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Foreign.
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Welcome back to the Joppa Podcast. Listeners can now earn CME by listening to the podcast. To receive your CME credit and access to your certificate, you just listen to the podcast, then complete the post test and evaluation in AAPA's learning central@cme.aapa.org today we're continuing our conversation on malpractice prevention and risk management. So if you haven't listened to Part one, I encourage you to go back and listen to that vital conversation. Today we welcome back our guests with expertise in legal medicine who will continue to help us understand the legal landscape of clinical practice. Before we begin, we'd like to remind you of our disclaimer. This is not formal legal advice and all PAs should consult their own malpractice insurance policies and legal counsel for specific guidance related to their individual practice. All right, so let's welcome back Christopher, Susan, Adam and Amanda. If you guys could just give us a little reintroduction before we dive in. Let's start with Adam, please.
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C
Sure. Thanks. Adam Broughton here. Just coming off of an ER shift, so working today, getting back from my emergency department shift. I've been an EMPA for 18 plus years and also work in education. I'm a full time faculty member at Northeastern and of course involved in APOM and Expert Witness as well as Turn it over to Chris.
- [01:23]
D
Yes, good evening. Hi. Chris Knell. I've been a PA for over 22 years practicing in mostly emergency medicine, orthopedics, urgent care, critical care and hospitalist medicine. Current President of apom, on the board of directors for adpa. I'm on faculty at two doctorate in medical science programs in the healthcare law and advocacy and legislation. End of things and currently precept students from Northeastern and Tufts University. Very happy to be here and I'll pass it off to Amanda.
- [01:53]
A
Hello, I'm Amanda Mallory Spillman. I just started my 19th year as a PA. I work in both emergency medicine and orthopedic spine surgery and I also Precept students from Mount St. Joseph University in Cincinnati as well as University of the Cumberland's Northern Kentucky campus.
- [02:07]
E
Hi everyone, I am Susan Ferrero. I've been a PA for 20 years. I've practiced in multiple specialties, mostly orthopedic surgery and emergency medicine. I have a medical legal consulting company that I started about two years ago and I do that full time now as a job. I am the Vice President of apom.
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B
Great. Thank you guys and welcome back everyone. So previously we were discussing the foundation of risk management and prevention, the role of liability insurance and Navigating the standard of care. We left off our discussion around electronic health record and the importance of documentation. Specifically, Chris and Adam were discussing AI and the use in documentation. I'd like to see if you guys can share your thoughts or concerns specifically on the use of AI in medical documentation.
- [02:56]
D
Happy to start it off? Yeah. I think we need to start embracing AI and what it's used for and how it can be helpful and how it can make us more efficient, more organized. Help with billing, help with just the cohesiveness of the chart. I think in this day and age of margins being tight in all areas of medicine, I think AI can definitely help us. But at the same time, we're not there yet with the technology and we need to work with our risk management departments. We need to make sure we obtain informed consent from patients, especially when we're using ambient AI, and understand that it can pick up background noise and all those types of possibilities. So it, you know, a lot of facilities are embracing it's using it in ambient listening, which I think is great. And I think all the feedback I've gotten, especially within our healthcare system, is that people love it and I think it will help out for wellness. So I think we need to continue to utilize it, but make sure that we're aligned with those key areas of informed consent and risk management.
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A
All right, so to switch topics a little bit, we know that medical malpractice law can vary significantly by location. Can you speak to how state specific laws and legal medicine principles can impact a PA's liability? And what should a PA know about the legal landscape in their own state? I can start off. I've done a lot of case review in various states. I live in Kentucky and I work in Kentucky and Indiana. But I've also reviewed some cases kind of in the Midwest and Western states. And PA practice laws vary from state to state. And something I've really run into is the role of the supervising or collaborating physician and what constitutes that supervision. A lot of attorneys will kind of go with this. Well, the physician should be kind of right there with them. They should be co signing all of their notes. They should be right there and have their kind of their thumb on the pa and that's really not the case. So I think really just understanding what your supervision laws entail and what that means. How many notes is your physician supposed to sign if they are supposed to sign any at all? I know in my state, or at least at my hospital system, if I discharge a patient, my supervising physician has to co sign that Note, I found that out the hard way. Unfortunately, luckily nothing bad happened, but the hospital system kind of sent me a not a nasty email, but just a kind of slap on the wrist kind of thing. But just understanding your, not only your state laws, but also your local laws, your hospital bylaws, there's really a lot that can go into it, and it's really going to vary from location to location and even from specialty to specialty. I'd also add, probably looking at your credentialing. So your credentialing. You know, I work in two specialties and my credentialing just came up for review. And don't everyone cringe at this? But even to do a pelvic exam, I had to be proctored for five cases, which is ridiculous. And that's a story for another day. But there are a lot of orthopedic things that I was credentialed for in orthopedics that I'm not credentialed for in the er. And so knowing your scope of practice, your physician's scope of practice, and kind of what the role of the supervising physician is, is really, really beneficial for you.
- [05:51]
E
I would echo what Amanda said. You want to make sure that if you've gone from specialty to specialty and there are things that you're comfortable doing that may not cross over into your current specialty. So make sure that you're aware of what your current scope is and what the current state laws are, and they change sometimes without you knowing, because that happened to me. Different things that you can or can't do may change at a legislative level in your state. It's up to you to be keeping up on that and then also being up to date on what you based on the facility. Because sometimes something is allowed in one state, but it's, you know, in the state, but it's not in the facility. So you have to kind of keep up on that. It's really your job to know what your scope is and make sure that you're staying in it, because that's your responsibility.
- [06:38]
C
Yeah. Especially as we're pushing for independent practice and other things, there's changes that are going on. And as we sort of highlighted already, it's your responsibility to know those not just at the state level, but also at the credentialing level. So it can be a moving target. And that's difficult. Ways I've found that's been helpful is joining my state organization, joining my state in Massachusetts. So joining the state Massachusetts association of PAs was excellent as far as just keeping up to date with that, even just, you know, sort of like a newsletter or whatnot. So especially at a time where we're looking to change practice and it oftentimes goes from state to state to state, it's great to get involved. And that can just be like a reminder or heads up about what's going on.
- [07:18]
D
Yeah. If I'd love to comment as well. So we actually talked about this at our CME event last night for apom. And with apom, we're really trying to focus on getting some great education for folks, realizing that it varies from state to state, but also having an attorney come and speak at one of our CME lectures that really talk to everyone about how to protect yourself from a regulatory standpoint, because it absolutely can change from a state level even to down to like your practice level, hospital level, hospital system level. Just because your state says one thing regarding your collaboration supervisory agreement doesn't mean that the system abides by that. So I think that's very important. I just had a case today for which I was discussing. I agree with Amanda. The attorneys will latch onto this topic for reasons that are unclear, but I think it's the perception by them as they try to sort of push forward with the case is that when they're trying to determine standard of care, they somehow latch onto the concept that pays are not going to offer that same level of care. And that's obviously not true, but they will sort of look at that and they'll try to exploit that. It's up to us to know our supervisory and collaborative agreements. It's up to us to know the protocols. We don't want to get ourselves in trouble anyway and put ourselves at risk. I would emphasize that to everyone to understand whatever it is, you know, if you have sepsis guidelines or if you're in the er, you have ESI scores that you have to talk to a provider about, or you're discharging a patient. If you're on the critical care service or CT surgery service or neurology service, whatever service you're on, know what your practice laws are, because it can come back and bite you. And you don't want that, number one, to affect you from a medical legal standpoint, from a med mal standpoint, but also from like a professional license standpoint.
- [08:59]
E
I would also add, make sure you know the policies and procedures of your facility, because those will come up in a lawsuit as well. They will pull those and they will compare it to what your care was. And sometimes things vary from facility to facility or Even you know what you're used to is the standard. So it's good to know what the policies are and make sure that you're following them. Because if you're looking for the hospital to back you and you're not following their policies and procedures, then that might be a problem. And they're not usually handing them out. It's something for you to have to find out on your own.
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B
Yeah, I think that's super important. You know, one of the things that this made me think of is just with my own clinical practice and the fact that I technically work for one medical group, but that one medical group, I have privileges with multiple hospitals that are all in the same system. But. But at each hospital I have different privileges. They're all slightly different. Like, I may be able to do this procedure at this hospital, but this other hospital doesn't allow for that procedure. So you have to keep that in mind as you are treating each patient because of those delineations between each facility and how the different policies are going to apply different places. So really important to think about.
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E
Absolutely. It can be a. Can be a lot to keep track of. You need a spreadsheet if you work
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A
in a lot of facilities.
- [10:19]
B
Definitely.
- [10:19]
A
I have the same problem. I work for an ER group that is credentialed or contracted with a hospital system. Well, that hospital system acquired another hospital in another state, and so they kept their old credentialing system. So they have a whole separate credentialing criteria. Plus the state license is different, but it's the same hospital group. So sometimes you're at that hospital and you forget, oh, shoot, I need. You know, my DEA is different over here and the whole thing is just totally different. So.
- [10:48]
B
So one of the things we previously were talking about on the previous episode was about the importance of patient communication. We kind of touched on it a minute ago. So patient communication is often cited as a key factor in preventing litigation. So what are some of the actionable communication strategies for PAs to foster patient centered care and build trust even in difficult situations or when a bad outcome occurs?
- [11:13]
D
This is absolutely one of the key components, not only communication from provider to provider. At the practice level, when you're signing out patients or whatever it may be, those are one of the key areas of concern. But with patient care specifically, you need to make sure that you have informed consent, that you have appropriate read back when you're doing discharge instructions, that you give them plenty of opportunities for them to understand what those instructions may be, why to follow up, what to be concerned about. You need to make sure that they understand that communication, that it's in their language, and that they have access to care and they have access to an understanding how they can contact your practice. Even if an adverse outcome occurs, even if a mistake occurs, an error occurs, the data shows that if you are kind, you are compassionate, you are empathetic, you are a good communicator, patients are less apt to approach the provider in a malpractice lawsuit.
- [12:02]
A
I think I said this maybe on the last podcast as well, but I like to discharge patients in their room whether I'm in the clinic or whether I'm in the er. I like to put all of their instructions in as I'm talking to them. That way it makes sure that I don't miss something. Because in the dispo, we use epic, but in the dispo, I have to put the diagnosis. And so I'll say, okay, well, I'm going to diagnose you with a lumbar radiculopathy. And then next it goes to the prescriptions. Okay, I'm going to prescribe you these. Is your pharmacy correct? Making sure that, you know, I'm going to send the medications to the right place, when they should start taking them, if they should stop any other medicines, and then it goes to their instructions or who they're going to follow up with and ensuring they have a primary care provider, or when they should come back and see me next, or return precautions for the er. And so what's really important, especially in the er, when there's. It's a lot of lower socioeconomic patients, is that you not only speak what you want them to do, but you also write it down as well. And so they have multiple points of contact and different types of contact as well, so that they really understand and it sinks in. And that way they don't go out the door and then totally forget exactly what you said. And then I would also document. So just copy paste whatever you told the patient and copy paste it in your note. And then that way it's in different spots as well.
- [13:18]
E
I would agree with Chris. It should be in their language. I know how much we all hate to use that translation phone. You know, in trying to use a family member or someone, a nurse that speaks Spanish or someone that is trying to help you, it's best to do it in their actual language and to do it the right way. I would keep in mind that in the United States, most people read, I think it's on like a middle, like a seventh grade level or lower. You know, that goes with understanding as well. You want to make sure that you're explaining things in terms that they can understand. And constantly asking, you know, does that make sense? Do you understand that? And someone mentioned, you know, repeat back. And I mean, I've gone in and I've given discharge instructions. I think they're paying attention. They're, you know, and then the nurse goes in there and they're like, no, she didn't tell me anything. And she's literally just in there. And I asked you if you knew, you know, what I said and you repeated it back to me, but they didn't understand it or they're on their phone and they're really not paying attention. So, you know, you really just need to make sure that they understand what they're being treated for, what the plan is and what they're going to do after discharge.
- [14:26]
C
I like to kind of think of it as partnering with the patient and being really clear, like, I'm discharging you, but that doesn't mean you can't come back to me. Like, here's the reasons why I want you to come back. I was, today was, was a Friday. And that means you're not going to see your doctor on Saturday or Sunday, you know, and so I'm your backup. You're going to come back to me in the ER if X, Y and Z happens. So I try to make it seem like we're welcoming you back rather than like, oh, this is, we're done with you. Don't come back and bother us. So just sort of couch a little bit different for my patients is one thing that I like to do.
- [14:57]
B
Yeah, I know that sometimes in the ER when I work there, I give them, hey, I'll be back here in two days. So if you're specifically wanting to come back and see me, I will be here. I won't be here tomorrow, you know, so I may give them that kind of short follow up to let them know where I will be and it's a good time to come back and I'll look for you.
- [15:17]
D
One last thing. From a liability standpoint, make sure that you're, whatever practice you're in, that you have some sort of follow up mechanism, such as like a follow up, like. So for those of us who have practiced emergency medicine, which there's multiple people within this recording right now, practice emergency medicine, that you have a follow up RN or a mechanism in place that will also provide that to them and they have someone to speak to, you know, because they don't have that Access like an EPIC or, for example, like the MyChart ACT Access. So that will also be very important because I can tell you that this came up in my case presentation that I presented yesterday for our CME event. So it's important to understand that because the attorneys focus on that.
- [15:53]
E
One more thing I would add is just in general, right. Listen. Just listen. You know, that's one of the best things you can do with communication with anyone. And impatience sometimes just giving them a chance to talk. I know we all are busy in no matter what situation, and you're just trying to get them to finish talking so that you can move on. But sometimes just building the best rapport is going to happen by just giving them a few minutes to let them just speak, because then they feel like they were actually heard. And when people feel heard, they're less likely to be upset if something were to go wrong.
- [16:24]
A
All really important points and I'll have to share as a primary care pa. I love that all of y' all are bringing up how important it is to say that patients can come back and that you're that point of access, too. It really is hard to just come back to the pcps. So thank you for that. Now, out of curiosity, for those of us working in collaborative practice agreements, what are the most important considerations for appropriate delegation and supervision that can help prevent legal exposure for both the PA and the collaborating physician?
- [16:51]
D
Yeah, so just make sure that the types of delineation of privileges that you have that you are aligned with your. It all depends on the state. Right. All depends on what the practice environment like. It may range like with the new practice laws in North Carolina or New Hampshire, for example. By the way, just make sure what you are doing in clinical practice that aligns with who your supervising physician is on paper, for example, because you don't want to get yourself into trouble because, you know, say you're. You're practicing outside your scope within that particular practice, like you're doing skin cancer excisions in the primary care practice, but your primary care physician that you are assigned to doesn't do that. So you just have to be careful with that and not practicing outside the scope. I can tell you that there's so many of these different areas. This is. I'm going to direct this to the young pas out there. There are so much information that I've learned and gained as I've gone on with my career that I wish I knew earlier on my career, because I can tell you there was definitely Areas of practice that I performed in that I just didn't know. And this is why AIPOM is so important, is because that we can provide that experience to you and let you know because we have that inside scoop, ways to protect you.
- [18:00]
A
I would also add, you know, whether you're in a supervising agreement or a collaborative agreement is just to make sure that you talk and ask questions of your physician. So even if it's just a, hey, I'm giving you a heads up. For example, yesterday in the clinic, I had a lady I had to send to the emergency room, which was funny because I work at that emergency room. So you can imagine me calling and sending someone to my own emergency room. But I just sent them a secure chat and I said, hey, just heads up, this person's going to the ER in case you get a call. Just little things like that, just to keep the communication lines open. I had another patient same day that was just a little complicated. And I said, hey, I'm thinking about this, this and this. Is there anything I'm missing? Is there anything you want to add? And he did. He added a couple of things. He's like, yeah, just have him come see me. Put him on my schedule for tomorrow. Okay, great. You know, it's not every patient, it's not even every week. This is a surgeon I've worked with for six, seven years, and sometimes I go several months without seeing him. But make sure that you're always talking if you've got questions. So just because it's a collaborative agreement and it gives you more leeway and some states are going more towards independent practice, just realize you're not on your own. You should reach out and ask questions. We don't know everything. We'd like to think that we know everything there is to know within our specialty, but the truth is we're going to miss things. We're going to be tired one day at the end of a shift or, you know, you're just frazzled by a patient or whatever, or something's difficult. Don't rely on looking something up on open evidence or up to date or whatever. Reach out to your collaborating physician. That's what they're there for.
- [19:31]
E
I would echo that and say you want to have a supervising physician that you can trust and that you have a close relationship with. I see too many PAs, especially brand new PAs post in these forums and chats and things about how they don't have a good relationship with their or any relationship really with their supervising physician. And I think that that's so important, especially when you're first out of school, you need somebody who's going to be there for you, who's going to back you, and someone who is going to mentor you. If you don't have that relationship and you don't have that support, it's probably not the right job.
- [20:07]
C
Yeah, just because you can doesn't mean you should. I guess would be my sort of take home for that. Where I've seen this gone awry is really in best of intentions and it might even be really trying to help the patient out and I don't know, doing a favor or whatnot. But there's probably something that is in the back of your mind saying like, oh, is this something that I should be doing? So, yeah, I think it's obviously, you know, review all of your privileges and whatnot and then just kind of check yourself as far as like, is this outside of my scope? Even when it's the best of intentions?
- [20:38]
A
All valid points. Handling medical errors or unexpected patient outcomes is a high stress situation. What is the best practice for PAs when it comes to disclosing these issues to patients and how does this approach affect potential legal ramifications?
- [20:53]
E
I would say you want to be transparent and you want to be genuine people, like people who are genuine. If you are coming across as hiding something that's not going to look well. You also want to be empathetic. Put yourself in the shoes of the person that you're giving the information to and how you would handle it and how you would want it to be given to you. I would also say it's good to apologize, but I would also say that with the caveat of you should know your state's apology laws, because there are different laws in different states that discuss whether or not a provider can apologize for an error and be held legally responsible and have the apology used against them. So you want to make sure you understand the law in your state so that if you are doing that, the last thing you want to do is feel like you're apologizing to someone and feeling truly sorry and then have it used against you in court.
- [21:46]
D
Just make sure that you go through the due process within your healthcare system, whatever process that is. So say you're working for a hospital system that you want to work, making sure that you're going through like the appropriate peer review, the medical executive committee, the credentials committee, the risk management team, the hospital attorneys. You want to go through that due process and just listen to their advice and you don't want to go rogue and calling a patient or going in the chart, doing things that you shouldn't be doing. You just want to make sure that every process that you go through, and I just want to go off of what Susan's saying about the apology laws. Do it, but do it the right way. You know, and know if your state is one of those states that has an apology law because you don't want to put yourself at risk. But absolutely, I think it's very, very important to contribute to that. I worked with an attorney in Michigan on a case recently and I really valued how they went about the case. They have a lower med mal litigation in states that like that, where they really work together collaboratively with the healthcare systems to on process improvement because no one wants to make errors, no one wants to have an adverse event. Let's all benefit from it, let's all learn from the event and make sure that the patient is made whole if they need to be, if there's something going on with them. So just listen to the advice of your healthcare system.
- [23:02]
A
I would add too, just because a bad outcome happens doesn't mean that you're going to have a lawsuit. We have lawsuits because of bad outcomes. And those bad outcomes sometimes are due to negligence and sometimes they're not. But I think the first thing to remember is just to leave your chart alone. Don't go back and amend things. You know, once you've signed that chart off, don't go back and go, oh yeah, I remember, wait, I said this and we had this conversation. Just leave it. Everything is timestamped in your ehr. And so we can pull that. We can do like a time audit log where we can go in and you can see exactly who went into the chart, at what time, what things were signed, when things were addended. So if you do have a bad outcome, you can go in the chart and look, but don't change anything that you've already written. Don't discuss it with anyone else other than your supervising physician or whoever, which physician you worked with that day, if that's applicable. And then also as Chris mentioned, your risk management or your hospital attorney or that sort of thing.
- [23:59]
E
I would also warn against not even going back in the chart if there's been a bad outcome. Something happens, you come back on your shift two days later and you find out that a patient you took care of had a bad outcome and you want to go back in and look at the chart. That's one of the things that is sort of a red flag when you're evaluating Records behind the scenes here. If you see a bunch of people going into the record, that kind of confirms that you know something is up, something happened. They know something happened. Because now you've had three nurses, pa, two doctors, the risk management person, all these people have gone into the chart so you know that something's up. It's tempting to open that chart again, but if you have closed it and you have been out of it, I would say just leave it alone. If you absolutely have to go into a record for some reason to put something in there, make it very clear that it's an addendum. Don't just add it to your regular charting, put an addendum. This is an addendum and I'm adding this. And this is why, because it happens sometimes you have to late chart and you say due to shift volume, I was unable to or I forgot to add this. The patient actually had an X ray that said X, Y and Z. So just be sure that you're adding that. It's an addendum and it's clear so that it doesn't look fishy. It's not completely bad to go into a chart afterwards, but if something bad happens, then you might have to find your exposed self explaining why you were in that chart afterwards.
- [25:18]
C
Just want to put a plug in for near misses and documenting and notifying people of near misses because a lot of times errors end up being system problems and it might be a system problem that has happened before and just didn't come up with such a catastrophic outcome or whatnot. So if you're working in a culture where those things are flagged and brought to attention, I think that's a great sign that you're going to be in less at risk for those really bad outcomes. Because sometimes it's system errors and it misses. So definitely want to plug flag those near misses, bring it to someone's attention. Quality improvement is huge and you can do it. You're the person that's interacting with the patients and so you really know where those potential pitfalls are.
- [26:01]
B
I think one of the things, a theme that we keep hearing is about communication. And there's so many different sides to communication. Specifically, one final part of that is poor communication during patient handoffs and how that can be a real source of medical errors. What are some best practices for PAs to ensure effective and safe patient handoffs, whether to another provider, a specialist, or just during like a shift change?
- [26:28]
E
I would say you want to make sure that both parties have the undivided attention, you know, kind of doing three things at once while you're sort of listening to a patient or listen to a provider talk about, you know, patient they're signing off. You want to make sure that you're actually listening and that everyone is undivided attention is going on. If you can do it bedside, that's even better. But we all know that that's not always possible. You want to document the handoff. I just reviewed a case recently and what saved the PA essentially was that she had very good documentation that she had handed off the patient to the physician and documented that this is what she was doing. She was handing it off to the physician, this is what he was going to dispo the patient based on how they were doing. And the physician never wrote a note, so it looked like it was all on her, but it wasn't because at the end of the day she had signed out. She documented it well the fact that he didn't maybe didn't even see the patient again and just discharged the patient without writing a note. So if you're taking the patient, then you need to document that you're seeing the patient and you're dispoing them and that you actually evaluated the patient. And if you're handing them off, you need to document it well that you're handing them off. Always do your own evaluation though of a patient that's being handed off to you.
- [27:38]
A
I would add to that documentation piece is if I'm handing off another patient in the er, I make sure that my note is complete for that patient before I leave. And that way, if there's any question, that way the physician I'm handing it off to or the other PA I'm handing it off to can look through my documentation and see this was my thought process, this was the history, this was the physical. That way, in case that patient needs to be admitted, they can accurately communicate with the hospitalist or if they need to contact a specialist or something like that, they have something to go off of versus remembering what I told them half an hour ago.
- [28:15]
D
I can't tell you how many cases I've seen have come across my desks where this has been the case. I can very specifically remember one case just in that two hours between a hospitalist signing off shift and then for the evening slash overnight team, a patient was especially. It's also the same kind that the nurses were doing sign off from shift to shift. An adverse event happened and the patient there was a fatality. That's all because of that poor sign out. And so you, you have to go through these processes and learn to these processes through your healthcare system, whatever, just like Adam had brought up earlier, so that adverse outcome doesn't happen again. So there has to be like a formal signup process. So if you're a hospitalist or critical care that you, just like Amanda and Susan had mentioned as well, you have to sort of sit down and make sure everybody's paying attention and that, that the plan is in place, that you're not saying anything negative about a colleague or a referral that came to the ear or anything like that. You want to be as professional as possible and then you want to approach that patient care appropriately. So if there's any concerns about that patient, you need to make sure you address it and document it.
- [29:18]
C
I'm a big fan of checklists, especially when you've had a long 10 hour shift in the ER like I had today and, you know, a formal checklist. I teach my students the SBAR method. You might have heard it or seen it in your hospital situation, background what your assessment is and then asking for the person's recommendations. The more tired I get, the more patients I have, the more frazzled I am, the more I need to lean on that and say, I really need to be systematic about this. Having a method is great because sometimes it's been a long day and you want to get out of there. But as we've pointed out right now they're high risk patients. So I sort of just kind of change my approach to any sign out as being this is a high risk patient. I don't care what the sign out is for toe pain, it's a potentially high risk patient. So just kind of shifting that perspective and then lean on a checklist would be my advice.
- [30:08]
E
We're all with an ER background, so our advice seems to be focused around an er. But I would even say even in an office setting, a primary care setting or a specialty office, it's. You're not really handing off a patient per se, because you've seen them and they usually leave, but maybe they're coming back to the office but you're not going to see them. In primary care, a lot of times you have the same patients, so you're not really handing them off to anyone else but yourself. But I've worked as a pa, I've often had to work in an office where you're covering the physician's patients or someone's off and you're seeing them. So I think documentation goes a long way. Making sure that what your Plan is for that patient at that visit is very clear to anyone who picks up that chart at the next visit. So that they know what you were thinking and that they know what needs to be followed up. That's essentially a good, I guess you'd call it like a ghost handoff. Right. Someone should be able to pick that up and know exactly what's going on with the patient and what needs to be followed up from the last visit.
- [31:06]
A
I would add to that, Susan, at least from the orthospine perspective. In clinic, I order a lot of MRIs, and there's a lot of what we call incidental omas. Incidental findings. You'll have enough. We found thyroid cancer and we found renal cysts. And usually it's some sort of tumor, cancer, cyst, something that I'm not going to deal with because I'm in orthopedics. But it needs to be addressed because I'm responsible for that. So I'll communicate with their primary care. If the radiologist recommends reporting a renal ultrasound or if there's a vascular issue, I'm going to message the vascular surgeon that's on call and just say, hey, I've got this. Can you follow up on this patient? And then documenting it? So I'm not really. I'm handing it off. I'm not totally handing it off, but at least I'm involving someone else in that patient's care. And then document. It always goes back to the documentation. Make sure you document when you talk to them, who you talk to, what the plan is, that sort of thing.
- [32:00]
E
If it's a high risk situation, say you've picked up a cancer on a scan and you're sending them to someone, I would always make a little sticky note in HR and check it to make sure that this person followed up so that their appointment didn't get canceled or they canceled their appointment and nobody knows. And then six months later, they're back with metastatic cancer. If it's a high risk situation, I would make a sticky note and just kind of have that there and breeze through them to make sure that. Okay, did they actually go see? Yes, it looks like they went and saw that person. I can check that off my list.
- [32:34]
B
Awesome. Such great advice. I can really hear all the expertise and I can tell that you guys have seen a lot in your review of cases. Definitely. All right, so we only have a couple of minutes left. Any final thoughts that you want to share? Any of, like, other sage advice that you want to give to our listeners?
- [32:55]
D
I think the best Advice that I can give is lean on the support of others, lean on your colleagues who have the experience, lean on your supervising physician, lean on everyone that has maybe more experience than you, for example, or a colleague for something you may not know. Focus on communication, documentation every. Explain everything away in your medical decision making, your assessment and plan, and just be as kind as possible to every patient. Oftentimes that simple gesture will sort of save you.
- [33:25]
A
Yeah, I was going to say just communicate and document. That's your best defense, is to communicate. And like Chris said, be kind, be empathetic. It doesn't really take much. You know, sit down with the patient, look them in the eye, just give them a few minutes to speak, listen, and that will go such a long way.
- [33:41]
E
I'll add, don't be afraid to practice or even make a mistake. I know that a lot of this is probably overwhelming and you start thinking about it, you know, nobody wants to be sued, but just, you know, lean on your education and your experience. You're a great provider. Just do your best, document well and don't be afraid that you're going to get sued. The chances are less likely than they are likely. It's just something you need to be aware of.
- [34:07]
C
You can't practice medicine constantly thinking about getting sued or what the legal ramifications are. It's like trying not to think of the pink elephant with each case. Doing your best. You're well trained. You likely have well trained individuals around you. As Chris mentioned, being kind to the patient is about doing your best for the patient. So that's going to come out. So all those themes there of kindness and communication and being transparent are all excellent advice that we've heard.
- [34:35]
E
Okay, that's all the time we have today. And these are such great tips. And being a hospital spa for about eight years, all these things apply to my practice. A lot of times the handoff. You guys just gave some excellent advice. So thank you again to our guests for taking the time to discuss such an important topic that we do not often get to discuss as PAs. And to our listeners, don't forget, you can now earn CME by listening to the podcast. To receive your CME credit and access your certificate, it's as easy as just listening to the podcast. Then complete the post test and evaluation in AAPA's learning central@cme.aapa.org thank you again and until next time,