midlevel supervision

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HooliganSnail

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Several of the places I am contracting with require mid level supervision.

I have personally seen good models where the PA/NP is basically like a senior level resident, they do their thing, then every case gets run by the attending. I am not saying the attending actually goes in and see's all of these patients, but they at least have been told about this person before they leave the department. I am totally ok with this type of arrangement. It seems efficient, It seems safe. It seems like good ER medicine.

One of my prospective jobs has a fast track area of the side of the main ED with a PA/NP staffing, and I am to provide "supervision". I am concerned that I will have to sign charts of patients I have never seen or even been told about, and this represents a major liability on my part, which is not worth the risk because I am working a flat hourly rate, and will not being getting any of the extra money this staffing model brings in. I am NOT ok with that situation.

How do you experienced doc's here handle the above situation, and how to express to a prospective employer that I am not Ok with that model?

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Let me make this quick and easy.

Don't take job 2 if you're not okay with the model. They're not going to change it for anybody.

Also, every job I have worked at has some degree of MLP full autonomy, so I would rethink my approach if I were you.
 
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I made sure I joined a group where I did get paid extra to sign the charts of people I've never seen or heard about.

I also made sure the PA whose charts I'm signing is literally working at the work station next to me. When you work with the same PAs for years and work that closely, it doesn't feel nearly as risky. Do I hear about every case? No. Do I want to hear about every case? No. Do I hear about every case I need to hear about? I think so.
 
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Several of the places I am contracting with require mid level supervision.

I have personally seen good models where the PA/NP is basically like a senior level resident, they do their thing, then every case gets run by the attending. I am not saying the attending actually goes in and see's all of these patients, but they at least have been told about this person before they leave the department. I am totally ok with this type of arrangement. It seems efficient, It seems safe. It seems like good ER medicine.

One of my prospective jobs has a fast track area of the side of the main ED with a PA/NP staffing, and I am to provide "supervision". I am concerned that I will have to sign charts of patients I have never seen or even been told about, and this represents a major liability on my part, which is not worth the risk because I am working a flat hourly rate, and will not being getting any of the extra money this staffing model brings in. I am NOT ok with that situation.

How do you experienced doc's here handle the above situation, and how to express to a prospective employer that I am not Ok with that model?

My experience with one of the big CMGs was that "midlevel supervision" meant your name ended up on a bunch of charts that you knew nothing about. Brand new NP grads went from being bedside nurses to seeing higher acuity patients in a day. This was completely unacceptable (along with many other things with that job). Walk away. Your analysis is accurate and what RustedFox said is true.
 
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We operate under the first model you describe above.

PAs have free reign to pick up anything that comes in, though they focus on available "faster track" and lac/abscess style cases as first pick if those are up.
The stated expectation is that every case is run by the ED attending who will sign the chart, and said attending will have the opportunity to see said patient.
The PAs are very excellent at telling us when we NEED to see a patient.
The expectation is we try to run by and see everyone, though if you are running multiple resus and the PA has two ankle sprains queued up to leave, you are allowed to waive that expectation.

This lets each attend do things a bit differently as far as supervision, level of repeat history taking, and how much free reign they give. It also lets you treat each PA differently, as some frankly are excellent and need minimal oversight even with rather sick patients and some are newer/greener and you'll want to be more thorough even with faster track cases.

Going to see the patients yourself, even the "basic" fast track, does take time, but pays some dividends with satisfaction. When we're rolling I like doing the 1-2 punch with the PA where they go see someone and get things started then I come back and seal the deal (i.e. "hey, I'm doctor Janders I'm working with PA Awesome you met earlier. Good news, your X-ray is negative its just a sprain!") and give them their discharge instructions, etc while the PA starts the next HPI. Always Be Closing.
 
I do not know of many community arrangements at high volume centers where they tell you about every patient. I don't want to hear about every cold and booger stuck in nose. Don't care. If they are good they know when to ask for help. Go to a place with good and experienced mid levels that can do this correctly. I am productivity based and in a round about way am also compensated for signing charts, as you should be.
 
My first job we had an off site urgent care and a fast track area both where I would just get sent charts to sign. Now I work side by side with my PAs and they run 50% by me and the rest the dispo on their own. It helps that we have a one year PA fellowship and don't hire new grads
 
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This is interesting. I'm looking at a contract right now and it took two months to negotiate the rate. I don't think a rate for signing charts came up. But the newest midlevel there has been there 12 years
 
This is tangentially related, but if you want your APPs to approach you, be approachable.

This does not mean you always have to have a smile and be chipper, but you can't be an a$$.

When I start working with a new APP, I introduce myself and say that I am here to back them up. I ask them to maintain a low threshold for reviewing cases with me until we get to know each other better. As time goes on we talk less about each case, but I do my best not to sigh or whine whenever the APP asks to talk to me/have me take over a case.

If you never talk to the APP's and/or act like they're ruining your day every time they try to talk to you, you're asking to be left out in the lurch.

Of course, docs should have more control over what they supervise. But patients should wear seat belts, use designated drivers and take their meds as prescribed...reality is what it is and you can either work in Shangri La, like WCI, or you can do your best to grow where you're planted.
 
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Let me make this quick and easy.

Don't take job 2 if you're not okay with the model. They're not going to change it for anybody.

Also, every job I have worked at has some degree of MLP full autonomy, so I would rethink my approach if I were you.


That is the problem though, the place may have MLP full autonomy, but legally that doesn't exist (many states have full NP practice rights, which means I don't have to sign their charts, which means they are out of the purview of this discussion)

Most of the responses on this forum have been "just get used to it, that's just the way it is", but that makes us all very vulnerable

Greg Henry wrote an excellent piece about this awhile back, and I have seen him give this lecture live as well. Let me just tell you that the room was completely silent when he was done, not because they were asleep, but because of that "o ****, we do this stuff all the time at my shop" feeling had hit everybody.

Are you Liable: The Truth About APPs - Emergency Physicians Monthly
 
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It's not that we aren't saying it's wrong. It's just that the majority of jobs out there are CMG jobs, and they do exactly this. You aren't part of the hiring or firing of those midlevels. You can refuse to work at such a place, and find your ability to get a job reduced by 90% or so. You can actively campaign against it, and be vilified in the court of public opinion that feels nurses can do no wrong, and all of those NPs were nurses once.
Rocks and hard places.

Or you can start your own group.
 
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Here is one of those cases. Copied from Charles Pilcher's Medical Malpractice Insights newsletter. You can sign up here: Subscribe to MMI




Can a cerebral aneurysm be mistaken for conjunctivitis?
"Error" results in $11.8 million verdict, $4 million against the doc who signed the PA's chart
Hernandez v Morton Plant Hospital et al. – Florida
Facts: A 17 yo male goes to the ED with pain around his R eye. A PA diagnoses and treats conjunctivitis. The attending physician signs the chart. Four months later the plaintiff has a ruptured cerebral aneurysm, undergoes emergency surgery, but suffers brain damage with L sided weakness and seizures. He requires a caregiver. An attorney is consulted and a lawsuit filed.
Plaintiff: The doctor never saw me. My problem was more than just "pinkeye." You should have asked me more questions. Your history and exam were inadequate. A CT would have found the aneurysm behind my R eye, and it could have been fixed before it ruptured. 

Defense: You did have conjunctivitis. The diagnosis was correct. You had no symptoms of an aneurysm, not even a headache. If you did have a headache, you should have told us. No reasonable provider would have done a CT under the circumstances.
Result: Jury verdict for $13.2 million (30% each for PA, MD, hospital) reduced by 10% to $11.88 million because patient was a poor historian. (DUH!)
Takeaways:
* This is a really spooky case. How does one confuse conjunctivitis with the sentinel headache of a cerebral aneurysm?! There's got to be more to this story.
* A now-disabled teenage plaintiff makes a compelling "victim" on the witness stand.
* Remember, we are liable for the care of our PA's. Even though the physician never saw this patient, he was responsible to the tune of almost $4 million.
 
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That's just unlucky. The reason it went to trial instead of being settled is likely because everyone knew it was frivolous. The verdict is entirely the result of manipulation of the legal system by a good attorney with a sympathetic client.

Every single one of us probably would have diagnosed the kid with conjunctivitis if he actually had a red eye. A non contrast CT brain has low sensitivity for unruptured aneurysms anyway and no one would've ordered a CTA or 4-vessel on this patient.

Nature of the business.
 
That's just unlucky. The reason it went to trial instead of being settled is likely because everyone knew it was frivolous. The verdict is entirely the result of manipulation of the legal system by a good attorney with a sympathetic client.

Every single one of us probably would have diagnosed the kid with conjunctivitis if he actually had a red eye. A non contrast CT brain has low sensitivity for unruptured aneurysms anyway and no one would've ordered a CTA or 4-vessel on this patient.

Nature of the business.

Nature of Florida?
 
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That is the problem though, the place may have MLP full autonomy, but legally that doesn't exist (many states have full NP practice rights, which means I don't have to sign their charts, which means they are out of the purview of this discussion)

Most of the responses on this forum have been "just get used to it, that's just the way it is", but that makes us all very vulnerable

Greg Henry wrote an excellent piece about this awhile back, and I have seen him give this lecture live as well. Let me just tell you that the room was completely silent when he was done, not because they were asleep, but because of that "o ****, we do this stuff all the time at my shop" feeling had hit everybody.

Are you Liable: The Truth About APPs - Emergency Physicians Monthly
Do you have any links to his talks on the subject?
 
Do you have any links to his talks on the subject?


I don't unfortunately, I know he gave it at ACEP 15. He comes and speaks to many residencies around my area from time to time (at least he used to, I think he is semi-retired now).

Great speaker, kinda abrasive, but in a fun way. His specialty is medical legal, and he always gives very enlightening talks about the subject. He is really good at pointing out the holes we dig ourselves into with the plaintiff attorney, presumably because he has seen it happen.
 
That's just unlucky. The reason it went to trial instead of being settled is likely because everyone knew it was frivolous. The verdict is entirely the result of manipulation of the legal system by a good attorney with a sympathetic client.

Every single one of us probably would have diagnosed the kid with conjunctivitis if he actually had a red eye. A non contrast CT brain has low sensitivity for unruptured aneurysms anyway and no one would've ordered a CTA or 4-vessel on this patient.

Nature of the business.


That is the scary part to me. I understand there will be silly lawsuits. I understand that lawsuits are about money, not about good medicine. I understand that is is exceptionally rare to be sued for more than you liability limits, and then 9/10 cases are won by the physician in court....

I am most terrified of having some huge verdict like this one. Most malpractice policies are for $1M, a 4M verdict leads to bankruptcy. They can take your personal assets. All those years of hard work, all that training, all that smart financial responsibility, paying loans, planning for retirement, getting a practical mortgage......out the window. A ruptured aneurysm in a 17yr old? Literally an act of God.

I know there are some ways to shield your assets from this sort of thing, but really they are quite inadequate.
 
Hooligan, time for some real talk. If you're terrified of a huge verdict landing against you and bankrupting you, then EM probably isn't the place for you. Being concerned and acknowledging that it could happen is appropriate but being terrified of it has no protective value. There's no way you can buff a conjunctivitis chart enough to prevent an idiotic jury from awarding $$$$ due to a devastating and undetectable disease process. You're going to see patients that have brewing pathology that is unrelated to their chief complaint, and some of them aren't going to follow up in the timeframe you told them to. That will make you the last doc that saw them and potentially put you on the hook. It comes with the territory.

On the spectrum of threats to us, losing a lawsuit above your coverage limits is way less common then other equally serious threats. You're far more likely to burnout or kill yourself (I realize those are not equal outcomes) because of the fallout from a bad case then you are to be bankrupted by a jury settlement.
 
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Also while Florida (where the suit happened) has a bad malpractice climate, it has good homestead laws, so they can't go after assets.


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Hooligan, time for some real talk. If you're terrified of a huge verdict landing against you and bankrupting you, then EM probably isn't the place for you. Being concerned and acknowledging that it could happen is appropriate but being terrified of it has no protective value. There's no way you can buff a conjunctivitis chart enough to prevent an idiotic jury from awarding $$$$ due to a devastating and undetectable disease process. You're going to see patients that have brewing pathology that is unrelated to their chief complaint, and some of them aren't going to follow up in the timeframe you told them to. That will make you the last doc that saw them and potentially put you on the hook. It comes with the territory.

On the spectrum of threats to us, losing a lawsuit above your coverage limits is way less common then other equally serious threats. You're far more likely to burnout or kill yourself (I realize those are not equal outcomes) because of the fallout from a bad case then you are to be bankrupted by a jury settlement.



I am very frustrated by the responses I have gotten from this thread. Mostly the answer's have been "That's just the way it is"

Concern about signing charts for patients I have not seen. Responses. Just get over it that is the way it is

Concern about big verdict, and the absurdity of not being able to separate business from personal assets. Just get over it that's just the way it is.

I can not be the only person around here who finds these things to be unacceptable.
 
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I am very frustrated by the responses I have gotten from this thread. Mostly the answer's have been "That's just the way it is"

Concern about signing charts for patients I have not seen. Responses. Just get over it that is the way it is

Concern about big verdict, and the absurdity of not being able to separate business from personal assets. Just get over it that's just the way it is.

I can not be the only person around here who finds these things to be unacceptable.
I'm sorry that was your take away from my post. Horrible, senseless things that destroy a life happen. Although we all try, nothing we do completely insulates us from those things. I drive attentively, but a trucker could fall asleep, suddenly cross into my lane and kill me. I can manage that risk but not eliminate it. Moving to a state with malpractice reform helps to manage the risk. Donating to PACs to lobby for reform if you can't leave is a way of managing risk. Being courteous, keeping patient informed, staying current on practice concepts, and actually giving a sh%# about the patient all help manage risk. None of them eliminate it.

There are plenty of jobs were you're not signing charts on patients you never had a chance to see. If you're not ok with supervision (and there are a lot of reasons not to be) then you can find a job were it isn't a requirement. If you want to avoid being sued, don't practice medicine. What you can't do is take a job were you know you'll be signing charts on midlevels you don't trust and whose patients you've never seen, take the bump in pay that comes from their RVUs (if there is one), and have the thought of being sued for someone you never saw eat you up inside.

As of about 3 yrs ago, my particular CMG had never paid out on a doc's behalf on a patient seen by a midlevel that the doc never saw. Could it happen? Yes. Is it an extraordinarily low likelihood event? Yes. I can understand wanting to feel safe and secure. In order to have that feeling as an EM doc, there's a lot of risk that you have to ignore. Unavoidable (by us) delays in lab/radiology testing, delayed med/fluid administration by nursing, pt crumping in ED after you've admitted and left but pt still holding in ED, specialist deciding to paint your care as negligent to cover their bad behavior, being physically assaulted by a patient, having the patient lie to you causing you to do something that looks horrible in hindsight, sending home a disease process that's too early to be detectable but patient re-presents too late to save, a precipitious delivery in the ED that results in a devastated baby, losing the ability to connect with your emotions because you're burned out by the horror show that runs through your head, losing your ability to connect with your partner/family because you can't leave emotional impact of the job at work, dying in a car wreck post-night shift because you fell asleep. Having a family member/loved one show up in the resusc bay while you're single coverage. Developing a substance abuse problem in a misguided effort to cope with the job.

I could go on, but you get the point. We're not trying to be unhelpful or unsympathetic. It's natural as an "about to be" or new attending to be worried about stuff that you eventually decide is low risk enough not to worry about. The problem is that there are plenty of jobs were there's not enough volume to add another physician but there's too much for the existing physicians to handle. Let's say $500/hr in patients comes through the door. 2 docs are on at a time and they're making $250/hr but burning out from seeing 3 pts/hr (let's say shop has a poor payor mix). Going to triple coverage drops the pts/hr down to a 2pph but now everyone's making $167/hr. That shop becomes understaffed really quickly in either of the doc-only scenarios. Let's say you hire a midlevel at $100/hr. Now the docs are making $200/hr but still only seeing around 2.2 pph. Depending on region of country, that's probably a sustainable doc pay rate assuming the shop is otherwise reasonable to work at. Let's say the midlevel is seeing patients in a fast-track that's geographically separated from the main ED where the docs are. Do you have enough time to constantly be running over to the FT to see the low-acuity patients prior to discharge while still handling your part of the main ED? Maybe. From watching my colleagues, the answer seems to largely be no. In the setting of midlevels that consistently chart in an undefensible manner, 90+% of docs will keep their mouths shut and just sign the chart. Especially if it's a scenario (unlike RF's shop) where they get RVUs for signing the midlevels chart.
 
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I am very frustrated by the responses I have gotten from this thread. Mostly the answer's have been "That's just the way it is"

Concern about signing charts for patients I have not seen. Responses. Just get over it that is the way it is

Concern about big verdict, and the absurdity of not being able to separate business from personal assets. Just get over it that's just the way it is.

I can not be the only person around here who finds these things to be unacceptable.
This is literally the exact same statement you posted earlier.
Are you part of your state college of emergency physicians? National? By yourself, you can't do much except refuse to work. At the ACEP level, the CMGs have enough power that you're unlikely to convince them. But yeah, you're not wrong, it literally is the way it is. Just like paying taxes, or driving on the right. What do you want us to do, rend our garments or something? I'm sorry it doesn't upset us as much as it apparently upsets you. Either move to a state with better malpractice laws (vote with your feet) or stop whining.
 
Several of the places I am contracting with require mid level supervision.

I have personally seen good models where the PA/NP is basically like a senior level resident, they do their thing, then every case gets run by the attending. I am not saying the attending actually goes in and see's all of these patients, but they at least have been told about this person before they leave the department. I am totally ok with this type of arrangement. It seems efficient, It seems safe. It seems like good ER medicine.

One of my prospective jobs has a fast track area of the side of the main ED with a PA/NP staffing, and I am to provide "supervision". I am concerned that I will have to sign charts of patients I have never seen or even been told about, and this represents a major liability on my part, which is not worth the risk because I am working a flat hourly rate, and will not being getting any of the extra money this staffing model brings in. I am NOT ok with that situation.

How do you experienced doc's here handle the above situation, and how to express to a prospective employer that I am not Ok with that model?

Solution:

1-Do not work in a Democrat run state where you're a sacrificial lamb for liberal trial lawyers. If you work in a Democrat state, support Democrats and vote Democrat, then accept your fate as an offering to the God's Of Malpractice attorneys. That's fine, that's your right as an American, but if you do so just own it. If you go 'blue' you're offering yourself up to be a victim of out of control liability and class envy.

2-After you've completed step 1, and you've refused to work in any liberal, trial-lawyer dominated state, and you've set up shop in a red, tort-reform state, just get good malpractice insurance, practice defensive medicine and don't worry about it. I've been falsely accused of malpractice twice, and had people try to sue me for it. And you know what?
Life goes on. If you've got money, people will try to rob you of it. It's a fact of life. It's also a fact of life, that there are ways to protect yourself.

Oh, and again, don't ever, ever, ever, ever, ever vote for the political party that, 1-considers tort reform blasphemy, 2-sees doctors as sacrificial lambs to feed trial lawyers through frivolous litigation without cap or restriction, and 3-views your paycheck as something they can blood-let through ever increasing tax rates to pay for their doomed-to-fail socialist utopia. That is the Democrat party. Sorry, it sucks to have to tell you that, but that's the reality. They might be better on certain issues, for you, but on this issue, they're truly enemies of the physician, in my opinion.

But if you want all those things, and you don't mind limitless liability for malpractice you didn't commit, then I absolutely recommend you consider jobs in liability hell-hole states, where you're open to lottery sized malpractice awards for things PAs do, or don't do. Also, if you're okay with all that, vote for Democrats who made it that way, and fight like hell every day to keep it that way.


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Solution:

1-Do not work in a Democrat run state where you're a sacrificial lamb for liberal trial lawyers. If you work in a Democrat state, support Democrats and vote Democrat, then accept your fate as an offering to the God's Of Malpractice attorneys. That's fine, that's your right as an American, but if you do so just own it. If you go 'blue' you're offering yourself up to be a victim of out of control liability and class envy.

2-After you've completed step 1, and you've refused to work in any liberal, trial-lawyer dominated state, and you've set up shop in a red, tort-reform state, just get good malpractice insurance, practice defensive medicine and don't worry about it. I've been falsely accused of malpractice twice, and had people try to sue me for it. And you know what?
Life goes on. If you've got money, people will try to rob you of it. It's a fact of life. It's also a fact of life, that there are ways to protect yourself.

Oh, and again, don't ever, ever, ever, ever, ever vote for the political party that, 1-considers tort reform blasphemy, 2-sees doctors as sacrificial lambs to feed trial lawyers through frivolous litigation without cap or restriction, and 3-views your paycheck as something they can blood-let through ever increasing tax rates to pay for their doomed-to-fail socialist utopia. That is the Democrat party. Sorry, it sucks to have to tell you that, but that's the reality. They might be better on certain issues, for you, but on this issue, they're truly enemies of the physician, in my opinion.

But if you want all those things, and you don't mind limitless liability for malpractice you didn't commit, then I absolutely recommend you consider jobs in liability hell-hole states, where you're open to lottery sized malpractice awards for things PAs do, or don't do. Also, if you're okay with all that, vote for Democrats who made it that way, and fight like hell every day to keep it that way.


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Yeah but its hard to support a party that doesnt believe in climate change, doesnt acknowledge same-sex marriage, denounces evolution, wants everyone to carry guns, and has no racial or ethnic diversity.
 
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And how does this narrative explain Florida?
 
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The crazy lawsuit was in Florida?


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Yeah but its hard to support a party that doesnt believe in climate change, doesnt acknowledge same-sex marriage, denounces evolution, wants everyone to carry guns, and has no racial or ethnic diversity.

Well... We all have to make value judgements when we decide who or what to vote for. And you have to make your own decision, based on your interests and your family's. But if you want limitless malpractice liability and punitive taxes on your physician income, then clearly the party to vote for, is the party that pushes the trial lawyers' agenda and fights against tort reform. That's the Democrat party.



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Well... We all have to make value judgements when we decide who or what to vote for. And you have to make your own decision, based on your interests and your family's. But if you want limitless malpractice liability and punitive taxes on your physician income, then clearly the party to vote for, is the party that pushes the trial lawyers' agenda and fights against tort reform. That's the Democrat party.



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...if you're a single issue voter, and your personal finance is your single issue.

Perhaps is should be, perhaps it shouldn't. That's another discussion.
 
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Just don't work in a place that makes you sign mid-level charts.
It's hard to find these hospitals if you have family reasons for staying in for example, New York State. I had a follow up question. Say a midlevel sends you a chart of a 30 year old patient who had head injury with less than 3s loc with a normal neuro exam And a huge head lac that they don't scan. But they don't document for example no anticoagulant use and no physycal signs of basilar skull fracture. Can I blatantly refuse to sign this chart ? What happens if I refuse? Like will the director sign it or will it just go unsigned ?
 
It's hard to find these hospitals if you have family reasons for staying in for example, New York State. I had a follow up question. Say a midlevel sends you a chart of a 30 year old patient who had head injury with less than 3s loc with a normal neuro exam And a huge head lac that they don't scan. But they don't document for example no anticoagulant use and no physycal signs of basilar skull fracture. Can I blatantly refuse to sign this chart ? What happens if I refuse? Like will the director sign it or will it just go unsigned ?

When it's just a documentation concern, I send these charts back to the midlevel asking/instructing them to buff the chart.

When I'm actually concerned that something was missed I call the patient and check on them.


I agree with the above posters that, if you are not unattached, this is a difficult issue to address on a systems level. However, I find that I still have a lot of ways to address things on an individual level. Mostly I accomplish this by talking to the APP and fostering a sense of collaboration ("if you do things the way I like to do them, I will work with you and go to the mat for you if there's a bad outcome"). It's rare that his doesn't work, but when it doesn't, you still have options. There was one midlevel that I had a lot of issues with. I started checking in with them on EVERY case they saw. It was a pain, but things went the way I wanted them to go. Eventually, they stopped scheduling this midlevel to work with me. I think at the midlevel's request.
 
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When it's just a documentation concern, I send these charts back to the midlevel asking/instructing them to buff the chart.

When I'm actually concerned that something was missed I call the patient and check on them.


I agree with the above posters that, if you are not unattached, this is a difficult issue to address on a systems level. However, I find that I still have a lot of ways to address things on an individual level. Mostly I accomplish this by talking to the APP and fostering a sense of collaboration ("if you do things the way I like to do them, I will work with you and go to the mat for you if there's a bad outcome"). It's rare that his doesn't work, but when it doesn't, you still have options. There was one midlevel that I had a lot of issues with. I started checking in with them on EVERY case they saw. It was a pain, but things went the way I wanted them to go. Eventually, they stopped scheduling this midlevel to work with me. I think at the midlevel's request.
But the midlevel can't buff the chart if they forgot to ask about anticoagulant use or check for hemotypanum. Isn't that fraud lol
 
But the midlevel can't buff the chart if they forgot to ask about anticoagulant use or check for hemotypanum. Isn't that fraud lol

In that case the patient needs to be called +/- return to the ED. Whenever possible, the APP who saw the patient is the one who calls the patient.

And anyone who fails to ask a head injury adult about anticoagulation needs some education.
 
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In that case the patient needs to be called +/- return to the ED. Whenever possible, the APP who saw the patient is the one who calls the patient.

And anyone who fails to ask a head injury adult about anticoagulation needs some education.
What if the PA is now on a one week vacation? lol I'm just wondering if I can completely refuse to sign a bad chart. I mean if you call the patient they may refuse to come back to be seen to avoid paying again. 10 to 20% of the time the number on the chart to call the patient is wrong too.
 
What if the PA is now on a one week vacation? lol I'm just wondering if I can completely refuse to sign a bad chart. I mean if you call the patient they may refuse to come back to be seen to avoid paying again. 10 to 20% of the time the number on the chart to call the patient is wrong too.
Ask your medical director. You can always refuse to sign it, but you might be asked not to come to work for your next shift. Nobody can make you do anything, but you might have to do stuff to pay your mortgage.
 
Ask your medical director. You can always refuse to sign it, but you might be asked not to come to work for your next shift. Nobody can make you do anything, but you might have to do stuff to pay your mortgage.
Yikes. I certainly don't expect this to be a frequent occurrence. But I can't be expected to sign a chart with a 60 year old chest pain who didn't get a cardiac work up because pain was reproducible on exam. Or another old person in an Mva with no mention of nexus or Canadian c spine rules. These are all things some midlevels at my current residency program have done.
 
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Sounds like you need to (nicely) tear your mlps a new one then...


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Right now I don't really care. The attendings sign their charts. And I'm not staying here after graduation. But I assume I'll run into similar issues
 
What if the PA is now on a one week vacation? lol I'm just wondering if I can completely refuse to sign a bad chart. I mean if you call the patient they may refuse to come back to be seen to avoid paying again. 10 to 20% of the time the number on the chart to call the patient is wrong too.

Our prefabricated attestation statement ("macro") says that I've reviewed the chart and that I find the care to be appropriate. If I don't think the care was appropriate I can't refuse to sign the chart, but I can edit the statement and write "I was not consulted on this case during the patient's ED stay. Upon reviewing the chart at 430pm on May 8th I noted that XYZ was not done. I contacted the patient at 445pm and asked him to return to the ED for further testing."

I do not do that often, but I have done it.

If it comes to that, I would avoid the temptation to slam your APP in the medical record. Just note the over site and then address it. After you've done that, apply @bravotwozero's above advice.
 
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