Current competency and the low volume physician: The case of the unsupervised PA (Part I)

Case studies are a great way to learn peer review best practices. Let’s take a look at a hypothetical one recently presented at a conference by Barbara Letourneau, MD MBA, FACPE, FACEP, senior consultant with The Greeley Company. The case raises the issue of current competence when a practitioner maintains inpatient privileges but uses a physician assistant (PA) for all of his or her inpatient care. Outlined below is the case scenario, the peer review committee’s initial inquiries, and the practitioners’ responses. It’s a case study for you to think about and perhaps even bring to your own peer review committee for discussion. Next month I will discuss some the implications of the case.

Case Scenario: A 65-year-old female diabetic had a history of recurring episodes of pneumonia. Her episodes were usually treated by her primary care physician in the clinic. She developed cough for three days and fever on the day she contacted her doctor. The doctor’s office instructed her to go to the emergency department (ED) to be admitted to the hospital. She presented to the ED with fever of 101.4 degress, shortness of breath, and a left lower lobe infiltrate on chest X-ray. Emergency physicians contacted the primary care physician’s PA, who came to evaluate the patient. Using the standard hospital order set, he did all the pneumonia core measures, started the patient on zithromycin IV, and requested that she be admitted to the general care floor. The next day the patient’s fever was 102 degrees, and oxygen saturation was 89% on four liters of oxygen. The sputum culture was growing oral flora and the blood culture showed no growth. The PA transferred the patient to the ICU and asked the hospitalist to take over the patient’s care. The hospitalist immediately started the patient on ceftazadime and gentamicin IV for possible pseudomonas. She improved in 24 hours and was discharged. The primary care physician never saw the patient.

The case was referred for peer review because of the unanticipated transfer to the ICU and the hospitalist’s concern that all of the primary care physician’s patients are managed by his PA. The primary care physician has admitting privileges but not ICU privileges. Neither the state nor the hospital allows PAs to practice independently.

Peer review committee’s Initial Inquiries:

The following are the questions posed by the quality staff to the peer review committee:

• Should the patient have been on anti-pseudomonal therapy at admission?
• Should the PA have been better supervised by the primary physician?
• Should the PA be able to admit and manage inpatients when the supervising physician has seldom managed inpatients?

The committee felt that the patient had two risk factors for pseudomonas: diabetes and frequent pneumonias. Therefore, the patient should have been on anti-pseudomonal therapy on admission. The committee also discussed whether the PA or the primary care physician was responsible for determining which medications were appropriate. The peer review committee sent a letter of inquiry to both the primary care physician and the PA.

The committee asked the PA the following questions:

• Did you consider anti-pseudomonal therapy for this patient on admission?
• Did you consult with the primary care physician regarding the choice of antibiotic therapy?  If not, why?
• If so, what were the primary care physician’s thoughts regarding the course of care?

The committee asked the primary care physician:

• What is your method of supervising your PA for inpatients?
• Did you discuss the antibiotic selection for this patient and consider anti-pseudomonal therapy?

The PA responded to the peer review committee’s questions with the following letter:

I do not typically consult the doctor when I admit a patient. He is very busy in the office and, because I have worked with him for more than 10 years, I have become familiar with how he practices. When the patient deteriorated, I transferred his care to the ICU and the hospitalist, as the doctor would have done. I did not consider anti-pseudomonal therapy because the patient has responded well to azithromycin in the past. However, I did use the standard pneumonia guidelines and standard order set to care for the patient. It would be helpful if the guidelines included criteria for anti-pseudomonal therapy.

The primary care physician responded:
The PA is an excellent practitioner who has worked with me for 10 years. He knows my practice, preferences, and patients well. He has a great deal of experience managing patients in the hospital, and I believe he does a great job. I am very busy with my large outpatient practice and am unable to come to the hospital often. The PA calls me when he has a question, and I trust him completely. In reviewing this patient’s hospitalization, I believe the PA's care was appropriate. This patient has had many episodes of pneumonia, which have responded well to azithromycin.

After receiving these responses, the peer review committee's discussion focused on the following questions:

• Since the standard order set did not include criteria for anti-pseudomonal therapy, should that be an acceptable reason for the PA or the primary care physician to not order it for a patient with these risk factors?
• Is the primary care physician relying too greatly on the PA’s knowledge to provide adequate supervision of acutely ill patients if his own fund of knowledge may not be current for the scope of inpatient practice?

As you ponder this case and the questions that the peer review committee posed, try to decide how this case could be improved and how you would rate the care provided by each practitioner. Come back next month, and we will discuss what the committee decided.

Robert J. Marder, MD, CMSL, is vice president of The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.