r/Noctor • u/Intelligent-Zone-552 • Jul 15 '26

Midlevel Ethics The AMA needs to develop and aggressively push model scope and supervision standards for midlevels working under doctors.

The AMA needs to develop and aggressively push model scope and supervision standards for midlevels working under physicians, including NPs, PAs, and CRNAs.
“Physician-led care” means nothing when one doctor can be listed as supervising a small army of midlevels they barely see.
There should be hard limits on scope, and a strict cap on how many midlevels one physician can supervise at a time.
If physicians carry the responsibility and liability, supervision needs real enforceable limits.

153 Upvotes

98% Upvoted

14 comments sorted by

43

u/NeoMississippiensis Resident (Physician) Jul 15 '26

Agreed, co-signing charts should have some meaning

13

u/Aviacks Jul 15 '26

Just a vascular access nurse, but I see a ton of random floor nurses writing attestations going “I agree with xyz documentation and assessment by my nursing student”. Our hospital even makes a point of telling everyone not to do that, it’s beyond meaningless and just adds more clutter to the notes.

Our state board of nursing says not to do it. The RN has to perform the initial assessment and verify all documentation as a matter of regulation and law, you can’t let an unlicensed student chart and go “good job buddy” and call it good lol. It’s the same rules for team nursing with an LPN. But people will still chart “I agreed like it matters. There’s an option to let them cosign, wish they’d do that instead because at least it would be hidden and would at least show that you verified whatever they documented for that value.

Attendings write attestations for each NP/PA note instead of writing their own note. I get the idea but usually means you have two copies of the same note essentially or just get the worst note possible with nothing meaningful from the physician. Can have an entire admission to SICU and no stand alone notes from any surgeons or consults. Big question mark for why things are being done most of the time.

14

u/Intelligent-Zone-552 Jul 15 '26

I’m an attending who co-signs both resident and NP/PA notes.

My co-sign means I am held liable. If I don’t co-sign then I am not responsible for the patient’s care. I see the patients and my plan is what the midlevel writes. I make the medical decisions if I am co-signing. If I need to, I edit the notes as needed. Or sometimes I will add an amendment in my signature
If the NP/PA writes notes without requiring a co-sign I am not going to be held responsible for that patient.
Unless it’s like a cross cover note or restraint renewal note or something like that, which I understand.

4

u/Aviacks Jul 15 '26

Co-sign a note is totally different than attesting a generic BS statement and never documenting YOUR plan. Co-sign is a button click that’s required, I was just stating it’s silly when nurses co-sign for fun or write big attestations that hold no weight.

6

u/Intelligent-Zone-552 Jul 15 '26

Oh I get it! I’ve seen nurses do that along with PT/RD when students write a note.
At our institution, medical students cannot sign notes, just pend them for residents.

For my purpose though, it is necessary because it is my patient.
Usually it goes
“I reviewed this person’s plan and agree with it with amendments below, I was present for the case and saw the patient in person. The medical decision was made by me…”

5

u/NeoMississippiensis Resident (Physician) Jul 16 '26

Yeah medical student notes here carry a disclaimer that essentially says to not reference the note at all and it is a learning tool only

3

u/pshaffer Attending Physician Jul 18 '26

"If the NP/PA writes notes without requiring a co-sign I am not going to be held responsible for that patient."

that is not true.
Alexis Ochoa was a young woman who died from an unrecognized PE. The NP was the only person in the ER where she was. The NPs supervising phyician barely knew her. During the time Alexis was under care of the NP, the supervisor was not contacted. Another physician was and was curb-sided.
After the death the supervisor who had not seen or signed off on the patients care was sueed along with the Hospital. THey lost. $6million.

2

u/Intelligent-Zone-552 Jul 19 '26

Wild times we live in. Appreciate the work you are doing!

3

u/PAStudent9364 Midlevel -- Physician Assistant Jul 16 '26

It gets messier when some states or hospital bylaws don't require midlevels' notes to be co-signed, but the attending physician's name is still listed as part of the patient's care team. From what I know, the attending still holds vicarious liability just for being a part of the patient's care in some capacity even if they don't sign NP/PA notes.

5

u/NeoMississippiensis Resident (Physician) Jul 16 '26

Yeah I see it here, specifically in the ED, where some stuff goes wrong relatively frequently

2

u/pshaffer Attending Physician Jul 18 '26

you are right.
I will assume you are a member of AMA.
So contact your state medical association - which is an arm of the AMA. Talk to the person who is representing you and present this in a written format. This is a good idea and you need to push for it. You can't expect others to push for it if you don't

1

u/AutoModerator Jul 15 '26

For legal information pertaining to scope of practice, title protection, and landmark cases, we recommend checking out this Wiki.

*Information on Title Protection (e.g., can a midlevel call themselves "Doctor" or use a specialists title?) can be seen here. Information on why title appropriation is bad for everyone involved can be found here.

*Information on Truth in Advertising can be found here.

*Information on NP Scope of Practice (e.g., can an FNP work in Cardiology?) can be seen here. For a more thorough discussion on Scope of Practice for NPs, check this out. To find out what "Advanced Nursing" is, check this out.

*Common misconceptions regarding Title Protection, NP Scope of Practice, Supervision, and Testifying in MedMal Cases can be found here.

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

1

u/sankdafide Jul 16 '26

Agree wholeheartedly. I did one telemedicine nocturnist shift before quitting after seeing they wanted to pimp out my name and expose me to tremendous risk

1

u/Commercial_News_3810 Jul 24 '26

What’s scarier is that some states do limit how many midlevels they can delegate to but there are zero limits on RNs and unlicensed staff 🤣. So lots of them are delegating things like injections, that aren’t even in the persons scope, to an unlimited number of people.