PA's in Podiatry

[Skippygonenuts]

I was reading the other thread about having multiple offices and was curious as to what about having a Physician Assistant run one of the offices alone on certain days and having the DPM check in on the other days and see some patients?

which leads me to the reason i started this thread--> I've seen quite a few contradicting things regarding whether DPMs can even hire PA's..I looked through a bunch of the "law stuff" and didn't clearly understand whether DPMs can hire PA's or not, specifically looking for the NJ NY area.

Even though i'm starting at a DO school this fall, i'm have been very interested in pod for a little less than a year now, and I talked my brother into it..he's in the application process now, so I'm trying to figure out as much as I can to see how we can possibly have a future business together and possibly hire some PA's for him and myself. Would we be able to? If I am not in the business with him for any reason, would he be able to hire a PA on his own?

Do these businesses happen often between MD/DO and DPMs? If so, what areas of medicine could a DPM possibly partner with besides Ortho?

thanks guys!

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[drift]

I was reading the other thread about having multiple offices and was curious as to what about having a Physician Assistant run one of the offices alone on certain days and having the DPM check in on the other days and see some patients?

which leads me to the reason i started this thread--> I've seen quite a few contradicting things regarding whether DPMs can even hire PA's..I looked through a bunch of the "law stuff" and didn't clearly understand whether DPMs can hire PA's or not, specifically looking for the NJ NY area.

Even though i'm starting at a DO school this fall, i'm have been very interested in pod for a little less than a year now, and I talked my brother into it..he's in the application process now, so I'm trying to figure out as much as I can to see how we can possibly have a future business together and possibly hire some PA's for him and myself. Would we be able to? If I am not in the business with him for any reason, would he be able to hire a PA on his own?

Do these businesses happen often between MD/DO and DPMs? If so, what areas of medicine could a DPM possibly partner with besides Ortho?

thanks guys!

Depends on the state. Generally, many states want an MD/DO to be the principle overseeing physician to PAs and then work for a pod. So, the PA may be able to work for a pod, but may still need a MD/DO to be the SP.

 

[dyk343]

It does depend on the state.

I shadowed a pod who had a physicians assistant that worked for him. The PA primarily did the orthotics and nail care in the practice.

 

[that1guyfromFL]

I was under the impression the PA's were a no go for us across the board.

Are you certain it was a PA and that he/she was employed directly by the DPM?
If so, what state was this?

 

[dyk343]

I was under the impression the PA's were a no go for us across the board.

Are you certain it was a PA and that he/she was employed directly by the DPM?
If so, what state was this?

Yeah he was a PA. 100% positive of it. I spent more time with him than the actual podiatrist. Again all i really saw him do was nail care and shoe fittings/orthotics. When a fungal problem popped up he called in the podiatrist.

And im keeping my state private due to anonymity reasons. I've been tracked down on here before because of things I've said so... yeah.

Edit: it was a private practice so im assuming he was employed directly by the podiatrist.

 

[PADPM]

I'm not really sure about the law and PA's. Although our practice is what I would consider busy, we've never considered hiring PA's. As busy as we are, we still have decided to perform the full scope of care on our patients, though we do utilize podiatric assistants to "finish up" for us.

Our podiatric assistants finish up for all nail care, remove bandages (although I remove my own post op bandages, my partners allow them to remove all bandages), remove sutures, apply tapings/strappings, take x-rays, fit patients for Cam Walkers, diabetic therapeutic shoes, etc., etc.

This works well for our group and is well accepted by our patients. However, we are still actually providing the "care" for our patients, and the only time assistants work independently are when fitting/dispensing diabetic therapeutic shoes.

Although I won't discuss where I practice since I prefer to remain "anonymous", I did actually break my rule and for personal reasons, did allow Kidsfeet to visit our practice this past week/weekend.

He was interested in seeing how our practice functioned, so I trusted that he would honor my anonymity, therefore I allowed him to visit our offices and he spent time with me and my partners in the office(s) and out to dinner. I will let him tell you if I've been blowing smoke in all my posts!!! Additionally, I'll let him tell you whether he thinks our system "works" by having our assistants finish up, etc. , without actually hiring a PA.

Although I'm sure some practices DO have a PA where it's allowed, we haven't found the need for that........yet.

 

[347932]

In the state I practice in, we are not allowed by state practice law to have a PA function within our practice. Someone locally tried it "under the radar" and almost lost his license because of it.

I did have a chance to meet with PADPM over the last week and I can certainly tell you what he professes is genuine. If he ever felt like becoming an author, he and his partners could likely write a book on running the most efficient operation I've ever had the pleasure of coming across (and I've come across many). He and his partner are not only genuine in their success, but are also, most probably, the nicest group of people I've ever had the privilege of getting to know. They are the real deal. All of us can learn much from their experience.

 

[janV88]

I did a quick search and so far I've found that Michigan allows Podiatrists to supervise PAs. California sort of allows it. They require an MD/DO to allow the PA to assist the Podiatrist. The MD/DO is the actual supervising physician. The Podiatrist must be part of the group of the supervising physician.

 

[Paulywog]

I met two different podiatrists that employ PA's at their practice. I met them at a recent conference but forgot what state they are in.

 

[PADPM]

Since there is a similarity between PA's and NPs, I would believe it would be okay to employ a nurse practitioner if your state doesn't allow the hiring of PA's. I'm not sure, but it would make sense that we would be able to hire an NP. That may be a very practical solution.

Our practice administrator has her RN and masters in health administration. We thought it was beneficial for someone that was "running" our practice to have clinical and administrative skills.

 

[deleted6669]

I would believe it would be okay to employ a nurse practitioner if your state doesn't allow the hiring of PA's. I'm not sure, but it would make sense that we would be able to hire an NP. That may be a very practical solution.

.

depending on the state an np may also need to work with oversight from a physician. in states which allow independent np practice an np could work for anyone they wanted or even open up their own solo practice.

 

[Skippygonenuts]

thanks for the response everyone..

PADPM, can you tell me a little more about what podiatry assistants CAN do? can they prescribe meds? can they assist in surgery? how different are they from physician assistants (besides the fact that they are much better trained in podiatry).

thanks!

 

[gasolino]

Surgical PAs on the avg makes around $120000... (i assume podiatry clinic is a surgical one). Why not hire a fellow DPM for $150000 starting?

 

[PADPM]

thanks for the response everyone..

PADPM, can you tell me a little more about what podiatry assistants CAN do? can they prescribe meds? can they assist in surgery? how different are they from physician assistants (besides the fact that they are much better trained in podiatry).

thanks!

Podiatry assistants can NOT write prescriptions. They are not "trained" in the same way as a nurse practitioner or physician assistant. It is not a true "professional" designation or college curriculum such as an NP or PA. A podiatric assistant is similar to a medical assistant with very basic training. Without trivializing what they do, they really assist in palliative care, taking x-rays if they pass the required certifying exams, pad, strap, remove/apply bandages, set up instruments, sterilize instruments, fill syringes, take vitals, remove casts, assist with office based procedures, etc. As far as I know, podiatric assistants do not give injections or perform any invasive procedures. I'm sure some doctors have their podiatric assistants do a little more than the law may allow, but as a rule, podiatric assistants are more analagous to medical assistants NOT physician assistants or nurse practitioners. The latter two have years of college training for their chosen fields and are also rewarded financially for that training.

 

[Podfather]

Podiatry assistants can NOT write prescriptions. They are not "trained" in the same way as a nurse practitioner or physician assistant. It is not a true "professional" designation or college curriculum such as an NP or PA. A podiatric assistant is similar to a medical assistant with very basic training. Without trivializing what they do, they really assist in palliative care, taking x-rays if they pass the required certifying exams, pad, strap, remove/apply bandages, set up instruments, sterilize instruments, fill syringes, take vitals, remove casts, assist with office based procedures, etc. As far as I know, podiatric assistants do not give injections or perform any invasive procedures. I'm sure some doctors have their podiatric assistants do a little more than the law may allow, but as a rule, podiatric assistants are more analagous to medical assistants NOT physician assistants or nurse practitioners. The latter two have years of college training for their chosen fields and are also rewarded financially for that training.

In our practice our MAs are trained to and perform all digital blocks for nail procedures in addition to all of the duties mentioned above. Most of my peers where I practice have them perform nail debridements. In our office we only see a few of those patients a quarter so I still perform that service. The key point when discussing MAs vs PAs/NPs, is the latter 2 can see patients in your absence(if permitted by state law) whereas the former requires on site supervision. I know of some DPMs who allow their MAs to screen patents when they are not there and have signed scripts available for their use after they call the DPM but IMO that is a risky behaviorand probably breaks state law.

There are some DPMs I know who do telemedicine with NPs sending information and video (mostly on wounds) via SKYPE from remote locations.

 

[PADPM]

In our practice our MAs are trained to and perform all digital blocks for nail procedures in addition to all of the duties mentioned above.

I'm actually very surprised to hear that your MA's are performing digital nerve blocks. I'm aware that MA's in some offices give injections (such as flu shots, B-12 injections, etc., ) but I've never heard of anyone having an MA or Podiatry Assistant performing nerve blocks.

Interestingly, when searching MA websites, and the duties of an MA, very few even mention injections as a "duty" of an MA, though it is mentioned on a few sites.

However, my primary concern with having an MA perform a digital block vs. a "simple" IM injection such as those previously mentioned, is whether your malpractice carrier actually covers you for that procedure. Though extremely slim, there are potential complications that can occur with a digital block, and does your malpractice cover you if your MA has performed that procedure?? A physician assistant or nurse practitioner is actually licensed, where an MA isn't (I believe they simply receive a certificate), though I may be wrong. Just a thought.

 

[Skippygonenuts]

sorry for sounding ignorant guys, but what exactly is an MA? Google keeps telling me its Massachusetts but I get this gut feeling that's not what your talking about.

Also, where can i find out the laws for NJ and NY as to whether a pod can hire a pa in those states?

Furthermore, would it be more financially profitable to hire an NP or a PA? and which one would know what they're doing better for podiatry? I've seen some nurses that have no clue what to do, but so far all the PA's I've met have been phenomenal, but I guess this could all just be the luck of the draw.

 

[dyk343]

sorry for sounding ignorant guys, but what exactly is an MA? Google keeps telling me its Massachusetts but I get this gut feeling that's not what your talking about.

Also, where can i find out the laws for NJ and NY as to whether a pod can hire a pa in those states?

Furthermore, would it be more financially profitable to hire an NP or a PA? and which one would know what they're doing better for podiatry? I've seen some nurses that have no clue what to do, but so far all the PA's I've met have been phenomenal, but I guess this could all just be the luck of the draw.

medical assistant...

 

[PADPM]

sorry for sounding ignorant guys, but what exactly is an MA? Google keeps telling me its Massachusetts but I get this gut feeling that's not what your talking about.

Also, where can i find out the laws for NJ and NY as to whether a pod can hire a pa in those states?

Furthermore, would it be more financially profitable to hire an NP or a PA? and which one would know what they're doing better for podiatry? I've seen some nurses that have no clue what to do, but so far all the PA's I've met have been phenomenal, but I guess this could all just be the luck of the draw.

I would guess that you would have to contact the State Board in each state to determine the laws.

"Skippy", no offense, but you are asking good/valid questions, but I'm not sure why your'e really so concerned with hiring PA's, NP's, etc., at this extremely early stage in your career. At this point, I would think that instead of worrying about what "may" happen 10 years from now, you really should first be concerned with which profession you want to spend your time with in the future, and then spend time shadowing doctors.

I'm confident that there are MANY, MANY successful podiatric practices that do not employ PA's or NP's. I would consider our practice very successful (Kidsfeet can attest to that) and we do not employ any PA's or NP's, nor do I personally know of any practices that employ any. I do know many practices that employ podiatric assistants and/or medical assistants.

As I've stated many times on this forum, I admire students like you who are trying to "look ahead" and plan for your future, but unfortunately, with the ever changing health care environment, you never know what's going to happen in 7 or 10 years. Therefore, my best advice is to worry about now, do the best you can in school to assure yourself the best future positions and the rest will fall into place.

 

[347932]

No one needs to pay a PA to help in their practice with what we do in. This is overpaying for work you can get for a fraction of the cost. You don't even need to get a certified MA (which are a dime a dozen around here). Medical Assisting is certificate program that trains these people with very little real world applications imho, and then tells them to expect $15 an hour for a job YOU to train them to do anyway. Its a waste of your time and your money as a practitioner. Most people in my community who have MA certificates never get the chance to use this "degree", as they have unrealistic expectations of what type of job they can expect to get, and how much they can expect as a starting hourly wage. They then owe $20K-$30K for an education they have a hard time justifying.

What most people I've had the pleasure of meeting with and helping in their practice do, is hire an unskilled worker (high school graduate for instance), who is willing to work and learn and then teach them, as on the job training, to do what THEY need them to do. Yes, there are issues with potentially hiring duds, immature workers, people who are untrainable...blah, blah, blah, but this will be the case whether you pay them $8.00/hour because they have no degree or training, or $15.00/hour because they have some fancy specialty degree or certificate.(Disclaimer:these are the wage potentials in my local community and may differ greatly depending on the region you practice in or intend on practicing in)

Realistically, in our profession, to get patient flow where you want it, your assistant should be able to and be comfortable with, burring nails, apply taping and unna boots (and removing them), fit people for cam walkers, do basic education (diabetic and [operative consents as witnesses for signatures only - added] and such), and taking down and replacing surgical dressings. Some practices do ask their assistants to cut toenails and do local injections (ingrown nail numb ups and heel injections for instance), but I'm personally not comfortable letting anyone but me take care of these things. Most of these are all things that can be trained with very little, if any, previous experience or knowledge (except cutting toenails and injections imho).

The only two medical specialties in my area that make very good use of PAs are the Vascular Surgeons and the Ortho Team that take care of the Level One trauma center locally. Otherwise, most others use PAs so the doctors can sit in his or her office and read or browse the internet while his or her MA's see all the patients under their "supervision". Several of these practitioners have gotten dinged by insurance companies for this practice, as people pay to SEE the doctor in the office, not a PA who does everything and then "consults" with the doctor for treatment protocols.

I was involved in such a dispute when I got a sinus infection and went to an urgent care facility and was seen by a PA who did a very basic H&P on me and then left the cubicle and returned with an Rx for some antibiotics within minutes and asked me to call within 10 days if I wasn't any better. I asked if I could see the doctor before leaving and was asked to wait. After 45 minutes I left in frustration. I then got an EOB in the mail and found out that my insurance was charged a Level 5 New Patient Office visit and was expected to pay $144 of this due to deductables. I complained to my insurance carrier AFTER paying my bill to not seem like I was the one skimming the system. The facility was sanctioned for this as I was not the first one who had the same complaint, and the facility almost lost their ability to see patients that had the same insurance I did. As a side note, think about how badly this is affecting our health care system. Food for thought.

 

[Foot Doc]

No one needs to pay a PA to help in their practice with what we do in. This is overpaying for work you can get for a fraction of the cost. You don't even need to get a certified MA (which are a dime a dozen around here).

As a side note, think about how badly this is affecting our health care system. Food for thought.

I agree

 

[PADPM]

Just a quick reply to Kidsfeet's post. I'm not sure about the law in the state where he practices, but where I practice and in most states it's actual ILLEGAL for anyone other than the doctor to go over the consent for a surgery/operation with a patient.

This is a point which is brought up at every risk management seminar I attend, and a fact that is often overlooked or misunderstood. Assistants, nurses, office staff, etc., are NOT allowed to review consent forms and have them signed. The doctor must be present.

Additionally, I personally have never witnessed any practice that allowed a medical assistant or podiatric assistant to give an injection for heel pain or any therapeutic injection.

 

[347932]

Just a quick reply to Kidsfeet's post. I'm not sure about the law in the state where he practices, but where I practice and in most states it's actual ILLEGAL for anyone other than the doctor to go over the consent for a surgery/operation with a patient.

This is a point which is brought up at every risk management seminar I attend, and a fact that is often overlooked or misunderstood. Assistants, nurses, office staff, etc., are NOT allowed to review consent forms and have them signed. The doctor must be present.

Additionally, I personally have never witnessed any practice that allowed a medical assistant or podiatric assistant to give an injection for heel pain or any therapeutic injection.

I digress PADPM. You are correct. What I've seen is that after the doc goes over the consent the assistant then serves as the witness and signs as such at the same time the patient puts their signature on the document. Thank you for pointing that out. I will edit my post to reflect this.

Some of the attendings I had the privilege of working with at both of my residencies had their assistants performing these injections.

 

[PADPM]

I have a personal issue with medical assistants or podiatric assistants performing therapeutic injections with a corticosteroid for heel pain, etc. Unlike PA's or NP's they have no real medical training. And according to most insurance coding, injections are actually a "surgical" procedure. I'm not even sure of the legality of having these types of injections performed by assistants.

I'm sorry, what's next, having the assistant treat all the patients? Kidsfeet, you personally witnessed our practice, and know we are busy. When I'm too busy to inject my own patient, it's time to quit. Sorry, that's something I simply can't justify.

 

[347932]

I'm sorry, what's next, having the assistant treat all the patients? Kidsfeet, you personally witnessed our practice, and know we are busy. When I'm too busy to inject my own patient, it's time to quit. Sorry, that's something I simply can't justify.

Agree 100%. I can't justify it either. Some do, however, and I haven't the foggiest idea why.

 

[PADPM]

Laziness? The feeling of beeing too self important? I don't know, I just can not justify the practice.

 

[Foot Doc]

Laziness? The feeling of beeing too self important? I don't know, I just can not justify the practice.

Prolly so. If I was on the other side of the exam table, I would not want an MA with no "real" training injecting me.

 

[Podfather]

I'm actually very surprised to hear that your MA's are performing digital nerve blocks. I'm aware that MA's in some offices give injections (such as flu shots, B-12 injections, etc., ) but I've never heard of anyone having an MA or Podiatry Assistant performing nerve blocks.

Interestingly, when searching MA websites, and the duties of an MA, very few even mention injections as a "duty" of an MA, though it is mentioned on a few sites.

However, my primary concern with having an MA perform a digital block vs. a "simple" IM injection such as those previously mentioned, is whether your malpractice carrier actually covers you for that procedure. Though extremely slim, there are potential complications that can occur with a digital block, and does your malpractice cover you if your MA has performed that procedure?? A physician assistant or nurse practitioner is actually licensed, where an MA isn't (I believe they simply receive a certificate), though I may be wrong. Just a thought.

The majority of my friends have their MAs do their blocks. I am ultimately liable for any malpractice issues on any activity my MAs perform. It would the same if an MA applied a dressing too tight, a cast incorrectly, or exposed a pregnant woman to an xray. Imagine if they called a RX in incorrectly? We train them in injection technique and even use cadaveric limbs in their training. We also have an orientation on suture removal, dressing application, cast removal etc. We even do mock phone calls. Calf cramping with SOB, narcotic seekers etc. We also run a mock in office cardiac arrest annually. I am always there and my MAs will seek my help if they are having a problem like a needle phobic patient.

 

[347932]

The majority of my friends have their MAs do their blocks. I am ultimately liable for any malpractice issues on any activity my MAs perform. It would the same if an MA applied a dressing too tight, a cast incorrectly, or exposed a pregnant woman to an xray. Imagine if they called a RX in incorrectly? We train them in injection technique and even use cadaveric limbs in their training. We also have an orientation on suture removal, dressing application, cast removal etc. We even do mock phone calls. Calf cramping with SOB, narcotic seekers etc. We also run a mock in office cardiac arrest annually. I am always there and my MAs will seek my help if they are having a problem like a needle phobic patient.

Don't you think performing an invasive procedure, like an injection, is a little bit different than applying a cast or dressing? Also, I would hope that if an MA does put a cast or dressing on, the "supervising" Doctor would check it before their patient leaves to make sure there are no issues, and if an issue is identified, it is corrected. Are you absolutely sure your malpractice will cover you if there is ever a case brought about by this? I would imagine something like this would be hard to defend in all honesty. Unlicensed personnel performing invasive procedures without direct supervision.

In the state I practice in, our office staff have to be certified to take radiographs, by taking a specialized course and passing an examination on the course material. If they are not certified, they are not permitted by state practice law to take radiographs. This in and of itself lends a certain amount of "training" over and above regular office procedure and such. Additionally, because of this, our malpractice will cover an issue if it ever comes about. Not certified and taking radiographs in our state? If an issue comes up, I hope you have deep pockets, because malpractice WILL NOT cover it. And you will be sanctioned because you are allowing non-certified staff to perform a procedure illegally.

 

[Podfather]

Don't you think performing an invasive procedure, like an injection, is a little bit different than applying a cast or dressing? Also, I would hope that if an MA does put a cast or dressing on, the "supervising" Doctor would check it before their patient leaves to make sure there are no issues, and if an issue is identified, it is corrected. Are you absolutely sure your malpractice will cover you if there is ever a case brought about by this? I would imagine something like this would be hard to defend in all honesty. Unlicensed personnel performing invasive procedures without direct supervision.

In the state I practice in, our office staff have to be certified to take radiographs, by taking a specialized course and passing an examination on the course material. If they are not certified, they are not permitted by state practice law to take radiographs. This in and of itself lends a certain amount of "training" over and above regular office procedure and such. Additionally, because of this, our malpractice will cover an issue if it ever comes about. Not certified and taking radiographs in our state? If an issue comes up, I hope you have deep pockets, because malpractice WILL NOT cover it. And you will be sanctioned because you are allowing non-certified staff to perform a procedure illegally.

Many years ago, I too was down right shocked that a DPM would let an MA take out sutures or apply a dressing (remember when the position of the toe etc was so important to all of us). Geez apply a cast only a doctor should do that. Podiatry because of it's history was always a hands on profession. At some point I realized that my job was and had to be the director of a healthcare team. That it was not only my technical skills but mostly my education that made me a doctor. I then began to see what other specialists and progressive DPMs were permitting their MAs do and researched as to how they were trained.

I slowly turned over tasks that I had personally performed for years and developed training for my staff. As a micromanager this was stressful and at first tried to prove that I had been right by being over critical as to the performance of the MA. Dressing changes, xrays, cast removals were the first activities I let go, followed by orthotic casting, suture removal, calling in Rxs, and strappings. I had the opportunity to visit a busy colleague who had MAs doing his digital blocks. They were very good at them and I was critical of him permitting this. He explained to me how he trained and evaluated his staff. I also have seen several practices where all RFC was provided by MAs. So I gave it a shot. I developed a training plan, workshop, and a period of mentoring and I am confident in the job my MAs are doing with digital blocks. I do spot monitor, query patients, and of course see each patient since I do the nail procedure. Are all MAs capable of this? Probably not and I have had some I was not comfortable in performing these so I wouldn't let them. I still do the few nail debridements that we see in our younger community but also feel this is a skill that could be turned over. I do perform my own heel and neuroma injections since IMO there are more risks and they require more experience and skill.

There is not a right or wrong answer here. I know a few DPMs who still do everything and know some that even let MAs debride/CXS wounds, serve as an assistant in the OR, and perform PT.

Ultimately it's your decision. I could give you an example of almost anything a MA does that if performed incorrectly could lead to problems. Even a poorly placed pad in a neuropathic patent or a simple comment interpreted as medical advice can be an issue. Whatever you delegate to others the key is training (by a school AND the DPM), monitoring, spot checks, patient feedback, and of course constant attention to detail by the DPM.

 

[347932]

Although I always appreciate your feedback Podfather, you haven't addressed my medicolegal concern. An assistant trained by you has no license to do anything, especially since your training method is not standardized across your county, state, or nationally.

What does your malpractice insurer say about this? The buck stops with you BUT, I would imagine that if a suit comes your way, where the claimant says he or she was given an injection by an untrained individual employed by you, and you were not in the room "supervising", you're malpractice insurer may have some questions you may not be able to answer.

To address your comment about MAs debriding toenails, firstly, if you read your insurance carriers' bylaws, I'm sure that YOU (the doctor) must be the one performing these duties if you intend to get paid. In my state, if I am caught doing this, I will owe a HUGE amount of money back and may be sanctioned by the insurance carrier. Secondly, isn't our premise that these patients need to have a physician perform these duties due to the high risk these patients are in for foot issues? Why did we fight so hard for this if we are then letting an untrained office worker take care of these issues for us. Its one thing to have an assistant burr some nails while we look over our shoulders to make sure they are not hurting anyone (which of course, we, as the doctors have examined the feet and cut the nails first), its entirely another to have an assembly line where patients show up and get herded back to a room and have an assistant there ready to cut nails, burr them down and then out the door.

 

[Podfather]

Although I always appreciate your feedback Podfather, you haven't addressed my medicolegal concern. An assistant trained by you has no license to do anything, especially since your training method is not standardized across your county, state, or nationally.

What does your malpractice insurer say about this? The buck stops with you BUT, I would imagine that if a suit comes your way, where the claimant says he or she was given an injection by an untrained individual employed by you, and you were not in the room "supervising", you're malpractice insurer may have some questions you may not be able to answer.

To address your comment about MAs debriding toenails, firstly, if you read your insurance carriers' bylaws, I'm sure that YOU (the doctor) must be the one performing these duties if you intend to get paid. In my state, if I am caught doing this, I will owe a HUGE amount of money back and may be sanctioned by the insurance carrier. Secondly, isn't our premise that these patients need to have a physician perform these duties due to the high risk these patients are in for foot issues? Why did we fight so hard for this if we are then letting an untrained office worker take care of these issues for us. Its one thing to have an assistant burr some nails while we look over our shoulders to make sure they are not hurting anyone (which of course, we, as the doctors have examined the feet and cut the nails first), its entirely another to have an assembly line where patients show up and get herded back to a room and have an assistant there ready to cut nails, burr them down and then out the door.

You may have to check with your insurer but when I queried exactly what an MA can do, I was told anything you want them to do since they are essentially an extension of you. So yes I am covered or I wouldn't let them do this. One could argue based upon your assessment that if during the removal of sutures the MA did something improper you wouldn't be covered. There are DPMs who say your are wrong if you let them do this for you and only the surgeon should. Ask your general surgeons how much they do and you may be shocked what MAs do in their practices. My point about training is that it needs to be done for all MA activities and that injections are no more important than say calling a RX or removing a cast. I have seen some pretty horrific skin injuries when residents have removed casts early on. BTW venipuncture OK? Non MAs do that it most practices.

Relating to toenails as I said, I still do the few that come to our practice. All of my RFC patients are not covered and would argue most should not be. If your insurers mandate that you perofrm the care on those covered well you answered your own question. I have no problem with MAs providing this service and with any patient who may be at high risk all care may need a higher level of training so the surgeon may need to perform it.

I am not telling you how to practice and you may feel digital blocks are not something you are comfortable with letting your MAs do. That is fine. Check with your insurer if you feel you have an exposure and if they have issue with blocks you better ask about everything they do.

 

[347932]

Relating to toenails as I said, I still do the few that come to our practice. All of my RFC patients are not covered and would argue most should not be. If your insurers mandate that you perofrm the care on those covered well you answered your own question. I have no problem with MAs providing this service and with any patient who may be at high risk all care may need a higher level of training so the surgeon may need to perform it.

Relating to this, I'm not sure how some people (not you, of course) can justify charging a patient cash for a service their assistant provides, if the patient indeed does not qualifiy for at risk foot care and nail debridment.

 

[Podfather]

Relating to this, I'm not sure how some people (not you, of course) can justify charging a patient cash for a service their assistant provides, if the patient indeed does not qualifiy for at risk foot care and nail debridment.

The same way someone charges for a strapping, PT session, orthotic casting/dispensing, on some occasions suture removal (a laceration repaired by the ER docs)diabetic shoe fitting/dispensing. In the case of the non-covered it is a service your office provides. You are paying the fixed and variable costs for the service. BTW the pedicurist charges for nail care????????????

Many covered activities performed by doctors of all specialties are not performed by the physician(some mentioned above) and are still billable. Some insurers require physician performance, a modifier to reduce reimbursement (sometimes this includes resident care), others do not have those stipulations.

How about the resident who makes rounds on say an ulcer, debrides it, and re-applies the dressing. You as the attending round later see the patient and co-sign the note do you bill the care?

 

[347932]

The same way someone charges for a strapping, PT session, orthotic casting/dispensing, on some occasions suture removal (a laceration repaired by the ER docs)diabetic shoe fitting/dispensing. In the case of the non-covered it is a service your office provides. You are paying the fixed and variable costs for the service. BTW the pedicurist charges for nail care????????????

Many covered activities performed by doctors of all specialties are not performed by the physician(some mentioned above) and are still billable. Some insurers require physician performance, a modifier to reduce reimbursement (sometimes this includes resident care), others do not have those stipulations.

How about the resident who makes rounds on say an ulcer, debrides it, and re-applies the dressing. You as the attending round later see the patient and co-sign the note do you bill the care?

We are not pedicurists. I assume that non covered people come to get their nails cut because they think they are better served by having a physician provide this service in a safe, and clean environment rather than in a nail salon where the instruments are not substerile (if they ever even clean them at all) and the provider is talking to their neighbor about lunch while weilding a sharp instrument.

No, I don't bill for the care if I am not physically present while the care is being provided. Neither should anyone else. I am co-signing a note as I am required to do by the residency administration and practice laws. NOT because I'm assuming I will get paid for time I didn't even spend with the patient. I even go so far as to notate in the chart that I was present for the care IF I am to bill for it. Seriously? Are attendings really doing this? Which insurances wouldn't bounce them if the carrier ever got wind?

 

[Podfather]

We are not pedicurists. I assume that non covered people come to get their nails cut because they think they are better served by having a physician provide this service in a safe, and clean environment rather than in a nail salon where the instruments are not substerile (if they ever even clean them at all) and the provider is talking to their neighbor about lunch while weilding a sharp instrument.

Yes I believe they come to my practice because they trust the care it provides. My patients would be alright if I started to let MAs provide it because they trust me and I would make sure they are being treated appropriately. They have a choice whether to go to a pedicurist for nail care but some still prefer to go to a DPM and are happy with the MA performing it. My point is if a pedicurist is paid without the doctor why can't a DPM charge for the service provided by their staff efficiently. I know of some who have hired a pedicurist or a non-licensed foreign chiropodist to perform these services.

No, I don't bill for the care if I am not physically present while the care is being provided. Neither should anyone else. I am co-signing a note as I am required to do by the residency administration and practice laws. NOT because I'm assuming I will get paid for time I didn't even spend with the patient. I even go so far as to notate in the chart that I was present for the care IF I am to bill for it. Seriously? Are attendings really doing this? Which insurances wouldn't bounce them if the carrier ever got wind?

So you strap all of your patients? If you let staff do the strapping, do /would you still bill for it? As for in patients: I am not saying you are billing for something you didn't do. You are managing the care of the in-patient. Your are seeing the patient, formulating the D/D, determining the treatment plan, and responsible for the care. If a resident debrides the wound and you evaluate it later and manage the care(and the insurer permits it or reimburses lower with a residency modifier) why not? If an insurer pays for the splint application after a surgery and your resident put it on when you were talking to the family you wouldn't include that charge?

 

[347932]

So you strap all of your patients? If you let staff do the strapping, do /would you still bill for it? As for in patients: I am not saying you are billing for something you didn't do. You are managing the care of the in-patient. Your are seeing the patient, formulating the D/D, determining the treatment plan, and responsible for the care. If a resident debrides the wound and you evaluate it later and manage the care(and the insurer permits it or reimburses lower with a residency modifier) why not? If an insurer pays for the splint application after a surgery and your resident put it on when you were talking to the family you wouldn't include that charge?

I know the residency you did. You in fact bragged about the training because you got to see patients at office in the absence of your director/attending. I do know that care was provided without direct supervision. I agree that is an excellent experience. Did any of those people pay for your services? Were their insurances billed? Now I do not permit that but let's not pretend it is a surprise. Many a patient were seen while others were in Baltimore.

Yes I do apply all the strappings myself. I am right there when my resident applies the splint in the OR. If a resident debrides an ulcer in my absence, no I do not bill for it. They will get yelled at though, as I specifically ask them to not do that. I want to see what's going on if my signature is going to go on the chart. Even when I was a resident and seeing 35 patients in my residency director's office every Saturday morning (8-12), with him physically present there "supervising", I was the one applying the taping, not his staff. You know him, ask away.

I couldn't care less what my attendings billed for. I DON'T. They agreed to this risks, and as their resident, I did what they asked as long it wasn't unethical or hurt someone. You know how residents are told that they will learn what NOT to do when they are in residency as well? Well, there you go. If I don't perform a service for my patients personally, I don't bill for it at this point. Even if its a service I can't bill for like a dressing change on a post op patient, I like to do this. For now, I have the time. Give me 5 years and maybe I'll change my song. Maybe.

 

[Podfather]

Yes I do apply all the strappings myself. I am right there when my resident applies the splint in the OR. If a resident debrides an ulcer in my absence, no I do not bill for it. They will get yelled at though, as I specifically ask them to not do that. I want to see what's going on if my signature is going to go on the chart. Even when I was a resident and seeing 35 patients in my residency director's office every Saturday morning (8-12), with him physically present there "supervising", I was the one applying the taping, not his staff. You know him, ask away.

I couldn't care less what my attendings billed for. I DON'T. They agreed to this risks, and as their resident, I did what they asked as long it wasn't unethical or hurt someone. You know how residents are told that they will learn what NOT to do when they are in residency as well? Well, there you go. If I don't perform a service for my patients personally, I don't bill for it at this point. Even if its a service I can't bill for like a dressing change on a post op patient, I like to do this. For now, I have the time. Give me 5 years and maybe I'll change my song. Maybe.

Sorry about the residency crack. It was a low blow and I edited out. You as a resident can not force attendings to do the right thing. I have no issues with your philosophy but do do some things differently. We do have our MAs perform digital blocks and in the past (I think)5 years have been pleased. No issues (yet) but I believe it is because of our training and follow-up. If we had our MAs provide a non-covered service like RFC (as I stated this doesn't happen now) I would have no trouble charging the patient. I put on most casts but when my MA does we still bill for it. Strappings are performed by our staff, xrays, orthotic scanning (previously casting), dressing changes, suture removals, phone in Rxs, shoe fitting and dispensing.

In house we only charge for the visit when we perform one. If a debridement was dome we bill solely for the visit. In the OR senior residents are left to close, apply dressings, and splints on many occasions while we prep the next patient and visit with family.

 

[347932]

No worries Podfather. Not only did residency teach me to be a surgeon, it gave me VERY thick skin .

 

[Feli]

No one needs to pay a PA to help in their practice ... This is overpaying for work you can get for a fraction of the cost. You don't even need to get a certified MA (which are a dime a dozen around here). Medical Assisting is certificate program that trains these people with very little real world applications imho, and then tells them to expect $15 an hour for a job YOU to train them to do anyway...

This is pretty much true IMO.^

The only real viable application I could see for a PA would be doing rounding and assessment of inpt hospital consults (ie the way pod residents do) while the DPM was in the office. A high amount of inpatient consulting is not how a lot of current pod groups funcion, though (unless they have residents)... most private practice DPMs don't like being in the hospitals anymore than they have to.

The assistant cares in the same office can be done by MAs or pretty much anyone trained for them. First assisting in surgery needs to be at least a scrub tech/nurse to my knowledge, but a surgical PA first assist such as ortho groups use would be overpaying unless they were also doing a significant amount of rounding/consulting for the group.

Surgical PAs on the avg makes around $120000... (i assume podiatry clinic is a surgical one). Why not hire a fellow DPM for $150000 starting?

This is a very good question.^
Unless the group was having a very hard time finding any reasonably trained and hardworking DPM who wanted to come to the area or do the tasks desired, an associate is probably a better value to the vast majority of pod groups.

 

[PADPM]

Our practice falls somewhere in the middle. We do allow our assistants to "finish up" on routine care patients, though the docs actually perform the care. Our assistants are certified and do take x-rays, our assistants fill syringes, apply strappings, sterilize instruments, remove bandages (except for my post ops), apply bandages, Unna's boots, remove sutures, set up for small in office procedures, measure/dispense diabetic shoes, etc.,etc.

However, our assistants do NOT perform digital blocks or give heel/neuroma injections or any therapeutic injections, nor do I see that happening any time down the road.

Kidsfeet,

You did spend some time visiting our practice, and you did witness our assistants "finishing up" with patients AND applying strappings. We do bill for those strappings and at the time I didn't sense that there was an issue with that practice. My sense was that you felt our office flowed very efficiently. Do you feel that billing for the strappings our assistants performed is not "kosher"?? I did spend time with each patient, made the appropriate diagnosis, discussed that with the patient and the assistant applied the strapping. Is there something in that scenario that ANY insurance company would have a problem with or would go against policy??

 

[doc1107]

So I visited a friend's father's practice recently. He has 3 offices, which made me wonder how he did it.

He has 2 other Pods working for him and one semi-retired as part time. He has MAs who did pretty much everything. From xray to nerve block to initial exam. The pods did the actual procedures but that way they can be in and out in 10-15 minutes.

Also, this made me wonder, why don't we have laughing gas in our offices? I hate giving nerve blocks since it hurts the patient so much. Anyone thought about using things such as laughing gas and/or mild anti-anxiety med before hand? I know a lot of newer dental offices have options where the patient can come in 30 minutes before appointment, take a anti-anxiety pill, and then they are calmer for the procedure.

 

[PADPM]

Some podiatric practices that I know, USED to use "laughing gas"/nitrous oxide, but don't anymore. This is governed by state rules and regulations and also requires time for the patient to fully recover, etc. It is still a form of anesthesia and is not without potential complications. It isn't a way to get in and out of rooms quickly.

I believe that most of us have utilized anti-anxiety medications for some of our patients undergoing small surgical procedures. However, this is not generally a routine event, and once administered the patient should be accompanied by someone who will be responsible for driving, etc.

Having an MA perform the "initial exam" depends on what is actually being performed. Our assistants take a brief medical history and vitals, but I make my diagnosis based on MY hands on examination and the history that I obtain. I will NEVER rely on the information provided by ANYONE else to reach a diagnosis. The hands-on exam performed by ME and the history performed by ME is the way I obtain a diagnosis for MY patient and that will never change.

And I would personally never expect less from a doctor.

 

[347932]

Kidsfeet,

You did spend some time visiting our practice, and you did witness our assistants "finishing up" with patients AND applying strappings. We do bill for those strappings and at the time I didn't sense that there was an issue with that practice. My sense was that you felt our office flowed very efficiently. Do you feel that billing for the strappings our assistants performed is not "kosher"?? I did spend time with each patient, made the appropriate diagnosis, discussed that with the patient and the assistant applied the strapping. Is there something in that scenario that ANY insurance company would have a problem with or would go against policy??

Let me clarify. As long as the doctor is actually there overlooking his or her staff I have ZERO problem with this and this is what I observed when visiting your practice. I also noticed that when your assistants were done, you and your partners made a point to pop back in and quickly scan the work and bid farewell to your patients. I think the way you and your partners operate is the way it SHOULD be done when you are as busy as you are. Trust me, I would have said something then if I thought there was an issue. No worries Doc, you run a very slick, ethical operation and should be very proud (and no I'm not just trying to kiss up)!

I do have a problem when the doctor runs a mill where he pops his head into a room, says hello, then calls out for an assistant to provide the care. I've seen this as well, and made comments to the practice to perhaps review their insurance agreements and malpractice coverage.

There is a difference between "helping to finish up" and having assistants do all the work, while the "supervising" physician is sitting in his or her office reading a book. I've seen that too.

 

[PADPM]

There is a difference between "helping to finish up" and having assistants do all the work, while the "supervising" physician is sitting in his or her office reading a book. I've seen that too.

Now THAT'S funny. I'm not sure if I remember where my personal office/desk IS in our office! While you were visiting our office you shadowed four of us on different days. During that time did you EVER see one of us even GO to our private offices during that time (other than to maybe do some charts on a computer), let alone sit down and read a book!!????

 

[347932]

Now THAT'S funny. I'm not sure if I remember where my personal office/desk IS in our office! While you were visiting our office you shadowed four of us on different days. During that time did you EVER see one of us even GO to our private offices during that time (other than to maybe do some charts on a computer), let alone sit down and read a book!!????

I kinda sorta remember you sitting down ONCE, but that was after the day was done and we were chatting before dinner.

Trust me PADPM, I could tell you stories of practices I've evaluated that would have you in stitches.

 

[Foot Doc]

Having an MA perform the "initial exam" depends on what is actually being performed. Our assistants take a brief medical history and vitals, but I make my diagnosis based on MY hands on examination and the history that I obtain. I will NEVER rely on the information provided by ANYONE else to reach a diagnosis. The hands-on exam performed by ME and the history performed by ME is the way I obtain a diagnosis for MY patient and that will never change.

And I would personally never expect less from a doctor.

Exactly. Plenty of times have I walked into a room after the MA has proclaimed "the new pt. in room 2 has a neuroma" only to discover upon examination a stress fracture or metatarsalgia.

Sometimes I run behind in office because of multiple orthotic castings, castings, procedures, etc and my patients may grumble a little when I come into the room. I simply explain that I am not an assembly line doc and i spend time with my patients and answer questions and explain the treatment plan. Their tone usually changes after that.

 

[hefe]

There is not a right or wrong answer here. I know a few DPMs who still do everything and know some that even let MAs debride/CXS wounds, serve as an assistant in the OR, and perform PT.

Ultimately it's your decision. I could give you an example of almost anything a MA does that if performed incorrectly could lead to problems. Even a poorly placed pad in a neuropathic patent or a simple comment interpreted as medical advice can be an issue. Whatever you delegate to others the key is training (by a school AND the DPM), monitoring, spot checks, patient feedback, and of course constant attention to detail by the DPM.

The same way someone charges for a strapping, PT session, orthotic casting/dispensing, on some occasions suture removal (a laceration repaired by the ER docs)diabetic shoe fitting/dispensing. In the case of the non-covered it is a service your office provides. You are paying the fixed and variable costs for the service. BTW the pedicurist charges for nail care????????????

• This is interesting, how often are DPM's using MA's to "perform PT" on patients. Are you referring to physical therapy or something else?
• Does this happen in a non allied health integrative environment, say outpatient clinic?
• Are these MA's doing PT work and billing PT codes under the DPM's approval without PT presence on-site overseeing?
• Are patients instead being charged cash for such services?
• To what scope/extend does such work take place?

Thanks in advance.

BTW I find these practice issues discussed interested (and concerning) even though I'm not a pod. Sad to see the extent some MA's are being allowed to perform given the background.

 

[Podfather]

• This is interesting, how often are DPM's using MA's to "perform PT" on patients. Are you referring to physical therapy or something else?
• Does this happen in a non allied health integrative environment, say outpatient clinic?
• Are these MA's doing PT work and billing PT codes under the DPM's approval without PT presence on-site overseeing?
• Are patients instead being charged cash for such services?
• To what scope/extend does such work take place?

Thanks in advance.

BTW I find these practice issues discussed interested (and concerning) even though I'm not a pod. Sad to see the extent some MA's are being allowed to perform given the background.

I do not perform PT in the office. There are some that have MAs perform ultrasound therapy, anodyne, whirlpools, etc. I do not know if they bill for it. I know several orthopedists that have a PT with several MAs who do treatments technically under the PT's supervision... You want to be really concerned, take a look what nursing assistants and LVNs are doing with the current nursing shortage.

 

[347932]

Podfather!!

How was the Super Bowl you lucky duck!!??