Current competency and the low-volume physician: The case of the unsupervised PA, Part II

In last month’s column on peer review, we discussed a hypothetical scenario that looked at the issue of current competence when a practitioner maintains inpatient privileges but uses a physician assistant (PA) for all inpatient care. To briefly recap the scenario, the primary care physician (PCP) with inpatient privileges turned over the care of a patient with diabetes and a history of pneumonia to his PA. The patient was unexpectedly transferred to the ICU, which called into question the PA’s choice of antibiotics. The medical staff referred the case to the peer review committee because of the PA’s antibiotic selection, the patient’s unanticipated transfer to the ICU, and the medical staff’s concern that all of the primary care physician’s patients are managed by his PA.

As we discussed last time, the peer review committee sent a letter of inquiry to both the PCP and the PA. The PA responded that he typically does not consult the PCP when admitting a patient because the PCP is very busy in the office and the PA is familiar with how the PCP practices. When the patient’s condition deteriorated, the PA transferred his care to the ICU and a hospitalist, just as PCP would have done. He used the standard pneumonia guidelines and order set to care for the patient and suggested the guidelines should have included criteria for anti-pseudomonal therapy. The PCP responded that the PA is excellent and knows his practice, preferences, and patients well. Because of his busy outpatient practice, he is unable to come to the hospital often and would have not treated this patient any differently.

The column ended at the point where the committee discussed the case, which is where we pick up this week.

The committee’s discussion focused on two main issues. The first issue was related to whether the PCP’s knowledge was current for his scope of inpatient practice. This concern was based on the PA’s response that the standard order set did not including criteria for anti-pseudomonal therapy. While, from a system improvement standpoint, the committee agreed it would be helpful to add criteria for anti-pseudomonal therapy to the current order set, they also felt strongly that the diagnosis and management of acute inpatients cannot solely rely on the content of orders sets.

Medical staffs expect practitioners who maintain inpatient privileges for acute pneumonia to be aware of patient risk factors for less common etiologies. While the PA does not have those privileges, the PCP does and should be aware of those concerns. The fact the PCP would not have treated the patient differently raised concerns that his own fund of knowledge may not be current and he may no longer have the ability to provide adequate supervision for his PA. The PCP’s over reliance on the PA’s knowledge for managing acutely ill patients was not acceptable. 

The second issue concerned communication processes between the PCP and the PA, regardless of the events and outcome of this case. Not communicating with the supervising physician to discuss the differential diagnosis was not appropriate even though the patient did ultimately recover fully. The fact that the PA may have done everything that PCP would have done is not a valid reason for the lack of direct communication between the two practitioners. This practice exposes the hospital, the PCP, and the PA to great legal risk if there were an adverse outcome.

The committee decided that the care was not appropriate for either practitioner in this case. Both the PA and the PCP were responsible for ensuring that the PA was practicing within the scope of his license and inpatient privileges. The committee recommended that the department chair work with the PCP to establish a routine communication system with the PA for all inpatient admissions. This communication should include medical record documentation, and the medical staff should monitor the communication for at least three months. The committee also recommended the PCP obtain continuing medical education on acute pneumonia care if he wishes to retain inpatient privileges.

The committee also recommended to the credentials committee that it review the general ability of physicians to retain inpatient privileges without adequate inpatient activity. Specifically, the committee should question whether it is appropriate for PCPs who don’t have any presence in the hospital should evaluate patients, even if the PA communicates with the attending.

This case was designed to illustrate the dilemma medical staffs face when determining current competence of physicians practicing inpatient care in an era of changing practice methods. Many physicians practicing predominately outpatient medicine have recognized that they are not using inpatient privileges and do not need them to maintain relations with either the hospital or payers. They want the best care for their patients and seek to have that care provided by those who do it routinely.

In this case, the PCP needs to either make a commitment to provide that care through both adequate supervision and up to date knowledge, or relinquish that privilege for the good of his patients. By setting clear credentialing standards, the medical staff has the responsibility to help him make the right choice.

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