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When Beverly Kimball, PA-C, started work as a physician assistant at Allina Medical Center, Forest Lake, MN, her supervising physician reviewed every dictation she made, even though she had 19 years experience. "He needed to see that he had a comfort level with the way I do things and to let me know how he preferred that I handle things," Kimball explains. Now, the physician reviews only about 10% of her dictation. "He reviews them, co-signs them, and puts a sticky note on them if he has any comments positive or negative," she adds.
State and federal laws require that midlevel providers be supervised by physicians, but in most places, the practice has leeway on how it will occur. Supervising physicians typically review a selection of charts and conduct regular reviews of the midlevel providers’ work. In some states, the physician must co-sign the charts whenever medication is prescribed.
The staff at Allina take a team approach to practice. For example, Kimball will call in a physician if she has any question about a patient’s diagnosis or if the problem is complicated. She’ll often trade patients with the physician in such a situation. The reverse is also true: Some of the male physicians who are seeing teenage girls with what could be an embarrassing problem will ask Kimball to swap with them.
At Bristol Street Pediatrics in Elkhart, IN, each doctor teams up with a pediatric nurse practitioner to provide continuity in care. For instance, each nurse practitioner does every other physical for the patients of one particular doctor. "If the NPs get in over their heads, they always call in a doctor for an opinion. The doctors are always in the building when the nurse practitioners see patients," says Anne Meden-Cutler, practice administrator.
At East Albany (GA) Medical Center, both the physicians and the physician assistants conduct peer review of each other every six months. During the process, the physicians review the charts of the physician assistants and vice versa. "It’s a learning process that allows you to get to know the skills of your PA or your MD and their preferences," says Ron Malcolm, PA.
At Dean Medical Center in Madison, WI, "pods" of physicians and physician assistants work as a group. A typical pod may include nine physicians and three physician assistants, with the supervisory role for each PA rotating among the physicians depending on when they are in the office. Wisconsin does not require direct on-site supervision for PAs, says Lou Falligant, PA-C, a physician assistant. Instead, the physician should be available either in person or by telephone. "Typically, if I am seeing 25 to 30 patients a day, I’m going to consult with the physician on only one or two of these. When the situation is more complicated, it helps to get two heads involved," Falligant says. When the chart notes come back from transcriptions, the physician reviews and countersigns all of them, Falligant says.
Wisconsin state law requires physicians to countersign only when the physician assistant issues a prescription, but the practice decided it provides good continuity of care for physicians to review and countersign all notes. "That way, they can give feedback if they see anything they think merits it," Falligant says.
Once a year, the physicians conduct a thorough performance appraisal of all the physician assistants in their pod. Each physician does his own appraisal, and a supervisor puts together a compilation of appraisals for each PA.