Midlevel supervision - am I crazy, or is this crazy?

Discussion in 'Emergency Medicine' started by RuralEDDoc, 10.01.14.

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  1. RuralEDDoc

    RuralEDDoc

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    Hi all,
    Long time reader here. I have appreciated the collective wisdom on this board for years.
    I'm a new attending (2014 grad) and am working at a rural ED in California. Closest tertiary hospital is 50 miles, closest university quaternary hospital is about 150 miles.
    We're busy for a rural hospital, ~55k visits/year.
    My job is ok overall, the nursing staff is actually pretty great, the ancillary staff is hit or miss, as are the hospitalists/specialists. Double coverage physician staffing during the day, single coverage at night, which honestly is absolutely brutal.
    My real question is about midlevel (an accepted term where I work, not meant to be derogatory) supervision. Our ED has about half of the patient volume seen in a "rapid care" area where patients are seen, treated, and dispositioned by PAs and NPs. Supervision is indirect. PAs/NPs can ask for help on a patient, or ask a clinical question, but it is entirely up to them to choose to do so. On an average shift, I get 20-30 charts to sign for patients seen by the PA/NP, and I have probably been told about one or two of them.
    I am expected to sign these charts without having the opportunity to see the patient. Many have been gone for 6+ hours by the time I see the chart. Charting by these providers is minimal, with no real medical decision making/ED course documented. Most of the cases are truly low acuity, ESI 4/5 cases, but there is the mix of back pain in the ~50 yr old population, febrile infants, epigastric pain in ~45 year old patients, "mechanical fall" in the elderly, etc., that on the surface are simply and low acuity, but have the potential for disastrous underlying pathology.
    PAs/NPs sign the charts, give them to me, then leave. I have the opportunity to call the patient back and ask questions, but that is difficult in the setting where I am seeing over two patients per hour in a high acuity setting.
    I am curious if this is a common scenario in rural settings with shortages of ED docs, or is this a crazy scenario. My gut says that this is the very definition of a high risk scenario that could have devastating outcomes for patients and my personal professional career (from a medical legal standpoint). I am told by some that this is very common, that I should get used to it as it's the wave of the future. I would like some feedback from other attendings - is my gut right, and I should flee, or is this "the real world" that they didnt talk about in residency?
    Sorry for the long post, and thank you for any responses.
     
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  3. two guys

    two guys 2+ Year Member

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    It is BOTH common and high risk. Whats more, depending on your payment model you may be losing income for giving your "supervision."

    What's your employment model? If its a SDG you have a decent chance at making some changes once you've been there a little longer. If you're not the one actually employing the midlevel (most CMGs and employee models) its a lot harder. Talk with your leadership about you're concerns, bring specific cases. Get to know the midlevels. I've started giving little 2 minute talks based on the previous days charts.

    I generally like having midlevels and have nothing against them. But I do think it is a complete farce for me to sign "I have reviewed and agree with the medical decision making" when they work in a different physical location from where I am and I like the ability to provide any type of feedback in real time on their care.

    As a new guy, you're up against the fact that the docs before you have just held their breath and signed the charts. This is now "the way everybody else does it." It shocked me at how hard it was to get my partners stirred up about this.
     
  4. sum dude

    sum dude 7+ Year Member

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    Welcome to the real world...this is common for most groups. Fortunately, they should be low acuity. I'd recomend talking with all the PA/NP's, encouraging them to ask you questions, ask to see any admissions, and be real nice and open with them about coming to you. There is nothing you can do about it--this is reality in most practices. You should also tell them to chart a little more to your liking (a few emails telling them what you'd like I've found usually fixes the problem--Midlevels are like residents in that they adjust work up according to attendings.) I'd also talk to the doctors at your group and ask them about what PA's you might want to "more closely watch," If it really bothers you, you might consider switching groups.

    On the brighter side, I've found most of the midlevels I work with are much more conservative than I am, overwork-up everyone, and are a big help when I need them. In general, I've found the older Midlevels' charting is terrible but clinical decision making is usually really good. One thing you might consider doing is going through charts at the end of the day--any patients who were discharged who you are uncomfortable with you can do a follow up call in a few days to see how they are doing--will increase Press Gainey and ease your mind....again, sorry, but this is reality. I'm sure there are groups that don't do this (academic maybe?), but I've worked at 6 different Community Centers, and they all did this.
     
  5. TimesNewRoman

    TimesNewRoman 2+ Year Member

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    I've seen some attendings document : I was available for questions but did not examine the patient.

    Is this common?
     
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  6. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    My department's standard documentation in such cases is, "I was present in the Emergency Department and available for consultation during this patient's stay, but I did not personally evaluate the patient. I agree with the documented plan." I think that last part is required by our coding department, it's also what leaves me on the hook should a bad outcome occur...
     
  7. RuralEDDoc

    RuralEDDoc

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    Thank you for the replies.
    It's good to know that I'm not alone here, but disappointing at the same time. The midlevel providers at my place are under such pressure to move patients, the documentation is minimal and sloppy. I imagine that aspect is similar elsewhere. I'm just waiting to hear "Excuse me, Dr. Rural? Here are your papers, you've been served". I realize that can (and probably) will happen on patients that I personally see, but its rough that I take the risk on approximately the 4,000 charts I'm expected to blindly sign a year.
     
  8. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

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    If the midlevels are making money for a CMG then you should try to get that changed. Have them hire an FP to supervise or something.

    If you are in an SDG know you profit from them. If you dont like this then in time you can work to change things.

    I am pro midlevel keeping in mind the only purpose for having them is for one of the 2 reasons below:
    1) Make more money
    2) Can not hire docs

    There literally is no other reason to hire an MLP.
     
  9. Birdstrike

    Birdstrike 5+ Year Member

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    I agree, completely. If your arrangement is that someone else hires the midlevels, you expose yourself to greater patient exposure and liability while making money for someone else, with no control over which midlevels you work with or don't, and little say on their competency or lack thereof, then it's a bad arrangement.

    The midlevel arrangement has to benefit you in some way, otherwise you're exposure yourself to lots of liability for no benefit. Frequently this is the arrangement many find themselves under. I've been subject to it before, and I think it's backwards and upside down. I only want to work with a midlevel again, if that physician assistant is truly my assistant not hired by someone who'll never work with him, then passed around amongst docs who have no personal connection or shared liability with that person.

    You have to ask yourself: Would an Orthopedic surgeon allow himself to be subject to such an arrangement in his own private practice, or a plastic surgeon?
     
    Last edited: 10.01.14
  10. Jamers

    Jamers Sexy Man 10+ Year Member

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    Its common. Where I work the midlevels see the same acuity that I see (yep, you read that right). Thankfully I don't have the situation you have (they have to report to me before the patient has left). However, there are situations where I can't get to see every patient (the midlevel is floating from another section and comes to present a case of an ankle sprain/ect and I have very ill patients I am caring for) Now the people I work with say I can just sign "agree with midlevel workup" and be "safe." How safe? I don't know. Where I did residency, the attendings would never see the midlevel patients unless "consulted" and would sign the charts "I was available for consultation but was never consulted." I don't know man.
     
  11. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

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    Truth is both arrangments (supervision of all cases and near complete independent MLP care) are ok. The question is what are you getting out of this arrangment? if the answer is nothing you need to change that.
     
  12. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    Agree with Ectopic. In our current set-up the hospital mandates that we hear about every case prior to discharge. In addition, signing the midlevel chart gives the same RVUs as if we had seen the patient ourselves. Obviously the RVU multiplier is lowered to reflect for the percentage of cases that have both an MD and an APC being paid, but psychologically it helps to know that you're getting paid for your supervision and that going to see the patient bumps that pay (since we bill for an MD visit vs. APC visit if personally evaluated by MD).
     
  13. shopsteward

    shopsteward 5+ Year Member

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    I don't see how you realistically have the opportunity to call the patients back and ask questions after they have left: that is a farce.

    As a minimum, if you are putting your signature to charts of patients you have not seen, you should know exactly why you are doing it. So what is the point of your signing the chart? What difference does it make? Presumably it is 1) a requirement (federal or state law? hospital policy? mid-level practice policy?) for the midlevels to be supervised, 2) to make you liable or 3) to charge more money. Knowing the answer to this question will help you determine what to do about the requirement.

    In the meantime, if possible, I'd immediately start adding the rubric to your signature "This patient was seen by the midlevel [without any input from me/who told me x/asked me about x].
     
  14. sum dude

    sum dude 7+ Year Member

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    Florida state law requires counter-signature. We put a generic note stating something like we did not see pt, but were available for questions and reviewed chart. Actually, the FAMA and FCEP oppose mid-levels opperating on their own, as theoretically you could have mid-levels run their own ED (especially a stand-alone) without ED docs (and before you say this sounds terrible, unknowing hospital execs only see things in $$$'s.)

    Every place is different--the Midlevels I work with are comfortable asking me questions, and I'm comfortable with them seeing people with input as needed. To expect to not sign at least 10 Midlevel charts per shift is not realistic, no matter where you are at, and I'm too busy to see ankle sprains and toothaches that the PA's see. I see admits, complicated pt's, young patients, occasional abdominal pain, etc., but I would not come out of Residency with the mindset that you can see every PA patient and still operate to an efficient level
     
  15. Boatswain2PA

    Boatswain2PA Physician Assistant 5+ Year Member

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    Do you see a big disconnect between the care that your experienced PAs give and the care you see other physicians give? If so, can you elaborate??
     
  16. Jamers

    Jamers Sexy Man 10+ Year Member

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    The care I see other physicians give? I assume you mean less experienced PAs? Either way yes. Example: patient with abdominal pain, elevated LFTs, jaundice, change in MS and hypotension with fever. PA presented it as sepsis with admission to GMF maybe tele. I had him call surgery who got an emergent MRCP to confirm the diagnosis. This was a PA working for 15 plus years. I am not trying to turn this into a PAs are inferior battle so if this is your intent this is my last post on the topic. That being said, most of the PAs I work with are very capable.
     
  17. Boatswain2PA

    Boatswain2PA Physician Assistant 5+ Year Member

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    No, not my intention at all. Just looking for where I should look to improve myself....

    It seems to be a relatively rare shop where EPs and PAs work together and see the same acuity (ie: alternating the next chart no matter what it is). I was wondering what your perspective is on how that works. Do you feel that the experienced PAs give less-good care when compared to the EPs overall in your shop? Do they miss things like Charcot's triad frequently?
     
  18. Taurus

    Taurus Paul Revere of Medicine 10+ Year Member

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    If this is common practice, am I the only one who sees a huge problem with how ED medicine is performed today? To save costs, it's just a matter of time and not if before groups like NP's especially the DNP's argue that they don't need supervision at all or that you only need 4:1 or higher ratio of nonphysicians to physician ratio to appropriately staff an ED. For a group to protect itself from the encroachment of midlevels, it needs to create a moat around it which only physicians are only allowed to do. Surgeons have done a great job at it. But primary care and ED have not.
     
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  19. secants

    secants about:blank 10+ Year Member

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    There was a good article in em monthly talking exactly about this. Coming from anesthesia I hope your field doesn't get ****ed like ours did
     
  20. exi

    exi 10+ Year Member

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    Reynolds' pentad. Markedly increased morbidity and mortality. Either way, acute badness.

    For those of you working in shops where there isn't any midlevel coverage, how do you feel about that overall?
     
  21. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

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    If I supervised 4 midlevels at a time I would earn $1M+ per yr. I would do it and retire in 5 years.
     
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  22. RuralEDDoc

    RuralEDDoc

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    Thanks for all of the replies.
    I've spoken with the medical director. While the details of the arrangement are still not entirely clear to me, it is clear that the arrangement benefits physicians financially in the group. The majority of the billing goes back to the treating PA, a percentage goes to the physician group (not the individual physician signing the chart), and a percentage goes to cover group overhead.
    I am a fan of money, and am not going to complain. We sign and take on liability, and get paid to do so. Fair deal, I suppose.
    Still, its tough to sign these charts.
    Of the 21 I signed today:
    1 was 17 yo male sp football game, CC severe neckpain/neck stiffness. No hx other than "Neck pain sp football game". No documented physical exam other than "muscle spasm" (this was the objective finding). Diagnosis was muscle spasm. DC w/ flexeril/ibuprofen.
    1 was 5 year old male. CC Mid abdominal pain, physical exam was "RLQ ttp. Non toxic". Yes, this was the extent of the exam. No labs or US. Diagnosis: Constipation. DC home w/ suggestion to increase water and vegetable intake. Naturally, the patient had a single documented HR of 151.
    Yup, those patients were called with "Hi I'm Dr. Rural, would you mind coming back into the ER for an exam? Thanks, sorry". Of course this was the end of my shift so someone else will unfortunately have to deal with the pissed off parents.
    These were the most egregious charts, most were fine, some were bad but not as bad as above.
    It's no wonder why the other docs just blindly sign the charts; reading them only increases stress levels!
     
  23. mercaptovizadeh

    mercaptovizadeh ἀλώπηξ 10+ Year Member

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    I would leave and find a physician only ER where you are accountable for the patients you see and none other. This kind of thing would eat me alive. It's a ticking time bomb. Over 5-10 years you will run into more than a few cases that were not worked up properly and the patient's care was delayed or the patient got worse.
     
  24. WilcoWorld

    WilcoWorld Senior Member 10+ Year Member

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    You have got to discuss these cases with the APP's in question. Explain why this is so concerning to you. It's the only way things will improve. Chances are, they're not trying to do a bad job, and if you are clear about how you'd like things done, they'll (mostly) comply. What has to go hand in hand with this is being open to discussing their cases in real time. For my first 5-10 times working with an APP I would start the shift by saying something like "Hey there, please don't hesitate to talk to me about any of your cases. I'm happy to see anyone you want me to."

    If you've done that, and they keep doing a crappy job, then you need to find a way to no longer work with that APP.
     
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  25. EctopicFetus

    EctopicFetus Keeping it funky enough 10+ Year Member

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    I agree with Wilco. I am aa fan of utilizing the MLPs (APPs) appropriately. I think a good MLP can do as good of a job as I do in a decent number of cases.

    From my own experience and things I have read they tend to order more tests and overall are more likely to be involved in lawsuits than docs.
     
  26. Birdstrike

    Birdstrike 5+ Year Member

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    In the ED you're going to see thousands of patients per year. If you're supervising midlevels it could get over 10,000. And I can tell you, the amount of "low acuity" stuff triaged and blown off by everyone but me that's turned out to be horrible badness over the years would frighten anyone that hasn't been in this game for very long. No doctor is 100% accurate either (except one, and his name is DocEspana).

    God love PAs and NPs, and I love working side by side with a good one. But I've had cases presented to me as, "Leg cramp. Ultrasound negative. You don't need to see this one. Sending home," that turned out to be a cold, dead leg with no pulse. I've had "Chronic knee swelling. You don't need to see," turn out to be MRSA septic knee. Some PAs I'd be comfortable not seeing any of their patients unless they felt out of their comfort zone. On the other hand, there are others where every single patient needs to be seen, because the clinical acumen is just not there. And that's essentially the physicians role, to supervise. Remember: It's our job to supervise, not their job to "be a doctor." If you're not supervising, then you are not doing your job. For one PA that might mean seeing every patient. For others it may mean simply reviewing charts and being available for questions. If you are taking on that liability and risk, by consigning slipshod care or sloppy charts for a few extra dollars per hour, you have to ask yourself not only, "Is it worth it?" but also, "Is it the right thing to do?" Also, it's no guarantee that any given midlevel program is making the docs money. There's a certain threshold of production they have to achieve to break even and for you to be able to afford their salary and benefit, let alone make a profit. So, if you're making more money from them, there's no guarantee it's very much, unless you drill down to the overall programs costs and profits, if any, and to whom it's going.

    If you're not comfortable with your PA, then you either need to train that person (labor intensive), replace the person with someone better, supervise more closely, or have an independent practitioner you don't have to cosign charts for. You need to think of them as an extension of you, like your employee, or your representative. When that bill comes to that patient, your name will be on that bill. Likewise, it will also be on the subpoena.

    I don't know that any amount of extra money is worth signing off on a bunch of charts from slipshod care and/or documentation. Is that really what you got into this for?
     
    Last edited: 10.07.14
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  27. Boatswain2PA

    Boatswain2PA Physician Assistant 5+ Year Member

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    I've been meaning to post something about what "supervision" means for a long time, but Dr. Birdstrike just beat me to it and, as usual, he put it better than I could.

    Supervision is a spectrum. Like Dr. Birdstrike says, it can range from "in the room, watching closely, approving everything", to "Call me if you need anything." I could be wrong, but I think there is a disconnect between what physicians experience as supervision in their resident training (gradual levels of increasing autonomy, but still supervised by attending), and what some states/hospitals require for mid-level supervision, which is mostly proscribed by "chart review".

    One is a useful form of supervision. The other is simply the result of a focus group of lawyers. An appropriate supervisor/subordinate relationship requires the former, while the risk managers/bean counters/lawyers requires the latter. That means we should be doing BOTH.

    Of course being a good supervisor is time intensive at first, although that time invested should pay off in the long run. This applies to all fields, not just medicine. In my first career I did search and rescue (SAR), and eventually commanded two SAR stations. I was totally responsible for all SAR operations within unit's area of responsibility. That does NOT mean that I was on every boat launched (although it was my job to be on the boat when I needed to be) But it did mean that I trained and certified the boat captains, the boat engineers, the boat crewmen, and everyone else at the unit in their positions, to be capable to perform their jobs. AND it meant that I had to personally keep an awareness of what was going on. Some of my boat captains had more leeway than others. Some could launch into heavy seas by themselves, others had to have me (or someone else I designated) on the boat with them. It was my job, as the supervisor, to know what each person could do, and couldn't do, and shouldn't do by themselves. And of course, I had the ability to weed out those who just shouldn't do that job.

    Sorry for the personal tangent there, but I think a lot of that correlates to how EPs could, and perhaps should, manage the mid-levels in their shop. SOMEONE should be the shop supervisor, setting the parameters for each mid-level. Some mid-levels (for example, PAs who have their CAQ in EM) can do intubations, central lines, reductions, conscious sedation, etc. Some can't. Some could learn, some couldn't.

    To RuralDoc: That may be the formerly acceptable norm for documentation in your shop. If it is/was, then I recommend you change that by talking to your mid-levels and raising that standard. If they continue to practice in such a way, they should be fired.
     
  28. Daiphon

    Daiphon Semper Ubi Sub Ubi SDN Advisor 10+ Year Member

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    For better or for worse, I think of APPs as "permanent residents."

    The comments above are in keeping with this - there are some residents who need close supervision, and others who don't... and it comes down to experience & trust. Can't be afraid to redirect them as needed, as they'll get more experience out of it and (as long as they take the redirection well) you'll build more trust.

    Win-win. d=)
     
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  29. Birdstrike

    Birdstrike 5+ Year Member

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    Dude. Why are you calling me "doctor"? You're making me feel weird.
     
  30. emedpa

    emedpa GlobalDoc 10+ Year Member

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    FWIW many of us (PAs) working in settings where we see higher acuity without direct oversight would be fired in an instant for notes like that. The docs I work with expect my exams and write ups to be every bit as good as theirs and if they aren't I hear about it. As a side note regarding compensation: at my primary job the doc who signs my charts gets 50% of the RVUs of each chart so a doc working with 2 PAs during a shift (our typical arrangement) is making bank. we estimated a few years ago that our PA group buys each doc the equivalent of a high end BMW each year and over 20 years pays for their house.
     
  31. RuralEDDoc

    RuralEDDoc

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    No, it's not. People suggested I figure out what the financial deal was, so I did, and reported on it. I started this thread because I was (and am) extremely concerned about the entire arrangement.
    I've spoken with the medical director and APP director about the above-mentioned provider, and gave him feedback on each concerning chart.
    The crux of the challenge is that inexperienced and unprepared practitioners are brought into this ED because its hard to keep good people here. Rural ED, high volume/stress, relatively low pay (Medicaid doesn't reimburse well).
     
  32. AlmostAnMD

    AlmostAnMD 2+ Year Member

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    Sorry if this is a silly question

    What happens if you ~don't~ sign the PA's note? Citing the fact you had nothing to do with the patients care. Just wondering.
     
  33. sb247

    sb247 wait...you mean I got in? 2+ Year Member

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    Or as a middle ground what ormc does. Np and pa run the fast track, but all charts must be reviewed by a doc prior to discharge.

    You can stamp the easy stuff and decide to see the more questionable patients
     
  34. Birdstrike

    Birdstrike 5+ Year Member

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    Are they billing the full fee as if all MD seen, or only the 80% PA-only discounted fee?

    That's the real question.
     
  35. sb247

    sb247 wait...you mean I got in? 2+ Year Member

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    I'd have to imagine that they are charging doc rates, why would any hospital charge the lower rate after making such a big deal out of making docs sign the charts?
     
  36. Birdstrike

    Birdstrike 5+ Year Member

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    I would assume that also, but are the docs actually seeing the patients?
     
  37. sb247

    sb247 wait...you mean I got in? 2+ Year Member

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    It would be great to know that....if the hospital is taking a cut of an 80% PA only fee and still has to pay the PA...how much money can there be left for the docs who now assume the liability? " We pay you a percentage" is a very fluid statement with a wide range on values
     
  38. Arcan57

    Arcan57 Junior Member 10+ Year Member

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    Two separate functions. You can't charge the higher rate (at least not to Medicare) without a physician examining the patient and recording their own work. The docs signing every chart is for either regulatory compliance or medicolegal protection.
    I assume they'd be fired if it continued after counseling. Our verbiage is that "I was available for consultation and have reviewed the (NP/PA) documentation and agree with management". There are some rules our hospital system imposes that help. 1) Every patient must be staffed with an attending prior to d/c. 2) Every ESI 3 or higher patient and everyone under the age of 5 must be seen by the MD prior to d/c.
     
  39. sb247

    sb247 wait...you mean I got in? 2+ Year Member

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    10,965
    Location:
    Galt's Gulch
    Status:
    Medical Student
    thanks for clearing that up
     
  40. Birdstrike

    Birdstrike 5+ Year Member

    Joined:
    12.19.10
    Messages:
    3,973
    Very interesting post from a PA that then entered medical school:

    "Two years after becoming a PA, I started medical school. Within the first month, it became clear that the depth of knowledge expected of physicians was vastly different and more intense than that of PAs... the respect I had had for the physicians I had worked with previously grew tremendously...my appreciation for physician education continues to grow. I process information completely differently than I had before. I no longer work just inside an algorithm but can now critically evaluate and develop unique plans for my patients in a way that my prior training did not allow. As a PA, I knew how to treat adequately most patients but as a future physician, I now know the why of the algorithms and can, hopefully, develop my own for patients who do not quite fit that algorithm.

    It was common, and I am sure it still is, for us, as PA students, to talk of PA school as comparable to medical school. Having now done both, I can unequivocally say that it is not."

    http://www.kevinmd.com/blog/2014/10/pa-md-appreciation-physician-education.html
     
  41. Boatswain2PA

    Boatswain2PA Physician Assistant 5+ Year Member

    Joined:
    03.03.10
    Messages:
    479
    And THAT is why I called you "Dr. Birdstrike"! Lol

    Unfortunately there is a small minority of PAs who claim equivalence with physicians. I think most of them do so because the PA profession is squeezed by the NPs who have been very successful in their push for independent practice.
     
    Birdstrike likes this.
  42. Birdstrike

    Birdstrike 5+ Year Member

    Joined:
    12.19.10
    Messages:
    3,973
    Well, I appreciate it. I was just messing with you though. But you don't really known if I'm even a doctor. Lol. It's all good.
     
  43. Arcan57

    Arcan57 Junior Member 10+ Year Member

    Joined:
    11.21.03
    Messages:
    2,618
    Status:
    Attending Physician
    If you didn't exist we'd have to create you?
     
    wholeheartedly likes this.
  44. Birdstrike

    Birdstrike 5+ Year Member

    Joined:
    12.19.10
    Messages:
    3,973
    Would you even want to?
     

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