If you read the October column, you know I took a beating from those who find my work too quixotic and ethereal. A particular person wanted me to get back to the real “old time religion” and speak to more concrete issues.
I’ve decided to oblige by revisiting one of the most tangible and pressing medical issues of our day: The supervision of advanced practice providers.
You might be happy that I’m giving Marx, Nietzsche and Foucault a month off, but I warn you that you might not like the nature of this discussion either. It involves what 75 percent of you do every day –the utilization of PAs and NPs – and I’m going to call it like I see it.
By the time you read this, I will have given my talk on Advanced Practice Provider Supervision at the ACEP 2015 Assembly in Boston. I am hoping, like Paul Revere, to make it out of town alive. Current Las Vegas odds have me at about 50-50. Why was I given this topic? Number one, because I’m old and can put up with your criticism. Number two, this is a real quandary, and in all candor, we don’t know what to do about it.
The lawyers love our confusion and indecision. If you’ve ever wondered if you could get sued for that patient that you didn’t see but for whose chart you signed? Let me just end the suspense: Yes, you can, and in the worst possible ways. And if you signed the chart and your group billed the 100 percent fee and not the 85 percent fee for simple supervision, you could be charged with a felony. Go ahead and ask yourself another question: How do I look in stripes?
Having watched depositions and lawsuits for 40 years, there is a definite trend in what is asked and how such inquiries are answered. When an Advanced Practice Provider (APP) is involved in a suit along with a physician, plaintiffs’ attorneys are looking on the chart to find proof of the physician’s involvement in the actual care and treatment of that patient. Physicians crumble under this type of questioning. “Show me, doctor, on this chart, where you actually saw the patient?” “Show me your policy for which cases must be seen by the supervising physician?” “Show me, doctor, the formal advancement program where you bring midlevel providers along and oversee their work as they develop and improve their skills.” “Are you aware, doctor, that the patient thought that the APP was actually a physician?” “Tell me, doctor, who would you see for one of your family members if you could?”
These questions are endless. I have trained both APPs and physicians to counterpunch on these issues. But there is only so much you can do. Now imagine these questions are being asked in a courtroom in front of 12 people picked from the voters’ rolls, who are watching a huge portion of their stagnant paychecks go into their health insurance premiums each month. If you don’t think I couldn’t make you squirm on the stand and inflame the jury, you are blind as to what is happening.
In the last two months I have made eight residency visits. At two of them, I tried out the supervision talk and then picked on non-suspecting senior residents and tortured them with 10 or 15 of these questions. They are always defeated because nobody ever told them that these types of questions would be asked or how to answer them. One young lady informed me that I was being hurtful. That’s the new word for those who lack the intellectual resources to fight back. Hypersensitivity is the surest sign of mediocrity. This is emergency medicine, not dermatology. If you can’t take the heat from me, imagine how well it is going to go when a great lawyer has you in court, writhing on the stand. Remember, those people have real money on the line don’t back off.
What we are lacking is a clear vision as to what supervision of non-physician clinicians means. We have more or less a reasonable idea when we’re talking about the residents and how we are going to watch them throughout the training years. It is interesting to note that the residents who have graduated from medical school and may have two or three years’ experience still require someone to be involved in their cases. We know what they should know. We know how long they’ve trained. We know what was taught at grand rounds and how to progress them in their knowledge base and responsibilities from year to year. I contend there is no such consensus in our working with APPs.
Before we can develop this consensus, we have to agree on our terms. After all, who we are as clinicians, and how we project ourselves to patients, impacts our work environment. When I was third year medical student working at Wayne County General Hospital, Detroit’s county hospital, a patient asked me: “Are you an intern?” I responded quickly: “No, sir.” I didn’t bother to tell him that I was only a third year medical student, two years behind the interns. I was honest but not candid. We need some candor badly in dealing with patients and at least letting them know who’s who, what’s what and who they’re actually going to see. How do we define ourselves as supervisors? Do we have an ethical, moral and legal obligation to the patient? Countless mothers and fathers, who seem quite ordinary, are able to rise to heroic heights in defense of their children. So what do you say when they are told they are about to see “the doctor”? Be honest. Who do you want your kids to see? And wouldn’t you be angry if you were deceived by a technicality? Is the nurse with a PhD degree to be called doctor? The extent to which patients are confused is unbelievable. And I hate to get philosophical again on you but what do medical vows mean? I know, let’s ask the jury.
This year between 30 and 40 percent of patients will be seen by APPs in emergency departments. Who needs to be overseen? When should the physician get involved? Do these various levels of providers turn on each other in the face of a lawsuit? These aren’t small issues. The number of EDs has decreased by 20 percent in the last 15 years. Free-standing EDs, minute clinics and urgent cares have increased. State boards are allowing NPs and PAs to open solo practices in some areas. I think this change represents a brave new medical world. If APPs can see every patient who would otherwise be seen by physicians, then what is our new role and responsibility? This subrosa debate goes on everywhere, but no one seems to have the courage to bring it to the surface.
This is not the first time I’ve raised these issues and have felt the wrath from all sides. Our leadership should know it cannot abrogate these professional roles and adopt a laissez-faire attitude on the scope of practice issues. The real question is: Who’s going to get to do what for how much money? Who’s the boss and does there need to be a boss? New rules are coming. What is our place in the formation of these rules?
I hope we can keep this debate ad factum and not ad hominem. I have already been called the usual list of names by the pseudo-cognizante. To raise certain questions is to be called an elitist. But we should be speaking by virtue of our oath for the welfare of patients and those who cannot ask these questions for themselves.
The Catholic philosopher John Henry Newman said: “To live is to change. And to be perfect is to change often.” The good cleric is correct but I would add: All change is not progress. We do not want progress by accident, but by intent. The vicissitudes of the marketplace cannot be the only force that decides who will be the second provider on the afternoon shift. Supply and demand are not sufficient drivers here. Neither is the fear of litigation. The clinician labor market is dynamic and in flux and we need to pursue some sort of organization and consistency.
Given this, there are some questions you as the physician should know how to answer before the patient’s lawyer asks them. Number one: How are your APPs screened and credentialed? Number two: Do the APPs have advancing levels of responsibility and training? Number three: Has the hospital or system credentialed them as they would any other provider? Number four: Who oversees the delineation of privileges? Number five: How do you prove you’re actually providing supervision? Six: Who did the patient think they were seeing? Seven: What is the written policy whereby the hands of physicians need to be laid on the patient? Which cases need to be presented to the physician level? I have not seen a deposition where an APP or physician involved jointly in the case has not had these questions asked. Most physicians do not even know if their supervising status triggers a separate set of insurance policy limits.
We know that we have a problem. We know that there should be a solution that we can agree with. We know we need to protect the patient. But we need to protect the physicians and the APPs as well. I’ve actually seen a case where the physician was driven into bankruptcy and had never laid eyes on the patient and was never asked to lay eyes on the patient, over a young man with chest pain.
As we go forward, I want this piece to provoke conversation as we search for a meaningful truth, not demagoguery. ACEP has no choice but to deal with this issue. The Emergency Medicine Residents Association (EMRA) – whether they realize it or not – are up to their eyeballs in this one. This is our area of interest and our responsibility. No one has been delegated the job of protecting us, except us. The input from the readership on this issue is both sought and appreciated. I commend the amenity of this debate to your care.
Advocatus diaboli – “the devil’s advocate”
Photo by Phil Roeder