Resident autonomy

[cbrons]

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At my school's FM program, I've noticed that in the clinic, after each patient, the resident (including 3rd years) have to present the patient to an attending who then takes notes and has to sign off on their A/P (and sometimes they even see the patient themselves). Evidently the residents also cannot write for Schedule 4 and below drugs and have to get those scripts signed by the attending (Nurse practitioners can now write for those same drugs themselves apparently).

This seems like a fairly extreme level of paternalism and I was just wondering if such micromanagement exists at most programs?

 

[VA Hopeful Dr]

Yes-ish.

All notes must be co-signed. This is a billing rule, but also a good idea just in general. At my program, 3rd years would see patients all day and then run their schedule with an attending at the end of the day once the attendings were comfortable with our abilities. 2nd years had to check out each patient as they saw them. All procedures had to be personally supervised, but otherwise after intern year the attendings only came in if you asked them to or if they were concerned about something.

I had a DEA number by day 30 of intern year (South Carolina is weird for the state controlled substance license which you must have before you can get a DEA number) and could write for Schedule 2 and below without a co-signature from then on.

That program does seem a bit more involved, but I won't judge too much without first hand experience.

 

[styphon]

Yes-ish.

All notes must be co-signed. This is a billing rule, but also a good idea just in general. At my program, 3rd years would see patients all day and then run their schedule with an attending at the end of the day once the attendings were comfortable with our abilities. 2nd years had to check out each patient as they saw them. All procedures had to be personally supervised, but otherwise after intern year the attendings only came in if you asked them to or if they were concerned about something.

I had a DEA number by day 30 of intern year (South Carolina is weird for the state controlled substance license which you must have before you can get a DEA number) and could write for Schedule 2 and below without a co-signature from then on.

That program does seem a bit more involved, but I won't judge too much without first hand experience.

I think the DEA/cosigner thing is state specific. In NY state, you cannot be licensed before finishing residency unless you are an American citizen who graduated from an American med school and have completed one year of residency, and you can't get your DEA # unless you are licensed, so you will need a cosigner in all years.

Residents in residency cannot bill and are not on insurance health plans - so they need their attendings signature (moonlighting is an exception).

 

[JustPlainBill]

We had to see patient's with the attending for the first 6 months of intern year -- every patient, no exceptions -- after that, we were voted on in a star chamber meeting and if enough attendings felt you were "safe", you could start seeing them on your own. You still checked out every patient to an attending and this continued until you graduated. if you did a procedure in clinic, you were supervised; hospital was a different story and depended on the attending --- for all 99214's the attending had to see the patient, so we didn't bill for many 99214's.

Most people got their license at the end of 2nd year since our PD didn't allow moonlighting -- control freak --- and got their DEA by the time they graduated 2/2 cost --- we used the attendings for any controlled meds we needed to prescribe.

 

[hallowmann]

What you described is likely governed primarily by the state board and state licensing requirements. Just because it might be more lax for NPs doesn't mean it is for physicians. As said above, the only residents that get their license and DEA numbers in NY for example are late year 3rd years, so you will always need a sign-off for controlled substances like that. As far as presenting, I'm sure it varies by program, but at the place I rotated at, interns were brand new at the time and watched like a hawk, 2nd and 3rd years presented every patient either immediately afterwards or whenever the attending was available to precept, and this really varied based on the patient schedule. A&P changed very little if any with the 3rd years, and the 2nd years occasionally had things added to the A&P by the attending.

 

[septoplasty]

At my program, interns are "guarded" for first 6 months (preceptor says hi to patients), followed by the secret meeting to qualify one with "autonomy" meaning, after that 6 months, intern see and eval patient, essentially do everything including A/P, but precept before getting patient out of clinic.

As a third year, i've come to like it. As an intern.. I didn't know ****, so I was happy to have the ability/requirement to go through the patient fully. Now its not as much and attendings give me a whole lot more freedom. Basically my "presentations" for patients have been "Hi, just here for CHF, DM, COPD, no big deal", and they say "okay". I believe since I moonlight, attendings seem to be a bit more "comfy" with it since they know i'll have looked at the complete picture/not missing anything huge.

But, there are still days that I ask/learn something from them that I wouldn't have thought of.. so I enjoy "precepting" after everycase, even if its nothing big.

Attending knowledge + Experience = something we can't match as residents (even if pgy-3).

As for controlled scripts, my state gives starting intern year, but again, if one is gonna do it, its the institutional DEA so preceptors go through it, which is great since i'm a state that has a high rx drug abuse population (particular area too), so i'm sure if we had our own "freedom" to rx, as an intern I would have gotten played so hard for Perco's.

Hope this gibberish helps.

 

[Bacchus]

Here in PA this is what we do:

Intern year: 1st 6 months (as required by CMS) you precepted ALL patients with the attending and they went in the room every time. After 6 months, you were on your own if you chose to be.
Second year: On your own unless you need an attending.
Third year: On your own unless you need an attending.

Mandatory precepts (by our program, unsure of the CMS rules): Pre-op evaluation, procedures (things such as joint injection didn't necessarily need the preceptor in the room) and pre-natal patients. If you want to up code, then the preceptor goes in the room as the CMS Primary Care exception rule allows preceptors after your first 6 months to sign off on your charts without seeing the patient. On the flipside, then residents can't bill above a 99213.

As far as prescriptions go, in PA as a DO resident, I was able to get my license (independent) after 1 year. The same is for the DEA. I waited until now, the tail end of PGY3, since I need them to start my job. Despite having two active licenses (training and "official"), I use my training license number for all official requests as I'm "protected." The same goes for controlled substances. I will not, until on my own, use my own DEA number. CYA, CYA, CYA.

 

[seap3]

We had to staff every patient with an attending the 1st 6 months. They only saw them if we asked them to. After 6 months, unless an individual resident heard otherwise, we no longer have to staff unless we want to. All notes are cosigned by attendings. Procedures are supervised until we have done enough and are checked off. I'm glad that we are not micromanaged having to staff every simple patient, which would take up a lot of time. But I also appreciate that faculty is there to discuss or see the more complex patients with us. We were able to use our institutional DEA from day 1 and could write for controlled substances without a co-signature.

 

[KnuxNole]

I'm a bit jealous of the peeps that can see all types of patients without having it staffed. Until we graduate, all Medicaid patients need to be presented and discussed with the attending, and they have to see the patient...but usually after intern year they just stop by and say hello. Otherwise, everyone else(Medicare,commercial,self pay) can be seen without an attending, and no co-signature on notes. Of course, if you need help they are there, which is nice because even though I don't have to formally present all patients, there are still some difficult and atypical cases I would like to run by someone, especially in a safety net such as residency. However, it does suck to have a clinic day with 10 medicaid pts and 1 preceptor for 4 residents...waiting in line can eat up time and slow down the day.

 

[Doctor4Life1769]

Good grief.
You're residents.

 

[topraman]

Similar to Seap3

I'm fortunate to be in a program known for its autonomy. It's essentially a trust system. Billing is a non-issue which is an amazing blessing (we are a county hospital and most of our patients have county insurance). Our notes are not co-signed.

In first year you are supposed to talk about all of your patients with a preceptor. Often this happens after you've already discharged a patient, sometimes it doesn't happen, or you don't really see a need - all of that is fine too. No one sees your patients unless you want them to. Rarely they may ask to do so or want to observe you to give you feedback but it's up to you. At this point all your scripts have to be co-signed on paper since there's no license. After first year you staff patients only if needed and you can e-prescribe anything. The type of encounter, pre-op, prenatal, peds, doesn't matter.

For procedures and ultrasounds, you ask for a preceptor if it's new to you. Or often just grab a senior. Otherwise you can do whatever you'd like and we're generally very comfortable with anything. For complicated patients or ones with specialty needs you have the option of just curb-siding, referring for consult only (co-management), or referring for ongoing management. Our specialists, many of whom are FPs, aren't paid fee for service so they are happy to be hands off, teach, and just answer your specific questions.

 

[Doctor4Life1769]

For those of you who don't have attendings signing off on chart notes, what about the potential for liability issues that could arise?

 

[Bacchus]

For those of you who don't have attendings signing off on chart notes, what about the potential for liability issues that could arise?

It sounds like a nightmare. Maybe they figure these people won't sue?

If I'm at all uneasy and end up precepting, I damn well state Discussed with attending, Dr. XYZ, in my notes.

 

[Doctor4Life1769]

It sounds like a nightmare. Maybe they figure these people won't sue?

If I'm at all uneasy and end up precepting, I damn well state Discussed with attending, Dr. XYZ, in my notes.

Oh these patients don't care, they'll sue.
I just find it funny that several are crying about having to precept and autonomy issues. I am actually really glad to be able to precept to my attendings at the end of my clinic days, doubly if I'm unsure and want to "run it by" an attending or have one come in and see a patient. It's opportunity for me to learn and it's covering my ass.