Attendings see every patient

[kayakr]

I accepted a new position in hospital medicine and am surprised that the attendings see every patient after the PAs/NPs every day. I don't mind this model now because I'm relatively new, but don't think I'd want to do this forever and it seems rather inefficient. Is this a common model?

[ventana]

I believe in my hospital there is bylaws that state the doc must see every admitted patient every day....

 

Antiquated, but not worth fighting at a teaching hospital.....

 

 

Hospital to Hospital and state to state I bet it varies.... Heck some hospitals might not even have a Doc on site some days...

[True Anomaly]

There is still a very big financial incentive for physicians to see patients in addition to the PA/NP because of the difference in reimbursement- so hospitals will still require it, for the most part

[Statko]

I used to work under a model like this and, at first, thought it was really dumb and inefficient.  Over time my opinion changed and I eventually viewed it as one of many really great ways the MD/PA relationship can work.  I would round on patients, do documentation/enter orders, and then bring any serious issues / concerns to the attending. The attending saw every patient (for billing reasons) but they trusted my instincts and took my concerns seriously. I was lucky - our attendings never treated us like newbies or students, they treated us as competent providers and colleagues. If I could go with the doc back into the patient room to debrief him in front of the patient, I often would ("Hi again, Mrs. X. I was speaking with Dr. Y about your blood pressure. We're going to work together to decide if we should change your medication.") If I couldn't go back with him to the room, we'd just catch up about it another time or he'd text me, etc.

 

Patients loved this. Our patient satisfaction scores were very high and we frequently saw handwritten survey comments about how the midlevels and docs worked as a team. In hospital medicine, usually patient satisfaction scores aren't that stellar... and, from the patient's perspective -- they typically want to see "the doctor" when they are in the hospital. With the NP-PA/MD approach used by the hospital I was at, they got BOGO. I loved it because I felt like I had the right amount of backup, communication was clearer between providers, and I never felt shy or stupid about raising a question or concern. I eventually came to view the system as less about the doc checking up on me and more about me protecting and serving my doctor. Your mileage may vary!

 

But in any case, I was wrong -- Nothing dumb or inefficient about happy patients and happy providers! :)

[Guest JMPA]

I used to work under a model like this and, at first, thought it was really dumb and inefficient.  Over time my opinion changed and I eventually viewed it as one of many really great ways the MD/PA relationship can work.  I would round on patients, do documentation/enter orders, and then bring any serious issues / concerns to the attending. The attending saw every patient (for billing reasons) but they trusted my instincts and took my concerns seriously. I was lucky - our attendings never treated us like newbies or students, they treated us as competent providers and colleagues. If I could go with the doc back into the patient room to debrief him in front of the patient, I often would ("Hi again, Mrs. X. I was speaking with Dr. Y about your blood pressure. We're going to work together to decide if we should change your medication.") If I couldn't go back with him to the room, we'd just catch up about it another time or he'd text me, etc.

Patients loved this. Our patient satisfaction scores were very high and we frequently saw handwritten survey comments about how the midlevels and docs worked as a team. In hospital medicine, usually patient satisfaction scores aren't that stellar... and, from the patient's perspective -- they typically want to see "the doctor" when they are in the hospital. With the NP-PA/MD approach used by the hospital I was at, they got BOGO. I loved it because I felt like I had the right amount of backup, communication was clearer between providers, and I never felt shy or stupid about raising a question or concern. I eventually came to view the system as less about the doc checking up on me and more about me protecting and serving my doctor. Your mileage may vary!

 

But in any case, I was wrong -- Nothing dumb or inefficient about happy patients and happy providers! :)

If you are "serving my doctor" then you are doing yourself and this profession a disservice.

[cbrsmurf]

There is still a very big financial incentive for physicians to see patients in addition to the PA/NP because of the difference in reimbursement- so hospitals will still require it, for the most part

 

Is the 85 vs 100% billing really worth it it if the MD can see and bill another separate pt during that time he would take to see a pt with the PA?

[Boatswain2PA]

If you are "serving my doctor" then you are doing yourself and this profession a disservice.

Why is that? I serve my wife, my father, my kids, my patients, "my" docs, "my" nurses/techs/janitors, etc etc etc.

 

I "serve" many.

[cbrsmurf]

I used to work under a model like this and, at first, thought it was really dumb and inefficient.  Over time my opinion changed and I eventually viewed it as one of many really great ways the MD/PA relationship can work.  I would round on patients, do documentation/enter orders, and then bring any serious issues / concerns to the attending. The attending saw every patient (for billing reasons) but they trusted my instincts and took my concerns seriously. I was lucky - our attendings never treated us like newbies or students, they treated us as competent providers and colleagues. If I could go with the doc back into the patient room to debrief him in front of the patient, I often would ("Hi again, Mrs. X. I was speaking with Dr. Y about your blood pressure. We're going to work together to decide if we should change your medication.") If I couldn't go back with him to the room, we'd just catch up about it another time or he'd text me, etc.

 

Patients loved this. Our patient satisfaction scores were very high and we frequently saw handwritten survey comments about how the midlevels and docs worked as a team. In hospital medicine, usually patient satisfaction scores aren't that stellar... and, from the patient's perspective -- they typically want to see "the doctor" when they are in the hospital. With the NP-PA/MD approach used by the hospital I was at, they got BOGO. I loved it because I felt like I had the right amount of backup, communication was clearer between providers, and I never felt shy or stupid about raising a question or concern. I eventually came to view the system as less about the doc checking up on me and more about me protecting and serving my doctor. Your mileage may vary!

 

But in any case, I was wrong -- Nothing dumb or inefficient about happy patients and happy providers! :)

 

I work in a similar model currently.  When I'm not assisting in surgery, I'm running clinic on my own, both new and established patients.  On nonsurgical days, sometimes I round with or without my SP.  At the clinic, the MD will see every pt patient I see after.  Plus side: it helps when I encounter something I'm not sure about (which happens not infrequently given that I am 2 years into a new subspecialty).  Negative: Really slows down my clinic.

[Statko]

If you are "serving my doctor" then you are doing yourself and this profession a disservice.

 

Respectfully disagree.

Medicine by its very nature is a profession of service. It's an honor to serve people and one that contributes greatly to my job satisfaction.

I am proud to serve my patients.

I am proud to serve every employee in the hospital - whether it's a doctor, custodian, or nurse. But my very livelihood as a PA is tied to my SP's license - so yeah, I have his back. And he has mine.

And I'm proud to serve this profession as a clinician, an educator, and a preceptor. If that's doing this profession a disservice, we must not share the same definition of what service is.

[Monte]

If you are "serving my doctor" then you are doing yourself and this profession a disservice.

 

Agreed.. Statko you're the perfect little subserviant sidekick.

[ventana]

I used to work under a model like this

 

Patients loved this. Our patient satisfaction scores were very high and we frequently saw handwritten survey comments about how the midlevels and

 

 

Please give consideration to never ever using the term midlevel....

 

Also, did you really need this doc to see every patient? Sounds like it was redundant and you were handling most the stuff, and needed a few consults here and there...... This is independent practice where you do what you know, know what you do, and then ask for help when needed. This is not midlevel, sort of kind of good care, this is not care between an RN and MD. You were providing the care the patient needed in the same way and held to the same standard as the Doc.

 

Honestly, it sounds like you were maturing in your medical knowledge, and although it is nice to always get the black v white answer from the doc, and know that you did not make the final call , it is unnecessary to force every and all PA into this standard.

 

 

 

I think it is wonderful that you had this opportunity as it can and clearly did have a great effect on you, we just need to foster this for all PAs and realize we too are providers of care........

 

 

 

As for the financial side. If a doc has 3-5 PA or NP with them and each sees ten patients, that is 30-50 patient visits that he can up charge the 15% - and that is a lot of dough!!! All for basically pencil whipping the chart with a short statement and signature...... What a great way to make more income, have a PA or NP do most the work, and the doc takes the credit......

[Statko]

Agreed.. Statko you're the perfect little subserviant sidekick.

Thanks for the kind words, Monte. :)

[ventana]

Statko

An honest question which I think might provide more background?

How long have you been out of school?

 

What I see is the learning curve is so steep and scary that these roles where you are still learning the trade with close oversight are very comforting for most newer grads. however the newer years melt away and then you really get down to the nitty gritty hard work and truly start to see the barriers, redundancy, and silliness that sometimes is forced onto you merely because you have a PA after your name.

 

I am truly not trying to put you down, and please do not take it that way. Just pointing out that sometime the folks with a longer time line (which you will be, and by the sounds doing a great job at) will likely have a different view. I personally attribute this to the amazing job we have and the emotional rewards of truly helping people. This combined with the fear of not killing someone, combined with the learning of applied medicine, over the first 3 years seems to be a bit of a blinder to the realities of a career as a PA. Those first 3 years out are pretty amazing journey which does sometimes limit your exposure to some of the bigger issues facing the carreer field as a whole.

 

Anyways, sounds like you had a great set up for learning. What are you doing now??

[ColoradoIMCardsPA]

I worked in an outpatient internal medicine clinic as a new grad. The doctors did not see the patients unless I sought them out to ask a question/asked them to see the patients.

 

Then, I worked in inpatient cardiology. I saw consults and follow-ups. The physicians rounded behind me on all of these. As they grew to trust my judgment more, their involvement in the care became minimal and they were mostly just "signing off." However they still made most of the more major decisions (e.g. stress test vs. cath) but I gathered the data, did the work, influenced the decision, and implemented whatever plan we settled on.

 

I think there is a spectrum in the utilization of PAs: on one extreme, a glorified secretary; on the other extreme, a completely independent practitioner. There are pluses and minuses to each of these. When practicing as more of a secretary, you are earning a near-6 figure salary or a 6 figure salary to be a secretary without making any major decisions. When you are an independent practitioner, you are practicing at the top of your license and may feel more of a sense of dignity.

[Statko]

Statko

An honest question which I think might provide more background?

How long have you been out of school?

 

What I see is the learning curve is so steep and scary that these roles where you are still learning the trade with close oversight are very comforting for most newer grads. however the newer years melt away and then you really get down to the nitty gritty hard work and truly start to see the barriers, redundancy, and silliness that sometimes is forced onto you merely because you have a PA after your name.

 

I am truly not trying to put you down, and please do not take it that way. Just pointing out that sometime the folks with a longer time line (which you will be, and by the sounds doing a great job at) will likely have a different view. I personally attribute this to the amazing job we have and the emotional rewards of truly helping people. This combined with the fear of not killing someone, combined with the learning of applied medicine, over the first 3 years seems to be a bit of a blinder to the realities of a career as a PA. Those first 3 years out are pretty amazing journey which does sometimes limit your exposure to some of the bigger issues facing the carreer field as a whole.

 

Anyways, sounds like you had a great set up for learning. What are you doing now??

Ventana,

 

Thank you for the thoughtful response and insight. I didn't find your response or questions as a put-down at all.

I've been out of PA school for 5 years, this particular job that I was writing about was (you guessed it!) was 2 1/2- 3 years into my career. Prior to that, I was working main ER exclusively. I started with the hospitalist group helping ER admissions/obs and then transitioned into floor work. As is obvious from my post, I had an excellent experience with the group, and I learned a lot. I left the job due to a family move.

 

I understand that there is a spectrum of experiences that shape people's tolerance and interpretations of what happens to them at work. I don't have the richness of experience that someone who's been in the field for 25 years has. That's why I enjoy participating in this forum... you see the whole gamut - from the anxiety over one's PA essay to discussions about RVUs. I hope when I have 25 years of experience, there's somebody still cranking it out with 35 years experience and giving me something new to think about. As a particularly relevant example, your previous comment about midlevels gave me pause; honestly, it's just not a trigger for me, but I understand the importance of words and how that affects the profession as a whole, so it's something for me to be mindful of.

 

Being a physician assistant is a second career for me. I have a doctorate and over eight years of clinical experience working in an allied health field before I made the switch to PA, so those who perceive me as naive or as a "perfect subservient" or new grad-type are incorrect in that assumption. I was miserable in my former field, and I thought PA would be the magic bullet. And guess what? It wasn't. The same anxiety and unhappiness followed me into my new career. I took a lot of time to think about what was really important to me and why I even wanted to be in medicine in the first place. The answer (for me) was service. I care about other people, and I want my work (and my life) to reflect that fundamental value. It grounds me and gives my work perspective and meaning, no mater what stage of my career I find myself in. Other people are motivated by other things, and good - that works for them. No judgement here. But at the end of my day, I've found I've largely been able to let go of anxiety about getting sued, workplace dramas, the stupid schedule, etc.

 

Right now, I am enjoying our first baby and out on maternity leave :) I changed gears and am working a pretty low speed gig in occ health. I'm an investor in the practice and work in a satellite clinic alone with SP available by phone/text if I need them (I never have... twisted ankles due to pizza deliveries really don't compare with what I was dealing with in acute care :) ). I also adjunct for a PA program and precept students.

[seekingtruths]

Agreed.. Statko you're the perfect little subserviant sidekick.

 

 

Really uncalled for. Jeez. 

[Monte]

Sorry to be harsh. She's happy creating an environment where she reports to her doc on most patients, debriefing them in front of the pt. This is creating that subservient theme where the pt is prone to think, "why not skip a step and ask for the doctor instead".. or "well the PA didn't know enough again, I'm happy the doc took over". 

[ventana]

Statko

Good for you on maternity leave! - as a father of a 3 year old I am learning oh so fast that they grow up with or with out you and with you is so much better!!

 

Appreciate the reply, and yes there is a wide range of experiences which PA's go through. I for one took about 10 years to get to the point where I really "understood" the profession (atleast from the PCP outpatient side as that is what I do). Then I started my own practice with a great doc who was 1% owner, and available for consult but never saw a patient. Great set up, and very educational in the true barriers to utilizing a PA as a PCP - needless to say there were many, all of which I overcame. However it was 60+ hour weeks and the arrival of my son ended up having a changing my desires in life.

 

 

So back to the PA issue - I do think that as you gain more experience as a PA in the PCP fields you truly realize that so many (if not ALL) the restrictions placed on us are purely arbitrary and hold ZERO clinical value. EMDPA once said it takes 10,000 hours to master a field - 5 years full time - and I truly believe this - it is at this 5 years that we should be able to test out and become independent from any type of useless regulations

 

What are some of these restrictions:

1) can't order VNA

2) can't certify or order Hopsice

3) can't sign and form for MASSHEALTH

4) can't sign a death cert - this is my favorite stupid one, has NOTHING to do with medical care - the patient is DEAD

5) can't sign for DM shoes

6) have to have the DOC name filed with all pharmacy - or they bug you for it

7) the State of MASS asked the Board of Medical Assistants for permission to incorporate - WTH - really? They admitted it was a mistake - so much for our name not being an bad thing

8) having to have my doc sign off on all these stupid forms - again no medical value

9) having to pay between 5-10% of my gross income to the doc (And this is a great doc that was wonderful to work with)

10) having to report every Schedule II script to the doc with in 96 hours

11) having to have quarterly meetings to review cases with the doc - what an enormous waste of time - if I had a question I would ask the specialist

12) doc moved out of area, at same time I realized the BS was not worth it and I was missing my son grow up - so practice closed, and my entire patient panel lost the ability to get house calls, and had to get a new PCP - in no way was this beneficial to anyone in the medical community.

 

 

We are far to connected to the Doc's and this becomes apparent only after you have gained some mastery of the field.

 

Hence why I beleive that for the first 5 years out in the PCP fields it should be mandatory to have supervision/collaboration which can be provided by either a Doc or an experienced PA.

This experienced PA is someone who has practiced in the field for > 5 years, has passed PANRE with a score in the 70+%, and then is granted the ability to practice with out supervision and ordered anything and everything a doc can. Removing all barriers to providing care.....

 

 

 

Phew long post, but this is a big deal and I have lived and learned the truth through the past 15 years.

[Statko]

Sorry to be harsh. She's happy creating an environment where she reports to her doc on most patients, debriefing them in front of the pt. This is creating that subservient theme where the pt is prone to think, "why not skip a step and ask for the doctor instead".. or "well the PA didn't know enough again, I'm happy the doc took over". 

Monte,

Your signature indicates you're a student, so I'm not sure where you are in your career and if you have any experience working in a hospital or hospital medicine.

Trust me, as a PA working within a huge hospital conglomerate, I wasn't "creating" any environment in the hospital - I was operating within it. For how I thrived/operated in my day-to-day work, I chose to employ an attitude of service which I won't reiterate in this post.

 

Our hospital policy  environment was that docs saw every patient (again, for billing purposes). Most of the time, the doc was mostly acting as what I (jokingly) liked to call "the mayor", going in, bs-ing with the patients, reviewing my notes, signing off and moving on to the next patient. If that's how the hospital wants to do business, fine. If I didn't like it, I could pick up another job somewhere else. HOWEVER, I liked the setup because if there was a complicated patient that I was concerned about, our group tried to employed a team approach where an effort was made to see the patient together. I never felt undermined or made to feel like I was a student by the doc, I felt supported and part of a team. It was a similar vibe as if I had called in a consult. I've never met a PA, NP, or doc in hospital medicine who felt totally comfortable with every patient -even the ones with "lots" of experience.

 

Our patient surveys did not indicate that patients felt like the PAs were incompetent or that they just wanted to skip a step and see the doc while they were laying in their hospital beds staring at the ceiling. NPs and PAs were often praised for spending more time with patients, remembering personal details, etc. Not a surprise there.

[Monte]

All I'm saying is that it's no wonder we still get mistaken for medical assistants. We shouldn't be okay with seeing the pt, just to have the doc follow up each time. 

[Maverick87]

I used to work under a model like this and, at first, thought it was really dumb and inefficient.  Over time my opinion changed and I eventually viewed it as one of many really great ways the MD/PA relationship can work.  I would round on patients, do documentation/enter orders, and then bring any serious issues / concerns to the attending. The attending saw every patient (for billing reasons) but they trusted my instincts and took my concerns seriously. I was lucky - our attendings never treated us like newbies or students, they treated us as competent providers and colleagues. If I could go with the doc back into the patient room to debrief him in front of the patient, I often would ("Hi again, Mrs. X. I was speaking with Dr. Y about your blood pressure. We're going to work together to decide if we should change your medication.") If I couldn't go back with him to the room, we'd just catch up about it another time or he'd text me, etc.

 

Patients loved this. Our patient satisfaction scores were very high and we frequently saw handwritten survey comments about how the midlevels and docs worked as a team. In hospital medicine, usually patient satisfaction scores aren't that stellar... and, from the patient's perspective -- they typically want to see "the doctor" when they are in the hospital. With the NP-PA/MD approach used by the hospital I was at, they got BOGO. I loved it because I felt like I had the right amount of backup, communication was clearer between providers, and I never felt shy or stupid about raising a question or concern. I eventually came to view the system as less about the doc checking up on me and more about me protecting and serving my doctor. Your mileage may vary!

 

But in any case, I was wrong -- Nothing dumb or inefficient about happy patients and happy providers! :)

 

Sounds like an awesome setup to me. Learning a lot + supportive environment + high pay + limited liability = a happy Maverick.

 

If you are "serving my doctor" then you are doing yourself and this profession a disservice.

 

From what I've seen, the vast majority of wildly successful people that I've met view themselves as servers. They serve their customers, serve their bosses, serve their spouses, etc.

 

This is a typical millionaire mindset. So they must be doing something right.

 

Agreed.. Statko you're the perfect little subserviant sidekick.

 

Get back to studying, kid. Grownups are talking.

[Monte]

Get back to studying, kid. Grownups are talking.

 

I may be overly opinionated, but you're no better for calling an adult kid with disrespect as intent. I made a valid point comparing the method with medical assistants, sorry you disagree.

 

Goodluck to you, Stat. If the format makes you happy.. then so be it!

[EMEDPA]

All I'm saying is that it's no wonder we still get mistaken for medical assistants. We shouldn't be okay with seeing the pt, just to have the doc follow up each time. 

as a new grad it's ok. with time, the doc and PA should both get comfortable with the PA taking over more of the pt load and only going to the doc with occasional questions or consults as needed. if they see every pt, that's not about pt care, that's about reimbursement..

[LT_Oneal_PAC]

I personally don't like the model. There is no evidence that it reduces liability, it hurts access to care by having redundancies, and I have great educators all around me that answer questions yet have no authority to force me into an action. Like I said, personal preference. I don't think there is something necessarily wrong with wanting a less autonomous job. Docs similarly do it all the time by choosing to work in larger facilities where they can have consults and turf patients. I remember an FM doc consulting the IM service I was on for a uncomplicated DVT. I may have been bothered by something like this in the past, but have since realized asking all people to function the way I want to isn't any more fair than the reverse. So now I limit my soapboxes to educating people on how words matter (not telling them what to say, just think about how it is perceived) and rallying against people who say I shouldn't practice autonomously.

 

Really we should just have full practice authority separate from a physician license after so many years of practice and take a specialty board (or don't if like practicing less autonomously), then let people decide for themselves what kind of job they want.

[charlottew]

My 2 cents - consider that in an inpatient setting, patient care is more of a team concept. Every patient is seen by multiple providers. No single person is dictating the patient's care. If it's my patient on the unit, I write all the orders for that patient (if I'm too busy, someone else on the team will write the order for me, then let me know after). Some parts of the plan I will ask the attending before implementing, other parts I just go ahead, and update the attending later. We have outside consulting teams (residents, NP/PA's, attendings) seeing the patients too - they'll make their recommendations, and we'll implement them (but with discretion as needed). If there's a big change I will reach out to the consulting team to update them/get their input, rather than waiting for them to round or see the updated daily note. This is surgical ICU by the way (so there is a surgical team attached to most patients).

 

I guess my point is, while I fully support PA's practicing as autonomously as they feel comfortable with/are qualified for, in some settings NO ONE is actually autonomous. Not even the attending.