In the following case, the group’s medical director over-utilized medical assistant (MA) externs for cost-saving purposes. Because he did not understand how his plan was putting patients at risk, he was resistant to negative input from his colleague. The physician conflict exacerbated the inherent risks of the externship program.
Allegation
The group did not have proper oversight of MA externs, which resulted in an adverse event.
Case File
Practice Structure
A busy family practice group was composed of two physicians, their two MAs, a billing manager, an office manager, and a part-time human resources (HR) person, as well as various medical assistant externs. Physician 1 was the medical director of the group. Neither of the physicians reported to the other or to any other person.
MA Externship Program
The practice had a robust MA externship training program. During office hours there were four to five externs working on administrative or clinical tasks. Externships generally lasted two months; consequently, there was a constant flow of individuals with varying degrees of competency cycling in and out of the office. The HR person had complete control over the externship program and received no direction or input from the medical director. She recruited, oriented, and trained the externs. When the HR person determined an extern had been adequately trained to do a medical task, an MA could then delegate the task to the extern when one of the physicians ordered it. Neither MAs nor physicians supervised the externs when they were completing tasks for which they had been deemed competent by the HR manager.
Physician 2’s Opinion
According to Physician 2, the practice had more externs than it could handle, the program was not appropriately administered, and many of the externs were incompetent. She avoided using externs whenever possible and denied any responsibility for supervision or training. She assumed the externs were overseen by Physician 1. She had complained to Physician 1 about the externs, but Physician 1 refused to discontinue or reduce the use of externs. The extern situation was driving Physician 2 to seek a position elsewhere.
Physician 1’s Opinion
Physician 1 believed the externs provided an economical workforce for the group, and they obtained valuable training in return—a “win-win” situation. He felt Physician 2 was overreacting to small issues with a couple of externs who had made regrettable, although minor, mistakes with no lasting consequences to patients.
Adverse Event
A long-term patient of Physician 2 came in for ear irrigation. Physician 2’s MA was not available. Unbeknownst to Physician 2, the irrigation was delegated to an extern. The extern punctured the patient’s ear drum. The patient sued both physicians and the group.
Discussion
Although both physicians denied involvement in the training or supervision of the MA, according to defense experts the physicians were ultimately responsible for what their MAs—or the MA externs to whom a task has been delegated by their MAs—did or didn’t do with their patients. The experts believed both physicians should have been more involved. For example, the experts believed unsupervised ear irrigation could be within the appropriate scope of practice for an MA extern, but the physician who ordered it would have to be satisfied that the extern was capable of unsupervised ear irrigation.
Competency judgments are generally the result of personal observation and discussion with other staff members in the office who have appropriate qualifications to evaluate MA extern competency. But in this case, neither physician had made any determinations about the competence of any of the externs with whom they worked. Had they observed the MA who caused the eardrum injury, they might have provided the guidance necessary to avoid patient injury. Experts believed the MA extern’s ear irrigation was below the standard of care.
Another problematic issue was that the medical director (Physician 1) was unfamiliar with the operation of the group practice. He was unable to clearly answer questions about reporting relationships, oversight, and supervision. He had to defer all questions about the externship program to the HR person. Unfortunately, the HR person’s records were incomplete—there were no copies of agreements with the externs (the paperwork was completed by and retained by the trade schools from which the externs were recruited) and supervision and evaluation documentation was sparse. This made it extremely difficult to locate the MA extern who did the irrigation. (The MA’s externship was long over by the time the matter was litigated.)
The case was settled on behalf of Physician 2 and the practice.
Medical Liability Risk Management Recommendations
Managing Trainees
The purpose of an unpaid educational externship is for the trainee to learn about the medical practice. However, delegation of duties to externs should only occur under appropriate circumstances. Physicians who absent themselves from determinations of the competency of externs who treat their patients are exposing their patients to potential injuries and exposing themselves to liability risk. Consider the following recommendations:1
- Have training contractual agreements reviewed by a healthcare attorney.
- Work with the attorney to craft the agreement in a way that fits your practice needs, protects your patient population and your practice and meets all regulatory criteria.
- Ensure that your professional liability insurance provides coverage for trainees or that liability for their patient encounters is otherwise covered.
- Create a plan for orienting trainees much like you would a new employee, and for evaluating trainee competency and performance.
- Do not delegate the responsibility of determining extern competency to anyone not qualified to do so.
- Be familiar with state laws covering delegation of duties to unlicensed staff.
- Provide adequate orientation and reinforcement to trainees and the people who will be supervising them regarding their specific roles, responsibilities, and scope of practice.
- Ensure that written job roles are in place.
- Ensure that all parties involved in the training program understand group, physician, staff, and trainee responsibilities.
- Ensure that all parties understand what procedures the trainees are allowed to perform and under what circumstances.
- Ensure that supervising physicians understand proper delegation of responsibilities.
- Ensure that all parties involved in the training program adequately document patient care, including setting up trainees to document under their own names in an electronic medical record, as opposed to documenting under someone else’s credentials.
- Inform patients of the training program and that supervised trainees may be involved in their care.
Managing Disagreements about Business Practices
Patient safety and risk management depend in part on physicians sharing a common vision of the practice and managing conflict when differences in the understanding of that vision arise. Consider the following recommendations:2,3
- Define leadership roles in the practice.
- Create an environment in which clinicians do not feel that raising issues will result in retaliation.
- Before making a change that affects the way clinicians treat their patients, obtain buy-in from affected parties.
- Conduct regular clinician meetings to encourage discussion, dispel misunderstandings, and build consensus.
- Define a plan for conflict resolution, involving a third party (e.g., a mediator) as necessary to help resolve intractable or complex issues.
References
1. “A Risk Management Program for Emergency Medicine: Basic Components and Considerations.” American College of Emergency Physicians Medical Legal Committee. ACEP. January 2013. (accessed 3/26/2017) (resource not available online at the time of publication)
2. Ellen Kandell. “Conflict in The Healthcare Arena: What Physicians Can Do About It.” Mediate. January 2011. (accessed 7/26/2019)
3. Louise B. Andrew, MD, JD. “Conflict Management, Prevention, and Resolution in Medical Settings.” Physician Executive. 1999 Jul-Aug;25(4):38. (accessed 7/26/2019)
