12 April 2010

The role of MLPs and consultants

In the comments to my "dealing with consultants" post, Seattle Plastic Surgery on Lake Union commented:
When consulting a specialist, its polite to have the ED physician speak directly with the on-call doc. PAs and other mid-levels can be quite good, but many really miss the mark. Certainly, in an academic ED, this system works differently, but the Harborview trauma-doc days are over. Asking a sleepy doc at home to come in to see a patient should be a doc2doc discussion.
This raises an interesting issue I commonly deal with.  First of all, in a limited context, SPSOLU is entirely right: if it's a patient I have personally seen and treated, of course I should make the call.  It should not be delegated to a nurse or any other practitioner.  That's a fundamental courtesy and also a practical necessity.

But I don't think that was the central point from SPSOLU.  He or she specifically criticized the use of "PAs and other midlevels," presumably meaning ARNP's.    These are Physician Assistants and Nurse Practitioners, for those not familiar with the terms.  In our state and our ER, these mid-level providers (MLPs) are licensed as "independent practitioners" and function autonomously.  They have a scope of practice of complaints and conditions which they are authorized to care for, and they work in an environment, Fast Track, which is supposed to ensure that their patients are appropriate for their skill set.  In our ER, 95% of patients seen by PAs are never seen by a doctor, and we are not required to review or sign their charts.  (Many states and ERs operate differently.)

The tension arises when a PA calls a consultant and the consultant is offended that it's not a "doctor" calling directly. 

The fact is that a MLP is not a physician, and they should be aware of the limits of their abilities.  On the other hand, it can be hard for consultants who do not regularly work with MLPs to respect them for the competencies they do have.

For example, if you consider a plastics consult.  The average PA at our facility will suture over 200 lacerations per year, based on our coding data.  The average physician will suture fewer than 50.  It's true that we tend to do the harder ones, and that we have operative training that would allow us to better recognize what can and cannot be done in the ED.  So there is a difference in quality.  Still, when one of my experienced PAs tells me that a laceration, for whatever technical reason, needs a plastic surgeon to repair it, so long as they can explain the reason to me clearly, I have no problem with that PA calling the surgeon directly.  More to SPSOLU's point, were I to make the call to the surgeon in the place of the PA, it's not clear to me that I would be adding anything of value to the patient's care by my involvement.

Truth be told, this is more of an issue for us with orthopedics and ENT.  Our plastics guys tend to be pretty good.  But it's routine for the ortho/ENT guys to leave irritated voice mails for our director, complaining about the indignity of the fact that they were called by a mere PA.  And you go back to look at the chart and it was something ultra-appropriate, like an intra-articular distal radius fracture.  What do you need an MD for in that case?

None of this is to defend dumb consults.  PAs who call inappropriate consults should be educated (ideally prospectively, or on the spot if needed), and PAs should have access to a doc to gut-check borderline or uncertain cases.  If it's a particularly challenging or unusual case, then indeed the physician should be involved and probably make the call.  However, I would also hope that a professional consultant, receiving an appropriate consult from a MLP who can reasonably articulate the necessity of their involvement, would have the reciprocal courtesy to respect the PA or NP for their expertise and experience.


  1. I can understand what Plastics means as I have also had trouble when called and cannot get even the basics of a history, exam or why they're even calling. Since I'm at an academic center I think I have a bit more patience for those whose clinical skills are still forming, but sometimes it is just ridiculous. In states where they are operating under a physicians license, I do think the attending needs to be at least available to answer questions that the non-MD/DO can't. Non-MD/DO practitioners who are licensed to practice independently do raise issues as apposed to those that are not.

    A related issue is numerous consults I get for simple issues (thanks for the easy money) that any decent MD could treat but the consult is coming from a PA/NP. The patient has never seen the "supervising" physician and I find myself trying to carefully parse my words but on a few occasions I have had to call directly and explicitly state that it was a PCP issue and that if they didn't know how or feel comfortable treating it, even with my consult item then they needed to have the patient see the physician instead.

    This lack of requisite, expected, skill happens among physicians too. When I was a primary care physician, I had patients redirected from cards and GI who were sent to our academic center for consults because this was "something a primary could do" and it was. Still, it was a bit awkward doing an "internal medicine consult" for another internist or family physician.

    BTW, I thought your post on dealing with consultants was brilliant.

  2. Shadow- Thanks for addressing my previous comment directly. Your response was on the mark. What I was alluding to, but did not specifically state, was an issue that irks me to no end: the inappropriate consult for laceration closure by the on-call plastic surgeon at 'patient's request'...these calls frequently come from mid-level practioners, in my experience. Why? I don't know. I do know that any ER doc that laid eyes on these minor injuries would NOT call me. From my perspective, I don't want to say 'no' to anyone, even if I think the consult is inappropriate (requesting specialist care where it is not indicated), lest I be slapped with an EMTALA violation and a reputation for being 'difficult'.

    In summary, I think ER docs have a better handle on the politics and economics of consulting specialists.

  3. True dat -- I have never ever called a plastic surgeon at the "patient's request." Sometimes the patient has to accept the fact that they will be told "no."

    Our PAs, FWIW, are also pretty well-coached not to call for that reason, and we back them up.

    Of course if we practiced in, say, Bellevue, it might be harder to say no to wealthy patients with a sense of entitlement.

  4. Shadowfax,

    I assume you mean Bellevue, WA, not Bellevue Hospital (which is where my mind went being a New Yorker ad all). The patients there have a completely different sense of entitlement

  5. Bellevue you say- never heard of it...

  6. I'll give you a PA's perspective on patient requests for plastics: I point out to patients that while I've been repairing lacerations for close to twelve years, if they wait for plastics they're going to be seen by a first or second year resident.

    I don't get turned down very often.


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