Programs where attendings don't staff every patient

[WallowaWanderer]

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I'm rotating now at a program where the residents get a ton of responsibility. Each junior resident is in charge of an entire pod where they see all the patients in that pod and make autonomous decisions without presenting to the attending (several times per shifts they run through the patients with the senior resident). The senior resident is in charge of the entire ED, supervising the junior residents, interns, andf students. The attending does not staff every patient but is there for the senior to consult on tough cases, help run codes, take medical student presentations, etc.

I think this approach would be a good fit FOR ME. I'm not saying it's better training - just better for me as I tend to learn best in a sink or swim environment. I think there's definitely pros and cons to it, and may not be the right thing for a lot of people. It's also not to say that residents in programs without this type of format don't have tons of responsibility and great training.

My question is - what programs provide this type of environment?

 

[EMIMG]

Attendings have to staff all patients. This is a requirement for billing purposes. Also, the residents are practicing with a limited educational license and therefore all patients need to have attending supervision.

 

[crewmaster1]

Attendings have to staff all patients. This is a requirement for billing purposes. Also, the residents are practicing with a limited educational license and therefore all patients need to have attending supervision.

Now, there is staffing and staffing. One could mean the attending does a full H&P on a patient, the other could be the attending gets a one liner and peeks behind the curtain to make sure the patient doesn't look like ****.

 

[EctopicFetus]

yep. i think this depends on what you mean. If the attending doesnt "staff" the patient as in take responsiblity for their care and they bill for this it is against the law.

That being said take "responsibility" doesnt mean telling me what to do. My attendings dont do this as i present my plan but every patient is "staffed" here. The input depends on my and the attendings comfort level. I certainly see patients and "staff" the patient with the attending about 30 seconds prior to me Dcing the patient.

 

[Midwest Medic]

I thought that the attendings had to only fully staff (indepentent physical and history from the resident) on Meidcare and Medicaid patients. I thought that Blue Cross and other private insurances would allow the attendings to staff and be able to bill for the residents work.

Which bring up another question...When you are on-call at night, say on ICU call. If you do not have an attending present when you intubate/line/code someone, but are available by phone, can that attending bill for that procedure?

 

[totalbodypain]

I thought that the attendings had to only fully staff (indepentent physical and history from the resident) on Meidcare and Medicaid patients. I thought that Blue Cross and other private insurances would allow the attendings to staff and be able to bill for the residents work.

Which bring up another question...When you are on-call at night, say on ICU call. If you do not have an attending present when you intubate/line/code someone, but are available by phone, can that attending bill for that procedure?

The attending doesn't have to document a full H&P to bill for Medicaid or Medicare if the resident does an complete H&P, only a cursory exam(limited number of body areas), review of the results of tests/studies and disposition. This bare minimum to document for billing means that they have to see a patient (if quikly and from the sidelines) unless they are going to falsify thier documentation. Any program where the attendings are failing to do this is not the place you want to be. Providing autonomy is one thing. Being dangerous is another. You do not want to be left holding the bag when it breaks and have the attending play the dumb route "I didn't know about that patient. The resident saw that patient and never told me."...
As to your question about billing on overnight. You have to be present to bill. When you are on call in the ICU, somewhere in the hospital is an attending that is covering (whether it is the hospital policy for the ED attending to cover codes, intubations etc. or is someone else). That attending can bill for your procedure.

 

[EM_Rebuilder]

I thought that the attendings had to only fully staff (indepentent physical and history from the resident) on Meidcare and Medicaid patients. I thought that Blue Cross and other private insurances would allow the attendings to staff and be able to bill for the residents work.

Which bring up another question...When you are on-call at night, say on ICU call. If you do not have an attending present when you intubate/line/code someone, but are available by phone, can that attending bill for that procedure?

I am in the ICU (surgical) right now and understand the attending must be present to bill for the procedure...they have also been dictating/writing a procedure note. They dont want us terns doing anything 'alone' and prefer us to have attendings around for billing purposes (also the NP works as well)...

 

[The White Coat Investor]

Now, there is staffing and staffing. One could mean the attending does a full H&P on a patient, the other could be the attending gets a one liner and peeks behind the curtain to make sure the patient doesn't look like ****.

Does this sound familiar to any of the other attendings:

"I have seen and examined the patient and agree with the resident medical decision-making."

That is staffing. And for a senior resident on an uncomplicated patient, that may be all I do other than lay eyes on them as they walk out the door. I'll usually beat the residents into the room on a sick patient, and if they're really slow, I'll write the orders too, just to embarrass them.

 

[EMIMG]

Yes, staffing can vary, but the bottom line is that theoretically the attending is responsible for each patient and they have to "see" each patient.
In terms of doing things in the ICU, technically procedures in the ICU or anywhere have to be done under the supervision of the attending physician.
Even when off-service residents do things in the ED, if their attending is not present, you can bill as you have "supervised" the procedure. So, you technically can bill for the neurosurg resident putting in an ICP monitor or the plastics resident suturing the lac....that is if their attendings are not there.

 

[BADMD]

Which bring up another question...When you are on-call at night, say on ICU call. If you do not have an attending present when you intubate/line/code someone, but are available by phone, can that attending bill for that procedure?

I was told that if a procedure note is properly filled out by an attending after the procedure was performed, then the hospital can bill for the hosptial portion of the procedure but not the physician portion of the procedure. So the central line kit gets paid for, but the act of putting it in cannot be billed for.

Supervision really includes a physical exam, in the case of the H&P or direct observation of the key portions of the procedure. To do anything less is potentially fraud if the services are billed for.

 

[Midwest Medic]

The reason that I ask about the ICU situtation is this....I did my internship at a small community hospital where there was only an ED physician in house at night. All the other docs were available by phone, but rarely came in for anything. The IM residents routinely did intubations, central lines, and ran codes with no attending present. The attending then signed the note in the AM and as far as I understand was billing for the procedure....fraud or not?

 

[Seaglass]

I thought that the attendings had to only fully staff (indepentent physical and history from the resident) on Meidcare and Medicaid patients. I thought that Blue Cross and other private insurances would allow the attendings to staff and be able to bill for the residents work.

Which bring up another question...When you are on-call at night, say on ICU call. If you do not have an attending present when you intubate/line/code someone, but are available by phone, can that attending bill for that procedure?

Attendings can only bill medicare for procedures they are physically present for.

 

[ditch doctor]

That is staffing. And for a senior resident on an uncomplicated patient, that may be all I do other than lay eyes on them as they walk out the door. I'll usually beat the residents into the room on a sick patient, and if they're really slow, I'll write the orders too, just to embarrass them.

There are few joys that compare to beating staff to a sick patient and writing orders first. It's really the little things in life....

 

[missmod]

I have been on a few away rotations at different intitutions (county, community, academic center) and from what I've seen, the degree of autonomy each resident gets depends somewhat on the program, but more on the attending's style and the resident's ability. For example, I've seen one attending be very hands on with a resident who was not very strong and full of self-doubt... the same attending checked in with a superstar resident only when they were ready to dispo. Either way, I dont think there is ever a patient who passes through the ED without the attending hearing at least their name and what will be/has been done to them.

 

[GeneralVeers]

I have been on a few away rotations at different intitutions (county, community, academic center) and from what I've seen, the degree of autonomy each resident gets depends somewhat on the program, but more on the attending's style and the resident's ability. For example, I've seen one attending be very hands on with a resident who was not very strong and full of self-doubt... the same attending checked in with a superstar resident only when they were ready to dispo. Either way, I dont think there is ever a patient who passes through the ED without the attending hearing at least their name and what will be/has been done to them.

The RRC has strict rules on resident supervision, and I don't think that it's policy ANYWHERE for residents to see and dispo patients without attending approval. The only exception to that policy would be residents with a medical license who are "moonlighting".

Attendings have different styles. Some see the patients and do their own brief history and physical, while others merely eyeball a patient to make sure that they are "alive".