Malpractice Risks With NPs and PAs in Your Practice

Mark Crane


January 03, 2013

In This Article

A $217 Million Malpractice Case Involving a PA

The second-largest malpractice award in US history focused directly on how a medical practice credentialed and supervised a midlevel provider. Although the facts in the cases are unique, they can provide lessons for all physicians who work with PAs.

In 2007, a jury in Tampa, Florida, awarded $217 million, including $100 million in punitive damages, to a man whose cerebellar stroke was misdiagnosed as sinusitis at a hospital ED in 2000. The then-44-year-old mechanic presented with headache, nausea, dizziness, confusion, and double vision. He had a history of hypertension, diabetes, and elevated cholesterol and had a family history of stroke.

A midlevel provider ordered blood tests and CT without contrast, which were approved by the ED physician. Both were employed by a medical group that contracted with the hospital to run the ED. The first CT scan was negative for stroke, as was a second one done a few hours later with contrast. The ED physician didn't repeat the examination, history, or neurologic assessment. Instead, he relied on the extender's findings to diagnose "sinusitis/headache," the lawsuit said. The doctor prescribed a painkiller and an antibiotic and discharged the patient.

The next morning, the mechanic awoke with a severe headache, slurred speech, nausea, confusion, and trouble walking. He returned to the ED. A new CT scan showed that he had had a stroke. A shunt was inserted into his brain to relieve intracranial pressure, but the damage was irreversible. The man was left paralyzed and with mental disabilities. He remained in a coma for 3 months and spent the next 6 months at care facilities. He remains paraplegic.

The lawsuit alleged that the patient presented with classic stroke symptoms that the ED doctor should have detected. The crucial part of the trial involved the midlevel provider. It took 16 months before the medical group revealed his name, describing him only as an "expediter" who served as a note-taker, or scribe, to help the ED doctors. When lawyers deposed him, they learned that he was an unlicensed PA, having failed the state licensure test for PAs 4 times. He denied during depositions that he performed patient examinations.

The ED physician testified that he'd assumed the midlevel was a licensed PA and that he didn't need to redo the history and examination. The doctor and his medical group blamed each other. The doctor said he would have redone the examination if he'd known that the expediter was unlicensed. The medical group's leader said it was the doctor's responsibility to ask the expediter about his status.

There had been no written guidelines for what the midlevel provider was authorized to do. "This group created this system that was ripe for mishap, to push more people through the ED so they could increase profits," said plaintiff's attorney David Dickey. "Instead of hiring a real PA or another ED doctor, they used the midlevel to save money."

The jury was clearly outraged, finding that the group had tried to conceal the midlevel's involvement from the plaintiffs and placed profits over patient safety.

Lawsuits involving midlevel providers are likely to grow as their numbers expand and their scope of practice increases owing to pressure from the doctor shortage and the Affordable Care Act. They can provide a tremendous benefit to your practice -- if you follow established protocols about supervision, say risk managers.