A Sign of the Future . . . Maybe . . . Maybe Not

[LT_Oneal_PAC]

I guess you missed it the first time... so I'll repeat.

 

Plantiff Lawyers would have a field day with this... because LEGALLY as in written in the PA practice laws, the word "SUPERVISE" is used for PAs (and in some states for NPs also). There is NO way to change the definition of "supervise" therefore there is no way to change the responsibilities of and what is required of one who "supervises."

Simply put... a "supervisor" IS responsible for the work that they supervise.

 

That is why there is a growing movement to change the terminology used in the practice acts from "supervise" to "collaborate." Because "collaborate" would mean that we have to work with physicians but does NOT add the burden of liability since one is NOT responsible for the work of those they collaborate with.

 

This would be the first step to erecting that "firewall" JmJ11 is talking about.

Example:

 

You can "collaborate" with me to bake a cake by giving me a few eggs and the recipe.

Now if I screw it up and the cake turns up crappy... its all on me.

 

Now if you "supervise" me baking a cake and I screw up the cake.

WE SCREWED UP THE CAKE because as my supervisor, you were ultimately responsible for the outcome of the cake.

 

Just a few thoughts...

 

I get it and heard it, just don't agree. If the word "supervision" would be a field day for plaintiff lawyers, why hasn't this happened with PAs working offsite? Sounds like as much of a legal mine field as anything else. But I'll err on the side of caution and defer to you and your experience, as a student I can't do much about it anyways.

 

BTW, I'm not saying this should be a priority over the name change or over anything really. I just think it can be done.

[Contrarian]

If the word "supervision" would be a field day for plaintiff lawyers, why hasn't this happened with PAs working offsite? Sounds like as much of a legal mine field as anything else...

 

Umm... it has.

The typical SP that gets sued due to a poor outcome secondary to the actions of a NPP that they were suppose to be "supervising" is "offsite" from the NPP or was simply off work or out of contact with the NPP on the day in question... so the NPP didn't consult. Now the SP is on the hook for the NPPs actions or inaction.

 

This also plays into why in some states, PAs CAN NOT legally work "offsite" until they jump through a couple hoops and is by written state special permission ONLY.

And other states set a requirement on the % of time a PA and their MUST be onsite at the same time.

[physasst]

How could it be argued that a physician should be held liable for those decisions?

 

You need to read up on vicarious liability, and specifically, the concept of "respondeat superior".

 

Just to be clear, the Physician's Insurers Association of America conducted a national review of closed claims (1985-2004) against PAs. They found that across all specialties, the most common reason for a lawsuit was "diagnostic error". When they did the post hoc root cause, however, this was attributed in most cases to "inadequate supervision".

 

http://www.apacinsurance.com/pdf/Physician%20Extenders.pdf

The most prevalent medical condition involved in claims attributed to PAs was acute myocardial infarction, most often due to a failure to diagnose. The most prevalent type of procedure involved the failure to render treatment. Although both the majority of claims and the greatest number of paid claims were made in general and family practice, the highest average indemnity payment was made on behalf of PAs in the specialty of neurosurgery. The highest average indemnity payment by type of misadventure was for the delay in performance (of a procedure) or treatment. However, the most prevalent treatment for which claims were made against PAs involved the prescription of medication.

The primary root cause of malpractice claims involving physician extenders and attributed to failure and delay in diagnosis is a lack of physician supervision. Contributing factors include misinterpretation of information provided by the patient to the PE, often as a result of the PE’s lack of skill in diagnosing and managing the case. To reduce this exposure, protocols should clarify that, in those situations where the PE is uncertain about the assessment of the patient or if the patient’s condition does not follow the customary or anticipated course, supervising physician should be promptly consulted. The importance of documenting the patient’s clinical symptoms with specificity cannot be overstated. Successfully defending failure and delay in diagnosis claims often depends on supporting the PE’s clinical rationale in the face of otherwise silent clinical symptomology.

 

You have to remember....as a PA, we are working UNDER the auspices of our physicians license. They delegate prescribing authority and everything else that you do. Respondeat superior really means and defines a "master-servant" relationship. It is frequently cited in cases of tort involving PAs.

 

You don't have to like that. But that's the way it is. If your supervising physician says that you cannot do something, even if you are educated and qualified to do so, you cannot do it.

[Contrarian]

Physasst... thanks for that...

 

Now please elaborate on how/if this is different from "collaboration."

[physasst]

Physasst... thanks for that...

 

Now please elaborate on how/if this is different from "collaboration."

 

It's not as clear with NPs, the term "collaboration" doesn't really mean that there is no vicarious liability for the physician. In fact, if they are working with a physician in a collaborative relationship, my understanding is that the courts treat it just like they would with a PA.....the question is the NP that is truly practicing independently...not sure on that. This seems like a good source of info...

 

http://www.mlmic.com/portal/files/Dateline/DatelineFall2010.pdf

Nurse practitioners (NPs) are somewhat different. In addition to performing the duties of a registered nurse, an NP may also diagnose illnesses and physical conditions, and perform therapeutic and corrective measures, so long as the NP’s services are performed in collaboration with a licensed physician according to a written practice agreement and written practice protocols that comply with

statutory requirements. An NP can practice independently and does not need to be supervised by a physician. The nature of the collaborative relationship was examined in the case of Quirk v. Zuckerman. The court stated that while the term “collaborate” was not legally defined by statute, its common meaning was, in essence, teamwork. More specifically:

[t]he nature of the relationship which constitutes collaboration is rather left to the proviso that all

services be performed in accordance with a written practice agreement and written practice protocols which

shall contain explicit provisions for the resolution of disputes between the nurse practitioner and the collaborating

physician …. However, the statute is clear that if the written agreement does not so provide,

then the collaborating physician’s diagnosis or treatment shall prevail if there be any conflict in diagnosis.. . .

Therefore, the ultimate responsibility for diagnosis and treatment rests with the physician if the written

agreement is silent.

Thus, physicians can be exposed to direct liability as a result of their collaborative relationships with NPs. The written practice agreement between the NP and the collaborating physician is critical in managing this liability. Unless the written agreement provides otherwise, the collaborating physician’s diagnosis or treatment will prevail over that of the NP. In that case, the ultimate responsibility

for diagnosing and treating the patient will rest with the physician. The facts of Quirk v. Zuckerman illustrate how direct liability may be imposed. In that case, the court found that the cooperation and teamwork between a physician and an NP created a physician-patient relationship, even though the physician did not perform a physical examination on the plaintiff.

[Contrarian]

Great... which is also my understanding of the liability with collaboration in states that REQUIRE it for NPs to practice.

 

So now with the two above explainations... please expound on how it would/could be different for a NP in a state (like WA which is where this discussion is about) that does not REQUIRE "supervision" or "collaboration" of NPs.

 

Where Physicians or healthcare organizations/hospitals can hire them as independent providers and treat them just as they would if they had hired another physician (but pay them less) because they are considered "independent" providers not REQUIRED to collaborate, consult, or be supervised.

 

Thanks in advance...

[physasst]

Great... which is also my understanding of the liability with collaboration in states that REQUIRE it for NPs to practice.

 

So now with the two above explainations... please expound on how it would/could be different for a NP in a state (like WA which is where this discussion is about) that does not REQUIRE "supervision" or "collaboration" of NPs.

 

Where Physicians or healthcare organizations/hospitals can hire them as independent providers and treat them just as they would if they had hired another physician (but pay them less) because they are considered "independent" providers not REQUIRED to collaborate, consult, or be supervised.

 

Thanks in advance...

 

Of course it's different. I've never said that it wouldn't be. But simply changing our term from supervision to collaboration wouldn't change the issue of vicarious liability.

 

Unless we can develop and create a "State Board of Physician Associate/Assistant Practice" in all 50 states that is outside the purview of the Medical Board......(never going to happen in a million years) we will ALWAYS be dependent providers. That's our job. That's what the job is.

 

What I would like to see, is a reduction in the paperwork requirements for hiring a PA. In my previous role in supervision, I hired both PAs and NPs, and I have to be honest, hiring an NP was a LOT easier with regards to the paperwork needed. It was much easier. I could see how it would be tempting to JUST hire NPs. That is a problem that could possibly be addressed with the FSMB.

[Contrarian]

Of course it's different. I've never said that it wouldn't be. But simply changing our term from supervision to collaboration wouldn't change the issue of vicarious liability.

 

Nor did I suggest that YOU said it wouldn't be.

But I Agree... which is why I wrote:

 

This would be the first step (with several others to follow) to erecting that "firewall" JmJ11 is talking about.

 

 

So for clarity...

 

In my mind, we would need to:

 

1.) Change the name from "Assistant" to "Associate."

Because "assistants" MUST have someone to "assist" and this usully means that the person they "assist" is in charge and therefore responsible for their actions/inaction... comissions/omissions.

 

2.) Change the verbiage from REQUIRED "Supervise/Supervision" to REQUIRED "Collaboration."

 

3.) Then later remove the "requirement" of collaboration altogether so that its optional.

 

As should be obvious... the above would/should open the door wide for PA independence in Primary Care and still allow for specialty utilization and inpatient practice in most cases when in collaboration with a Physician.

 

 

I'd even like to see it done in a stepwise fashion with milestones achieved granting one more independence.

 

 

Something stepwise like:

 

New Grad PA-C years 1-6 = "Assistant Status" which requires "supervision"

PA-C years 6-12 = "Associate Status" which then requires "collaboration"

PA-C years 12+ With CAQ = "Associate Status" with no requirements of collaboration."

(Is optional for specialty care)

 

Just a few thoughts...

[Contrarian]

What I would like to see, is a reduction in the paperwork requirements for hiring a PA. In my previous role in supervision, I hired both PAs and NPs, and I have to be honest, hiring an NP was a LOT easier with regards to the paperwork needed. It was much easier. I could see how it would be tempting to JUST hire NPs. That is a problem that could possibly be addressed with the FSMB.

 

Un-huh...

 

There is a movement NOW, here in this state seeking a change that would basically remove the requirement of a practice and PA to have to "submit" paper work to the state "and wait" for approval before a PA can begin practice.

 

Basically, this would be a change from seeking approval to one of notification and all the details of the "practice plan" would reside at the practice level and be available for inspection/audit if requested by the state.

 

So instead of a PA-C being offered a job, then filling out the practice plan, getting the SP and Alternates signatures, sending it to the State Medical Board, waiting for them to send it back Approved, then starting practice... the PA can accept the offer today, fill out the form, fax a copy to the State and stick the original in a file cabinent and go see patients TODAY...

 

Its making its rounds now... so we will see how it goes.

[Michael Palmer]

In the state i live N.P. cannot prescribe any controlled substances, P.A,'s have 3-5 rights.This really has restricted the N.P.'s from job offers other than primary care.The only cough med. they can prescribe is a liquid promethazine option.

[jmj11]

Un-huh...

 

There is a movement NOW, here in this state seeking a change that would basically remove the requirement of a practice and PA to have to "submit" paper work to the state "and wait" for approval before a PA can begin practice.

 

Basically, this would be a change from seeking approval to one of notification and all the details of the "practice plan" would reside at the practice level and be available for inspection/audit if requested by the state.

 

So instead of a PA-C being offered a job, then filling out the practice plan, getting the SP and Alternates signatures, sending it to the State Medical Board, waiting for them to send it back Approved, then starting practice... the PA can accept the offer today, fill out the form, fax a copy to the State and stick the original in a file cabinent and go see patients TODAY...

 

Its making its rounds now... so we will see how it goes.

 

That would be a big help. I started the process of hiring an out-of-state PA in March. I just got his license completed about two weeks ago (the FBI background check alone took four months) now I start the process of getting him credentialed with the insurance companies, which will take another four months. I needed him in two weeks from now and I thought I had plenty of time (7 months) but it will end up taking at least 9.

[Hemegroup]

Nor did I suggest that YOU said it wouldn't be.

But I Agree... which is why I wrote:

 

 

 

 

So for clarity...

 

In my mind, we would need to:

 

1.) Change the name from "Assistant" to "Associate."

Because "assistants" MUST have someone to "assist" and this usully means that the person they "assist" is in charge and therefore responsible for their actions/inaction... comissions/omissions.

 

2.) Change the verbiage from REQUIRED "Supervise/Supervision" to REQUIRED "Collaboration."

 

3.) Then later remove the "requirement" of collaboration altogether so that its optional.

 

As should be obvious... the above would/should open the door wide for PA independence in Primary Care and still allow for specialty utilization and inpatient practice in most cases when in collaboration with a Physician.

 

 

I'd even like to see it done in a stepwise fashion with milestones achieved granting one more indendence.

 

 

Something stepwise like:

 

New Grad PA-C years 1-6 = "Assistant Status" which requires "supervision"

PA-C years 6-12 = "Associate Status" which then requires "collaboration"

PA-C years 12+ With CAQ = "Associate Status" with no requirements of collaboration."

(Is optional for specialty care)

 

Just a few thoughts...

 

.............................yup. i think there might be some additional per prior experience, but yup.