Medical-Malpractice Risks & Legal Liability of Non-Physician Provider Care
With healthcare costs rising each year at ~5% per year 1, there is a push by insurance companies, hospital boards, and governments to reduce costs. A recent trend over the past decade in the United States is to employ the use of Nurse Practitioners (NP) and Physician Assistants (PA), instead of using licensed physicians.
The rationale for using NPs and PAs is to provide primary healthcare services in a timely manner while reducing the costs associated with patient treatment. This has resulted in a change of healthcare delivery from the inpatient hospital location to the outpatient office environment2.
DISCLAIMER: Dr. Dalawari shares interesting and relevant medical-legal news in the press. He also shares case verdicts & settlements from the public record. He has no professional or personal relationship to the cases.
Medical Malpractice, Legal Liability, Licensed Physician, Nonphysician Provider, Nurse Practitioners, Physician Assistant, Medical Expert Witness, Medical Lawsuits.
At a glance
Statistics show an increasing trend since 2010 toward the use of Nurse Practitioners (NPs) and Physician Assistants (PAs).
- Trends of Utilizing NPs and PAs for Primary Healthcare Services
- General Medicine Risks Associated with NPs and PAs
- Patient Cases Under the Care of a Nonphysician
- Nonphysician Supervision of Medical Procedures
- Malpractice and Liability Issues with Nonphysician Care
Conclusion: Increased use of NPs and PAs is likely to increase the risk of medical malpractice and liability issues for many facilities. This proliferation of medical lawsuits will necessitate the use of a medical expert witness.
Trends of Utilizing NPs and PAs for Primary Healthcare Services
In the United States, it is estimated that 270,000 NPs and over 131,000 PAs are in current practice2.
The trend has been increasing each year since 2010
when the adoption of the Patient Protection and Affordable Care Act (PPACA) became the law2.
The American Association of Medical Colleges (AAMC) approximates a physician deficit of approximately 122,000 physicians by 2035 in the United States2
With this background information, it makes sense for advocates of primary healthcare reform to applaud the ever-increasing numbers of NPs and PAs in the marketplace.
However, serious questions are being raised by patient care advocates and professional organizations pertaining to the consequences of this trend.
- Are the online teaching programs for NPs and PAs adequate when compared to the rigorous years of supervised training for licensed physicians?
- Do the cost savings and looming physician shortage justify lowering the quality, safety, and efficacy when using NPs and PAs for routine and complex medical consultations?
- Does more timely access with a nonphysician provider mean substandard patient-reported outcomes?
- What are the medical malpractice risks and the legal liability associated with using NPs and PAs for primary healthcare services which are traditionally provided by licensed physicians?
General Medicine Risks Associated with NPs and PAs
The data in the literature is mixed when reviewing the scope, quality, safety, and outcomes for medical procedures and consultations provided by NPs and PAs.
Some advocates for the increased utilization of NPs and PAs point to the benefits of more access to timely care, reduced costs for patients, and freeing up time for specialists like Cardiologists.
However, beneath these surface benefits there lies a tangled web of medical malpractice risks and liabilities which may not be known by the broader healthcare community.
Among NPs, PAs, and physicians for routine patient examinations, the quality of care seems comparable, but indications are diminished for patients with several comorbidities 3.
Growing the scope of practice for nonphysicians may reduce healthcare costs for Medicare, but there is a deficiency of robust research evaluating the economic repercussions of replacing physicians with nonphysicians4.
Difficulties persist concerning the productivity, economic savings, and the quality of care delivered by NPs, PAs, and physicians in a diverse acute care environment and amid patients with complex healthcare needs5.
In 2019, NPs were authorized to practice medicine in 23 states while not under the supervision of a licensed physician6.
This has led to a proliferation of online NP schools where some states require a minimum of 500 hours of training6. Compare this to the ~15000 hours of training a licensed physician must have in order to promote the best possible outcomes for patients6.
The Center for Disease Control (CDC) estimates that 213 million adults will have an interaction with a healthcare professional6.
These statistics reveal the growing divide between who and how primary healthcare services are being delivered to vulnerable patients.
Many patients may be unaware of the improper medical advice given by a nonphysician provider, who may not have the knowledge, skills, and training to give the best possible medical consultation.
Patient Cases Under the Care of a Nonphysician
A patient named Brad Guilbeaux visited a nurse practitioner named Kevin Morgan in 20156.
The NP ordered blood tests, and the patient showed normal levels for the thyroid gland and testosterone. The patient wanted more vitality, so the NP prescribed testosterone and thyroid medication for the next 18 months6.
The NP, who trained in an online program, was not aware that these medications, in excess, could cause an increased risk of a cardiac event.
Unfortunately, the patient died of cardiac arrest due to excess hormone therapy on Feb 23, 2017, 6. The Nurse Practitioners license to practice was rescinded in Dec 2017, as the Texas Board of Nursing concluded that the NP caused another death, and harmed 10 others by overprescribing medication6.
Another patient was a 19-year-old female named Alexus Ochoa-Dockins, who was transported to the Mercy El-Reno hospital emergency room with chest pain and difficulty breathing on Sept 27, 2015, 6.
She was seen by an NP named Antoinette Thompson, who graduated in Dec 2014 from an online master’s course which required a minimum of 500 hours of clinical experience6.
The NP in this case allegedly had no prior nurse practitioner experience in the emergency room, when she was hired in Jan 20156.
The young woman with a suspected pulmonary embolism was now in the care of an NP with less than one year of experience6.
These cases highlight the dangers and pitfalls for some patients who see an NP or a Physician Assistant in an urgent care or emergency situation.
Nonphysician Supervision of Medical Procedures
For several decades, the standard exercise test to evaluate coronary artery disease (CAD) has been utilized as a diagnostic procedure with staffing concerns that have altered over a period of years7.
Historically, physicians supervised this testing, but medical surveys and data from exercise laboratories confirm that physical therapists (PTs), exercise physiologists (EPs), nurse practitioners (NPs), and physician assisstants (PAs) are routinely overseeing this procedure.
Although the safety and efficacy of the exercise test are comparable in laboratories where physicians and non-physicians administer testing, there are currently no consistent standards for how this exercise test supervision by nonphysician providers is administered7.
The lack of coordination and standards can adversely expose licensed physicians and hospitals, who utilize nonphysicians, to malpractice litigation if a misdiagnosis or advent event occurs.
Medical Malpractice and Liability Issues with Nonphysician Care
Employing nonphysician providers may improve access to medical treatment and increase efficiency, but at what cost?
It can get complicated by adding a supplementary level of accountability and potential liability for licensed physicians8.
Some faults which have been recognized in legal cases against nonphysician providers encompass9:
- Deficient patient check-up, which may be to linked to a hasty exam and/or patient consultation.
- A botched diagnosis, in which the nonphysician may be hesitant or misconstrue data about the patient condition.
- Absence of a suitable transfer of care to a licensed physician, where the nonphysician may endeavor to remedy complicated medical conditions beyond their skill or training level.
- Negligent falsification by a nonphysician, where no disclosure is made to the patient who may be credibly ignorant about the caregiver’s credentials.
- Insufficient supervision, in which responsible physicians neglect to properly oversee nonphysician practitioners, with an increased occurrence in broader physician organizations.
The increased use of NPs and PAs may increase the risk of medical malpractice and liability issues for hospitals and private outpatient facilities.
This proliferation of medical malpractice lawsuits each year in the United States necessitates the use of an expert witness. These medical expert witnesses are licensed physicians who provide credible testimony and evidence in a court of law.
Attorneys should utilize medical expert witnesses to convey the truth about the competencies, skills, and judgment required to assess and perform medical procedures.
Having a medical expert will give a judge or jury the clear, concise, and concrete facts to render a fair judgment for the plaintiff who may have suffered under the care of a nonphysician provider.
DISCLAIMER:Dr. Dalawari shares interesting and relevant medical-legal news in the press. He also shares case verdicts & settlements from the public record. He has no professional or personal relationship to the cases.
References - Sub-Title (h3)
1. Trends in health care spending. American Medical Association website.
https://www.ama-assn.org/about/research/trends-health-care-spending. Published 2018. Accessed February 2020.
2. The scope of practice and medical professional liability. SVMIC website. https://home.svmic.com/resources/newsletters/209/the-scope-of-practice-and-medical-professional-liability. Published September 2019. Accessed February 2021.
3. Sarzynski E, Barry H. Current evidence and controversies: advanced practice providers in healthcare. The American Journal of Managed Care. 2019;25:8
4. Martínez-González NA, Djalali S, Tandjung R, et al. Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. BMC Health Serv Res. 2014;14:214. https://doi.org/10.1186/1472-6963-14-214
5. Rich EC. Advanced practice clinicians and physicians in primary care: still more questions than answers. Ann Intern Med. 2016;165(4):290-291. https://doi.org/10.7326/M16-1326
6. Al-Agba N, Bernard R. Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare. Boca Raton, USA: Universal-Publishers; 2020. http://www.bookpump.com/upb/pdf-b/7343164b.pdf
7. Myers J, Forman DE, Balady GJ, et al. Supervision of exercise testing by nonphysicians: a scientific statement from the American Heart Association. Circulation. 2014;130:1014–1027. https://doi.org/10.1161/CIR.0000000000000101
8. Moses RE, Feld AD. Physician liability for medical errors of nonphysician clinicians: nurse practitioners and physician assistants. Am J Gatroenterol. 2007;102(1):6-9. http://www.ncbi.nlm.nih.gov/pubmed/17266683
9. Scope of Practice Laws for Nurse Practitioners and Physician Assistants. ECRI website. https://www.ecri.org/components/PPRM/Pages/LB5.aspx?PF=1&source=print. Published Jan 2015. Accessed Feb 2021.