Mid-level providers admitting patients w/o MD seeing patient

[Doc_Mcstuffins]

Looking at a hospitalist position in which mid-level providers only do the admitting shift everyday. My question: how comfortable would you be if a PA/NP is admitting patients under your name but you're not seeing the patient? Is this a common thing? Is this a deal breaker and you wouldn't accept a job if this was the case?

I've been told the NP is independent but may occasionally ask the physician questions. PA is highly functional, but her notes require cosignature. The physicians do not usually see the patients unless she identifies a problem that requires the hospitalist team. There is level of trust with the PA since the team is aware of her skills.
Mid levels are only ones who do admitting shift from noon until 8pm.

I'm 2 years out of residency and have actually worked in academic medicine so I did have residents admit patients overnight under my name & nothing bad happened but at my academic center, pas weren't allowed to admit patients unless an MD saw them the same day. I was told by attendings in residency to avoid this situation in which mid-levels admit under your service (especially early in your career) since you're putting yourself at undue risk or liability. I've never worked at this hospital nor do I know anyone who has so I can't vouch for their abilities other than trust their word the mid levels are good.

---

Members don't see this ad.

 

[DaTruMD]

It's too risky man. Don't do it. It just takes one **** up to have your name plastered all over the news/internet even if you do everything right.

 

[visari]

I get your point but, as you said, how is this different from residents admitting under the attending's name from late afternoon until next morning without him/her seeing the patients. isn't it basically the same thing?

 

[Psai]

I get your point but, as you said, how is this different from residents admitting under the attending's name from late afternoon until next morning without him/her seeing the patients. isn't it basically the same thing?

Because the resident is a doctor in training and the midlevel is not a doctor

 

[deleted480308]

The country is too big and there are too many jobs out there to risk everything on a np/pa that you don't know

 

[scpod]

Looking at a hospitalist position in which mid-level providers only do the admitting shift everyday. My question: how comfortable would you be if a PA/NP is admitting patients under your name but you're not seeing the patient? Is this a common thing? Is this a deal breaker and you wouldn't accept a job if this was the case?

Here's what happened to me today. The NP on overnight admits an 83yom w/ a h/o CABG with some "tiredness" and questionable chest pain. The first troponin is negative. The second troponin results about the same time the patient finally makes it to the floor, around 1:30 to 2am. No one bothers to look at it. The call that should have come notifying the oncall person of a critical value never happens. At 10 am I see the guy who I was told was not complaining of any pain and had normal labs on arrival. I look up the repeat troponin and its 14.2. Yes, there should have been a call when that resulted, but there wasn't, and the NP never thought to check on it herself. Who would get fried if something bad happened? Me. My name is on the chart. He went to the cath lab and got stented. All is fine now. But you really have to be careful when you aren't seeing the patient.

Then, there is the billing issue... but that's for another time.

 

[gutonc]

Here's what happened to me today. The NP on overnight admits an 83yom w/ a h/o CABG with some "tiredness" and questionable chest pain. The first troponin is negative. The second troponin results about the same time the patient finally makes it to the floor, around 1:30 to 2am. No one bothers to look at it. The call that should have come notifying the oncall person of a critical value never happens. At 10 am I see the guy who I was told was not complaining of any pain and had normal labs on arrival. I look up the repeat troponin and its 14.2. Yes, there should have been a call when that resulted, but there wasn't, and the NP never thought to check on it herself. Who would get fried if something bad happened? Me. My name is on the chart. He went to the cath lab and got stented. All is fine now. But you really have to be careful when you aren't seeing the patient.

Then, there is the billing issue... but that's for another time.

This particular case is a huge systems issue and should generate a patient safety report (or whatever your hospital calls it) naming the lab tech, the unit secretary, the charge RN, the floor RN, the NP the ED RN, the ED doc and the ED clerk who were involved. Because every single one of those people could have been the point of failure in this case.

But don't pretend that you haven't ever forgotten to follow up on a lab that you either ordered or were signed out. Because that's just BS.

I'm not defending this particular setup, and maybe you're right, the NP was the one who f***ed up. But this really is no different than the scenario where the resident(s) missed the elevated trop overnight and the day team, or well rested attending, are the ones that picked it up.

 

[Geraltofrivia]

This happens often at the community hospital I'm rotating at and it terrifies me. I've also seen midlevels routinely calling for consults which could've been handled by the attending physician as well.

 

[Instatewaiter]

Here's what happened to me today. The NP on overnight admits an 83yom w/ a h/o CABG with some "tiredness" and questionable chest pain. The first troponin is negative. The second troponin results about the same time the patient finally makes it to the floor, around 1:30 to 2am. No one bothers to look at it. The call that should have come notifying the oncall person of a critical value never happens. At 10 am I see the guy who I was told was not complaining of any pain and had normal labs on arrival. I look up the repeat troponin and its 14.2. Yes, there should have been a call when that resulted, but there wasn't, and the NP never thought to check on it herself. Who would get fried if something bad happened? Me. My name is on the chart. He went to the cath lab and got stented. All is fine now. But you really have to be careful when you aren't seeing the patient.

Then, there is the billing issue... but that's for another time.

Would your cath lab have been activated at 2am for an NSTEMI? Most interventionalists won't take a stable NSTEMI in the middle of the night unless they are having unremitting CP, hemodynamic/electrical instability and the like. Sounds like the guy was on the floor so a stable NSTEMI... So probably a near miss because he probably wouldn't have gone to the lab before the morning anyway.

 

[bdth]

this is some outside hospital level BS

 

[gutonc]

this is some outside hospital level BS

Here's the thing man...pretty much everywhere is "outside hospital". I have privileges at/round at 9 different hospitals. They range from the Level 1 Trauma Center/University to the other Level 1 Trauma center/community (the busier of the 2), to a 100 bed near-critical access hospital where my answer is always "transfer downtown".

It's cool to be all high and mighty about this when you're a resident (just like I was), but the reality is that you're more than likely going to practice at outside hospital. So get used to it and figure out how to deal with it.

 

[Instatewaiter]

this is some outside hospital level BS

How so?

 

[Gavanshir]

In my experience, the PAs that I've worked with are like super residents on steroids. They are extremely diligent and thorough and would not miss anything that a resident wouldn't miss. They are also very good team players and easy to communicate with.

 

[DetectiveAlonzo]

In my experience, the PAs that I've worked with are like super residents on steroids. They are extremely diligent and thorough and would not miss anything that a resident wouldn't miss. They are also very good team players and easy to communicate with.

Are they cute doe???

 

[Psai]

In my experience, the PAs that I've worked with are like super residents on steroids. They are extremely diligent and thorough and would not miss anything that a resident wouldn't miss. They are also very good team players and easy to communicate with.

Except you're a psych intern?

PAs are good at their jobs but definitely are not at the same level as the residents. I see them doing things like consulting ct surgery for "tortuous aorta" on xray. If your PAs are just as good as the residents, that means your residents need to step up their game.

 

[badasshairday]

So you would not even see the patient at all after the NP or PA? If you are not seeing the patient at all, then it is totally different from the university set up in which a resident admits patient overnight and you see them th next day.

 

[doctor-mom]

Looking at a hospitalist position in which mid-level providers only do the admitting shift everyday. My question: how comfortable would you be if a PA/NP is admitting patients under your name but you're not seeing the patient? Is this a common thing? Is this a deal breaker and you wouldn't accept a job if this was the case?

I've been told the NP is independent but may occasionally ask the physician questions. PA is highly functional, but her notes require cosignature. The physicians do not usually see the patients unless she identifies a problem that requires the hospitalist team. There is level of trust with the PA since the team is aware of her skills.
Mid levels are only ones who do admitting shift from noon until 8pm.

I'm 2 years out of residency and have actually worked in academic medicine so I did have residents admit patients overnight under my name & nothing bad happened but at my academic center, pas weren't allowed to admit patients unless an MD saw them the same day. I was told by attendings in residency to avoid this situation in which mid-levels admit under your service (especially early in your career) since you're putting yourself at undue risk or liability. I've never worked at this hospital nor do I know anyone who has so I can't vouch for their abilities other than trust their word the mid levels are good.

yes, I turned down a job for same reason.
The pay was more but there is no way I'm risking my career/license on a midlevel without me see-ing the pt.

 

[Raryn]

Would your cath lab have been activated at 2am for an NSTEMI? Most interventionalists won't take a stable NSTEMI in the middle of the night unless they are having unremitting CP, hemodynamic/electrical instability and the like. Sounds like the guy was on the floor so a stable NSTEMI... So probably a near miss because he probably wouldn't have gone to the lab before the morning anyway.

Except that the medical treatment is changed by a positive troponin. If I admitted that guy for CP r/o MI with a negative trop, I wouldn't have heparinized him initially... but once the second one came back I'd have ordered therapeutic heparin and notified the on-call cardiologist. I wouldn't expect him to be cathed immediately (the next morning or even the day after that is perfectly fine), but I certainly would order full medical therapy at that point.

Would heparin make a huge difference? Probably not. But it certainly is standard of care.

 

[Gpan]

So get this, recently I REFUSE to co-sign or supervise any PA/NP . Then the group backed off and said ok I do not have to do it. THEN when I started working. The next day, there are forwarding me some H&P from a NP/PA to co-sign in my message box. F THAT SHHH. so BE CAREFUL OUT THERE. These damn groups will say anything and do anything to get you work for them THEN go behind your back to do the opposite !!!!!!!!

 

[KnuxNole]

This happens where I am at right now, midlevels admit and round on patients. The admits that are assigned are usually observation patients or "simple" patients that they do on their own, if they happen to get a complicated one they usually ask a nearby MD to take a look at the patient with them. Same thing with daily rounds, usually they are completely independent, but once in a while, especially with a complex patient, will ask that a MD takes a look at the patient as well. Although it is "encouraged" for a physician to sign their progress notes for billing, sometimes it gets so busy that none of the MLP notes even get touched.

At first I thought this was a normal occurrence around the US, but after looking at the thread further, it doesn't seem to be the case. Should I actually be worried? I like my job but am worried about the whole liability issue...

 

[VentJockey]

One of my jobs has midlevels who I supervise, and I think the ones we have are really great. One in particular is extremely good, I mean, might as well be a board certified internist. The thing is, these midlevels know when to ask for help. In that community, reality is they aren't ever going to recruit enough docs to staff a hospitalist program without midlevels helping out. And that's going to become the case in more and more instances. I discuss all the admissions with the midlevels, but don't see the patient myself unless I have a specific reason. I feel very comfortable. Yes, something could fall through the cracks, because no one is perfect. But we're talking about overnight admits that get seen by another hospitalist the next morning, and discussed with me that night. I think the midlevels do a very good job of appropriate disposition, initial treatment and starting the workup. They also do a great job of knowing when I need to get involved right away. I had one midlevel get handoff from another hospitalist about a patient, it didn't sound right, they did some digging and then came to me and I ended up transferring the patient to the unit. Basically they caught something another attending didn't. So, in short, I consider mid levels to be a valuable part of our team and I'm very comfortable working with them. Yes, humans are humans, but I think the ones I work with do a good job and I'm very willing to continue working with them. I also think the massive shortage of physicians, which in some places is crippling hospitals and stressing the docs we do have, pretty much means we'd better get on board with the wise use of mid levels because the need out there is way greater than all the hospitalists in the country can handle. And when you have 20 admits in a night, you have to ask which is better: 1) I see them all myself--which means high risk of mistakes when I'm doing one admit every 35 minutes, 2) Let them pile up in the ER and wait until the day people get there, or 3) Smart use of a midlevel to get them their initial care, dispo and workup. I think the 3rd option is realistically the best for the patients. Maybe some day I'll get sued because of something a mid level did. And my defense will be that we are doing our very best with the resources we have in our community.

 

[DaTruMD]

And my defense will be that we are doing our very best with the resources we have in our community.

I don't think that defense will get you off the hook.

 

[dhavalp]

One of my jobs has midlevels who I supervise, and I think the ones we have are really great. One in particular is extremely good, I mean, might as well be a board certified internist.

 

[VentJockey]

I don't think that defense will get you off the hook.

You're right, probably won't. In essence, the argument I'm seeing in this thread, and in 100 other threads about whether hospitalists should do certain procedures, or when to call a consultant, is to mitigate one's risk in every way. I tend to think its an argument of someone who has never practiced outside the walls of a tertiary care center full of specialists sitting around twiddling their thumbs all day. In most of the country, there's a dire shortage of hospitalists. There's an even more dire shortage of specialists. That means we have to take on situations that have risk for the good of our patients and our communities. The idea that midlevels shouldn't work in a hospitalist environment, or that an attending should re-do all of their H&Ps if they do, is not realistic to the resources available in a large number of communities in our country. Its also not realistic to suggest that someone with the skills and traininig of a board certified internist like myself is really necessary for the first 12 hours of a hospitalization for a large portion of our patients. Midlevels have a very legitimate role to play in our health care system, and in fact it is an essential role since there aren't enough doctors. Bad things do happen to good people. I could get hit by a car walking across the street. I could get sued because I'm supervising a midlevel. But I'm not going to retreat from working to meet the needs of my community simply because there is risk. Realistically, mid levels need to play a non-trivial role in hospital medicine, and I'm happy to support them in doing that, because I want to see patients get the care that they need. A better conversation to have is what constitutes appropriate supervision of a midlevel. The way I do it is I triage the calls from the ER and assign the cases to the midlevel that I think are appropriate to them. Then, I discuss the patients with them, and see any ones that I think it is necessary to see (i.e. things don't add up, there is a questionable physical exam finding, there is high risk of decompensation, etc). Then, the next morning, the patient is seen by the rounding hospitalist (a physician). I think this is an appropriate level of supervision. If you are just getting random charts to sign from a midlevel you don't know, from patients that haven't been discussed with you, this is probably not an acceptable level of supervision.