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Legal Insight - The Physician Assistant

By Linda Blythe, RN, CPHRM
Risk Management Consultant

Providing quality patient care in a timely manner and economical environment has always been a challenge. Greater utilization of the physician's expertise can often be achieved by effective delegation to a qualified physician assistant (PA). However, along with delegation comes an increased risk of liability when the PA's duties and responsibilities are misappropriated or overextended.

A Broadening Net
While the majority of medical malpractice claims are directed primarily at the physician, an increasing number of claims involve physician extenders under ever-increasing theories of liability. Nearly half of all malpractice claims contain one or more legal and associated issues. Vicarious liability, such as the liability a physician confronts for the acts of another, is among the most prevalent legal theories advanced. "Failure to Supervise" claims may involve several issues and are extremely difficult to defeat. These claims frequently relate to an episode of care that was directed independently by the physician extender without appropriate oversight of the supervising physician or absent defensible documentation to the contrary.

Defining the PA
Florida Statute 458.347(1)(e) defines Physician Assistant as: "[A] person who is a graduate of an approved program, or its equivalent, or meets standards approved by the boards and is licensed to perform medical services delegated by the supervising physician."
Supervision is defined as: "[R]esponsible supervision and control. Except in cases of emergency, supervision requires the easy availability or physical presence of the licensed physician for consultation and direction of the actions of the physician assistant."
(Note that the term "easy availability" includes access by way of telecommunication.)

The supervising physician must use the general principles adopted by rule of the Medical Board in developing the scope of practice of a physician assistant under both direct and indirect supervision.

Credentialing
Appropriate credentialing of the PA supports the provision of quality healthcare to patients. A consistently applied credentialing process also helps to avoid allegations of discrimination related to decisions to non-renew or limit the privileges of the PA. An effective credentialing process for all allied health professionals should include:

• A completed and signed application;
• A verified copy of:
  • Educational completion
  • Experience/training for specialty practice
  • Current licensure/certificates
  • CPR certification
  • Current professional liability insurance coverage
• A signed consent for checking an applicant's references;
• At least two letters of personal reference;
• Verified references from other facilities where the applicant has worked, including status of clinical privileges;
• A criminal background check, and
• Verification that an applicant's health status would not impede job performance.

Privileging
An appropriate PA privileging program should include:

• A written Collaborative Practice Agreement on file that names a supervising physician;
• Delineation of clinical privileges;
• Appropriate scope of patients to be seen by PA in the physician's office, as well as in the hospital, including:
  • The type of cases the allied practitioner can handle or manage without direct physician supervision
  • The type of cases or clinical situations and diagnoses that require direct supervision or physician consultation
• Approved pharmacology list for PA prescriptive service, and
• Clinical care guidelines or pathways that spell out specific protocols for clinical patient management. Such protocols should be signed by the supervising physician and the licensed physician assistant.

Some recommended limitations in the scope of cases include those patients in intensive care units, office patients with signs and symptoms of serious complications, such as chest pain, abdominal pain, or respiratory distress, as well as new office patients that are presenting with serious complaints, illnesses, or as fresh post-operative patients.

Recognition
Appropriate identification and recognition of the PA should include:

• Name tags and professional designation as physician assistant (never referring to the PA, or allowing a patient to refer to the PA, as "Doctor")
• Countersignature of supervising physician, along with physician's brief assessment and support of care plan, medication orders, or treatment plans
• That the entire office staff, physicians, and physician assistants acknowledge the title and are aware of the job description of the PA
• That the patient agrees to be seen by the PA and aware that he or she may see the physician instead

In an office practice, on hospital rounds, or in specialty areas such as surgery or interventional procedures, the expertise of a qualified physician's assistant can enhance and extend the skills of a physician. Appropriate delegation of PAs not only safeguards patients, but also the physicians who rely on them.