We all know that there’s a remarkable shortage of physicians in America and that it’s growing worse.  This is especially true in primary care but it’s present across all specialties.  This shortage alone is a significant stress on practicing physicians.  But when it is coupled with corporatization, the increasing complexity of medical care, unrelenting electronic charting requirements and the explosion of administrative tasks, physicians barely keep up each day.

This is one of the reasons that physician assistants and nurse practitioners are increasingly used in hospitals, clinics, and emergency departments.  Among the other reasons we see increased employment of these professionals is that they can be trained in a shorter time than physicians and (as such) they cost their employers less money.

All across the land, physicians work side-by-side with PAs and NPs, in busy practice settings.  The original idea was that this would free physicians to use their time more effectively. On first pass, this seems like a great compromise.  See more patients for less.  The mid-levels (although many resent this term) often spend more time with patients and connect with them more effectively as a result.   However, there are always costs.  One of those costs is that physicians typically have to co-sign the medical charts of their NP and PA co-workers.  Which means they are also accountable for the clinical care they provide.

Unfortunately, it sets up a situation both perilous and unfair, especially when the PAs and NPs are hired by a health care organization to work with physicians rather than hired directly by physicians.  The problem is that there’s a gulf between ideal and real.  You see, every lawyer and consultant in health care says physicians should read every chart generated by a non-physician provider under their license.  It’s a great idea in theory. But in practical application, it simply can’t happen.  There’s not enough time.

As an emergency physician in a busy community department, I can say quite honestly that the PAs and I are both working as fast as we can.  And unless he or she asks me to directly see a complex patient, I don’t have time to review their work.  Sure, I try to be constantly aware of what’s going on all around me and give guidance as much as I can.  But to sit down and do a thorough evaluation of a chart?  Next to impossible.  Equally so in large, high acuity referral centers.

What could we do?  Well, hospitals could pay us to stay over or come in extra days and do detailed reviews of charts.  But that would be costly.  Sometimes we do chart audits.  Pull a designated percentage of charts and see how things are going each month.  Not a bad idea, but very incomplete.  Mistakes can easily be missed.

There’s another option which is growing in popularity.  Some states allow independent practice, particularly of nurse practitioners.  That is, they are not supervised by a physician.  They practice on their own.  So, no physician needs to sign that chart.  Reasonable?  Maybe, maybe not.

I know some NPs and PAs I trust absolutely. They are not only formally well educated, they work hard at increasing their skills and knowledge.  They have spent years ‘in the trenches’ and know their limitations.  However, education is big business and colleges are churning out lots of mid-level practitioners.  In fact, PA schools are popping up everywhere and online NP programs are the rage.  (For a thought exercise, just imagine touting the wonders of your online MD!)  With this lucrative market for degree mills, with this increasing need for these health care workers in the marketplace, we are seeing a decrease in quality.  And an increase in danger.

The result?  Physicians are being asked to sign charts in support of care they cannot review and which may be provided by inexperienced, under-educated and over-confident providers.

This isn’t to say that there aren’t incompetent, dangerous physicians.  Of course, there are. And we should always be diligent to discover them and protect the public from them.  But the educational process, the amount of didactic and clinical hours spent in medical school and residency, the vetting of physicians both before, during and after training is much more rigorous.  Furthermore, physicians outside of training aren’t co-signing for other physicians.  Full accountability rests on the practitioner.

Ultimately, this seems to come down to money.  Administrators can pay the NPs and PAs significantly less.  From a budget standpoint, it makes sense.  However, to do so and still expect physicians to be party to and accountable for care they really don’t have time to supervise?  That’s grossly unfair and frankly unsafe. Especially when they’re expected to be just as fast and ‘satisfaction friendly’ as ever before.

This may seem like I’m bashing on NPs and PAs. That’s not my intent.  In fact, closer supervision would be much more educational for those clinicians. It would help them to become better at their jobs.   It would protect them and the physicians involved from the agony of litigation.  And more important, from the deep, aching remorse of causing harm to a patient who trusted them for help.

Still, if the consensus remains the same, if physicians keep hearing “you have to sign the charts, everybody does it, so don’t worry about it,” then we’re really hurting several groups.  We’re neglecting to educate and mentor our co-workers.  We’re abusing the authority and accountability of physicians (and neglecting their insights and experience).  And worst of all, we’re putting patients in peril for financial expediency.

I’m frightened that I may one day sign off on a dangerous mistake just because I didn’t have time to provide proper supervision.  And that possibility should make physicians, PAs, NPs and especially administrators very nervous indeed.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of the Practice Test and Life in Emergistan. 

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