Is There an Epidemic of Poorly Supervised PAs Harming Patients? A Rhetorical Question

[jmj11]

In the last few months I've been involved in filling out a lot of forms, credentialing my new clinic with the states Medical Quality Assurance Commission, malpractice insurers and now health care insurance companies. Some of the forms are simple, asking one or two page of questions. However, regarding the latter two types of credentialing, about 50% of the forms are devoted to the question of "Is there a Midlevel (paramedical, physician extender, PA, NP etc.) in your practice?" Then, if the answer is yes, the rest of the page is devoted to scrutinizing the supervision of such person.

 

These forms give no attention to any scrutiny of the physician's qualifications, practice habits or prior record of care (exception being prior lawsuits or claims in regard to buying mal practice insurance).

 

If you were from another planet, you would get the impression from these forms that there is an American pandemic of patients being hurt day after day by poorly supervised PAs. I don't have any stats, but I would estimate that <1% of patients, who are injured by the medical system, are done so by a PA (or NP) who lacked proper medical supervision. I wonder how many PAs have caught errors and saved patients from harm?

 

Food for thought. We need to change the way that culture sees us.

[jdenning]

Very interesting Mike.

 

My own experience has been that the more experience I acquire, the less supervision I need. It's important to remember to ask for extra help when I need it though. It might be to verify a weird lab result, or an incidental finding on imaging or PE. think in the back of my mind I have always known that my liability is "higher" than that of the physicians, so if anything I tend to overdocument or "hyper-document" as one of our physicians notes. One of our docs has told me that my H and Ps are by far more thorough and complete than any of the physicians in the group....

 

One would think that the SPs would be under more scrutiny, because ultimately they are the ones responsible, but personally I don't ever want to be in that position, so I think it's better to cover all the bases so to speak.

 

No one has ever told me, but I suspect my liability coverage is more expensive than that of the docs I work with. Go figure.

[EMEDPA]

at least in em, pa liability insurance costs a lot less than docs...but still about 4x primary care....

[Avalon]

This thread seems directly related to the reason I logged on tonight to post a query of my own, so perhaps I'll ask it here: How would you define "poorly supervised"? Are there generally accepted guidelines on the amount, frequency, or structure of supervision that would be deemed adequate for a new graduate in order to prevent harm patients? I am in my first PA position in family practice and I have reason to question the adequancy of my "supervision".

[jmj11]

This thread seems directly related to the reason I logged on tonight to post a query of my own, so perhaps I'll ask it here: How would you define "poorly supervised"? Are there generally accepted guidelines on the amount, frequency, or structure of supervision that would be deemed adequate for a new graduate in order to prevent harm patients? I am in my first PA position in family practice and I have reason to question the adequancy of my "supervision".

 

You know, I've been accused by some (mostly med students, physicians) of advocating for PA independence. Nothing could be further from the truth. I look back to when I got out of PA school, and I didn't know crap (okay a little crap) on how really to practice medicine. My first position (only for six months) had virtually no supervision (impaired MD was suppose to supervise 5 pas). Then I took a job where I worked side by side with a brilliant doctor for five years.

 

My point is that you have to have common sense on this supervisory-PA relationship. I've now worked in headache disorders for 29 years. Surely, I don't need supervision like I use to. Right now I don't know any regional doctors who would know more than me who could. But if I were to go back to ER medicine, I would want a ER doc (or experienced PA) in a close relationship because there would be many things I don't know.

[Avalon]

Agreed, jmj11. I am asking specifically with regard to first positions as a PA, or first positions in a new specialty for a seasoned PA. Essentially, I feel as if I am functioning "idependently," to borrow your word, and that this independence is premature for my level of knoweldge and competence as a new graduate. While my SP is on site probably 80 % of the time that I am in clinic seeing patients, he is as well seeing patients (at twice or more of the volume that I carry) and is only available if I interrupt him from his own schedule. He reads and co-signs my notes (we are on an EMR system), but his comments are infrequent and confined to issues that seem to be more economically than clinically relevant (e.g., why did I not ask about vaccine status or do spirometry on a smoker).

 

After three months of such an arrangement, I reluctantly asked for one hour of case-based supervision per week; he agreed, attended for exactly two weeks, and subsequently began scheduling patients again during this supervisory time, without an explanation to me. I am left with trying to manage the persistent and palpable daily anxiety that I am delivering sub-standard care at best, and harming patients at worst. Three times now my SP has left the state during my clinical hours without informing me more than a day in advance. As I have a limited frame of reference to which I can compare my supervisory experience, I am looking to essentially answer the question of whether this is considered "adequate." I find myself very envious of your side-by-side expereince with the "brilliant MD". Does he need a new PA?

[jmj11]

No, he has a new PA. He took my place in 87 and has been there since. He (both the old Sp and the PA who took my place) are still good friends.

 

It sounds like your SP sees the world through $$$$ glasses. It will come back to bite him and you if he is not investing in your training.

 

My SPs for the last 8 years rarely spoke to me. But that was a good thing. I wanted them out of my hair. But those first six months 29 years ago were a nightmare.

[Avalon]

Ah, yes, that's the word. I am in a nightmare.

[Contrarian]

Are you the first PA-C that this SP and/or Practice has worked with...???

If not, were the previous PA (s) experienced and therefore semi-autonomous...???

If so, what was YOUR health care experience prior to PA school...???

Is there a possibility that you may have "over-sold" yourself to this physician during the interview and inadvertently contributed to or set up this perceived problem...?

 

Anywho...

Your concern is charming and demonstrates a level of clinical maturity in and of itself.

If you were practicing in some obscure sub-specialty, I'd be concerned... but you are not, its Primary Care.

If you studied and took your education seriously while in PA school, which I have little doubt you did as it seems congruent with your concerns, you already have all the tools you need to be successful and provide "gold-standard care" to any patient that presents to you in that Primary Care setting.

 

Sounds like you are having "first-flight" jitters but all your feathers are intact and functioning properly. Sort of like that sudden, fleeting rush of anxiety about flying and/or heights one experiences when they look out the window of a plane... even though they have flown and maybe skydived hundreds of times.

 

As long as the SP is commited to being amiable and available for consultation (regardless of their physical location)... you should be prepared to do the best for every patient you interact with. If YOU can't do this, folks WILL question the point of you being there slowing down the patient flow and revenue generation... and this is the very scenario that all too often leads to those practices hiring other types of NPPs in the future.

 

To do so, you should surround yourself with easily accessible up-to-date references.

5MCC, Epocrates on a Ipad, Xoom, Galaxy pad or other tablet PC in your hand/exam room at the point of care.

These references should also be on your smart phone in your pocket or on your hip at all times.

You should spend MOST of your idle time reading some type medical related material for the next few yrs.

 

As a new grad, personally, I NEVER went anywhere without a medical reference book and the ones that were really good... I read cover to cover maybe 2-3 times per yr. I kept "The Residents Manual of Medicine" (Ambati et.al) in my vehicle and would read it when/wherever I was sitting waiting on something or someone (I just looked across the room and see it on my bedside table as I write this). Tarascon's Primary Care pocketbook is ultra-portable, about the size of a typical man's wallet and full of useful medical trivia. The "Secrets" series (Primary Care Secrets, Surgery Secrets, Emergency Medicine Secrets, etc) is a bit larger and less portable but also a great series of books to keep laying around everywhere YOU spend time.

 

You will likely get the highest yield from reading "The Saint-Francis Guides" (Inpatient/Outpatient/Pediatrics/Cardiology) and the "Common Symptom Guide" from cover to cover 10-20 times. Doing this now will adequately prepare you to INDEPENDENTLY care for pretty much 99% of what you will encounter in the Acute/Primary Care setting and instill a significant level of clinical competency and confidence.

 

Still today, my wife and kids know to put all of my medical journals in my bathroom because I peruse and read them while administering my kingdom from my throne...:heheh:

 

Just a few thoughts and another opinion on the internet from a stranger...

 

YMMV

 

Contrarian

[rcdavis]

^^^^ ditto.

 

And what I sense from your posting is a desire for feedback.. A sense of " what am I/ could I be missing?"

 

If your SP won't meet with your for CCPs.. Then maybe you could take an initiative, call a few ( 4-5) local PAs and see if they would like to start a journal club or meet monthly where in one would present a case and discuss it.

 

Or... You could present cases here !!!!

 

Trust me, you wil get feed back.

 

You don't have to be an expert like deborah or Andersen or empac or David c or Mary ran.. Just have and be what you do and are.. An interested PA interested in honing his craft.

 

Regardless, you will do well.

 

Davis

[ventana]

welcome to the frightening moments of learning the art of medicine.

 

sounds like you should have a little more supervision

 

I was like you - wanted (and still do sometimes but much less frequently) the feedback of someone else on some cases every once in a while. This is good - means you are thinking and aware there is a lot more out there then you know (this is one of the cardinal rules of practicing good medicine-and it protects your patients)

 

Be honest with your doc - don't be afraid to interupt him with questions - make sure you pause and ask yourself rather you really need to ask the question, but if in doubt ask.....

 

as far as supervision - if he can be reached by tele that should be enough......

 

 

 

 

 

 

I maybe 1 question per month, and mostly they are stylistic questions, not hard medical questions - you too will get there. Sounds like you are doing a good job and learning a lot

[andersenpa]

I wish all the "haters" out there who think PAs are unskilled loose cannons who overstep their dependent role could read this thread.

[bnel]

This thread seems directly related to the reason I logged on tonight to post a query of my own, so perhaps I'll ask it here: How would you define "poorly supervised"? Are there generally accepted guidelines on the amount, frequency, or structure of supervision that would be deemed adequate for a new graduate in order to prevent harm patients? I am in my first PA position in family practice and I have reason to question the adequancy of my "supervision".

 

I am in a similar situation to you. Directly out of school I went to work in a rural health center with very minimal supervision. I worked close with the doctor for three weeks only and then saw them once a week, until they decided the satelite clinic I worked was too far for them to drive and for a time I saw them very seldomly. I called them on the phone alot. I was thrown into a a clinic managing very serious medical illnesses with very little specialty back up, a hospital with an ER 35 minutes away that hated taking patients from our clinic because it is across a state line. I did this for almost a year before they hired another doctor to work closer and she comes to my clinic 2-3 times per week. I have been here for 3 1/2 years and I think I understand what you feel about supervision.

 

When I started, I felt like I knew nothing, because I didn't. I wanted to keep learning by being around the other fantastic doctors that worked with me, but they are so far away, I only see them rarely now, and I never get a chance to learn from them, other then phone calls. They do all kinds of procedures that I have only heard them describe. Joint injections, suturing techniques, etc. I feel like I stopped learning when I started working, never having a chance to even observe what the 25 year veteran doctors do. In rural medicine the more you can do the more valuable you become. Unfortunately the new doctor working in the area I closely work with, chooses to do none of these procedures, and seems consumed by the possibility of a lawsuit. I have learned little clinical skills from her, and she refers everyone. I understand the frustration of wanting feedback from a supervisor and not getting it; of wanting to learn more skills and not being able too.

 

It has been very valuable learning time for me, and I am a better PA for it. I survived and my patients did too. I am thinking of changing to another field though, maybe surgery.

[Contrarian]

Forgot to add...

 

Another often taken solution to the concerns above is to simply resign...

 

Then you can go get a "safe" and "secure" developmentally stunting position in a practice being micro-managed by a physician with un-diagnosed axis-II/cluster C issues ... as a over-paid "medical-assistant" and scut-beee-oootch...

 

Here... you can show the general public... and physicians what we PA's are "really" about.. .:ohnoes:

 

Contrarian

[Avalon]

Thank you all for your valuable insights and responses. I feel well supported, as always, on the Forum.

 

Contrarian, you raise several valid points, but I can assure you I in no way "oversold" myself to this practice. I specifically inquired about the availability of my SP to oversee my more complex cases and expressed my sense of uncertaintly regarding my skill level as a new PA. I was told, verbatim, that he would see every patient, if I so requested, in the first several months to facilitate my learning and medical decision making. Of course I never requested this, as I completely appreciate the delicate balance between presenting as an autonomous, competent provider on the one hand, and knowing my limitations and when to seek guidance on the other.

 

My prior healthcare career, for more than 20 years, was as a psychologist and a university professor. My clinical work focused on psychological presentations with medical co-morbidities, and my lab researched topics in mind/body medicine. While some (perhaps you?) would argue that this is not relevant healthcare experience, I would disagree; the interpersonal, listening, analytical, and communication skills that comprise the foundation of this work are essential in medicine as well.

 

My SP has had other mid-level providers; two have departed on poor terms in the last six months (an NP just prior to my hiring and a PA just subsequent to my arrival). The NP had 20 years of experience as an ED nurse but was a new graduate of her NP program, and the PA was trained in the 1970s.

 

bnel, your experience really resonates with me, and I was struck by your comment that you feel as if you are no longer learning. This is a sentiment I did not express well in my first post: I entered this, my first position in medicine, expecting to continue to learn, to grow as a medical provider, and to refine my craft. I have profound disappointment that this is not occurring. Thanks for helping me to see this more clearly; it is definitely a component of my anxiety and disappointment. ePocrates is, as Contrarian suggested, always in my pocket, and I give what little spare time I have to continued, self-initiated learning, but I somehow thought part of my first clinical position would include mentoring in the art.

[jmj11]

I wish all the "haters" out there who think PAs are unskilled loose cannons who overstep their dependent role could read this thread.

 

 

I totally agree. I think how much I appreciated my first good SP. He had me follow him for an entire month before I saw my first patient. For the entire 4 years I was there, he briefly visited with every new patient I saw to make sure i was correct and had many teaching moments.

 

When I went to Mayo clinic 15 years ago, even though I had 14 years experience under my belt at the time, they still had one of their headache specialists briefly meet with every single patient for the first three months. I appreciated the learning experience. After three months, however, both I and the docs were very ready to let me fly on my own.

 

Even now, that I'm starting my own clinic, I did hire a headache specialist as my SP, while in the past eight years my SPs were neurologists who didn't know a lot about headaches and I was totally independent. But I didn't like that arrangement, although it looked good on paper (they were in the same building as me almost every day . . . although they almost never spoke to me and certainly didn't teach me anything). I have a lot more experience in headache than this new SP, however, if I had my wishes I would have an SP who still knew a lot more than me so I could continue to learn until the day I retire.

[winterallsummer]

The problem is right there in the name. ASSISTANT. The connotation of the word assistant is someone who is not capable of doing so they help. Change the name and everything else will follow. My 2 cents.