No on-site supervising physician

[gmf04]

The other PA and myself at my office are soon to be without an MD in our office. Multiple doctors/practitioners, staff are leaving this corporation due to dissatisfaction.

Despite giving a 3 month notice and the other MD giving a 3 month notice prior, there has been no attempt to replace either doctor.

I feel the "leadership" of the company is planning to stretch the guidelines for on-site supervision as far as they can. They already have another office with 1 NP and 1 PA who have been without an MD for 8 months now. That PA said her new supervising MD has never been to their office. Management has appointed myself and the other PA a supervising physician who is not at this office. I know that is legal. However, my concerns are these "supervising" physicians and our company have no intention of these MDs EVER being at our office. Patients are not happy with the fact that there is no doctor and I feel it is setting us up for a very risky situation liability wise. I am in a large city and really there is no need to be without a doctor indefinitely. We are not in a rural area where the only way we would be able to provide care would be to practice alone. I know state laws are different. I am in Virginia and the guidelines states the supervising has to be accessible in person or by phone within an hour time.  I'm looking for anyone's input or experience with this situation.

[MediMike]

I work in critical care and rarely see the attending physician on shift unless I stop by the tele ICU to say hi.

What specialty are you in? Years in practice? Is there an expectation of the patients to see both you/your colleagues AND a physician? Do you staff the majority of your patients? Do you think that if there is an issue you won't be able to get a hold of the MD?

I'm asking all of these questions to try and suss out exactly what your concern is regarding liability. You have no more liability than you did when the MD was on site. You are following the law. Now if you can't reach the physician then yeah, you've probably got a problem on your hands.

Your practice location doesn't really matter, it's all about what's legal. 

[CAdamsPAC]

My Supervising Physician (SP)is often hundreds of miles away from my practice location, but is reachable by phone and at times telemedicine. We regularly discuss patients as needed and my chart notes are reviewed  by my SP. In Alaska it's pretty  much the rule, not the exception that PAs & NPs practice at sites removed from the location of their  SP. Mutual respect and open lines of communication are paramount when the SP is not physically present. It seems to me that your employer is playing games that keep money in their pockets by having fewer physicians on the payroll.

Edited October 4, 2019 by CAdamsPAC

[Reality Check 2]

Check EVERYTHING out yourself.

Is the new doc they put on your license practicing the same type of medicine as you are and does this person have a board certification in what you do?

ie. a gynecologist should not be the SP for a Family Medicine or Internal Medicine PA and an Internist should not be the SP for someone who sees kids and does Family Practice.

Check to make sure this person knows exactly who you are, where you are and that you have contact numbers on hand.

Make sure this person even knows he/she is now a supervising physician for a PA.

Don't assume anything.

I do not call my SP basically ever - he is somewhere in the hospital most days. He doesn't sign any of my charts and I openly review patients with colleagues - as they do with others - in a collegial manner and learning environment.

Sounds like you work for a not so awesome entity and should really consider other options that wouldn't put you in a questionable situation. 

And patients really shouldn't have a problem with no doc on site. Competent PAs are alone all over the place and it is awesome, safe, competent and effective. 

My crusty old 2 cents

[ventana]

I think in these cases you are wise to ask your board. Get their opinion on what you situation is and could be.  Get it in writing then you are never hanging you own license out there.....

 

This also tends to trump any bad ideas management conjures up..... (BTW all they are doing is likely trying to make MORE money so they can give themselves pats on the back and a raise.....)

[MediMike]

Completely agree that administration's main goal here is to make money, but unless I'm missing something obvious here there is no increased liability for this individual. 

Maybe a decreased comfort level (which is fine) but no issues surrounding the legality of them practicing without an on site physician.

[gmf04]

I think my concern comes from the expectation of the patients that they have the option to see a doctor when they come to our office. It's not the norm in our area to have an office with no MD ever available. I have been practicing close to 20 years now and feel comfortable when working alone or with the other PA. I'm family practice/internal medicine and we have a large amount of medicare/medicaid complex/non-compliant patients. The issue as well comes from having so many more of these patients when the doctor leaves.  Our volume of patients can range from 16-26 in a day on average. Its nice to have these types of patients divided up among us in the office, with the MD being able to see some of these patients as well. Patients who require a PCP to be listed on their card aren't always happy about having to call their insurance company and request a provider they don't know, who is not at our office or listed as a provider at our office, who they really don't have the opportunity to ever meet or see. We had to do this temporarily before for several months, but now this appears to be a longer term plan. I guess overall my biggest concern are those patients who would like to see an MD and will not be able to. When these patients start off angry, they look for any reason to find fault with what we do, even if it was appropriate care or treatment. So many doctors are leaving this company that its difficult to even schedule them with an MD at another affiliated office without having to wait weeks or months. 

Thanks for everyone's feedback!  It is disappointing that the most likely motivation behind this is all financial and these decisions are made by people with no healthcare background. 

[LT_Oneal_PAC]

22 minutes ago, gmf04 said:

I think my concern comes from the expectation of the patients that they have the option to see a doctor when they come to our office. It's not the norm in our area to have an office with no MD ever available. I have been practicing close to 20 years now and feel comfortable when working alone or with the other PA. I'm family practice/internal medicine and we have a large amount of medicare/medicaid complex/non-compliant patients. The issue as well comes from having so many more of these patients when the doctor leaves.  Our volume of patients can range from 16-26 in a day on average. Its nice to have these types of patients divided up among us in the office, with the MD being able to see some of these patients as well. Patients who require a PCP to be listed on their card aren't always happy about having to call their insurance company and request a provider they don't know, who is not at our office or listed as a provider at our office, who they really don't have the opportunity to ever meet or see. We had to do this temporarily before for several months, but now this appears to be a longer term plan. I guess overall my biggest concern are those patients who would like to see an MD and will not be able to. When these patients start off angry, they look for any reason to find fault with what we do, even if it was appropriate care or treatment. So many doctors are leaving this company that its difficult to even schedule them with an MD at another affiliated office without having to wait weeks or months. 

Thanks for everyone's feedback!  It is disappointing that the most likely motivation behind this is all financial and these decisions are made by people with no healthcare background. 

If people are unhappy about not seeing an MD, then they can go somewhere else. If it affects enough revenue, then the company will find a way to make it work.

[rev ronin]

With 20 years of experience, it sounds like you're vicariously concerned for patient satisfaction.  With 7 years in, I'm surprised how FEW patients have ever opted to see a physician rather than me.

If I were going from "doc on site" to "no doc on site" I'd ask for and expect a raise.  Maybe nothing huge, but $2-5 an hour would be reasonable to request.

[Guest Paula]

My only concern would be how are your services being billed?  If under your own NPI number then all is good.  But if your company is trying to bill the medicare patients under "incident to" billing and there is no physician on site, you are in trouble.

 

Unless medicare did away with incident to...which I doubt has happened yet. 

I like working without a physician on site.  It just seems freer and liberating.

[ventana]

13 hours ago, MediMike said:

Completely agree that administration's main goal here is to make money, but unless I'm missing something obvious here there is no increased liability for this individual. 

Maybe a decreased comfort level (which is fine) but no issues surrounding the legality of them practicing without an on site physician.

 

 

This is a statement you want to get in writing from you state board.   It will protect you.  

 

Early in in my career I would tell pts they had choice to see doc, now I don’t waste my breath.   Just practice good medicine.  

[thinkertdm]

Every patient has the right to see an MD.  However, practicality dictates that you may need to schedule or go to a different location to do so.  Nothing says that the patient gets to see an MD, when they show up, out of the blue, and snap their fingers.  That is taking patient satisfaction to a more ludicrous level than it is now.  I've had patients accost me because they didn't like what I had to say (usually in the area of antibiotics) and demand to see the MD.  Because "the law" says I have to have one, and they get to see one if the want.  So I have to explain that the SP is there for me to collaborate with, not them; and if they want to see an MD, they would have to make an appointment, because the MDs were booked up.

So, if they show up expecting to see an MD, explain that there are none at your location, they can either make an appointment or do a little driving.  Then offer to talk to them to see if you can show them what you can do.

 

[Cideous]

I love it when a patient only wants to see a "real doctor".  One less visit.

[ventana]

24 minutes ago, thinkertdm said:

Every patient has the right to see an MD.  However, practicality dictates that you may need to schedule or go to a different location to do so.  Nothing says that the patient gets to see an MD, when they show up, out of the blue, and snap their fingers.  That is taking patient satisfaction to a more ludicrous level than it is now.  I've had patients accost me because they didn't like what I had to say (usually in the area of antibiotics) and demand to see the MD.  Because "the law" says I have to have one, and they get to see one if the want.  So I have to explain that the SP is there for me to collaborate with, not them; and if they want to see an MD, they would have to make an appointment, because the MDs were booked up.

So, if they show up expecting to see an MD, explain that there are none at your location, they can either make an appointment or do a little driving.  Then offer to talk to them to see if you can show them what you can do.

 

 

 

to ask a question

 

We always talk about the patients "right" to see the the Doc, but where is this written?

I have never seen it is state law, never seen it in insurance regulations, maybe in insurance credentialing?  is this just something that has been passed down?

 

In my prior job (corrections) it was clearly and absolutlly stated that the inmates DID NOT have the right to see anyone but me.  I provided the care and they were stuck with it (I did a really nice job and was not restrictive and always got people in - in 5 years I don't think I ever had a serious complaint)

 

 

So is this idea of "they have a right to see the Doc" actually supported in fact ?  Or is it once again just our subservient nature to the doc??  (not trying to argue, I am actually curious if it is written somewhere??) 

[GetMeOuttaThisMess]

In my setting it isn't an option since our SPs aren't onsite anyway.  Don't like it?  Go see your own PCP, or find one.  Some of ours complain that we can't do MORE for them than what our clinic is designed to handle.  I like those.  Let's keep it simple and low stress.  To be honest, with one old gray headed geezer since day one, no one has ever asked to my knowledge.  It's all about the lack of, and color of, the hair.

Edited October 5, 2019 by GetMeOuttaThisMess

[thinkertdm]

In Florida, there is a subsection that states:

Quote

When prescribing, the PA must:

• Clearly identify that he/she is a PA and the patient has a right to see the physician before a prescription is prescribed or dispensed by the physician assistant.

In Pennsylvania:

Quote

§ 18.171. Physician assistant identification.

 (a)  A physician assistant may not render medical services to a patient until the patient or the patient’s legal guardian has been informed that:

   (1)  The physician assistant is not a physician.

   (2)  The physician assistant may perform the service required as the agent of the physician and only as directed by the supervising physician.

   (3)  The patient has the right to be treated by the physician if the patient desires.

 (b)  It is the supervising physician’s responsibility to be alert to patient complaints concerning the type or quality of services provided by the physician assistant.

 (c)  In the supervising physician’s office and satellite locations, a notice plainly visible to patients shall be posted in a prominent place explaining that a ‘‘physician assistant’’ is authorized to assist a physician in the provision of medical care and services. The supervising physician shall display the registration to supervise in the office. The physician assistant’s license shall be prominently displayed at any location at which the physician assistant provides services. Duplicate licenses may be obtained from the Board if required.

 (d)  The physician assistant shall wear an identification tag which uses the term ‘‘Physician Assistant’’ in easily readable type. The tag shall be conspicuously worn.

 

 

In general, people have the right to be seen by whomever they want, just like they have the right to go to whatever restaurant they want, or eat what they want.  In certain situations, patients lose certain rights.

[surgblumm]

I cannot read every response to this age old question but agree that many of us , myself included, have practiced without the on-site supervision and practiced within our education and knowledge and were gifted with intuition which told us when to turf to the physician who was our SP according to the office management. For those patients which desire to see a "real doctor" , I would simply tell them how this corporation works and they have invested their trust in you and if they are not satisfied, they are welcome to contact management or find a UCC or practice that has a physician.

[sas5814]

I have never had a position where I had my SP on site. It has never been an issue. The Florida language about a patient's right to see a physician is odd and a bit troubling but that is what you get when we are subordinated  to a medical board. 

I worked in a rural ER where I was solo with the local docs on backup. On rare occasions someone would demand to see a physician. I'd tell them the physicians were on call if I needed them. They weren't to be called in all night long just because someone didn't want to see a PA. I would them give them directions to the big hospital 20 miles away.

They may have a right to see a physician. That doesn't mean we have to magically produce one where one isn't available.

Edited October 6, 2019 by sas5814

[Guest Paula]

On another similar note to the question of laws where patients have the right to see a physician:  When they say to  you "I want to see a real physician"  do you explain to them you are not a fake physician, not a physician, you are a PA, a real PA, not an NP or a fake NP or a real NP.   

Our description of things is so odd.