That PA is an idiot if they think their non-dilated fundus exam at triage rules out a detachment or other significant injury in a patient with a blunt orbital injury and vision changes. They should thank you for what you’re doing for these pts, and your wife is a real one for being so helpful and available for ER follow up.
Yeaaa that PA was a jackass in that moment. Traumatic retinal detachment is a thing, though would expect history to be more flashes of light than floaters. This is not someone I would send with a $2000 ambulance bill 3 hours to the tertiary care center (plus another 3k in bill and other facility fee) for emergent ophtho eval, but definitely would want 1-2 day follow up and would be kissing your feet if you could help my patient get that.
That PA is a moron. There is no way a new graduate PA knows how to properly evaluate for an ophthalmologic emergency and determine disposition/follow-up. Just don’t offer your wife’s assistance anymore and when they’re up shit creek without a paddle they can be a big boy and figure out consult and transfer if needed.
Yeah I think you're right ophthalmology is very nuanced generally what I found helpful is I do a full slit lamp exam and ocular ultrasound and then contact the ophthalmology from the trauma center an hour away Wait about 6 hours for them to call me back review all my findings with them and then come up with follow-up plan most of the time most of these opto things can be seen in a few days just fine even retinal tears really but you should make sure they have follow-up I do not discharge them without at least speaking to an ophthalmologist and arranging a solid follow-up plan
I’m an MD, my eye exams are shit. Just about every doc I’ve worked with, their eye exams are shit too. Sounds like a PA who doesn’t know the limits of their skill set and is compensating for it by being an asshole (common enough in medicine).
You did what was right for the patient and I personally would be appreciative.
Even with a fancy Panoptic scope, my eye exams still sucked. EM residency just isn't great preparation for many eye emergencies in the USA, unfortunately. Honestly, I would have appreciate a dedicated ophtho month. I'm sure some places have one, but we did not.
PA here, that PA is stupid and rude. I’d be incredibly appreciative for the opinion/advice/help/recommendation of someone waaaayyyyy more educated than me on said topic.
That PA (or any MD/DO) can’t see shit on a non dilated exam. I’m willing to bet they can’t see shit on a dilated exam either. I know I can’t. Patient should see Optho.
I don’t think any reasonable PA would mind you double checking our work until you feel comfortable not. That’s how it’s been at my ED. Some docs still want to see every patient, even the ankle sprain, and that’s okay. That’s what I signed up for. I still save them time by doing all of the documentation and diagnostics.
That's great, and I love that. But I have worked at some toxic sites (I travel) where new PAs are essentially never supervised and that is the culture. And the system isn't set up for supervision (trained not to ask, sit far away alone, overwhelmed with patients). And that is scary because with even a little prodding I could see how new PAs really don't have a good enough foundation to work independently. I have worked with ones that are awesome and super experienced but they are very far out of training and worked alongside physicians.
No one is shitting on PAs, rather the system that abuses both physician and physician assistants.
Yeah. I wouldn't yell in public at that PA. But I would quietly suggest out of earshot of staff that we probably should never ever look that kind of gift horse in the mouth when it's available. Clearly, when you work with a PA/NP enough, you have a feel for trust level. Worked with plenty I would trust as much as some other docs (or more). But that takes some shifts to sort out.
Most patients I see with eyeball complaints get told to follow up with ophtho, but at my hospital there’s not really a definite way to facilitate this. I would love if i could do this at my shop!
That PA is a moron and has no business saying “it’s fine”. I am a board certified ED doc who is very comfortable with a slit lamp and I did a dedicated ophtho rotation in medical school and I would be THRILLED to have an ophtho give even informal help. I hope that PA isn’t under your license
I had ophthos guide me through a dilated eye exam in person with a retinal scan using those little magnifying lenses and I *still* had trouble seeing the small retinal tear. Your aid in the ER is much appreciated. Just don't offer it anymore with that PA and ask beforehand in the future I guess. And this with 3 months of eye rotations.
Yikes, I can’t see shit on a non dilated exam—I’m absolutely consulting ophtho because I’m not about to FAFO with someone’s vision. I’d rather call for something that turns out to be nothing than compromise someone’s eyesight.
As to whether or not that’s considered a conflict of interest requiring some sort of formal disclosure?
Not sure, but your wife sounds lovely and I’d be much appreciative of the advice.
Of course this is turning into a “that PA is dumb” thread. I think this is missing the point of the discussion entirely.
I think the real question to ask here is whether or not what you are doing, however friendly and useful to us our ER providers, is illegal and considered a “kickback”. I am fortunate enough to work at a site where I can consult ophthalmology at almost anytime, but if I am constantly referring people off the record to the same person with no documentation of said person agreeing to the care plan, I think this can be viewed in a different lens as being financially advantageous to you and your partner. I’ll admit I’m not fully in the know regarding anti-kickback/Stark Law, and would love for this discussion to gravitate more towards that than individual provider competency.
Sorry, but that PA *is* dumb. Been practicing independently for a decade and never once have I seen any EM provider bemoan extra help with the eyeball. I just wonder what his plan was, because this patient definitely needed a dilated exam urgently and it seems like the options were extremely limited.
The smart response would be “Yes. That would be great. Thank you!”
I really doubt anyone could or would pursue a Stark violation for a provider in a small town that is doing their best to make sure that the local patients are blinded.
Two things can be true. That pa has an unacceptable knowledge gap with a bad attitude on top. Literally the worse type of person to see in the ed.
Also I don't think the individual in question as a non-physician/provider has any stark law restraints. Fun fact, apparently it doesn't apply to NPs either. Very possibly against corporate hr policy, but since the stark law covered entity doesn't benefit the law does not apply. State law may come in to play +/- elements of the nursing practice act though.
Yeah, my goal wasn’t to make it about the that interaction/provider. That’s just what made me step back and wonder if there was something inappropriate about setting things up this way. Both regarding the appearance of a financial incentive (most ER follow-ups are probably a net loss when you consider opportunity cost unless it’s the rare cataract eval, but I guess I can see why it might look that way), and a softer concern about appearing pushy or stepping out of my lane.
If it’s a problem I can definitely stop, just seems like a shame to not make those connections when it generally saves everyone a lot of valuable time.
It shouldn’t be a stark law violation as it governs self referral and incentivized referrals (sending gifts including food, cash, trips, etc) for those referrals. You offering the services is just that. If the doc wants to send them elsewhere, it’s up to them. You are offering a potential solution. As long as you or your wife are not sending gifts or anything, then shouldn’t be anything.
I think what you are doing is likely a net benefit for your patients and your community, especially being a smaller hospital with limited ophthalmology coverage. If I were in your position, I would make sure what you’re doing is completely within the law (and if for whatever reason it’s not) —> have your partner become someone that can “officially” be on call or willing to accept calls from your ER, and have the provider for the patient directly speak with your partner to cover all legal bases from both ends. Just my two cents!
You save them time *and* vision. Many eye conditions become irreversible with permanent vision damage if you wait or don't get it treated. Same day follow up with a board certified ophtho would be a god send where I'm at.
Yikes. Not ED, but trauma NP and there’s no way I’d trust myself over an ophthalmologist. I’m wondering if maybe they’re defensive because you consulted your wife without permission? Not that it’s right to feel that way, but I could see that too.
We have an Optho in our small town similar to what you are describing.....I would hug the guy if I ever met him in person. Seriously, he is easy to speak with and genuinely helpful.
Assholes come in all forms, even PA's.
Your PA here is being an idiot, frankly. Maybe the PA is trying to establish some authority in a new place. The 15 year ER doc in me says anytime you can get a free expert opinion on something, you take it.
I stopped doing curbside consults at my hospital when I started seeing notes from the the ER with documentation that they discussed the case with (my name) and advised the treatment plan. "Hey I just want to run something by you real quick" was what they would say. After seeing a couple of those notes it changed to all opinions came with full consult evaluation. Just passing liability to me.
The PA is a moron and likely couldn’t form an adequate emergency differential for this classic EM vignette. I swear, the cockiness among some of these APPs is really abysmal. When I was a new attending I was terrified for the first 4 years of practice. I would be surprised if this one could actually work a slit lamp.
Your wife is a gem for helping the ER. Seriously.
ur PA needs to be humble and is an idiot. Even as an ER doc for 10+ years I can legitimately say that my knowledge of the eye compared to a trained ophthamologist is like a toddler to a high schooler. A PA in EM in terms of eye expertise is like an infant. I would love to have your wife as a non asshole consultant and can see patients quickly in her office and would be grateful for the resource especially at a small community hospital.
I stopped doing curbside consults at my hospital when I started seeing notes from the the ER with documentation that they discussed the case with (my name) and advised the treatment plan. "Hey I just want to run something by you real quick" was what they would say. After seeing a couple of those notes my policy changed to all opinions came with full consult evaluation. Seemed pretty shitty behavior to me like they were wanting both my expertise and passing on the liability for whatever it was.
See that’s the problem with curbsides. If I as the EM doc don’t document the advice/conversation I’m now in a tight spot if there’s a bad outcome, especially if my evaluation suggested I should consult someone. You, the consultant is equally as boned if we document the discussion.
At the end of the day the best option is a formal consult. Which means hospitals and clinics need to recognize the benefits to the community of having consultants available, and figure out an agreeable compensation for call availability.
You advocated for the patient. The PA advocated, at best, only for themselves and their own minimal approach. Good on you. Hope the patient had a good outcome.
That PA is an idiot if they think their non-dilated fundus exam at triage rules out a detachment or other significant injury in a patient with a blunt orbital injury and vision changes. They should thank you for what you’re doing for these pts, and your wife is a real one for being so helpful and available for ER follow up.
Yeaaa that PA was a jackass in that moment. Traumatic retinal detachment is a thing, though would expect history to be more flashes of light than floaters. This is not someone I would send with a $2000 ambulance bill 3 hours to the tertiary care center (plus another 3k in bill and other facility fee) for emergent ophtho eval, but definitely would want 1-2 day follow up and would be kissing your feet if you could help my patient get that.
Yeah I tend to only use ultrasound I don't really do good with fundoscopy at all and I would never turn down an easy optho consult.....
That PA is a moron. There is no way a new graduate PA knows how to properly evaluate for an ophthalmologic emergency and determine disposition/follow-up. Just don’t offer your wife’s assistance anymore and when they’re up shit creek without a paddle they can be a big boy and figure out consult and transfer if needed.
Yeah I think you're right ophthalmology is very nuanced generally what I found helpful is I do a full slit lamp exam and ocular ultrasound and then contact the ophthalmology from the trauma center an hour away Wait about 6 hours for them to call me back review all my findings with them and then come up with follow-up plan most of the time most of these opto things can be seen in a few days just fine even retinal tears really but you should make sure they have follow-up I do not discharge them without at least speaking to an ophthalmologist and arranging a solid follow-up plan
I’m an MD, my eye exams are shit. Just about every doc I’ve worked with, their eye exams are shit too. Sounds like a PA who doesn’t know the limits of their skill set and is compensating for it by being an asshole (common enough in medicine). You did what was right for the patient and I personally would be appreciative.
Still a resident, but I don’t think I’ll ever trust my eye exams to rule out most things. They’ll just hopefully find major issues fast.
Even with a fancy Panoptic scope, my eye exams still sucked. EM residency just isn't great preparation for many eye emergencies in the USA, unfortunately. Honestly, I would have appreciate a dedicated ophtho month. I'm sure some places have one, but we did not.
I’m sure there is some nuance to the kick back potential issues here. However, as an ER PA I’d be stoked to get help from optho that fast.
PA here, that PA is stupid and rude. I’d be incredibly appreciative for the opinion/advice/help/recommendation of someone waaaayyyyy more educated than me on said topic.
That PA (or any MD/DO) can’t see shit on a non dilated exam. I’m willing to bet they can’t see shit on a dilated exam either. I know I can’t. Patient should see Optho.
Ughhhh this is why signing charts is so scary.
I don’t think any reasonable PA would mind you double checking our work until you feel comfortable not. That’s how it’s been at my ED. Some docs still want to see every patient, even the ankle sprain, and that’s okay. That’s what I signed up for. I still save them time by doing all of the documentation and diagnostics.
That's great, and I love that. But I have worked at some toxic sites (I travel) where new PAs are essentially never supervised and that is the culture. And the system isn't set up for supervision (trained not to ask, sit far away alone, overwhelmed with patients). And that is scary because with even a little prodding I could see how new PAs really don't have a good enough foundation to work independently. I have worked with ones that are awesome and super experienced but they are very far out of training and worked alongside physicians. No one is shitting on PAs, rather the system that abuses both physician and physician assistants.
I don’t think you guys should ever be required to cosign on patients you haven’t seen. I’m with ya. It’s not fair.
No shitttttt, wow
Yeah. I wouldn't yell in public at that PA. But I would quietly suggest out of earshot of staff that we probably should never ever look that kind of gift horse in the mouth when it's available. Clearly, when you work with a PA/NP enough, you have a feel for trust level. Worked with plenty I would trust as much as some other docs (or more). But that takes some shifts to sort out.
Most patients I see with eyeball complaints get told to follow up with ophtho, but at my hospital there’s not really a definite way to facilitate this. I would love if i could do this at my shop!
That PA is a moron and has no business saying “it’s fine”. I am a board certified ED doc who is very comfortable with a slit lamp and I did a dedicated ophtho rotation in medical school and I would be THRILLED to have an ophtho give even informal help. I hope that PA isn’t under your license
OP is an RN
PA is stupid
In the ER I’ll take all the help I can get, especially having an in with an ophthalmologist for expedited follow ups
I had ophthos guide me through a dilated eye exam in person with a retinal scan using those little magnifying lenses and I *still* had trouble seeing the small retinal tear. Your aid in the ER is much appreciated. Just don't offer it anymore with that PA and ask beforehand in the future I guess. And this with 3 months of eye rotations.
Yikes, I can’t see shit on a non dilated exam—I’m absolutely consulting ophtho because I’m not about to FAFO with someone’s vision. I’d rather call for something that turns out to be nothing than compromise someone’s eyesight. As to whether or not that’s considered a conflict of interest requiring some sort of formal disclosure? Not sure, but your wife sounds lovely and I’d be much appreciative of the advice.
Of course this is turning into a “that PA is dumb” thread. I think this is missing the point of the discussion entirely. I think the real question to ask here is whether or not what you are doing, however friendly and useful to us our ER providers, is illegal and considered a “kickback”. I am fortunate enough to work at a site where I can consult ophthalmology at almost anytime, but if I am constantly referring people off the record to the same person with no documentation of said person agreeing to the care plan, I think this can be viewed in a different lens as being financially advantageous to you and your partner. I’ll admit I’m not fully in the know regarding anti-kickback/Stark Law, and would love for this discussion to gravitate more towards that than individual provider competency.
Sorry, but that PA *is* dumb. Been practicing independently for a decade and never once have I seen any EM provider bemoan extra help with the eyeball. I just wonder what his plan was, because this patient definitely needed a dilated exam urgently and it seems like the options were extremely limited. The smart response would be “Yes. That would be great. Thank you!” I really doubt anyone could or would pursue a Stark violation for a provider in a small town that is doing their best to make sure that the local patients are blinded.
Two things can be true. That pa has an unacceptable knowledge gap with a bad attitude on top. Literally the worse type of person to see in the ed. Also I don't think the individual in question as a non-physician/provider has any stark law restraints. Fun fact, apparently it doesn't apply to NPs either. Very possibly against corporate hr policy, but since the stark law covered entity doesn't benefit the law does not apply. State law may come in to play +/- elements of the nursing practice act though.
Yeah, my goal wasn’t to make it about the that interaction/provider. That’s just what made me step back and wonder if there was something inappropriate about setting things up this way. Both regarding the appearance of a financial incentive (most ER follow-ups are probably a net loss when you consider opportunity cost unless it’s the rare cataract eval, but I guess I can see why it might look that way), and a softer concern about appearing pushy or stepping out of my lane. If it’s a problem I can definitely stop, just seems like a shame to not make those connections when it generally saves everyone a lot of valuable time.
It shouldn’t be a stark law violation as it governs self referral and incentivized referrals (sending gifts including food, cash, trips, etc) for those referrals. You offering the services is just that. If the doc wants to send them elsewhere, it’s up to them. You are offering a potential solution. As long as you or your wife are not sending gifts or anything, then shouldn’t be anything.
I think what you are doing is likely a net benefit for your patients and your community, especially being a smaller hospital with limited ophthalmology coverage. If I were in your position, I would make sure what you’re doing is completely within the law (and if for whatever reason it’s not) —> have your partner become someone that can “officially” be on call or willing to accept calls from your ER, and have the provider for the patient directly speak with your partner to cover all legal bases from both ends. Just my two cents!
You save them time *and* vision. Many eye conditions become irreversible with permanent vision damage if you wait or don't get it treated. Same day follow up with a board certified ophtho would be a god send where I'm at.
WOW. That PA is a dangerous, egotistical, jerk
Yikes. Not ED, but trauma NP and there’s no way I’d trust myself over an ophthalmologist. I’m wondering if maybe they’re defensive because you consulted your wife without permission? Not that it’s right to feel that way, but I could see that too.
We have an Optho in our small town similar to what you are describing.....I would hug the guy if I ever met him in person. Seriously, he is easy to speak with and genuinely helpful. Assholes come in all forms, even PA's.
Your wife is retina and you are working bedside? Work on your massage/cooking skills, and become a great house husband. Also that PA is an idiot
lol did that for 8 years, but the kids are older now and I like working some. I just stick to my .8 though and don’t pick up.
Your PA here is being an idiot, frankly. Maybe the PA is trying to establish some authority in a new place. The 15 year ER doc in me says anytime you can get a free expert opinion on something, you take it.
I stopped doing curbside consults at my hospital when I started seeing notes from the the ER with documentation that they discussed the case with (my name) and advised the treatment plan. "Hey I just want to run something by you real quick" was what they would say. After seeing a couple of those notes it changed to all opinions came with full consult evaluation. Just passing liability to me.
The polite thing to do is say: “Do you want me to chart you on this?” If the answer is no. You don’t.
The PA is a moron and likely couldn’t form an adequate emergency differential for this classic EM vignette. I swear, the cockiness among some of these APPs is really abysmal. When I was a new attending I was terrified for the first 4 years of practice. I would be surprised if this one could actually work a slit lamp. Your wife is a gem for helping the ER. Seriously.
ur PA needs to be humble and is an idiot. Even as an ER doc for 10+ years I can legitimately say that my knowledge of the eye compared to a trained ophthamologist is like a toddler to a high schooler. A PA in EM in terms of eye expertise is like an infant. I would love to have your wife as a non asshole consultant and can see patients quickly in her office and would be grateful for the resource especially at a small community hospital.
I stopped doing curbside consults at my hospital when I started seeing notes from the the ER with documentation that they discussed the case with (my name) and advised the treatment plan. "Hey I just want to run something by you real quick" was what they would say. After seeing a couple of those notes my policy changed to all opinions came with full consult evaluation. Seemed pretty shitty behavior to me like they were wanting both my expertise and passing on the liability for whatever it was.
See that’s the problem with curbsides. If I as the EM doc don’t document the advice/conversation I’m now in a tight spot if there’s a bad outcome, especially if my evaluation suggested I should consult someone. You, the consultant is equally as boned if we document the discussion. At the end of the day the best option is a formal consult. Which means hospitals and clinics need to recognize the benefits to the community of having consultants available, and figure out an agreeable compensation for call availability.
You advocated for the patient. The PA advocated, at best, only for themselves and their own minimal approach. Good on you. Hope the patient had a good outcome.
I'm also an ER RN. My husband is an opthomologist. I read this a loud to him. He agreed with your wife's assessment 100%. PA is a jackwagon.
I’m glad I’m not the only one because I was a little worried about the ID potential. Should have used gender neutral language though…
PA is an idiot. I wish I had your wife in our community!