Another bad op/ed on PAs

[BruceBanner]

KevinMD.com, famous purveyor of denigrating op/eds and backhanded compliments to PAs, has another gem out on the dangers of cosigning our charts. Comments are also depressing.

https://www.kevinmd.com/blog/2018/11/the-risks-of-co-signing-pa-and-np-charts.html

Highlights:

-PAs and NPs are everywhere now
-Hospitals use them for cheap labor
-Dozens of new programs churning out new grads in the name of profit (true, to be fair)
-Docs are too busy to review charts (only docs are busy?)
-There is risk because we arent vetted through post-grad training
-Author drops the obligatory "I know a couple PA/NPs I totally trust" to avoid seeming like he's bashing the profession
-Physicians are being asked to sign charts in support of care they cannot review and which may be provided by "inexperienced, under-educated and over-confident providers."
-"I’m frightened that I may one day sign off on a dangerous mistake just because I didn’t have time to provide proper supervision. "

Sigh. I'd comment but I'm too busy, burnt out, and used my 10 mins of free time write this post, lol.

[EMEDPA]

here's a thought...don't sign the charts....many states don't require it. my charts have no mandatory review or cosignature in my state. better yet doc, if you don't favor signing PA charts , support the move to do away with it everywhere.

[thinkertdm]

If KevinMD and his ilk were doing the job, they wouldn't need us.

To clarify, doing the job includes providing low cost health care.  Boom.  I can't tell you how many times lately I've looked at the person trying to pay for: -the office visit, necessary work up, and the treatment.  Sometimes it's easy to blame the patient; if he didn't smoke, if he didn't use drugs, if he didn't do whatever.  However, I've started to realize (especially trying to pay for insulin that is nearly the cost of a car payment) that these people are me.  Are my mom.  Are my dad.  Are my son. 

I am ashamed to work with MD's sometimes, because the patient is, figuratively, and a lot of the time, literally, using money he doesn't have, to find out what is wrong.  And the MD is more than glad to take that money, only giving the patient a pat on the head.  Demeaning.

I speak from experience because I don't tell the office what I do.  And I hate, Hate, going to the Dr. office.  It makes me feel diminished as a person, especially when I am sick. 

So at work, I try to do what very few do- listen.  I take as much damn time as I need.  That's why I work at the VA, because they allow me to do that, and I don't have a bean counter telling me I'm not making enough money. 

So, KevinMD.  You can suck it.  Because while you may make your patients feel better that they have been blessed that a true MD has swept into the room, my mom will call me frustrated because she doesn't understand what the hell you are talking about, because she doesn't know what an echocardiogram is.  And she is scared.  And you did shit to help her with that.  And that's why she went to see you.  The chest pain was secondary.

Sorry.  the point is, the good MD's are too busy to write posts, and will gladly work with you.  The bad MD's sit and whine, like little babies who no one wants to play with.

[thinkertdm]

PS: Some may argue it's not the MD's fault everything is so pricey.  But they did nothing to stop it, did they?

[ventana]

Pure garbage. 

 

They are paid paid to supervise.  

 

They just just like to step on others to get a better view.   

 

 

Also lets let’s talk about the opioid epidemic in FL which was 100% driven by docs.  Or the local docs that wrong hundreds of thousands of opioids only to be told not to.  Whom have now switched to benzo prescribing.   Where is their accountability?  Where is kevinmd on these??  What about the doc’s getting 250k per year to work IM where a PA manages the same panel for 125k.   

 

[narcan]

I know it's my "job" to be on the team and hate this op-ed with every fiber of my being, but he makes a fair point. Most large EM groups are requiring this, there isn't enough time for supervision, education or collaboration, and it's all being driven by corporate greed.

I do agree that the answer is independent practice with collaborative agreements and then the PA/NP is responsible for knowing their limits, just like an obstetrician knows not to do lap choles.

Side point, the proliferation of online programs with create your own rotations with your friends by educational institutions that are owned by Corporate America can't possibly match the quality provided by an established, reputable, academic program.

[beattie228]

Some really great remarks in the comment section of the piece by a gentleman with the UN Peter B (not being facetious). He is both a PA and a medical malpractice attorney. Well written, thought out responses to the PA bashing nonsense without getting into heated arguments about semantics. I truly hope he is involved with AAPA lobbying efforts, PAs For Tomorrow as well as discussions with government representatives because the profession needs more folks like Peter B sounding off loud and clear to the general public. 

 

 

[sas5814]

Peter Berg. Smart guy. I don't always agree with his take on things but his responses are thoughtful and factual. He is actually retired and lives in Mexico.

[BruceBanner]

12 hours ago, narcan said:

I know it's my "job" to be on the team and hate this op-ed with every fiber of my being, but he makes a fair point. Most large EM groups are requiring this, there isn't enough time for supervision, education or collaboration, and it's all being driven by corporate greed.

I do agree that the answer is independent practice with collaborative agreements and then the PA/NP is responsible for knowing their limits, just like an obstetrician knows not to do lap choles.

Side point, the proliferation of online programs with create your own rotations with your friends by educational institutions that are owned by Corporate America can't possibly match the quality provided by an established, reputable, academic program.

I actually dont disagree with much of what the article said, which is partly factual. It IS a risk cosigning someone else's charts when you werent involved in care. New graduates ARE a liability if not properly supervised and mentored. PA and NP programs are 100% for-profit, despite whatever organization they are affiliated with, and have been churning out increasing numbers of new grads for over a decade. Docs go through a much more through vetting process via residency. None of this is news.

What I dont like is the intimation that only PAs are capable and likely to make egregious errors, and his assumption that they are legally culpable if a PA gets popped for a lawsuit.

[sas5814]

yea the tone was actually pretty mild for this website and most of the points he made were valid. Peter did a great job of working against the comments. My comment was "support OTP and this won't be an issue". Now lets see if they want to do something or just bitch and whine.

[Guest NOLAPA]

Whoa, there colleagues- lotta uninformed and unhelpful "bashing" going on here,

I have followed Dr.Leap for years, he is passionate, usually very balanced and I found his article informative and raising a valid point

As a PA with a 38-year history of ER practice in eight states and an expert witness, I happen to agree with Dr.Leap and insightful and thoughtful premise, written for physicians to incorporate ER settings where charts are required to be signed. He was actually on the money. My only disagreement is with the phrase that physicians vetted more rigorously.

He IS actually champ[ionoing the point that the Physician should not be on the hook for chart signature. That, however, is a rulemaking issue in the state legislature and in the facility of practice.  

[sas5814]

I think for the most part there wasn't much bashing and a reluctant agreement with most of the points.

I am unaware of any state mandated chart co-signature. Maybe it's out there but I'm unaware. Chart reviews which are conducted retroactively yes.

Most counter signature rules are local/institutional where, for the most part, the physicians write all the rules. So maybe his target audience for this op-ed is his colleagues

[EMEDPA]

the state of Oregon requires 10% chart review within 1 month. totally worthless. I believe CA also has a 10% chart review requirement as well, unless things have changed. WA does not have chart review requirements for PAs with their -C.

[CAdamsPAC]

On 11/14/2018 at 11:23 AM, BruceBanner said:

KevinMD.com, famous purveyor of denigrating op/eds and backhanded compliments to PAs, has another gem out on the dangers of cosigning our charts. Comments are also depressing.

https://www.kevinmd.com/blog/2018/11/the-risks-of-co-signing-pa-and-np-charts.html

Highlights:

-PAs and NPs are everywhere now
-Hospitals use them for cheap labor
-Dozens of new programs churning out new grads in the name of profit (true, to be fair)
-Docs are too busy to review charts (only docs are busy?)
-There is risk because we arent vetted through post-grad training
-Author drops the obligatory "I know a couple PA/NPs I totally trust" to avoid seeming like he's bashing the profession
-Physicians are being asked to sign charts in support of care they cannot review and which may be provided by "inexperienced, under-educated and over-confident providers."
-"I’m frightened that I may one day sign off on a dangerous mistake just because I didn’t have time to provide proper supervision. "

Sigh. I'd comment but I'm too busy, burnt out, and used my 10 mins of free time write this post, lol.

 "However, education is big business and colleges are churning out lots of mid-level practitioners.  In fact, PA schools are popping up everywhere and online NP programs are the rage.  (For a thought exercise, just imagine touting the wonders of your online MD!)  With this lucrative market for degree mills, with this increasing need for these health care workers in the marketplace, we are seeing a decrease in quality.  And an increase in danger."  This guy is stealing my thunder on this profession's growth!!

[CAdamsPAC]

On 11/14/2018 at 2:24 PM, thinkertdm said:

If KevinMD and his ilk were doing the job, they wouldn't need us.

To clarify, doing the job includes providing low cost health care.  Boom.  I can't tell you how many times lately I've looked at the person trying to pay for: -the office visit, necessary work up, and the treatment.  Sometimes it's easy to blame the patient; if he didn't smoke, if he didn't use drugs, if he didn't do whatever.  However, I've started to realize (especially trying to pay for insulin that is nearly the cost of a car payment) that these people are me.  Are my mom.  Are my dad.  Are my son. 

I am ashamed to work with MD's sometimes, because the patient is, figuratively, and a lot of the time, literally, using money he doesn't have, to find out what is wrong.  And the MD is more than glad to take that money, only giving the patient a pat on the head.  Demeaning.

I speak from experience because I don't tell the office what I do.  And I hate, Hate, going to the Dr. office.  It makes me feel diminished as a person, especially when I am sick. 

So at work, I try to do what very few do- listen.  I take as much damn time as I need.  That's why I work at the VA, because they allow me to do that, and I don't have a bean counter telling me I'm not making enough money. 

So, KevinMD.  You can suck it.  Because while you may make your patients feel better that they have been blessed that a true MD has swept into the room, my mom will call me frustrated because she doesn't understand what the hell you are talking about, because she doesn't know what an echocardiogram is.  And she is scared.  And you did shit to help her with that.  And that's why she went to see you.  The chest pain was secondary.

Sorry.  the point is, the good MD's are too busy to write posts, and will gladly work with you.  The bad MD's sit and whine, like little babies who no one wants to play with.

Aim your fire at Edwin Leap MD the author, not KevinMD.

[CAdamsPAC]

22 hours ago, narcan said:

I know it's my "job" to be on the team and hate this op-ed with every fiber of my being, but he makes a fair point. Most large EM groups are requiring this, there isn't enough time for supervision, education or collaboration, and it's all being driven by corporate greed.

I do agree that the answer is independent practice with collaborative agreements and then the PA/NP is responsible for knowing their limits, just like an obstetrician knows not to do lap choles.

Side point, the proliferation of online programs with create your own rotations with your friends by educational institutions that are owned by Corporate America can't possibly match the quality provided by an established, reputable, academic program.

But, these "schools" confer Masters & Doctorates, that's good because all those letters say "we good"  if not better than those without them! Just keep writing the checks and all will be good!!!

[ohiovolffemtp]

A better question is why are places requiring physician signatures on the charts.  It's really not about supervision but rather about going from the 85% reimbursement if only a PA or NP signature is on the chart to the 100% reimbursement for having the physician signature on the chart - "incident-to" billing.  If a medical service was reimbursed based on what the service was vs the license of the person who signed the chart this entire issue would go away.  I suspect so would also many of the barriers to OTP.

 

[Kaepora]

1 hour ago, ohiovolffemtp said:

A better question is why are places requiring physician signatures on the charts.  It's really not about supervision but rather about going from the 85% reimbursement if only a PA or NP signature is on the chart to the 100% reimbursement for having the physician signature on the chart - "incident-to" billing.  If a medical service was reimbursed based on what the service was vs the license of the person who signed the chart this entire issue would go away.  I suspect so would also many of the barriers to OTP.

 

Ding ding ding. 

[rev ronin]

A physician signature on the chart does not amount to legitimate incident-to billing.  Can we find an organization that does this in a systemic fraudulent manner, drop a dime on them, and watch the chaos as they hit the news and other organizations figure it out?

[EMEDPA]

2 hours ago, rev ronin said:

A physician signature on the chart does not amount to legitimate incident-to billing.  Can we find an organization that does this in a systemic fraudulent manner, drop a dime on them, and watch the chaos as they hit the news and other organizations figure it out?

probably harder to find one that does not. 

[AbeTheBabe]

5 hours ago, EMEDPA said:

probably harder to find one that does not. 

Easy, we don't bill incident to at all! Not worth the headache/hassle.

[ohiovolffemtp]

At all of my EM sites, different staffing companies for each, there's a standard note to the effect "I was available for consultation and to review labs, imaging, and endorse prescriptions.  Unless specifically stated, I did not see the patient".   In many cases the "face to face" note is based on a very brief patient encounter that consists of only asking the patient a few questions or asking them if they have any.   

[Kaepora]

10 hours ago, ohiovolffemtp said:

  In many cases the "face to face" note is based on a very brief patient encounter that consists of only asking the patient a few questions or asking them if they have any.   

Our physicians just add an addendum at the bottom of our notes.  "I have independently seen and examined the patient, and agree with the CRNP's assessment and plan as outlined above."