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Dear Director,
Our physician assistants are fantastic and have functioned independently for a long time, but recently we had a bad outcome and now the hospital wants us to supervise all PA cases. This seems like a waste of time and it will slow down our docs. What do we do?


I have worked in different facilities that required varying levels of PA supervision and have come to appreciate that many factors come into play, from the complexity of patients to state laws to patient expectations. Clearly, with physician shortages, mid-level providers (or, as many prefer to be called, Advanced Practice Providers) bring an important piece of efficiency and staffing to the ED and should be utilized to their maximum potential.

Let’s agree that most EDs benefit from Advanced Practice Providers (APP) from an efficiency and business perspective. I’ve worked with a few APPs who were as good, if not better, than some of the doctors in my group (they know who they are). I’ve also worked with APPs who were unaware of their limitations (unfortunately, they probably don’t know who they are). If left unsupervised, this latter group could put patients, and our group, at significant risk. Deciding how to use APPs (urgent care, main ED, next chart in the rack, etc…) and what level of supervision is required becomes the key administrative question. Also important is that your APPs know exactly what their limitations are so that they know when they’re in over their heads.

Most patients who come to the ED expect to see a physician. While some super-users of the ED (such as a large family who ends up in the ED with different kids for sports injuries) may understand the role and expertise of the APP, most patients probably do not. If a third of our visits are ESI 4’s and 5’s and can be seen in urgent care, an APP is likely to provide a very similar level of service to a physician. However, even a small percentage of those patients may require a little higher medical knowledge to fully appreciate the differential diagnosis. Additionally, if APPs are seeing ESI 3 patients, a physician’s input or supervision likely benefits the patient. I think that putting the patient’s needs first regarding the evaluation is a good starting point. While I happily let my PAs suture without my supervision, I wouldn’t let them decide how to manage respiratory failure independently.

How we supervise APPs in my current ED is actually very different than how it was done in my last department. Although my philosophy on APPs hasn’t changed and both groups were highly competent, the politics of my current ED require a more hands-on approach from our attending staff. In part, this is because state law requires that the PA tell the physician about the patient while the patient is in the ED. While some docs might be okay with loosening this restriction and not even hearing about it in real time, I wouldn’t want to defend myself or our group to the state medical board about why we didn’t follow their policy. Hospital culture also plays a large role in how APPs are supervised. Are APPs used throughout the hospital? In what capacity? How comfortable is the medical staff interacting with APPs and how well does the medical staff know your individual APPs? The orthopedists and plastic surgeons talk to my PAs on a daily basis and the specialists have developed a certain level of trust when they talk on the phone. But my PAs almost never talk to a cardiologist at my hospital, so there isn’t the same level of trust. The newer the idea of a PA program is to your facility, the more supervision will be necessary.

Supervision can be a very vague term. It may be defined by the state as well as CMS and may have more to do with billing and coding than with actual face-to-face patient contact. I worked in one ED where it was expected that every APP patient would undergo a thorough evaluation by the attending physician prior to discharge. This meant that on an overnight shift, a patient with a routine, uncomplicated toothache ended up waiting an hour for me while I managed two critically ill patients. This didn’t make a lot of sense from a quality, efficiency or billing standpoint, but it was what our department had decided to do. I also worked in an ED where supervision was so loose that the doc might just sign the chart after the fact. Once, at this facility, a patient was presented to me as a toothache; I was bored so I went and said hello only to end up diagnosing him with Bell’s Palsy. This obviously changed the management of the patient as well as my perspective on PA supervision.

In my experience, even lower acuity patients like to see the supervising physician for the face-to-face interaction. It’s good for patient satisfaction and it’s good for providing high quality care. With proper documentation, it might even let you bill a little higher. This is also good from a responsibility point of view, particularly for ESI 3s, or even 2s if your APPs are managing those, since the physician is ultimately responsible. We’ve all seen too many cases go south too quickly to have a hands-off approach. Supervising APP care could take under a couple of minutes per patient and can be as simple as a quick review of the chart and introducing yourself to the patient as the supervising physician. For those more complicated patients that take longer, the input that you provide may improve the quality of the care and keep you out of a courtroom later. After all, isn’t it better to say “I saw the patient and provided real-time input” than “I supervised from my computer 20 feet away from the patient’s room”?

Although each PA signs a supervisory agreement with a physician, advance practice nurses are not required to do that, and in many places are allowed to practice independently. This presents the potential for a two-tiered system in your ED if you use both PAs and APNs. My approach has been to treat APPs as equals and have the same supervisory level regardless of the individual degree.

There is no doubt in my mind that APPs will continue to weave themselves into our staffing fabric and will become even more integral to the care that we provide. Supervision of this group of providers may vary by state law and most certainly will vary by your local hospital culture. Providing a consistent and thoughtful approach, even with a brief hands-on and face-to-face interaction, will bring the most benefit to the patients and the department quality and safety. Balancing efficiency with minor illness and supervising from a distance may still have a role, as long as the supervising occurs.

Michael Silverman, MD FACEP is Chairman of Emergency Medicine at the Virginia Hospital Center in Arlington, VA and a partner of Emergency Medicine Associates.

 

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