Muggles: "Can I download MDCalc and use it, too ?!"

[RustedFox]

MDCalc is a great app. Nobody here is going to disagree.

It's especially powerful when you can pull the CDM rules up on your phone at the bedside, and "walk" the chest pain patient, or the worried mom of the PECARN patient thru the logic of the decision-making. It talks a lot of muggles off of the ledge. Nobody here is going to disagree.

But...

I have had a rash of muggle-mommies ask me during my bedside "shared decision-making" (with MDCalc as the focus) ask me the same question:

"Can I just download this and use it, too ?"

I always answer politely.

"It requires you to have a physician-level understanding of medical knowledge."

I get rebuttals to this statement surprisingly commonly.

"But; if all you have to do is click thru things [sic] on a screen, then anyone can do it! I mean, my cousin in is nursing school; so she knows what this all means."

It is at this point that I generally want to punch the muggle-mommy in their muggle-mommy-mouth.

Can you calculate a GCS? [I actually say this.]
Do you know what a basilar skull fracture looks like? [I actually say this.]
Can you make a decision regarding the true clinical suspicion for ACS? [I actually say this.]
Do you even know the metric system? (uh, no) [I don't actually say this.]
Can you do more than one simple mathematical calculation in sequence, with or without the assistance of a calculator? [I certainly don't say this, but Jeeeeezus, do I want to!]

Listen, muggles:

I doubt that you can do any of those things, seeing as how you "give up" when I ask you how many milligrams of ibuprofen you've given your muggle-baby for its muggle-fever, because that would require TWO "math problems".

I have seriously had multiple muggle-mommies say to me: "Oh, I ask my husband to do math problems. He's not here now."

This is in the well-off, well-educated, "country-club" area of my city. I work in the "Country Club ER" where the kids all go to private schools that get them into the Ivy-Leage University of their choice.

Hold up. *Record scratch. Freeze-frame.*

I just pulled back my boxer shorts and looked between my legs.

I have a penis. It kinda swings back and forth, and it feels nice and tingly when I touch it. Gets bigger, too.

Therefore, I am now responsible for doing all of the "math problems" that are necessary to "do".

Wait a sec:

Mrs. Fox has something to say:

"RustedFox is good at math, but I am far better."

Guys, she's right. Ask me to do 2x2 digit multiplication in my head [EX: 36 X 14], and there's a decent amount of cognitive delay. Not unreasonable, but I have to think it thru.

She has the answer in three seconds or less, and leaves my flaccid penis swinging in the breeze.

This is reason number 6 X 12 why it's okay to hate the muggles.

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Members don't see this ad.

 

[Apollyon]

72?

 

[Tenk]

I helped a patient’s family member buy something on Amazon the other week. Much more enjoyable than MDCalc. Next time try that instead.

 

[GeneralVeers]

This is why I keep all the knowledge in my brain where it belongs. Never let the muggles in on our secret ways.

 

[thegenius]

I'm surprised I've never had a patient ask me "where is that website you are getting this from"

6 x 12 is approximately 32 to most muggles.

 

[deleted859535]

So hey, we talked about RustedFox's penis today.

 

[RustedFox]

So hey, we talked about RustedFox's penis today.

Dick-jokes are always funny.

 

[TooMuchResearch]

So hey, we talked about RustedFox's penis today.

I thought that was just usual business around here

 

[GeneralVeers]

So hey, we talked about RustedFox's penis today.

He also talks about it over in the "Travel Teams" thread. He really likes his dick.

 

[RustedFox]

He also talks about it over in the "Travel Teams" thread. He really likes his dick.

Refer to pior post, 3 posts above.

Also *In Sean Connery Voice*... your mother seems to like it, Trebek.

 

[southerndoc]

A lady asked me if she could download VisualDx with its Derm Expert feature after seeing me take a picture of a rash and identify it with my iPhone. She balked at the idea of paying $500/year for access. I'm only using it because I have a limited free trial.

 

[Boatswain2PA]

What about us mudbloods...can we use it? (Referring to MDCalc, not a rusty phallus).

 

[KeikoTanaka]

What about us mudbloods...can we use it? (Referring to MDCalc, not a rusty phallus).

Omg
If...
Patients = Muggles
Midlevels = Mudbloods

Then..
Pharmacists = Potion Masters
Administrators = Money Hungry Goblins or Death Eaters??
Cleaning Staff = House Elves
Scribes = Pet Owl/Frog/Cat

I can't think of anymore lol

 

[RustedFox]

What about us mudbloods...can we use it? (Referring to MDCalc, not a rusty phallus).

It seems the MLPs at my site cannot, as they too frequently get charts back from me with charting problems that would have been solved if they could use it.

 

[GeneralVeers]

It seems the MLPs at my site cannot, as they too frequently get charts back from me with charting problems that would have been solved if they could use it.

Half of mine forget their basic Defense Against the Dark Arts training when it comes to consultants pushing back against consults.

Also why do I have to have them calculate a HEART score every time they present a patient to me with chest pain? You need to have this done and ready to go before presenting as a rationale for your dispo.

 

[RustedFox]

Half of mine forget their basic Defense Against the Dark Arts training when it comes to consultants pushing back against consults.

Also why do I have to have them calculate a HEART score every time they present a patient to me with chest pain? You need to have this done and ready to go before presenting as a rationale for your dispo.

"So, do you think I should scan this patient's neck or not?"

What does the NEXUS rule say?

"Um."

Recite the criteria to me.

[They get thru 1 or 2 criteria before they stall and look at me for the answer.]

 

[BoardingDoc]

"So, do you think I should scan this patient's neck or not?"

What does the NEXUS rule say?

"Um."

Recite the criteria to me.

[They get thru 1 or 2 criteria before they stall and look at me for the answer.]

I vastly prefer Canadian C-spine in lower risk patients given that it omits "midline tenderness."

 

[RustedFox]

I vastly prefer Canadian C-spine in lower risk patients given that it omits "midline tenderness."

Me too, but the powers that be have decided that the NEXUS is what we will use and be judged upon when time comes for chart review.

 

[BoardingDoc]

Me too, but the powers that be have decided that the NEXUS is what we will use and be judged upon when time comes for chart review.

Wait, your shop dictates what decision making tools you use? They literally tell you how you are required to practice medicine?

 

[GeneralVeers]

Wait, your shop dictates what decision making tools you use? They literally tell you how you are required to practice medicine?

No, the malpractice attorneys aka "Dementors" do. NEXUS is considered "standard of care".

 

[thegenius]

Are you suggesting that there is actual evidence that applying a clinically accepted decision rule, but not applying a different one that measures the same thing, exposes one to a lawsuit they can’t win?

 

[Boatswain2PA]

It seems the MLPs at my site cannot,

Delores Umbrage never got good results from her students either.

Half of mine forget their basic Defense Against the Dark Arts training when it comes to consultants pushing back against consults.

"So, do you think I should scan this patient's neck or not?"

What does the NEXUS rule say?

"Um."

Recite the criteria to me.

[They get thru 1 or 2 criteria before they stall and look at me for the answer.]

Pay for a Weasley, you're not gonna get a Hermione. I've found CMGs don't pay for good PAs, but my N=1 in that regard.

 

[RustedFox]

Delores Umbrage never got good results from her students either.




Pay for a Weasley, you're not gonna get a Hermione. I've found CMGs don't pay for good PAs, but my N=1 in that regard.

Not sure I follow. The pay is the pay is the pay.
Weasley or Grainger; if youre gonna be an ER MLP, then you'd better at least be able to know bare-bones ER stuff such as how to clear a C-spine.

 

[Boatswain2PA]

Not sure I follow. The pay is the pay is the pay.
Weasley or Grainger; if youre gonna be an ER MLP, then you'd better at least be able to know bare-bones ER stuff such as how to clear a C-spine.

The CMG I work part-time at (VEP) pay is pretty terrible at that location (obviously can't speak for other locations) while seeing as many patients an hour as you can sign up for. This is in a geographical area where competent ED PA/NPs can make 20-30% more working 24/48/72 hour shifts in sleepy little hospitals seeing 5-10 patients per day. The result? VEP gets a lot of new grad NPs who work there for 6 months before they are suicidal and move on to an UC or FP position. This puts more stress on the EP who has to pick up the slack, and (in my opinion) is a significant cause for the high EP turnover at that site (or worse yet for VEP, they hire locums EPs to fill in). This is at a 30K/year shop with very high acuity (probably 25% admission).

So they're paying for Weasley's, and they are getting Weasley's.

There really are competent PA/NPs out there. You gotta find them, you gotta hire them, and you gotta pay them if you want them to stay. You also can't treat them like **** (aka my other comment). And you gotta cull the herd because there are problems with both professions (PA & NP) that you don't have with BC/BE EPs. With PAs, we can (still) move between specialties, so that PA who comes highly recommended from Cardiology might have a mental meltdown when trying to see 2 pph in the ED. NPs, on the other hand, "specialize" by doing 2 years of online school and then 500 hours of shadowing hours in their chosen "specialty".

Want to find a Hermione? Pay for it. At that VEP site there is an NP who is truly outstanding, but she (like me) only do a shift a month or so there because the pay sucks. The full timers there are 2 new grad PAs and an experienced ortho PA.

 

[southerndoc]

Canadian rules are more specific and better. Although we don't like the idea of somebody telling us to use this rule or that one, having a health system standardize a rule actually decreases your chances of being solely liable in a malpractice case. Example: HEART score <4 should be discharged. You basically have your health system covering all liability because they've developed a policy that you are following.

 

[BoardingDoc]

NEXUS is considered "standard of care".

I assume you mean that at RF's shop it's the de facto standard of care because of their edict to use NEXUS; not that NEXUS is standard of care in general. In the former case, I could see how that could be true (though maybe @southerndoc would know if deviating from a hospital policy to use another equally valid rule is somehow "wrong"). The latter case certainly can't be correct.

 

[GonnaBeADoc2222]

Delores Umbrage never got good results from her students either.

It is not my responsibility to teach midlevels. That's the job of their schools. Forget cspine - you should graduate from midlevel school with a working ability to run a fast track, which mine cannot. Labs on vomiting children, trops/ekgs on everyone, plain films on back pain, antibiotics for URIs, the list goes on and on. I shouldn't have to hear "I've never put in a rhino rocket" from someone who has been out of midlevel school for 1+ years.

The couple good ones I have are an absolute pleasure to work with and I breathe a sign of relief whenever I see their names on the schedule.

I'd rather send the Weasleys home, take their pay, and see all their patients. All they do is add work and stress to my day.

 

[RustedFox]

My responses are in italics for the sake of ease-of-reading.

It is not my responsibility to teach midlevels. That's the job of their schools.

Agree. Even then, I hear the argument of "you need to teach your midlevel". I tried this, as ordering "c-spine x-rays" was an ingrained part of the culture at one of my shops. I wound up with a gang of MLPs telling me that I was "wrong', despite me having e-mailed the entire group the relevant literature. In my experience; they don't want to be taught, especially anything that they don't like. The older they were, the more vociferous they were with their objections.

I'm pretty convinced that the issue here is that "they don't have residencies", which is where you really learn just what you're doing, and not just the science of what you're doing. Before someone pipes up and says "Nuh-uhhh, PA residencies exist"... that's not a residency. A residency is a residency. 3+ years of get your ass up and pay attention, with in-service exams, board prep, conferences, and all the trimmings.


Forget cspine - you should graduate from midlevel school with a working ability to run a fast track, which mine cannot. Labs on vomiting children, trops/ekgs on everyone, plain films on back pain, antibiotics for URIs, the list goes on and on. I shouldn't have to hear "I've never put in a rhino rocket" from someone who has been out of midlevel school for 1+ years.

Chart review on a Bell's Palsy patient: "CN 2-12 intact". When I asked him which CN was involved in Bell's Palsy, the answer I got was "five?" This was from a PA that has been in EM for 10 years or so. Was approached by the same PA to put in a suprapubic catheter, because; "I don't know how". *Put it in the hole, Stuart!*


The couple good ones I have are an absolute pleasure to work with and I breathe a sign of relief whenever I see their names on the schedule.

Agree. These are very few and far between in my experience.


I'd rather send the Weasleys home, take their pay, and see all their patients. All they do is add work and stress to my day.

My home-base shop did just this recently. We now have 1 MLP from 12p-12a, and a "four-doc-day". Our CMG gave us the blessing on this, but it wasn't easy to get that blessing.

 

[RustedFox]

For the record, in my fantasy metaphor here; "Muggles" are simply non-medical people. MLPs, RNs, EMS, and even the techs aren't expressly Muggles as a rule.

And thank you for explaining the Dolores Umbrage metaphor, as I had no idea who that was. I saw all the HP movies and I've been to the Universal Studios attraction a few time (I live in Florida); but I'm not deep in the mythos.

 

[thegenius]

My responses are in italics for the sake of ease-of-reading.

It is not my responsibility to teach midlevels. That's the job of their schools.

Agree. Even then, I hear the argument of "you need to teach your midlevel". I tried this, as ordering "c-spine x-rays" was an ingrained part of the culture at one of my shops. I wound up with a gang of MLPs telling me that I was "wrong', despite me having e-mailed the entire group the relevant literature. In my experience; they don't want to be taught, especially anything that they don't like. The older they were, the more vociferous they were with their objections.

I'm pretty convinced that the issue here is that "they don't have residencies", which is where you really learn just what you're doing, and not just the science of what you're doing. Before someone pipes up and says "Nuh-uhhh, PA residencies exist"... that's not a residency. A residency is a residency. 3+ years of get your ass up and pay attention, with in-service exams, board prep, conferences, and all the trimmings.


Forget cspine - you should graduate from midlevel school with a working ability to run a fast track, which mine cannot. Labs on vomiting children, trops/ekgs on everyone, plain films on back pain, antibiotics for URIs, the list goes on and on. I shouldn't have to hear "I've never put in a rhino rocket" from someone who has been out of midlevel school for 1+ years.

Chart review on a Bell's Palsy patient: "CN 2-12 intact". When I asked him which CN was involved in Bell's Palsy, the answer I got was "five?" This was from a PA that has been in EM for 10 years or so. Was approached by the same PA to put in a suprapubic catheter, because; "I don't know how". *Put it in the hole, Stuart!*


The couple good ones I have are an absolute pleasure to work with and I breathe a sign of relief whenever I see their names on the schedule.

Agree. These are very few and far between in my experience.


I'd rather send the Weasleys home, take their pay, and see all their patients. All they do is add work and stress to my day.

My home-base shop did just this recently. We now have 1 MLP from 12p-12a, and a "four-doc-day". Our CMG gave us the blessing on this, but it wasn't easy to get that blessing.

The last three lawsuits at our shop over the past 5 years all involved PAs, and I was named on one of them too because I was the supervising doc (although in my case the PA did everything basically right)

 

[Groove]

The last three lawsuits at our shop over the past 5 years all involved PAs, and I was named on one of them too because I was the supervising doc (although in my case the PA did everything basically right)

Did you just sign the chart or did you place an attestation? If you merely signed it, did they drop you?

I'm curious about charts where the doc merely signs the note and does nothing else... I wonder if many plaintiff attorneys end up dropping the physician who essentially was never involved in favor of going after the MLP who was the primary treating clinician. I haven't been named yet in an APC suit but I'm sure I will be eventually.

 

[GeneralVeers]

Did you just sign the chart or did you place an attestation? If you merely signed it, did they drop you?

I'm curious about charts where the doc merely signs the note and does nothing else... I wonder if many plaintiff attorneys end up dropping the physician who essentially was never involved in favor of going after the MLP who was the primary treating clinician. I haven't been named yet in an APC suit but I'm sure I will be eventually.

They won't drop the physician. They will say legally the physician was responsible, and the injury happened due to improper or inadequate physician supervision. These are in some way worse, as you take all the legal responsibility, but have never seen the patient and in some cases have no input on their treatment or disposition.

 

[Groove]

They won't drop the physician. They will say legally the physician was responsible, and the injury happened due to improper or inadequate physician supervision. These are in some way worse, as you take all the legal responsibility, but have never seen the patient and in some cases have no input on their treatment or disposition.

Do you have any insight into whether one of these has gone all the way to trial and actually lost? I can't help but think one could mount a vigorous defense that they were never consulted on the pt, never saw the pt and were signing the chart due to CMG requirements. Is the plaintiff counsel arguing a case of implicit approval in management of the pt due to nothing more than the physicians signature?

Do these usually settle or do they go all the way to court? If I were plaintiff attorney, I would think it easier to spend my energies going after the actually treating clinician.

 

[GeneralVeers]

Do you have any insight into whether one of these has gone all the way to trial and actually lost? I can't help but think one could mount a vigorous defense that they were never consulted on the pt, never saw the pt and were signing the chart due to CMG requirements. Is the plaintiff counsel arguing a case of implicit approval in management of the pt due to nothing more than the physicians signature?

Do these usually settle or do they go all the way to court? If I were plaintiff attorney, I would think it easier to spend my energies going after the actually treating clinician.

Most lawyers want to settle regardless of the type of case. Going to trial is expensive, and a crapshoot for them. I'd actually be more worried about one of these midlevel cases than one I saw on my own. Essentially you are 100% responsible, and if you say you didn't see the patient, or didn't know about them, then the Plaintiff's attorney will just nail you on inadequate supervision. It's a no-win scenario and I'd probably just settle it outright if I could.

 

[southerndoc]

Do you have any insight into whether one of these has gone all the way to trial and actually lost? I can't help but think one could mount a vigorous defense that they were never consulted on the pt, never saw the pt and were signing the chart due to CMG requirements. Is the plaintiff counsel arguing a case of implicit approval in management of the pt due to nothing more than the physicians signature?

Do these usually settle or do they go all the way to court? If I were plaintiff attorney, I would think it easier to spend my energies going after the actually treating clinician.

Yes, I'm aware of several. Physicians can't seem to grasp the idea that they are responsible for PA's and NP's care, but in the view of the court they are. You are responsible for their training, their supervision, and any care which they render whether you knew about the patient while they were in the department or not. There has even been a case where a PA assigned an ER physician not working that day to her chart. That ER doc ended up settling.

Rarely -- if ever -- will a supervising physician be dropped. It's just an added $1 mil of coverage ripe for the picking. If you and your PA each have $1 mil of coverage, the plaintiff can get $2 mil potentially if both of you are litigated.

 

[BoardingDoc]

There has even been a case where a PA assigned an ER physician not working that day to her chart. That ER doc ended up settling.

Wait, what? Unless there is some other circumstance to that case you're not mentioning, that seems trivially easy to defend in court.

 

[southerndoc]

Doesn't matter if you're in the department or not, if you're listed as the supervising physician then you are the supervising physician. What difference is there with you being in the department and not seeing the patient?

 

[BoardingDoc]

Doesn't matter if you're in the department or not, if you're listed as the supervising physician then you are the supervising physician. What difference is there with you being in the department and not seeing the patient?

You wrote that the EM doc listed was not working that day. That seems to indicate that someone else was supposed to be listed as the supervising doctor. It isn't the fact that the MD wasn't physically present, it's that the chart appears to have the wrong name on it and this is simply a clerical error.

That said, if the ED in question had a policy whereby all of the docs are part of some supervisory pool for all of the PAs, I could see how this would still fly.

 

[thegenius]

Did you just sign the chart or did you place an attestation? If you merely signed it, did they drop you?

I'm curious about charts where the doc merely signs the note and does nothing else... I wonder if many plaintiff attorneys end up dropping the physician who essentially was never involved in favor of going after the MLP who was the primary treating clinician. I haven't been named yet in an APC suit but I'm sure I will be eventually.

I never saw the patient.
I put in an attestation saying that I was the supervising physician that day. I don't recall, but I think the case was discussed with me by the PA.

PA saw a pt that complained of bilateral eye pain. PA said that on her exam she saw bilateral corneal abrasions and prescribed her ophthalmic abx. Somehow the patient left the ED with tetracaine and she used it over the next several days, then saw an ophthalmologist and was diagnosed with corneal ulcers from using too much tetracaine. The damage was apparently irreversible.

The hospital, nurse, PA and myself were all named in the lawsuit. The pt said, under oath, that she never saw a male provider or doctor. I was never dropped even though we asked repeatedly.

Case was eventually settled for $500K, 250K came from the hospital/RN, and $250K came from PA/MD. Thankfully TeamHealth decided that of the $250 from the PA/MD, 100% should come from the PA malpractice policy. So I was effectively "dropped" from the case, nothing was ever reported under my insurance even though I wasn't literally dropped from the case.

Some observations
1. If there is state law describing doctor supervision of a midlevel, then you are liable for 100% of what they do. Literally! If they accidentally step on a patient's foot and cause pain, and the pt wants to sue, you are held liable for their actions. You are held liable for their decision making, tests ordered, thought process, what they say, what they do.

2. You will never be dropped from a case. There is no incentive to do so.

3. It doesn't matter if you are present for the case, saw the pt, didn't see the patient, were at home. If you are named the supervising physician you will be sued. If there is no supervising physician named, then the plantiff lawyer might name every single doctor working that day. They might name the chief of the department. There has to be a supervising physician and they will find out who it is.

4. Experts in their own field, whether they are up to date on knowledge, are considered superior to ER physicians knowledge about something. For example, I think the patient in my case alleged to have used tetracaine at home either BID or TID for 5 days. I can't remember. All the lousy evidence that exists talking about ophthalmic tetracaine toxicity are from very old studies where people were using it like 10 times a day for weeks. There is recent evidence that you can send someone home with a short course of tetracaine (24 hrs worth) for corneal abrasions and it's OK. People who get PRK (photorefractive keratectomy) often go home with a few days of tetracaine or something similar. based on all the research I did, I have a hard time believing if someone used 1 drop BID or TID for 5 days they would get irreversible cornea damage. But....because an ophthalmologist said the pt did, it's like an immutable claim.

So that's why I'm careful about emerging evidence about new things to do...unless it becomes officially stated in clinical policy...I try not to jump on board. With respect to this case...the only way I would change my practice is if the AOS (American Ophthalmological Society) said it's OK to discharge someone with tetracaine, not evidence produced by Emergency Physicians.

5. It seems like lawyers don't like going to court. Everything is very carefully measured....they would much rather settle. You feel really rather helpless during their decision making. "You can settle for $150K...your insurance will pay it....or you can risk going to court, having a jury find you liable for $1.5M and you are on the hook for $500K."

 

[thegenius]

You wrote that the EM doc listed was not working that day. That seems to indicate that someone else was supposed to be listed as the supervising doctor. It isn't the fact that the MD wasn't physically present, it's that the chart appears to have the wrong name on it and this is simply a clerical error.

That said, if the ED in question had a policy whereby all of the docs are part of some supervisory pool for all of the PAs, I could see how this would still fly.

There was another PA case in our group that was litigated.

PA saw a young woman in her 30's who came in with family because she wasn't talking. I think there may have been a psych history but I can't remember. PA ordered labs, CT Head all of which were negative and discharged the patient ascribing her symptoms to a psychiatric problem. Pt came back two days later with a subacute stroke on CT Head and plaintiff won like $5M from combined hospital, MD's, PAs, etc.

The PA never listed the supervising physician on the chart. The PA even admitted to not running the case through a supervising physician. The supervising physician happened to be the one on shift at that time, per our department policy. So she (the MD) was named, along with the assistant chief of the department and the chief of the department in the lawsuit and each one of them all had substantial money taken from their insurance policies.

 

[BoardingDoc]

There was another PA case in our group that was litigated.

PA saw a young woman in her 30's who came in with family because she wasn't talking. I think there may have been a psych history but I can't remember. PA ordered labs, CT Head all of which were negative and discharged the patient ascribing her symptoms to a psychiatric problem. Pt came back two days later with a subacute stroke on CT Head and plaintiff won like $5M from combined hospital, MD's, PAs, etc.

The PA never listed the supervising physician on the chart. The PA even admitted to not running the case through a supervising physician. The supervising physician happened to be the one on shift at that time, per our department policy. So she (the MD) was named, along with the assistant chief of the department and the chief of the department in the lawsuit and each one of them all had substantial money taken from their insurance policies.

Based on that hospital policy, that makes sense. It sucks for the doc, but I get it. The case I was responding to named a doc that wasn't even working that day, so I still feel like it makes no sense from a medmal point of view.

Your case also reaffirms my decision to never work in a shop where the pa is allowed to see a patient and not run it past an attending.

 

[thegenius]

Based on that hospital policy, that makes sense. It sucks for the doc, but I get it. The case I was responding to named a doc that wasn't even working that day, so I still feel like it makes no sense from a medmal point of view.

Your case also reaffirms my decision to never work in a shop where the pa is allowed to see a patient and not run it past an attending.

If that doc is the supervising physician then why wasn't he/she working that day? If he's the supervising physician he is liable...even if he is on a spaceship halfway to Mars. Doesn't matter where you are.

 

[GonnaBeADoc2222]

There was another PA case in our group that was litigated.

PA saw a young woman in her 30's who came in with family because she wasn't talking. I think there may have been a psych history but I can't remember. PA ordered labs, CT Head all of which were negative and discharged the patient ascribing her symptoms to a psychiatric problem. Pt came back two days later with a subacute stroke on CT Head and plaintiff won like $5M from combined hospital, MD's, PAs, etc.

The PA never listed the supervising physician on the chart. The PA even admitted to not running the case through a supervising physician. The supervising physician happened to be the one on shift at that time, per our department policy. So she (the MD) was named, along with the assistant chief of the department and the chief of the department in the lawsuit and each one of them all had substantial money taken from their insurance policies.

Discharged a young person who was talking and then not talking. Smart.

 

[GonnaBeADoc2222]

Based on that hospital policy, that makes sense. It sucks for the doc, but I get it. The case I was responding to named a doc that wasn't even working that day, so I still feel like it makes no sense from a medmal point of view.

Your case also reaffirms my decision to never work in a shop where the pa is allowed to see a patient and not run it past an attending.

The place I work primarily is a minefield of non supervision. There just isn't time. It is terrifying. I'm looking forward to being able to find a much better place to work once certain familial constraints are resolved.

 

[GeneralVeers]

If that doc is the supervising physician then why wasn't he/she working that day? If he's the supervising physician he is liable...even if he is on a spaceship halfway to Mars. Doesn't matter where you are.

I think the issue we have is the definition "supervising physician". A supervising physician is supposed to be physically present whenever the PA/NP is seeing patients in order to answer questions or do their own eval if necessary. If the physician wasn't present, and it was simply a clerical error of the PA/NP picking the wrong physician, I'm surprised the defense didn't get this thrown out rather easily.

 

[Groove]

I never saw the patient.
I put in an attestation saying that I was the supervising physician that day. I don't recall, but I think the case was discussed with me by the PA.

PA saw a pt that complained of bilateral eye pain. PA said that on her exam she saw bilateral corneal abrasions and prescribed her ophthalmic abx. Somehow the patient left the ED with tetracaine and she used it over the next several days, then saw an ophthalmologist and was diagnosed with corneal ulcers from using too much tetracaine. The damage was apparently irreversible.

The hospital, nurse, PA and myself were all named in the lawsuit. The pt said, under oath, that she never saw a male provider or doctor. I was never dropped even though we asked repeatedly.

Case was eventually settled for $500K, 250K came from the hospital/RN, and $250K came from PA/MD. Thankfully TeamHealth decided that of the $250 from the PA/MD, 100% should come from the PA malpractice policy. So I was effectively "dropped" from the case, nothing was ever reported under my insurance even though I wasn't literally dropped from the case.

Some observations
1. If there is state law describing doctor supervision of a midlevel, then you are liable for 100% of what they do. Literally! If they accidentally step on a patient's foot and cause pain, and the pt wants to sue, you are held liable for their actions. You are held liable for their decision making, tests ordered, thought process, what they say, what they do.

2. You will never be dropped from a case. There is no incentive to do so.

3. It doesn't matter if you are present for the case, saw the pt, didn't see the patient, were at home. If you are named the supervising physician you will be sued. If there is no supervising physician named, then the plantiff lawyer might name every single doctor working that day. They might name the chief of the department. There has to be a supervising physician and they will find out who it is.

4. Experts in their own field, whether they are up to date on knowledge, are considered superior to ER physicians knowledge about something. For example, I think the patient in my case alleged to have used tetracaine at home either BID or TID for 5 days. I can't remember. All the lousy evidence that exists talking about ophthalmic tetracaine toxicity are from very old studies where people were using it like 10 times a day for weeks. There is recent evidence that you can send someone home with a short course of tetracaine (24 hrs worth) for corneal abrasions and it's OK. People who get PRK (photorefractive keratectomy) often go home with a few days of tetracaine or something similar. based on all the research I did, I have a hard time believing if someone used 1 drop BID or TID for 5 days they would get irreversible cornea damage. But....because an ophthalmologist said the pt did, it's like an immutable claim.

So that's why I'm careful about emerging evidence about new things to do...unless it becomes officially stated in clinical policy...I try not to jump on board. With respect to this case...the only way I would change my practice is if the AOS (American Ophthalmological Society) said it's OK to discharge someone with tetracaine, not evidence produced by Emergency Physicians.

5. It seems like lawyers don't like going to court. Everything is very carefully measured....they would much rather settle. You feel really rather helpless during their decision making. "You can settle for $150K...your insurance will pay it....or you can risk going to court, having a jury find you liable for $1.5M and you are on the hook for $500K."

Thanks for sharing the details. That's insane. Stories like this make me even more paranoid since I currently work in a shop where we are too high volume to see all the MLP patients and they only really consult us on patients where they need help with their MDM. I've often wondered whether it makes any real difference in attesting specific things like "I was available for consult but was not consulted on this pt and the APC acted independently, etc.." It doesn't sound like it makes much difference. What's funny is that when I got the AFMD role, I started getting MLP credentialing paperwork to sign as their supervising physician. Luckily, I had the wherewithal to refuse and insist that the FMD sign all of them. He would be "unavailable" and ask our practice manager to send them over to me to sign. Now I know why.

 

[GeneralVeers]

Thanks for sharing the details. That's insane. Stories like this make me even more paranoid since I currently work in a shop where we are too high volume to see all the MLP patients and they only really consult us on patients where they need help with their MDM. I've often wondered whether it makes any real difference in attesting specific things like "I was available for consult but was not consulted on this pt and the APC acted independently, etc.." It doesn't sound like it makes much difference. What's funny is that when I got the AFMD role, I started getting MLP credentialing paperwork to sign as their supervising physician. Luckily, I had the wherewithal to refuse and insist that the FMD sign all of them. He would be "unavailable" and ask our practice manager to send them over to me to sign. Now I know why.

Good move. Never sign anything you aren't directly responsible. This is why I refuse to sign EKGs for patients who are admitted or aren't under my care. I also won't put orders or see patients physically in the ED who aren't under my direct care. Every patient where your name is attached is a potential liability as you can get named if their is a suit, even if you aren't the treating physician and are just doing a favor for the nurse.

 

[thegenius]

@Groove
No problem man. Happy to share. At the end of the day, I think either one only works at a place without PA's, or if you do (and the majority have PA's) make sure you get something for taking the risk of signing their charts. I heard at one point that our PA's increased our pay by like 20%, but even that math is nebulous and hard to calculate, and therefore hard to actually measure.

 

[Groove]

Do we even have many EDs left with no MLPs? All of the places I've worked in the SE have MLPs with limited oversight. I think if I was a partner in a SDG and could help craft the perfect environment, I'd push for an MD only practice. I wouldn't care if I had to see additional 4s and 5s.

 

[GeneralVeers]

@Groove
No problem man. Happy to share. At the end of the day, I think either one only works at a place without PA's, or if you do (and the majority have PA's) make sure you get something for taking the risk of signing their charts. I heard at one point that our PA's increased our pay by like 20%, but even that math is nebulous and hard to calculate, and therefore hard to actually measure.

At my place they typically increase my pay 30-50%. I get RVU credit for all the patients I see. On my own I typically see around 20-25. If I have a quick PA (or 2) they can add 30 patients to my RVUS, and I'll get credit for 50+ patients on a shift. Not a bad chunk of change, and worth the risk of supervising them. At least they discuss every patient with me and we review labs/imaging prior to DC.