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To use mid-levels, or not?!

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  • To use mid-levels, or not?!

    I have had recent discussion and debate with a colleague of mine regarding mid-levels providers. We both work in the same hospital-employed group now. There are 4 physicians and 6 mid-level providers. (5 NPs and 1 PA). My colleague refuses to oversee their work, citing potential medico-legal consequences if there is a mistake.

    At my former employer I thought nothing of this, perhaps due to the great skill set I perceived in the mid-levels. I also assumed that this is frankly a necessity in todays healthcare market due to physician shortages and long patient wait times for specialty appointments.

    How do you view mid-level providers? Does anyone refuse to work with them? If you do work with them, how do you mitigate medico-legal risk without micromanaging?


  • #2
    I won’t refuse to work with them, (I can’t since I’m an employee), but I refuse to supervise them.

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    • #3
      Legal issues are just one of the concerns. Poor or at least different care is a much more common concern. They might practice differently and it might not jive with your style.

      They also suck up the easier visits. Minor injuries, UTIs, URIs, Etc. Making your day more complicated and frustrating. Sure you can bill higher but I would rather see 2 99213s in place of 1 99214. It also helps keep they variety in the day and personally I like the quick stuff that makes people feel better. More satisfying compared to tweaking DM meds.

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      • #4
        We employ them so obviously they are a benefit to our group. If I didn't directly employ them then they would have to make my job easier and I would also have to be compensated for the supervision.

        How does your hospital feel about your colleague refusing to supervise them? I'd guess the hospital is quietly trying to find you a new colleague.

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        • #5
          I have always been confused about liability with midlevels. I hear people concerned about liability for things they do themselves, which is reasonable, so I have no clue how you trust another pseudo-independent person.

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          • #6
            I’m only going to supervise a midlevel if
            1. I’m being paid for it
            2. They are making my life easier, seeing my inpatients/post ops to allow me to see new patients.

            Otherwise why would I want the increased liability and decreased patient satisfaction?

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            • #7
              I think there are multiple considerations here.
              1. Do you have control over the midlevels you hire? (new grads from a 100% acceptance, 100% online school that requires no experience are not going to be okay)
              2. Do you plan to actually supervise them, seeing patients with them, making treatment plans, reviewing all of the charts, etc?
              3. Are you under the thumb of a corporate overlord who makes you sign off on the charts of multiple midlevels whose patients you never see or do you run your own practice?
              4. Would it bother you if a midlevel you took the time to train and supervise opened a practice next door, offering the "heart of a nurse" and advertising "wholistic" care?
              5. Would you be willing to take the legal and financial responsibility for medical errors committed by a midlevel you are supervising?
              6. Are you in an independent practice state where the NPs don't need you to supervise, but want your signoff for financial and legal reasons only?

              It seems to me that the good old days of physician groups hiring NPs and PAs to help them out in limited circumstances are over. These days it is corporate healthcare trying to hire less expensive labor, which drives down physician reimbursement when they lobby for pay parity (as in Oregon).

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              • #8
                Originally posted by mkintx View Post

                4. Would it bother you if a midlevel you took the time to train and supervise opened a practice next door, offering the "heart of a nurse" and advertising "wholistic" care?
                That would bother me until I realized that I could brand my practice offering the "Brain of a physician" advertising "Real" care. The patients they syphon off will likely not be missed

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                • #9
                  Originally posted by Lordosis View Post

                  That would bother me until I realized that I could brand my practice offering the "Brain of a physician" advertising "Real" care. The patients they syphon off will likely not be missed
                  You do know that the actual phrase they use includes that, right?

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                  • #10
                    Originally posted by mkintx View Post

                    You do know that the actual phrase they use includes that, right?

                    Massive eye roll…🙄🙄🙄

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                    • #11
                      Corporate hires and manages ours.

                      I try to have the least amount of interaction with them as possible. I’m sure I’m still vulnerable legally even though I perform no formal supervision of them as they do see some patients who I have seen before and who are technically “mine” even though the employed set up doesn’t allow me to truly take ownership of them. Nor am I compensated for the time that I do have to give.

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                      • #12
                        Originally posted by mkintx View Post

                        You do know that the actual phrase they use includes that, right?

                        Brain of a 'physician', not doctor. Everyone is a 'doctor' these days.

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                        • #13
                          From a non-physician perspective, huge difference between a PA and a NP.
                          A PA is purely a productivity enhancement too. If you train, direct, supervise and have hire/fire authority, it comes down to productivity and how effectively your personal practice can use the PA.
                          NP is adequately discussed above.

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                          • #14
                            Originally posted by CordMcNally View Post

                            Brain of a 'physician', not doctor. Everyone is a 'doctor' these days.
                            I love how with one side of their mouth they say theres no problem being called "doctor" because no one owns the word "doctor" and they have a doctorate, and on the other hand they use "brain of a doctor" clearly meaning "brain of a physician" because they know everyone knows being "a doctor" means being a physician.

                            Comment


                            • #15
                              Originally posted by Turf Doc View Post

                              I love how with one side of their mouth they say theres no problem being called "doctor" because no one owns the word "doctor" and they have a doctorate, and on the other hand they use "brain of a doctor" clearly meaning "brain of a physician" because they know everyone knows being "a doctor" means being a physician.
                              I generally couldn't care less who wants to be called doctor. If somebody with any kind of doctorate degree wants to introduce themselves as "doctor" in a public social setting, more power to them, although that's my sign to stay away from that person as they're probably a real stick in the mud. But, in a hospital or healthcare setting, doctor should only be used for physicians in order to not confuse patients and to clearly delineate roles.

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