Who's really in charge? Physician assistants and nurse practitioners are common in health care facilities. But how much responsibility do they have? If a patient is injured, you need to find out who--the midlevel provider, the supervising doctor, the facility, or all of them--is responsible.
Once upon a time, a person seeking medical care walked into a doctor's office, hospital, or clinic expecting to see a doctor who would perform the examination. Not anymore. Most patients seeking primary care today will leave the office, clinic, or hospital without ever being seen by a doctor. They will be examined, possibly get some tests and even a prescription or two, and be discharged with instructions from a midlevel provider mid·lev·el provider
A medical provider who is not a physician but is licensed to diagnose and treat patients under the supervision of a physician. .
The role of physician assistants and nurse practitioners--collectively called midlevel mid·lev·el
The middle stage or level, as in a series, course of action, or career. providers--in health care is growing. Once they gained statutory recognition and licensing, their ranks expanded to meet patient needs for health care--particularly in primary care, where physicians have become scarce. Health care facilities save money by employing midlevel providers to see patients in place of doctors, because the physician can bill for supervisory functions and still see and treat other patients. (1)
Not to be confused with medical assistants, who perform routine clinical and clerical tasks, physician assistants (PAs) are formally trained to provide diagnostic, therapeutic, and preventive health care services, as delegated by a physician. Working as members of a health care team, they take medical histories, examine and treat patients, order and interpret laboratory tests and X-rays, and make diagnoses. They also treat minor injuries by suturing, splinting splinting /splint·ing/ (splin´ting)
1. application of a splint, or treatment by use of a splint.
2. in dentistry, the application of a fixed restoration to join two or more teeth into a single rigid unit. , and casting. PAs record progress notes, instruct and counsel patients, and order and carry out therapy. In 48 states and the District of Columbia District of Columbia, federal district (2000 pop. 572,059, a 5.7% decrease in population since the 1990 census), 69 sq mi (179 sq km), on the east bank of the Potomac River, coextensive with the city of Washington, D.C. (the capital of the United States). , PAs may prescribe medications.
Nurse practitioners (NPs) are independent advanced-practice nurses who provide ambulatory, diagnostic, clinical, and primary care. NPs have graduate education and clinical training beyond their preparation as registered nurses. They are licensed to practice in all states and in the District of Columbia under statutes that define their scope of practice. (2)
Clinically practicing physician assistants and nurse practitioners are always supervised by physicians, and the number of PAs or NPs one physician can legally supervise is limited by statute. (3)
Formal training of midlevel providers dates back to 1965, when the University of Colorado University of Colorado may refer to:
recognition by an appropriate authority that the performance of a particular institution has satisfied a prestated set of criteria.
cattle herds which have achieved a low level of reactors to, e.g. , formal education programs and pass national exams to obtain licenses.
Full-time PA programs last at least two years. Most programs are in schools of allied health, academic health centers, medical schools, and four-year colleges; a few are in community colleges, the military, and hospitals.
All states and the District of Columbia have legislation governing the qualifications or practice of physician assistants. All jurisdictions require PAs to pass the Physician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants and open only to graduates of accredited PA education programs.
In 2005, more than 135 education programs for PAs were accredited or provisionally accredited by the American Academy The American Academy in Berlin is a non-partisan academic institution in Berlin. It was founded in September 1994 by a group of prominent Americans and Germans, among them Richard Holbrooke, Henry Kissinger, Richard von Weizsäcker, Fritz Stern and Otto Graf Lambsdorff and opened in of Physician Assistants (AAPA AAPA American Academy of Physician Assistants. ). More than 90 of these programs offered the option of a master's degree master's degree
An academic degree conferred by a college or university upon those who complete at least one year of prescribed study beyond the bachelor's degree.
Noun 1. , and the rest offered either a bachelor's or an associate degree. Most applicants to PA educational programs already have a bachelor's degree. More than 325 colleges and universities educate nurse practitioners, and more than 115,000 NPs practice across the country. (4)
Now, in the 21st century, midlevel providers' domain has expanded beyond primary care to every aspect of health care delivery in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . PAs and NPs practice not only in primary care specialties, such as general internal medicine, pediatrics, and family medicine, but also in areas such as emergency medicine, obstetrics, and geriatrics geriatrics (jĕrēă`trĭks), the branch of medicine concerned with conditions and diseases of the aged. Many disabilities in old age are caused by or related to the deterioration of the circulatory system (see arteriosclerosis), e.g. . PAs specializing in surgery provide preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
the preparation of a patient before operation. and postoperative care postoperative care,
n care after surgery or other invasive procedures, usually of a supportive nature. and may work as first or second surgical assistants. (5)
While the increased use of midlevel practitioners has had many salutary effects, extending access to health care and ostensibly os·ten·si·ble
Represented or appearing as such; ostensive: His ostensible purpose was charity, but his real goal was popularity. relieving physicians of ordinary primary responsibilities with patient care, it has also had dangerous and sometimes deadly results.
* Hospital emergency departments often delegate walk-ins to midlevel providers who are not supervised directly or consistently.
* Private family clinics use "sign-in logs" to separate patients who need or want to see a doctor from those who can see midlevel providers, leaving this clinical decision to the patient--the person least capable of making it.
* Surgeons use midlevel practitioners as assistants and then delegate follow-up responsibilities including ordering medications and determining when to discontinue them--to them. In some cases, surgeons effectively abandon their patients.
* In large measure, health care in prisons is provided almost entirely by PAs who are hesitant--because of budgetary pressures--to order testing or transport to a hospital, and whose supervision consists of having a physician review the charts weekly at most.
* Specialists depend on midlevel providers for monitoring and follow-up even in complicated medical cases, expecting them to alert the specialists to drug reactions, drug toxicities, and other complications that often exceed the midlevel provider's expertise.
In such instances, increased reliance on midlevel providers may result in patients receiving substandard care. For example, if a patient sees a midlevel provider without ever seeing the supervising doctor, the PA or NP may fail to recognize a significant sign--such as a drug toxicity or disease process--that results in injury. Reluctant to "overuse overuse Health care The common use of a particular intervention even when the benefits of the intervention don't justify the potential harm or cost–eg, prescribing antibiotics for a probable viral URI. Cf Misuse, Underuse. " imaging or diagnostic tests, a midlevel provider may choose not to order an essential chest X-ray chest x-ray,
n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease.
chest X-ray Chest film, see there , CT scan CT scan: see CAT scan.
See CAT scan. , or even a complete blood count test, thus overlooking the tools to diagnose pneumonia, embolism embolism
Obstruction of blood flow by an embolus—a substance (e.g., a blood clot, a fat globule from a crush injury, or a gas bubble) not normally present in the bloodstream. Obstruction of an artery to the brain may cause stroke. , tubal pregnancy tubal pregnancy
An ectopic pregnancy developing in the fallopian tube.
Pregnancy in one of the fallopian tubes. , or stroke. In a lawsuit alleging injury due to a midlevel provider's negligence, defendants may include the hospital or facility, supervising doctors, and the PAS and NPs themselves.
Standard of care
Midlevel practitioners' professional associations have developed as sources of knowledge, continuing education continuing education: see adult education.
or adult education
Any form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904). , philosophy, and advocacy. For example, the American Academy of Nurse Practitioners (AANP AANP American Association of Naturopathic Physicians. ) has formulated standards of practice and publishes an online journal. (6)
While associations of specialized PAs exist, the American Academy of Physician Assistants (AAPA) is the only national professional society that represents the interests of PAs in every area of medicine. Like the AANP, the AAPA has developed written standards and ethics.
Trial lawyers can use these organizations' standards to establish the standard of care for midlevel providers. For example, the first tenet of the AAPA's Statement of Values is: "Physician assistants hold as their primary responsibility the health, safety, welfare, and dignity of all human beings." (7) This tenet provides the basis for the question fundamental to liability: "Do you agree with the PA principle that any risk of serious injury or death is always unreasonable and always unacceptable if reasonable PA measures would either minimize or eliminate that risk?" This is the question upon which liability turns in every case. The standard of care rests on the availability of reasonable prevention measures.
Proof of liability
Each state has enacted enabling statutes that define and regulate the permissible activities of midlevel providers. These statutes prescribe the foundation and dimensions for establishing the liability of PAs and NPs, and doctors' duties of supervision. Typically, states regulate PAs and NPs by defining their scope of practice, requiring supervision by a licensed physician, requiring some level of written direction, and controlling the level of education required for licensure. (8)
Scope of practice. What a physician assistant or nurse practitioner is required to do depends considerably on the enabling statutes found in state law. Indiana's Physician Assistant Act, for example, explicitly makes a PA the agent of the supervising physician supervising physician Medical practice A licensed physician in good standing who, pursuant to state regulations, engages in direct supervision of physician assistants whose duties are encompassed by the supervising physician's scope of practice . (9) Midlevel providers are held to the standard of care applicable to the doctor. Thus, liability in any given case requires proof of the standard of care in the supervising physician's field. As a practical matter, this means not only including the supervising physician as a defendant, but also presenting expert testimony Testimony about a scientific, technical, or professional issue given by a person qualified to testify because of familiarity with the subject or special training in the field. by a physician in that field, as well as a midlevel provider.
In general, a physician assistant will see many of the same types of patients as the physician does. The cases physicians handle generally are more complicated or require care that is not routinely part of the PA's scope of work. For unusual or hard-to-manage cases, the PA may refer the patient to the physician or work in close consultation with the patient and the physician. Physician assistants are trained to know their limits and refer patients to physicians appropriately.
The Georgia Supreme Court's holding in Central Anesthesia Associates v. Worthy illustrates the extent to which the statutory definition circumscribes PAs' practice. (10)
During a tubal Tubal (t`bəl), in the Bible, son of Japheth. ligation ligation /li·ga·tion/ (li-ga´shun) the application of a ligature.
tubal ligation sterilization of the female by constricting, severing, or crushing the uterine tubes. , Brenda Worthy suffered cardiac arrest cardiac arrest
Abbr. CA A sudden cessation of cardiac function, resulting in loss of effective circulation.
A condition in which the heart stops functioning. and became comatose co·ma·tose
1. Of, relating to, or affected with coma.
2. Marked by lethargy; torpid.
comatose (kō´m under anesthesia administered by Bonnie Castro, an RN who was employed by Central Anesthesia Associates (CAA Caa
See CCC. ), a corporation of eight anesthesiologists, and enrolled as a senior student nurse anesthetist nurse anesthetist
A person who, after completing the basic education of a nurse, is further trained in the supervised administration of anesthetics. in the anesthesia school CAA operated at the hospital. Castro had written the anesthesia plan and conducted the preoperative consult, on which she placed the name of a CAA anesthesiologist Anesthesiologist
A medical specialist who administers an anesthetic to a patient before he is treated.
Mentioned in: Anesthesia, General, Appendectomy, Parathyroidectomy
anesthesiologist who later denied having seen or signed it. On the anesthesia record anesthesia record
A written account of drugs administered, procedures undertaken, and cardiovascular responses observed during the course of surgical or obstetrical anesthesia. , she wrote the name of another CAA anesthesiologist, who also denied any involvement.
In administering anesthesia by mask to Worthy, a deviation from acceptable care, Castro was supervised by David Krencik, a physician assistant also employed by CAA who had left the operating room operating room
n. Abbr. OR
A room equipped for performing surgical operations. for 10 minutes when the patient suffered cardiac arrest. The appeals court held that the nurse "had a duty not to practice medicine beyond what the law allowed" and that the PA "had a duty not to undertake and supervise her performance, as he was not authorized under the statute to do so. (11) The supreme court affirmed.
Where patient injury occurs in clinical instances such as that in Worthy, plaintiff lawyers can use the statute's limitations, AAPA guidelines, and the patient chart to show that the midlevel provider acted beyond the permissible scope of practice. This liability picture often involves clinic or hospital protocols specifying when the PA should refer the patient to the physician.
Statutes and protocols are not the only determinants of PAs' and NPs' scope of practice. The patient's consent or lack of it can determine whether midlevel providers practiced beyond their limits. The plaintiff lawyer should always examine whether the patient consented to being treated by a midlevel provider instead of a physician. In Worthy, the court pointed out that the hospital's consent form, which the patient had signed, clearly specified that the anesthesia would be supervised by an anesthesiologist.
Another case that demonstrates this concept is Sanborn v. Zollman. (12) In this case, the patient planning liposuction Liposuction Definition
Liposuction, also known as lipoplasty or suction-assisted lipectomy, is cosmetic surgery performed to remove unwanted deposits of fat from under the skin. surgery clearly crossed out provisions allowing assistants at surgery and specified that she wanted the surgeon to perform the surgery. The Sixth Circuit Court of Appeals held that she had stated a claim for battery when the clinic proceeded with the surgery using assistants.
Supervision. Although physician assistants and nurse practitioners work under a physician's supervision, a PA or NP may be the principal care provider in a rural, inner-city, or prison clinic, and a physician may be available only one or two days each week. However, some states require that the supervising physician or designee des·ig·nee
A person who has been designated. review the patient encounters within 24 hours. (13) In such cases, the midlevel provider confers with the supervising physician as needed as needed prn. See prn order. .
For example, in a remote clinic with an elderly patient complaining of intense abdominal pain Abdominal pain can be one of the symptoms associated with transient disorders or serious disease. Making a definitive diagnosis of the cause of abdominal pain can be difficult, because many diseases can result in this symptom. Abdominal pain is a common problem. accompanied by decreasing blood pressure, the midlevel provider who suspects an aortic aneurysm Aortic Aneurysm Definition
An aneurysm is an abnormal bulging or swelling of a portion of a blood vessel. The aorta, which can develop these abnormal bulges, is the large blood vessel that carries oxygen-rich blood away from the heart to the rest of the may immediately transport the patient to a hospital. The severity of the patient's condition may require the midlevel provider to summon the physician, confer with Verb 1. confer with - get or ask advice from; "Consult your local broker"; "They had to consult before arriving at a decision"
ask, enquire, inquire - inquire about; "I asked about their special today"; "He had to ask directions several times" the physician by phone, or even transport the patient to a regional facility. PAs also may make house calls or go to hospitals and nursing care facilities to check on patients, as long as they report to the physician afterward.
In a case involving a midlevel provider, the trial lawyer should identify the supervising and sponsoring physicians and the specific employer. For example, a typical interrogatory in·ter·rog·a·to·ry
Asking a question; of the nature of a question; interrogative.
n. pl. in·ter·rog·a·to·ries Law
A formal or written question, as to a witness, usually requiring an answer under oath. directed to any putative defendant--including the clinic, hospital, physician, and midlevel provider--would ask the following about a defendant PA:
* What was the physician assistant's date of hire?
* What is the name of the PA's supervising physician?
* How many other PAs were supervised by the same physician, and what are their names?
* How many patients were assigned to each PA?
* After patients were examined by the PA, were they also seen by the supervising physician before leaving the clinic?
* Did the supervising physician require that the PA confer with him or her as to each patient before the patient left the clinic?
* Was the PA required to retain each patient in the clinic until the supervising physician had signed the patient's chart?
The health care team concept can be an important theme in cases where the patient's care is shared by the physician and the PA. It can be central to proving liability and causation. According to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the AAPA's Statement of Values, "Physician assistants work with other members of the health care team to provide compassionate and effective care for patients." The AAPA's guidelines also address the PA's role and responsibility: "[T]he care that a PA provides is an extension of the care of the supervising physician.... Physician assistants have an ethical obligation to see that each of their patients receives appropriate care." (14)
Any medical negligence scenario involving a PA or NP requires investigating both the midlevel provider and the supervising, employing, and sponsoring physician. The PA is the physician's representative, treating the patient in the style and manner developed and directed by the supervising physician. This construct can help prove liability and causation for both the midlevel provider and the physician.
The AANP, the AAPA, and the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. (AMA (Automatic Message Accounting) The recording and reporting of telephone calls within a telephone system. It includes the calling and called parties and start and stop times of the call. ) endorse the idea of the health care team. In 1995, the AMA developed suggested guidelines for how physicians and PAs should work together to deliver medical care. The guidelines state, for example, that the physician is ultimately responsible for coordinating and managing patient care and ensuring the quality of health care provided to patients; the physician must be available for consultation with the PA at all times, either in person or through telecommunication systems or other means; and patients should be made clearly aware at all times whether they are being cared for by a physician or a PA. (15)
Rockefeller v. Kaiser Foundation The mission of the Kaiser Foundation is to assist individuals and communities in preventing and reducing the harm associated with problem substance use and addictive behaviours. External links
A verdict is generally directed in a jury trial where there is no other possible conclusion because the side with the Burden of Proof has not offered sufficient evidence to for the plaintiff on questions of whether the defendants committed negligence per se negligence per se (purr say) n. negligence due to the violation of a public duty, such as high speed driving. (See: negligence, per se) as a result of the PA's treatment of the plaintiff in the absence of a board-approved physician.
Written direction. Statutes permitting midlevel practice require explicit written direction, though the form may be a job description, guideline, protocol, or collaborative agreement. South Carolina's statutory provision is remarkable for its brevity: "Physician assistants may perform: (1) medical acts, tasks, or functions with written scope of practice guidelines practice guidelines Medical practice A set of recommendations for Pt management that identifies a specific or range of range of management strategies. See Peer review organization, Practice standards. Cf 'Cookbook' medicine. under physician supervision." (17)
Georgia's statutory scheme is more detailed. (18) The physician seeking to employ a midlevel provider files an application with the Composite State Board of Medical Examiners listing the supervising physician(s) for that PA and including the PA's job description. That written description, which must be filed with the board authorizing the use and delegation of the physician assistant, controls the general scope of permissible activity.
However, the job description still must be interpreted in the particular circumstances of a case. For example, the job description often contains broad statements authorizing the PA to "perform those routine medical treatments and diagnostic procedures for which he/she is qualified by training and which fall within the normal scope of practice of the supervising physician as delegated by the supervising physician." It may authorize the PA to "gather data on all new patients or established patients with new problems, to include a complete medical history and physical examination, medical record review, [and] appropriate initial diagnostic studies" and note that he or she "will be responsible for transmitting that information to the supervising physician(s) for review."
This language obviously requires further discovery to develop evidence showing, for example, what is routine, what is within the PA's training, and what the physician's normal scope of practice is. Frequently, these areas require expert testimony.
Cases raising the questions of whether the PA acted beyond his or her permitted scope of practice and whether the supervising physician failed to supervise the PA often concern sudden or unanticipated conditions where the physician may not even be present in the facility. The job description for the PA often provides a catchall catch·all
1. A receptacle or storage area for odds and ends.
2. Something that encompasses a wide variety of items or situations: delegation in these circumstances, such as: "Should a life-threatening emergency situation arise in the absence or unavailability of the supervising physician, the PA is authorized to initiate appropriate evaluation and treatment."
Again, the terms of the job description require evidence and interpretation in the specific case to help a jury determine whether the PA's training justified this delegation and whether supervision was appropriate under the circumstances.
The statutory requirements for PA and NP practice indicate directions for pretrial discovery pretrial discovery n. (See: discovery) . The trial lawyer should identify the level of education the PA or NP attained and obtain all the written contracts, job descriptions, (19) collaborative agreements, and specific protocols that were in force at the time of the alleged negligence. A typical interrogatory follows.
Identify each of the following that the defendant physician assistant was provided and/or was expected to use in managing the defendant's patients before January 20, 2003, and identify by whom each was provided or enforced:
* protocols used for examining the patient
* guidelines/protocols for assessing the patient's risk factors
* a checklist of necessary preoperative laboratory tests
* guidelines/protocols for charting
* circumstances requiring the PA to notify the physician of abnormal test results
* specifications requiring the PA to consult the physician immediately
* algorithm(s) for examining, assessing the risks of, evaluating, testing, clearing, and scheduling the specific type of patient
* written collaborative agreement(s) specifying the defendant PA's duties
* written position description specifying the defendant PA's job duties and responsibilities.
In addition to seeking answers to written interrogatories Written questions submitted to a party from his or her adversary to ascertain answers that are prepared in writing and signed under oath and that have relevance to the issues in a lawsuit. , discovery should include requests that the defendant facility, supervising physician, and midlevel provider produce
* any employment contracts or contracts for services between the defendant PA and the hospital, defendant surgeon, or defendant clinic
* each document, standard, guideline, protocol, collaborative agreement, policy, procedure, or other direction identified in answers to interrogatories
* each policy, protocol, or procedure manual; checklist; algorithm; or other handbook issued by the defendant's employer to the defendant PA directing physician assistant practices
* the defendant PA's job description in effect at the time of the incident.
The written protocol or job description required by statute is essential to defining the scope, responsibility, and potential liability of midlevel providers. (20) The Georgia Physician Assistant Act is a typical example in defining the job description. (21)
The midlevel provider's contract of employment with the clinic, office, or hospital is important because it can incorporate statutes and standards of practice by reference, making them part of the defendant's actual or constructive knowledge constructive knowledge,
n information and understanding derived from circumstances. of his or her own standard of care. Curricula, training programs, manuals, and handbooks frequently use written algorithms--flow charts showing graphic representations of complex processes, such as a differential diagnosis differential diagnosis
Determination of which one of two or more diseases with similar symptoms is the one from which the patient is suffering. Also called differentiation. of chest pain--for diagnosis and treatment.
Once established as reliable and authoritative, algorithms make excellent exhibits that graphically show the binary path of the correct decisions to be made at each point, based on diagnostic information such as chest X-ray, cardiac enzymes cardiac enzymes Lab medicine A group of 3 enzymes–AST, total CK, and LD, once used to diagnose and monitor suspected MI. See β enolase, Cardiac markers, CK-MB, Flipped pattern, Troponin. , and vital signs. The algorithms also show outcomes of decision pathways such as "administer oxygen," "monitor," and "admit"--making them useful not only for standard of care but also for causation.
Incentives. Many clinics, hospitals, and physician practices specify economic incentives for the PA or NP in their contracts. One common type of incentive is a bonus for exceeding a threshold number of patients processed monthly or quarterly. The trial lawyer should discover the process by which midlevel providers' performance is evaluated, especially the incentive system that encourages speed and volume without monitoring quality of patient care.
Another important aspect of midlevel practice concerns continuing professional training and keeping up with new diagnostic and treatment methods. Midlevel providers are required to earn continuing education credits each year for licensing. Exploring these subjects and the depth and breadth of the "classes" can be revealing. Sometimes the class is nothing more than an infomercial for a device or product, conducted by the seller. The defendant's actual or constructive knowledge about complications, signs requiring testing, significance of abnormal test results, and other tools for diagnosis--in the form of seminars, journals, and professional literature--provides important proof of liability.
A typical duces tecum [Latin, Bring with you.] Commonly called a Subpoena Duces Tecum, a type of legal writ requiring one who has been summoned to appear in court to bring some specified item with him or her for use or examination by the court. notice of deposition of the midlevel provider should ask for
* the most current curriculum vitae curriculum vitae CV, resume Medical practice A formal listing of a person's professional education, objectives, work history, including location and dates of service at a particular hospital, health care facility, university, the role filled at the time of service, , showing his or her background, training, employment history, and education
* all documents, reports, statements, records, literature, and tangible items that the witness reviewed in preparation for the deposition
* all documents, records, and tangible items evidencing the defendant's care for the patient in office and clinic
* the original of all medical records and personal notes pertaining to the patient that are in the defendant's possession, custody, or control
* the contract, job description, and collaborative agreement employing the defendant
* a list of CME CME
See: Chicago Mercantile Exchange
See Chicago Mercantile Exchange (CME). classes and any other training, workshops, or seminars attended by the defendant
* a list of all CME classes and any other training, workshops, or seminars specifically regarding the procedure and diagnosis at issue
* all professional articles in the field of physician assistant practice authored by the defendant
* all literature, research, or online searches concerning any issues in the case that the defendant reviewed for examination and treatment of the patient
* all literature, research, or online search materials that the defendant reviewed for the deposition
* each performance evaluation Performance evaluation
The assessment of a manager's results, which involves, first, determining whether the money manager added value by outperforming the established benchmark (performance measurement) and, second, determining how the money manager achieved the calculated return of the defendant's job performance by his or her supervising physician, clinic director, and any other person performing evaluation of the defendant's work for five calendar years before the incident at issue.
Trial lawyers concerned with preventing health care errors and encouraging safer patient care need to recognize and pursue midlevel providers' negligence. We must enforce the duties of the employing hospitals and the supervising and sponsoring physicians as more than rubber stamps. In doing so, we can develop the law of nondelegable duty of the hospital, clinic, and physician. We must enforce the requirement for written protocols and collaborative agreements--and hold midlevel practitioners to their own professional standards.
(1.) Charles L. Hudson, Expansion of Medical Professional Services with Nonprofessional non·pro·fes·sion·al
One who is not a professional.
nonpro·fes Personnel, 176 JAMA JAMA
Journal of the American Medical Association 839-41 (1961).
(2.) See the American Academy of Nurse Practitioners Web site at www.aanp.org.
(3.) See e.g. Mich. Comp. Laws Ann. [section] 333.17548 (West 2006). The number of PAs one physician can supervise varies among the states. Georgia, for example, allows one physician to supervise four PAs (Ga. Code Ann. [section] 43-34-103 (b) (2) (A) (West 2006)); South Carolina South Carolina, state of the SE United States. It is bordered by North Carolina (N), the Atlantic Ocean (SE), and Georgia (SW). Facts and Figures
Area, 31,055 sq mi (80,432 sq km). Pop. (2000) 4,012,012, a 15. limits one physician to supervising two PAs (S.C. Code Ann. [section] 40-47-955 (D) (2006)).
(4.) U.S. Bureau of Lab. Statistics, Occupational Outlook Handbook, 2006-07 Edition, www.bls.gov/oco.
(5.) Ruth Ballweg et al., Physician Assistant: A Guide to Clinical Practice 1-22 (3d ed., W.B. Saunders Co. 2003).
(6.) See J. Am. Acad. Nurse Pract., http://aanp.org/Publications/JAANP/JAANP.asp; see also The Nurse Practitioner, www.mpj.com.
(7.) Am.Acad. Phys. Assts., Guidelines for Ethical Conduct for the Physician Assistant Profession, www.aapa.org/policy/23-EthicalConduct. pdf, at 3.
(8.) See e.g. Mich. Comp. Laws Ann. [subsection] 333.17062, 333.17076, 333.17001 (West 2006).
(9.) Ind. Code [section] 25-27.5-5-3 (2001).
(10.) 333 S.E.2d 829 (Ga. 1985).
(11.) 325 S.E.2d 819, 824 (Ga. App. 1984).
(12.) 40 Fed. Appx. 916 (6th Cir. 2002).
(13.) See e.g. Ind. Code [section] 25-27.5-6-1 (2006).
(14.) Am. Acad. Phys. Assts., supra A relational DBMS from Cincom Systems, Inc., Cincinnati, OH (www.cincom.com) that runs on IBM mainframes and VAXs. It includes a query language and a program that automates the database design process. n. 7, at 4.
(15.) Am. Acad. Phys. Assts., Information about PAs and the PA Profession, www.aapa.org/geninfo1.html.
(16.) 554 S.E.2d 623 (Ga. App. 2001).
(17.) S.C. Code Ann. [section] 40-47-935, art. 7 (2006).
(18.) Ga. Code Ann. [section] 43-34-100-108 (West 2006).
(19.) See e.g. Ga. Code Ann. [section] 43-34-102(5) (West 2006).
(20.) See e.g. Ga. Code Ann. [section] 43-34-26.1 (West 2006).
(21.) Ga. Code Ann. [section] 43-34-103(5) (West 2006).
LINDA MILLER ATKINSON is a partner in Atkinson, Petruska, Kozma & Hart, which has offices in Gaylord and Channing, Michigan.