

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    So the safest thing for the patient and you is to have your chair/medical director be responsible for signing all of these midlevel charts on patients you don’t see. It places the risk with somebody who actually has hiring/firing/remediation power and thus will likely lead to more appropriate guidance of midlevels thus making it safer for patients. The chair/Med Director also gets paid for admin tasks like this while you do not. Talk to the other pit docs and band together and ask for this- I’ve seen this work successfully at multiple places.
     
  4. Stagg737

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    Nope. As said, if your name is on the chart then you're liable as the supervising physician. Idk how realistic it is for your situation, but if you're required to supervise mid-levels then namethatsmell's idea of having the med director/chair sign the charts of patients you don't see is what I'd push for.

    Personally, if I didn't get to see a patient or I wasn't very familiar with them (not realistic for most ED cases) I wouldn't take a job where I had to sign that chart.
     
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  5. deuist

    deuist Stealthfully Sarcastic
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    Unfortunately, you are correct. Most of the CMG jobs are going to have you co-signing charts without ever seeing the patient.
     
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  6. Groove

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    Is anyone actually familiar with a case where the physician signed the chart but was otherwise never involved in their care and was successfully sued? (I.e. lost the case or settled) It seems to me that you could probably manage a decent defense. Especially if you are forced to sign these.
     
  7. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
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    I'll let you know.
    Signed MLP chart, never saw patient. Patient seen by next doc after shift change.
    Sued.
     
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  8. Groove

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    Yikes. They sued the MLP too though, yes? Probably just naming anyone in the chart. I seem to remember an old med dir telling me he got named for a MLP chart and then dropped.
     
  9. RustedFox

    RustedFox We're all stars now. In the GOAT RODEO.
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    Yep. Sued me, the MLP, and the doc that actually saw the patient.
     
  10. TheComebacKid

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    Just out of curiosity, do mid levels purchase malpractice insurance? How does "suing" a mid level work exactly?

    I was under the impression physicians primarily take on all the liability of mid level provider work
     
  11. southerndoc

    southerndoc life is good
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    Yes.
     
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  12. southerndoc

    southerndoc life is good
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    They can be sued individually just like a nurse can be sued. If the APP and/or doc are employed, they will also sue the employer. Respondiat superior (specifically master-servant rule) doesn't always apply because it was professional services rendered.
     
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  13. thegenius

    thegenius Senior Wharf Rat
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    No.



    I speak from experience, not empiricism.
     
  14. thegenius

    thegenius Senior Wharf Rat
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    Me!
     
  15. Groove

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    I thought this was interesting:



    In addition, many physicians have misconceptions about insulating themselves from liability. It is commonly assumed that if physicians distance themselves from the care provided by advanced practice providers, they will limit their liability exposure. However, this is only partially true. As a supervising physician, it is likely you’ll be named in a claim and lawsuit if negligence is alleged regarding an advanced practice provider you are supervising. This is particularly true when you are physically located in the same treatment area (e.g. emergency department) and at the same time as the advanced practice provider.

    If the supervising physician was never informed about the patient, this would be very useful in their defense, as one cannot be expected to provide care for those they do not know exist. However, if the advanced practice provider discusses the case with the physician or the physician knew or should have known about the patient, their inaction will likely be challenged as unreasonable.

    Reasonableness of actions is the underpinning of all tort liability claims. Operational policies that clearly define how advanced practice providers will function in your emergency department and the physician’s supervisory responsibilities are very risk protective. In other words, if an advanced practice provider saw a patient and the physician did not see the patient and did not discuss the case with the provider, the physician will have a strong defense if that level of supervision comports with the department policy defining the required level of supervision.
     
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  16. Birdstrike

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    You are "protected" only in the sense that your malpractice insurer will defend you when you're sued regardless of what happened, whether there's a mid-level around or not. But you are in no way protected by your lack of involvement. In fact, that could make you more liable. That's the Catch 22 of supervising people. If you were closely involved and malpractice occurred, you're potentially liable because you were closely involved and didn't do things differently. If you weren't closely involved and malpractice occurred, you're potentially liable because you weren't supervising (which is your duty) closely enough to make sure things happened differently.

    Any setting where you don't have control over hiring or firing the mid-levels, yet incur increased reliability without directly benefiting from having a mid-level through either increased pay, more time off or lessened workload, you're getting a raw deal. Most likely, where you work, they'll probably tell you that you benefit in one or all of those 3 ways. But unless you're doing the hiring and firing, managing the finances or are able to directly compare the job with mid-levels and without mid-levels, there's no way to know if that benefit is really flowing to you. It may be. Or, the benefit of having midlevels mid-levels could simply be getting skimmed off and kept by the people running the show. And ultimately, all three of those benefits of having midlevels (increased pay, more time off or decreased work load) are financial or can be converted to a financial value (time worked = patients seen = salary = dollars).

    I like the idea of working with a good mid-level if I have control over the hiring/firing and finances. In that setting, both the mid-level and the doctor (who's also the employer) benefit. I do not like the idea of someone putting a midlevel next to me as an equal, who I have no role in hiring/firing, yet to whom I have to donate an umbrella of liability protection to, while gaining no benefit in finances or work load. That scenario is all win for the mid-level, a lose lose for the doctor, and all win for the employer. Most EM jobs use some form of the second scenario.
     
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  17. turkeyjerky

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    So it seems like the worst possibly policy is when mid levels can see patients independently, but the doc is then on the hook to sign the charts after the fact.

    Out dept (enshrined in policy) has the mid levels see the ultra low acuity pts independently, but we never review the chart or anything--so in the event of a suit I could claim to never have had a relationship with the patient and should be off the hook, right? Higher acuity patients get discussed with the doc real time, and generally I'm personally seeing and involved in these cases. (our mid levels generally function at a lower level than other shop--they're not seeing critical or complicated patients)

    Honestly, it seems to me the best personal policy be that, if you are expected by your corporate overlord, to sign off on midlevel charts, that you have them staff the case with you real time.

    For the posters above who've been sued for midlevel cases or are aware of them. Did you just sign the chart, or did you sign a chart writing a caveat that you were availed, but never actually consulted by the midlevel?
     
  18. RoyBasch

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    This IS the policy of many community shops.


    Not off the hook at all. If anything you are at greater liability because you have a duty to supervise the midlevel and you negligently failed to do so as indicated by your documentation if you write something like "I am signing this chart administratively but did not see the patient and was not involved in their care..."

    Furthermore, "ultra low acuity" is relative in emergency medicine. "Triage" is not a perfect system. Everyone who has been practicing for a little bit can regale you with stories of a level 5 dental pain that had an acute STEMI or a level 5 foot pain that was in septic shock, etc. etc. I would say midlevels are particularly poorly trained to recognize these cases and their attendant bad outcomes. In my experience across the board mid levels consider much narrower differential diagnoses and much more likely to fall victim to anchoring bias ("there's just no way that level 5 foot pain could have a bad infection...")

    Most community shops are busy enough and staffed such that there is literally not enough time to see all your own patients and STAFF all of the midlevel patients and see them as well. It is not like an academic shop where the attending is staffing every resident case. In the community the attending has many of their own cases with no additional mid level or resident support to help with documentation, phone calls, reassessments, orders, etc.

    My personal approach is to be peripherally aware of every mid level case, check the vitals, triage note, orders and workup. If everything seems to add up I just passively allow things to move forward. If something is not adding up I will bring it up with the midlevel and discuss the case with them. If my take is that the patient seems sick (vitals, workup, triage note, etc) I have a low threshold to step in and actively manage the case, or to boot the mid level off the case and take over entirely. I do read the mid level charts I sign carefully and if I have questions I call or email the mid level and sometimes we do have to call patients back if something important was missed.

    Mid levels are here to stay in EM, their liability is your liability and it's just part of the game. It's wistful thinking if you think you can work with them and the "right" written legal gymnastics will somehow protect you from their miss if and when it happens.

    If you absolutely cannot stand the possibility of shouldering mid level liability you can practice at a shop with no mid levels. This will almost always be 12 hr shifts in low volume areas. When they have surges of patients you will sometimes wish you had a mid level.

    The quest to avoid mid levels will greatly limit your employment options and many of the jobs without them have lower pay because the better wages are made possible by the more extensive collections enabled by greater patients per hour seen enabled by midlevels.
     
    #18 RoyBasch, Feb 11, 2019
    Last edited: Feb 11, 2019
  19. turkeyjerky

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    Just a quick point since you responded personally to me. Our departmental policy is that MDs are not involved in level 4s and 5s send by a midlevel, unless requested. If they see a 3 or above we have to be nclved and policy is that we personally see the patient (not always followed, and might just be a drive by). But if I don't see the patient I don't sign an attestation, my names not on the chart. I do think this is a reasonable policy, although it occipital leaves met in the table. I'm employd though, so I doubt it would hold for a SDG.

    But can you point any case law establishing that "being against to supervise = establishment of a physician-patient relationship". I don't know, that's why I'm asking

    Not news to me. I have had a few NPs come through who are used to this, and its a pain to break them of the habit.
     
  20. thegenius

    thegenius Senior Wharf Rat
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    Guys this is pretty straightforward.

    If there is a state law that says something to the effect of
    "NPs, PAs, APPs, [whatever] must all be supervised by a physician"

    then they do not work independently and the supervising physician CAN / WILL get sued along with anybody else the plantiff's attorney wants to sue. That includes nurses, the hospital, chief of the ED, anybody

    If the supervising physician is not identified on the chart, the plantiff's attorney will find out, one way or another, who is the supervising physician. If I were a plantiff's attorney and the chart didn't specify the supervising physician, I would sue all docs who worked on that day. And I would consider suing all doctors who worked for that ED group if they signed a contract saying they would be a supervising physician.

    I would sue whomever I want, for the maximum amount of money I could possibly get.
     
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  21. thegenius

    thegenius Senior Wharf Rat
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    Who is the supervising physician on those level 4 and 5 charts?
     
  22. turkeyjerky

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    There isn't one

    Edit--there isn't one clinically or for billing. Legally it's the Dept chair's
     
    #22 turkeyjerky, Feb 11, 2019
    Last edited: Feb 11, 2019
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  23. namethatsmell

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    That’s about the best system one could hope for, unless you’re in an “independent practice” state for NPs...then they can spread their wings and roll the dice for themselves...
     
  24. RoyBasch

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    The legal requirement to be supervised is one of the few backstops that requires ERs to actually have us (board certified physicians) at all. Once this is gone, we will be gone or at the very least our wages will be significantly depressed. Whatever minor victory is won by not being legally responsible for mid levels will be Pyrrhic, in as much as we will not be be as employable and at as high wages.

    I would not assume that hospitals/employers are very concerned about differences in quality of care that board certified physicians provide compared to midlevels. I would also not assume patients even know or care either.
     
  25. EmergDO

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    I'm pretty sure I remember SouthernDoc saying that NP independence does not remove much of the liability from "supervising" them, because the courts still consider the physician to be the highest level of available care or something like that.
     
  26. namethatsmell

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    Perhaps you're thinking of docs who agree, in a contract, to supervise midlevels. Otherwise this makes as much sense as a self-employed independent primary care NP getting sued and having the self-employed independent primary care MD in the building next store getting added to the suit.

    As mentioned, a lawyer will add every single name they can to a suit. Many will be removed as they throw their muck on the wall to see what sticks.

    Nothing is impossible, but I would not lose any sleep about being sued if supervising mid-levels is not in your job description.
     
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  27. EmergDO

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    It's definitely possible that I'm confused, it was a little bit ago and don't remember exactly. I would 100% love to be wrong.
     
  28. thegenius

    thegenius Senior Wharf Rat
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    This is especially true for the level 4 and 5 charts.

    Hard to saw what patients want....it's multi-factorial
     
  29. Birdstrike

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    Yes. Every mid-level has at least one default "supervising physician" listed, somewhere, for this exact reason. It may be the ED director, group president, "acting physician on duty" or it might your name on some paperwork somewhere. That way, even if no doc touched the patient, saw the patient, talked to the PA, or was anywhere near the building the day the patient was seen, somebody is listed somewhere as the default supervising physician for that mid-level. Lawyers aren't stupid, guys. They know how to find your malpractice insurance money-pot.
     
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  30. KGflyboy

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    What about all the independent practice states? Why would there ever be a physician supervisor listed anywhere if they are working independently? In theory, a group of NPs could form a SDG and staff an ED without any docs involved on paper or in person. I'm not saying this is happening, and my example is extreme, but the law does allow this in most states.
     
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  31. illegallysmooth

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    My midlevel attestation says something about how I was available for consult and they did not consult me. I do not expect it to exonerate me in a lawsuit. I hope it will lower the percentage of fault they decide to pin on me. Keyword: hope.
     
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  32. Groove

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    Re-posting from an older thread.

    I have no idea if that statement protects me in any legal way but IMO it certainly can’t hurt.
     
  33. WilcoWorld

    WilcoWorld Senior Member
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    Does your billing/coding department ever give you a hard time about that verbiage?
     
  34. Groove

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    Never. Again though, I’m only using it on the high risk charts. The rest, I don’t put any attestation at all, I simply sign. I only attest if I was actually consulted or if I saw the pt. I feel I could mount a better defense if I ever got dragged into a suit on the non-attested ones since CMG essentially forces us to sign these.
     
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  35. Nikj

    Nikj NigelWhiskers
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    Question, for those of us who have no contract experience.

    When you enter into a contract with a CMG, are they requiring that your name automatically go on the charts of any of the patients who are taken in during the time you are working, regardless of if you or a NP/PA saw them? Or is it more of a "if you don't put your name on it we'll piss you off so you quit, or we will figure out a way to fire you." ? And in both situations, are you still required to sign the patients file that day, or soon after, to meet not your contractual obligations with the CMG but your legal medical requirements? Basically my question here is that if you don't sign the chart, obviously you are probably breaking contractual obligations, but are you breaking legal medical laws and thus liable?

    I feel like the current arrangement by the CMGs is breaking anti-trust laws. Specifically that they (the CMGs) are the primary employer in many regions/hospitals while simultaneously having the "requirement" of Physicians to sign the charts of patients of whom they have not seen, thus exposing them to the un-do burden of risk of lawsuits.

    Following up, if a mid level is practicing in a state where they have independence, what benefit does the CMG have in placing supervisory burden in the laps of Physicians? Does it make them less liable and at risk for being sued? Because if they are then this would further add to a reasonable argument of violation of anti-trust laws.
     
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  36. Groove

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    Good questions. It depends on the state, hospital bylaws, and CMG policy. Lack of independent practice rights in a particular state necessitates the need for physician supervision and makes the issue more simple. Ultimately, medicare and medicaid stipulate that for payment to be made for services rendered by an MLP, all regulatory guidelines must be met for that particular state. In states without independent practice authority, a physician must cosign the charts. Even in states allowing independent practice rights, you will still likely be expected to sign the medical charts. Again, you not only have medicare/medicaid state requirements to think about but also hospital policy and CMG policy. Between all of them, it would be the rare exception to find yourself in a job where you simply aren't required to sign APC charts in any capacity.

    Now, the reason most CMGs want you to cosign the charts is multifactorial (see above) but ultimately it all comes down to billing. APCs can only bill for 85% of the physician fee schedule for medicare. If the physician is consulted, examines the patient or otherwise is involved in the medical decision making, then as long as an attestation qualifying that involvement is included in the chart, the service may be billed at 100% physician fee schedule. So....CMG is VERY interested in incentivizing you to put as many supervisory attestations as possible on the APC charts....so they can bill 100% We're talking about big breadcrumbs lost off the table when you neglect to add a supervisory attestation. What happens when you simply sign it without adding the attestation? It simply gets billed for 85%

    Most CMGs will every so slightly pressure you to add a full supervisory statement without going so far as to require it. Why? Because, if you didn't actually see the pt and/or provide medical decision making, then adding a supervisory statement to that effect would be fraudulent billing. So as to minimize any chances of mass revolt from the physicians against APC supervision and subsequent increased malpractice risk, they closely align APC supervision with your compensation. What does this mean? At most shops, this means that the more charts you co-sign, the more you get paid. At my current gig, this can equate to almost $25/hr and more in some places. The clever part is that in many shops, if you add a supervisory attestation so that they can bill for 100% the physician fee schedule, you will see the increased billing compensation show up in your paycheck. This is a strong incentive for you to commit fraud and I've seen plenty of docs do it where they add a supervisory attestation and never saw them or talked to the APC about the pt. The CMG can't be blamed because they never actually required you to provide the attestation in your contract.

    In short, most jobs will require you to, at the very least, sign the APC chart and provide supervisory management, especially if you are consulted on a patient in the ED. Most places will not force you to add supervisory attestations, though they will provide strong incentives for you to document them although this will increase your medicolegal risk exposure. I'm obviously not a lawyer, but my perception has always been that simply signing the note out of expected obligatory duties for your hospital/employer is much lower malpractice risk vis-a-vis adding a supervisory attestation....but it's not zero. I don't know if that answered all of your questions but hopefully sheds some light on the issue.
     
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  37. Dr.McNinja

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    You'll also have to sign the LWOT/LWOBS/Eloped charts as well.
     
  38. Nikj

    Nikj NigelWhiskers
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    You did clarify a few things, but one thing I am still not grasping is the responsibility part. So for my understanding I'll give two scenarios, if you could answer them.

    For both scenarios lets consider practice in a State where midlevels have full independent practice.

    Scenario #1: Physician in ED, has contract with CMG that says they support/advise midlevels. On a random day, a patient comes in, is seen by a midlevel, the midlevel does not consult or ask for help in anyway from the Physician. The Physician does not sign/attest the patients chart. The midlevel missed an obvious EKG finding, and the patient dies of an MI at home. Who is responsible in this scenario?

    Scenario #2: Physician in ED, has contract with CMG that says they support/advise midlevels. On a random day, a patient comes in, is seen by a midlevel, the midlevel asks for consultation but the Physician is unable to provide consultation because they are stuck in, lets say trauma, so the midlevel continues with their plan of care, and the patient leaves. The Physician refuses to sign/attest the patients chart later on because they were not involved in any aspect of care. The midlevel missed an obvious EKG finding, and the patient dies of an MI at home. Who is responsible in this scenario?

    When I say responsible, I mean who is at risk for malpractice, not breach of contract.


    Also with such control over the market, why would Physicians allow this negotiation power to lie with the CMG? I mean if all physicians stopped co-signing charts tomorrow the entire system would collapse. Should be way more SDG's in existence.
     
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  39. shookwell

    Physician 10+ Year Member

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    I refuse to take jobs where I am expected to sign midlevel charts unless the midlevel fully presents the patient to me prior to dispo. That means I turn down some locums gigs but that practice is complete bull****. If you want a doctor who wasn't involved to sign the charts, it can be the director or some admin, no reason for me to do it. I wish we were all in the position to do this.
     
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  40. Groove

    Groove Member
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    In virtually all shops, EKGs are reviewed by the attending physicians who are obligated to sign them and per most hospital policies, indicate the presence or absence of STEMI. Therefore, both scenarios are a bit unrealistic. For the sake of argument though...

    #1 This is a question for a malpractice attorney. Nobody really knows. I would argue that the primary malpractice burden lies on the MLP who independently saw and managed the pt. However, as others have alluded to on here, that does not exclude the possibility of partial culpability on the part of the co-signing physician as well as culpability on the part of the supervising physician listed on their credentialing paperwork.

    #2 Unrealistic scenario but the answer would be similar to #1. In reality, if you are tied up in a trauma, they are going to find another attending who is free. If you are the only attending and they needed your help with management, then they are probably not going to discharge them before you are available to assist. Regardless, if they consulted you, chances are they are going to put your name in the chart that you were consulted so it would be unwise not to add an attestation clarifying your involvement or lack thereof in the pt's care.

    Again, the culture of co-signing APC charts is multifactorial per my first post for all the reasons that I listed. It's not a CMG vs SDG thing, you would easily find yourself needing to sign them in an SDG for all the reasons that I listed. The difference being that you might have a bit more of a voice in group policy making decisions. (I.E. In exchange for no APC signatures, group floats idea of fixed salary or RVU (lower compensation, but no APC component), medical director has to sign all charts and in exchange demands higher stipend and compensation to offset increased risk, group votes on it....etc.)
     
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    Last edited: Feb 17, 2019 at 4:33 PM
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  41. Groove

    Groove Member
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    The easiest jobs to find where you can make these types of stipulations/demands are locums jobs where you are desperately needed and nobody really cares that you won't sign APC charts as the medical director or full time docs are happy to sign them instead and benefit from the increased compensation. Then again, most people don't do locums long term.

    If you've found a FT gig at a nice place where you don't have to sign any APC charts, consider yourself to have found a diamond in the rough. Definitely not the norm.
     
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  42. MechEDoc

    MechEDoc maybe minor rocket surgery...
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    They aren't. I worked at a HCA facility that proudly advertised 100% board certified physicians. It was a 100% lie. I wasn't board certified at the time (board eligible), there was another doc who never did his boards... 30 years ago and as a result could never sit his internal medicine boards. Never mind the FP that sucked at procedures and fell behind by $400k+ of charting (he got fired). And this is ignoring the 50% of the patients seen by the PAs and NPs. Three of the midlevels were very good. They got offered $30 more and hour by a private group. The CMG couldn't nearly match their pay and replaced them with a fresh DNP that was pretty clueless and wore jeans to work in the ED...
     
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  43. RoyBasch

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    Like skiing in jeans.
     
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  44. Vandalia

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    You didn't understand. What they meant was that 100% of their board certified physicians were board certified.
     
  45. pencilcase

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    Some of the hypothetical questions above assume all physicians have the same ideas, pressures, personalities and ideals in life. We cannot all just walk out of an ER that requires we sign mid level charts. A lot of docs cannot just leave a job at the drop of a hat... they have houses with mortgages, children in schools in the area etc. The same applies to when SDGs get bought out by CMGs. The docs resist until they can’t anymore and then the group is sold.

    Disclaimer: I do not work with midlevels directly at my current job.

    Even in states with independent Midlevels, in the ED, the midlevels must have a supervising doctor. That’s what my past medical director said when I asked. As far as who the supervising doc is: depends on the healthcare system. Tenet requires it to be a doc actually on duty at time the patient was seen. In the VA EDs, the midlevels do have independent practice without needing co signatures.
     
  46. pollyspockets

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    As someone graduating this summer, how do you judge jobs that have you with mid levels? The sdg I think I will be signing with has 1-2 apps on at a time and all patients are to be staffed with attending. There is double attending coverage about 18 hours of the day.
     
  47. Hercules

    Hercules Son of Zeus
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    What do you mean by how do you judge them?
     
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  48. BoardingDoc

    BoardingDoc Don't worry. I've got my towel.
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    You judge the job the way you would judge any job. Money. Location. Hours. Working environment. etc etc etc. As far as the midlevel situation goes, you're going to be in one of 4 camps.
    A: there are midlevels who basically work on their own. You will likely be expected to sign charts.
    B: you will have some cases presented to you and some not and you can vary your attestation accordingly
    C: you work at a shop where the midlevels function essentially as residents and run every case past the attending. Whether you choose to physically see the patient or not is your call.
    D: There are no midlevels

    It sounds like the sdg you're looking at is option C. This is currently the situation I'm working in as well and I'm fond of it. I know which PAs I trust and which I need to pay closer attention to. I generally try to physically see most if not all of the midlevel patients after hearing about them, but that's just my personal practice. It only adds about 5 min total to see the pt, examine them and write a small attestation assuming they are as presented. If not, I'm glad I saw them so I can modify the plan.
     
  49. Groove

    Groove Member
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    Personally, I think the best situation is having MLPs working semi-independently in a low acuity fast track. I don't want to see toothaches and ear infections all day long. Nor do I necessarily want or need to hear about them. By having them see very low acuity FT pt's, that minimizes risk and allows the docs to see all the higher acuity pts. We currently have a similar system at my current job and I don't mind it as long as they stay in their area and triage is functioning appropriately. When they have a mis-triaged pt that looks more complicated, they come and find me.

    Another exception worth mentioning is whether the ED has medical pods or not. In one of my old jobs, the MLPs treated higher acuity pt's, however these were in isolated medical pods working closely alongside an attending. We sat next to each other, the pt rooms were only a few steps away and I could closely see exactly what they were doing and even though we didn't have to talk about every single pt, they would frequently run things by me or ask me questions and it worked pretty well. I didn't mind that system either and the MLPs were strong at that site.
     
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  50. deuist

    deuist Stealthfully Sarcastic
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    I like the idea of having midlevels perform the easy, yet time consuming procedures such has sutures, splinting, and incision/drainage. The physicians could see the patients, come up with a treatment plan, and then have the midlevel perform the necessary tasks.
     
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