Directors Corner by Michael Silverman, MD 

Dear Boss,
I have been called by a couple of PMDs recently who said they don’t like talking to our mid-level providers who are caring for their patients in the ED. We have a busy ED and our MLPs see about 40% of our patients and although their admission rate is low, they definitely admit a few patients and have interaction with numerous attendings and consultants each day. How should I handle this?
You are not alone is this battle. I come across this on about an annual basis. While being a hospital based EP puts you in the position of trying to please everyone, we all know that’s not always realistic. Getting to an answer will involve some research as well as some politics.

Define the Problem
Is it patient management, bad outcomes, bad experiences, or does the attending just not like MLPs? I worked with an OB once who essentially refused every consult when it was called by our PA. After reviewing cases and beating around the bush with him for a while I finally just asked him what he thought about MLPs. He came clean, admitted to not ever liking PAs based on an experience he had over a decade ago. So we discussed the ED PA’s training and supervision, he gave them a chance and hasn’t had a problem about an inappropriate consult since.

As for you, ask whether the experience between your PAs and admitting physicians is based on one negative interaction or a variety of issues. Can you identify one specific MLP who may be practicing a little bit differently than the others? When people complain about my department I always ask for specific instances and offer the opportunity to call me any time with a specific problem. I think it’s always better to get to problems in real time than to have vague instances when people see you in the doctor’s lounge a month later. Be ready, however, to admit to wrong doing if your provider makes a mistake. An apology and a plan to educate and remediate may be necessary. 

What Are the Options?
One of my internists suggested that an EM attending see every patient that the MLP wants to admit prior to calling an attending. Sounds good on paper, but if your MLPs practice (mostly) independently, would your staffing really allow for attendings to duplicate a work up and make the phone call to the admitting physician? That doesn’t sound very efficient, would likely delay the admission process and would back up my ED. Should the MLP run the case by the ED attending prior to making the phone call for admission? This actually seems more reasonable and something that I preach in my ED.
While I’m not a fan of having separate pathways for individual providers, how about this for a scenario: If Dr. Smith is on call and we know he hates PAs, the attending talks to him about the patient. But if his partner Dr. Jones is on call and he’s PA friendly, the PA can call about their patient. This is clearly not ideal, but if it’s only one or two private attendings in the hospital and everyone in the ED group knows that WWIII will break out if they get called by a MLP, maybe having an unwritten policy makes sense.

Finally, Educate
I don’t know about you, but most emergency physicians are pretty busy at work and we’re not looking to duplicate another’s efforts. If your MLPs practice independently and that’s the business model and how they’re credentialed, then the duplication of effort is inappropriate and you need to convey to the private attending about how things run in the ED but that you welcome feedback and criticism to make improvements. If your attendings typically oversee the MLP cases and are involved to begin with, making a few additional phone calls to certain privates probably isn’t too much to ask to maintain hospital harmony.

When complaints come, having specifics and the chance to educate and improve your staff and ED is always a great thing. Don’t forget to follow up with your private attendings and make sure things are moving in the right direction. Sometimes it’s easier to prevent a fire than to put it out.

Mike Silverman, MD is the chairman of emergency medicine at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy.
Dr. Silverman was recently named Affiliate Medical Director of the Year by TeamHealth East.

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