Where are you at one this???

[CAdamsPAC]

OK ,for those of you that are working in "teaching hospitals" I'd like to know just how much time or interactions you have with your SP in the course of you days? How much of your daily duties involves working with Residents/Fellows and or having them direct your activities? Am I correct in assuming that these Residents or Fellows are not licensed physicians?That being said, would a PA be in violation of the requirement that a licensed physician serve as the SP when following the directions of the unlicensed physicians? Where would this activity leave us when the "fit his the proverbial shan" under this set of working conditions?

I've noticed the trend of PAs being placed in the role of "junior house officers" functioning as scut dogs for Residents and truly wonder if this is a legally acceptable practice. Your thoughts and experiences, please.

[deborah212]

I work with my SP probably 2 weeks total a year. The rest of the time is with other attending physicians. In contrast to my first job as a hospitalist (also at a teaching hospital) where I would round independently on patients, this team functions much more like the resident model you described. Ie. I come in, get sign-out, round myself quickly putting in orders as needed, then round again with the attending. Present the patient with overnight events, vitals, my physical, my plan for the day... then we go see the patient together. I do like this model because a) everyone is on the same page b) sick patients are identified early (as opposed to me rounding in depth separately and not seeing everyone until after lunch) c) there's teaching predominantly on clinical management.

 

However, it is definitely duplication of work, and depending on the attending, can lead to micromanagement. When I go to the ED to do an admission, I'll do the H&P, write the orders, and call the consults. Some attendings want to hear more, some what to hear less. If the admission comes in late, they won't hear about it from the me necessarily unless the patient is sick.

 

There are no residents/fellows on the PA hospitalist service. If a physician can't bill as an attending, they aren't cosigning my notes. We do interact with the fellows frequently on the consult services, but the aren't directing my activities besides making recommendations.

 

I'd also be interested to hear if there any PAs incorporated into a resident team on a medicine service other than the ICU, where this seems to be predominant.

[HopefulPA]

Both jobs hardly any contact with my SP. And no working under residents/fellows. The first job a PA-hospitalist to cover for private attendings not on site, (and it usually wasn't easy to get a hold of attendings with issues). I had allot of Automony...really too much atomony... My newest position is as House Officer for IM non-teaching service admissions.

 

As a point of information, correct me if I am wrong but I thought all residents/fellows ARE liscensed physicians?

[EMEDPA]

all fellows are licensed. interns are not licensed. most pgy2 and all pgy3 are licensed.

[medic25]

I work with my SP of record clinically maybe once every couple of months, although we do spend plenty of hours together in the academic office. All of our fellows are also attendings who are just completing fellowships in subspecialties (EMS, ultrasound, Global Health) and have the same privileges as any other attending. We are never supervised by residents; the junior residents present to the seniors (PGY 3/4), but we go directly to the attending. Doesn't mean we won't call the senior over for a little help (e.g. get them to look for an ultrasound-guided peripheral line if we don't have time to do it ourselves), but everything falls back to the ED attending.

[ventana]

in my hospital system and state all residents and interns have their own medical licenses before they can touch a patient (used to get 2-3 of them hangin out in radiology for the month of july till their license came through)

 

They however are not full unrestricted licenses - they carry restrictions as they are in residency or internship

 

again in my state - you can not touch a patient or provide care unless you are licensed (if you are functioning as a medical professional - ie PA or MD or DO) in that capacity

 

not sure it helps

 

 

 

 

As for supervision - I ahve thought of this exact question before - they can not legally be you supervision, but we have no requirement for personal supervision so your attending is your supervisor and if the resident is trying to kill the patient you should step in, as for taking direct orders from a resident - it happens - just like a 2nd LT in the military offically out ranks a chief master sargent - but the chief can and does give orders to the 2nd LT...

[coloradopa]

OK ,for those of you that are working in "teaching hospitals" I'd like to know just how much time or interactions you have with your SP in the course of you days? How much of your daily duties involves working with Residents/Fellows and or having them direct your activities? Am I correct in assuming that these Residents or Fellows are not licensed physicians?That being said, would a PA be in violation of the requirement that a licensed physician serve as the SP when following the directions of the unlicensed physicians? Where would this activity leave us when the "fit his the proverbial shan" under this set of working conditions?

I've noticed the trend of PAs being placed in the role of "junior house officers" functioning as scut dogs for Residents and truly wonder if this is a legally acceptable practice. Your thoughts and experiences, please.

 

Bunch or somewhat interrelated issues, my take from the ICU setting:

1) I don't interact much with my SP but I have daily interactions with the designated attendings (or Alternate SP according to Georgia). In the ICU we are expected to work autonomously. We are expected to get their input when we have questions and expected to notify them when there is a change in trajectory. We round with them daily with the on call resident so that everyone is clear on the plan.

 

2)We aren't directed by the residents or fellows and in Georgia that would be illegal. Only a physician with an unlimited license can supervise a PA. Residents in Georgia have limited medical licenses. We have non-acgme fellows who theoretically can supervise a PA, but the second part is that the physician must be listed with the BOM on either the SP or alternate SP form. Since they don't bother to do this they have no supervisory capability. In reality we are asked to seek out the fellow for input and coordination and directed to talk to the attending if we disagree with the treatment plan. At night when we have a fellow all calls go to them first and they update the attending again with direction to call the attending directly if we think the treatment plan should be different. This actually works out pretty well since for the most part our fellows are very experienced and very capable.

 

3) PA integration in the resident team. We have more than 60 PAs and NPs working in 8 ICUs in two hospitals. Five of the ICUs do not have residents and the ICUs are managed by the PAs and NPs along with the attendings. In three of the ICUs there are residents.

a)In one ICU there are two residents and the ICU is 18 beds on two floors. Typically the residents will cover one floor and the PAs will cover the other floor. If a resident is off the PAs will help cover the "resident" floor. The residents and the PAs cover overnight together (I think the residents cover four nights per week and the PAs three). The PAs and residents round together on all patients.

b)In another ICU there are three residents and the ICU is 14 beds on two floors. The residents are 1:3 overnight call. There is also a PA or NP in house until around 11 pm. The PAs and NPs work a variety of shifts covering the day. Currently all the patients are assigned to the residents and the NPs and PAs assist in the management and round with the residents and attendings. From a billing perspective they don't collect much and I've heard this is changing.

c)another ICU is twenty beds on one floor with between 3 and 6 residents and 9 PAs and NPs. The residents take call proportional to the number of residents (no call for interns). The PAs and NPs are organized with two PAs or NPs during the day, one PA during the evenings and two NPs or PAs at night. This allows "strategic napping" by the resident. On weekends there is one PA during the day and one NP or PA at night. The shifts overlap enough that there are always three people (residents PAs and NPs) present during the week and always two on the weekends.

 

4) PAs doing scut. You can be assigned almost any role by the supervising physician. Traditionally scut has meant data collection with no actual input into the plan. Such as when you have the intern write down all the labs and I&Os so the resident can do the note and the plan. This is a legal role for the PA as long as it is directed by the supervising physician. Given the cost of employing the PA I think that it would be unusual for a PA to be utilized this way. What I see more in surgery patients is that the PA manages the patients on the floor while the residents are in the OR. While a resident would consider this scut, this is a perfectly valid model for a PA who can probably manage the floor patients much more efficiently in terms of admission and discharge once they have experience. Most of our surgery teams have a PA who does a function similar to this.

 

5) The most common mistake I see is that attendings have PAs "supervise" residents doing procedures so that they can bill for them. My interpretations along with others is that this constitutes fraud at least in the Medicare population since its pretty clear that physician in this case actually means attending physician with an unencumbered license.

 

I've also had residents tell me that they are in charge of me and are going to tell me what to do. I kindly ask them to get further direction from the attending and usually educate them on state law. At this point I knew most of the Chiefs ad interns and have all their number as well as the attending numbers in my phone. I have no hesitation to move things up the chain if I disagree with the direction the medical plan is taking.