Supervising Midlevel Providers in Emergency Departments

Managing the Emergency Department is a team sport. That means sharing information with one another, trusting your teammates to perform to the best of their ability, and working together towards a common goal. To that end, one responsibility of [most] ED physicians is supervising mid-level providers.

In my new book, How to Not Kill your Patients, I’ve gathered advice from experienced ER physicians and included a chapter further explaining how to mitigate the risk of co-signing charts of patients you may never have even seen.

Is there a way to minimize your risk? What if there is a particular chart you're not comfortable co-signing since you didn’t lay eyes on the patient?

You can say just that. For instance, “Physician Attestation: This patient was not presented to me and the case was not discussed with me while the patient was in the department. I was not involved in the care or decision-making process of this patient.” Will that actually work? No. Your name is still listed as the supervising physician and you are responsible for co-signing the chart. It doesn’t hurt to write it but a better solution is to speak to the APP involved in the care of that patient and express your concerns. Have them write an addendum clarifying anything. Remember that we all make mistakes. For the most part, they are very open to feedback and dedicated to learning and bettering their care. Many of our midlevel providers are reimbursed for attending training courses. Educate them when appropriate so that everyone benefits. If their charting is not to your liking, send them an email. In my experience this usually fixes the problem.

Consider doing patient call-backs on any questionable chart you come across. This can be time consuming, but call-backs significantly improve patient satisfaction. This is an opportunity to see how the patient is doing the day after the ED visit and an opportunity to have them return or follow-up if symptoms are not improving. This can be a great way to use scribes as well!

What’s your liability in all of this? If an APP makes a mistake, can you be sued?

Absolutely. When you are expected to see x number of patients per hour and have two or three APPs working alongside you, there’s no way you can see every patient whose note you will ultimately be signing. Not until 24 hours later when you’re clearing up your queue of charts will you realize how many charts you actually have to sign. You can take the time to put an addendum on each one – indicating whether or not you saw the patient, your findings, your return precautions, your assessment – but with the vast majority of them you will just read the note, edit it if necessary, and co-sign it. Most hospitals do not have a written policy for which cases must be seen by a supervising physician.

In one case where both the physician and PA were named, a patient presented to the ED with a fracture that was misdiagnosed by the PA. “The patient never saw the physician, and he didn’t even know the patient was in the hospital,” said the malpractice defense attorney. But “A 2010 decision by the Tennessee Supreme Court held that a supervising physician can be held vicariously liable for the negligence of his or her PA even if the physician never saw or treated the patient. This means that the doctor may automatically be held liable if the PA is found to have been negligent.”

A scary case to keep you on your toes

A 58-year-old male presented to the ED with abdominal pain. The PA ordered labs and an acute abdominal series. She ordered Dilaudid and Toradol before reporting to the ER doctor that ‘all results are normal’. He evaluated the patient and agreed to discharge home. The only problem? The white blood cell count was 14,000. The doc had no idea because he hadn’t bothered to check the results for himself. The patient went to another ED six hours later with a perforated appendix.

Learning points

Our job is to supervise APPs; it is not their job to be a doctor. Until you develop a rapport and level of comfort with midlevels, you should have a lower threshold for seeing patients that they consult you on. Think of APPs as an extension of you – your name is on the patient’s prescriptions and discharge paperwork. More importantly, your name is on the bill that comes to that patient. Most importantly, your name will likely be on the subpoena as well.

Dr. Sajid Khan Sajid R. Khan, MD, is a board-certified Emergency Medicine physician with over 10 years of experience working in a variety of settings from inner-city level 1 trauma centers serving 100,000 patients per year to 3-bed rural Eds. A published author, Dr. Khan has written a number of books including, The Ultimate Emergency Medicine Guide, a comprehensive review book that is the highest-rated and most up-to-date text for Emergency Medicine physicians preparing to certify.

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