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Ethical question for my fellow PA brothers and sisters.


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Relatively new PA here (graduated 2016) working rural medicine and am experiencing my first “curbside consult” of sorts. Some family friends know that I am a medical provider and their kids play a lot with our kids ect,etc.... long story short, the mother is asking if I am able to sign their kids (pleural) camp physical forms. Healthy kids and the parents are not opposed to me doing a physical exam but this is would be a visit without an EMR attached to it. I’ve done a few things like look in their kids ear, saw a foreign body, and recommended a good urgent care to go to in the past, but this is something different. Gut says no as to not start something as I’m sure more requests would come. Any thoughts?? 

 

Thanks to you all in advance

 

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I am still in PA school so take this with a grain of salt. But I also coached high school varsity athletics for 6 years, and every year providers from a local ortho office, doctors, PAs, and NPs came and conducted physicals for our athletes on site and no medical records were ever made. 

As far as opening yourself up for more favors to come, that’s a whole new ballgame haha. 

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You are using your medical training and license to state "this child is healthy enough for..."

99.9 percent of the time, it doesn't matter.  But when little Jimmy drops dead because he had HOCM, I hope your spouse works, because your malpractice won't cover it and you will lose your license.  And your job. When a relative asks medical advice, I ask them who their doctor is, because that's who they need to call.

But it's your license.  Roll the dice.

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I wouldn't do it.  I don't even suggest people have thee done at UC/walgreens/CVS, and I and damn well don't recommend them getting them signed at chiropractors.  In my opinion these should be completed by the PCM who knows kids history.

I do occasionally curbside for some family members (not immediate family, but not remote family), and I keep it very, very limited.  Friday evening tooth pain as my (professional) brother-in-law has wife & kids in the car heading out for vacation?  Yup, I'll do that.  Wednesday morning sore throat for my (somewhat inappropriate) other brother-in-law?  Nope, you should go get that checked out.

My SP (well, one of them) has given me the okay to do this type of stuff, and I have a locked file cabinet in my home office where I file a quick SOAP note.

And my malpractice would cover it if I would ever be sued. 

Edited by Boatswain2PA
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43 minutes ago, thinkertdm said:

99.9 percent of the time, it doesn't matter.  But when little Jimmy drops dead because he had HOCM, I hope your spouse works, because your malpractice won't cover it and you will lose your license.  And your job. When a relative asks medical advice, I ask them who their doctor is, because that's who they need to call.

My thoughts exactly! 

 

36 minutes ago, Boatswain2PA said:

I wouldn't do it.  I don't even suggest people have thee done at UC/walgreens/CVS, and I and damn well don't recommend them getting them signed at chiropractors.  In my opinion these should be completed by the PCM who knows kids history.
 

I agree. I do these often in the small rural UC I work at as access to a PCM is tough as an established patient, let alone a new one. Ultimately I’ve declined to do it. A giant load of liability given how many kids they have. Honestly, I thought it was rather bold to just out and ask but I guess it would make sense as a parent. Quicker and free. 

 

Thanks for the input. I appreciate it. 

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DO NOT DO IT.  PEIROD.

 

 

I can not stress enough what a horrible amount of liability this is for you.  The off the cuff natures of it may make it seem benign, but trust me, it is not.  NEVER do something like this.  Also smile and tell them you would be happy to see them in clinic and perform a good exam, but outside of work you don't practice medicine.  If they give you a hard time, excise them from your life.  They are not worth it.

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I follow the Washington State Quality Medical Assurance newsletter, which list (among many other things) those MDs and PAs who have lost their license. For MDs it is almost always sexual. For PAs it is mostly, something along the lines of "providing medical care without documentation." Some of those are writing Rx for narcs for family and friends, but some of them are providing other medical services "off the record."  I have done exactly what you have said, but I create a chart note and fully examine the kid, before I sign off. If I remember right, I cleared it by the practice I was in at the time (about 20 years ago, so I don't remember). 

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3 minutes ago, jmj11 said:

I follow the Washington State Quality Medical Assurance newsletter, which list (among many other things) those MDs and PAs who have lost their license. For MDs it is almost always sexual. For PAs it is mostly, something along the lines of "providing medical care without documentation." Some of those are writing Rx for narcs for family and friends, but some of them are providing other medical services "off the record."  I have done exactly what you have said, but I create a chart note and fully examine the kid, before I sign off. If I remember right, I cleared it by the practice I was in at the time (about 20 years ago, so I don't remember). 

Thanks for your response.

I read the same WSQMA and it certainly came to mind. Not a list I want to be anywhere near.  I had no struggle with saying no to them. They definitely understood after I explained the huge liability/ ethical conundrum I would be undertaking as not only their friend but as a professional. 

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18 minutes ago, Cideous said:

DO NOT DO IT.  PEIROD.

 

 

I can not stress enough what a horrible amount of liability this is for you.  The off the cuff natures of it may make it seem benign, but trust me, it is not.  NEVER do something like this.  Also smile and tell them you would be happy to see them in clinic and perform a good exam, but outside of work you don't practice medicine.  If they give you a hard time, excise them from your life.  They are not worth it.

I did invite them to my clinic. Doubt they will actually come but at least I offered. Thanks for the advice. Glad my gut feelings are still something I can rely on. 

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No...way...in...hell would I do one of these without documentation.  I'm already trying to get our clinic manager to understand why I am hesitant to do screening BP checks since there is no such thing as a paper record and if one of these folks (same employer as I though maybe not seen in our clinic, thus no "chart") had neuro sx. with a severe reading as defined by JNC8 and needed ED evaluation I sure want to be able to document it.  "But you're not providing care to these folks.  You're only giving them a sheet from AHA explaining the meaning of the reading." wouldn't be worth a flip in a court of law because my standard of care is different than an MA or LVN, etc.  I'm expected to know how to interpret these values and what to inquire about.

I did one of these school physicals a couple years back on a kid <10 y/o who couldn't flex their hip 90 degrees.  Mom responds with "Dad's a coach and it's only a hip strain."  Mom, have you ever heard of an epiphyseal slip and I don't have x-ray to confirm or rule out?  Next patient same day shows up in an ortho boot expecting to be cleared.

I had one last week, pre-teen, premature beats out the wazoo and I tell mom that I can't clear.  She then mentions "Oh, he was seen by a cardiologist and cleared."  I ask mom how they assessed the patient and she says that he wore a monitor for a day.  Great!  I then asked about an echo.  "No, they didn't do one of those."  Kid then chimes in and says "Yes they did."  I explained the setting and the kid says "Yep, that's what they did." down to the cold gel on the chest wall.  Duh, mom.  Got a letter of clearance from the cardiologist stating that they cleared the kid.  What if this was one of your neighbor's kids unbeknownst to you?

 

Edited by GetMeOuttaThisMess
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I agree with Cideous and his first comment. As a PA dinosaur and as a malpractice expert and a currently still practicing PA of 46 years I can only say this is the beginning of a slippery slope. You will have friends and relatives requesting prescriptions, antibioics, pain meds, anti hypertensives and all of this is WITHOUT a medical chart. That is the main missing ingredient besides not doing a personal evaluation  and examination. These not only add to your exposure for malpractice but to loss of licensure in some states. Since you are a neophyte,I would say that your response should be that it is against your rules of patient care or scope of practice to write anything without a chart, a previous history and a collaborating physician and a malpractice policy that allows you to do these things. If you are working for anyone else, you just plain are not covered by their insurance of your practice standards.

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Guest ERCat

What, to save them a 50.00 copay for an urgent care or even less for a pediatrician bonus. Just don’t. Echoing what others have said, most of the time it will feel nice and nothing will happen but if there is any bad outcome you’re on the line with zero protection.

I hate when family and friends ask for meds but I admit I have done it before. I have prescribed amoxicillin for my husband, and Voltaren gel for my father in law when his knee hurt. I have refilled my grandmother’s inhaler. These things seems very benign to me but even this is taking a risk.

Most of the time I use the “my supervising physicians wouldn’t approve” line and it works.

 

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Dont make a habit of putting your license on the line, even if it seems innocuous. We've all done it, but it sets a precedent for 2 things:

1. People expect you will do them favors PRN and essentially work for free.

2. You are 100% liable if something goes wrong. That's your ability to put bread on your table.

I have really grown to resent being curbsided by acquaintances. It's disrespectful in the regard that this is how I make a living and they are not only asking me to work for free, but also being ignorant of any liability I may assume by giving them A/P type advice. Because if they or their kid has a bad outcome, in all likelihood they will blame me if they followed my advice.

Edited by BruceBanner
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Agree 100% with the above. My friends and family are of the mindset that they can't come to me for things because I don't want it to jeopardize my relationship with them. A close friend of mine is an accountant. When I meet up with him for a beer, I don't bring my tax forms for him to look over. We'll occasionally bring up something work related as these things tend to go, but it doesn't replace my need for an accountant come tax time.  Should be no different for us as PAs. It may seem like an easy Z-pack or inhaler, but it's when things turn south where you'd really wish you didn't get involved.

 

I'll answer an occasional medical question or look at a rash one someones leg when hiking, but I don't make a habit of blurring the line between friend/family member and PA.

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On 5/7/2018 at 9:09 PM, mooredc said:

I am still in PA school so take this with a grain of salt. But I also coached high school varsity athletics for 6 years, and every year providers from a local ortho office, doctors, PAs, and NPs came and conducted physicals for our athletes on site and no medical records were ever made. 

As far as opening yourself up for more favors to come, that’s a whole new ballgame haha. 

Oh MAN  NOOOOOOO

 

one question

 

Who is you doc covering you as you practice medicine on this kid???   crickets.......

 

 

then a SLEW of other issues but that above one has teeth - practicing with out a doc is illegal....

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