|by Jock Hoffman, Managing Editor for Patient Safety, CRICO|
The shortage of primary care physicians (PCP) in the U.S., paired with the drive to lower costs, is challenging access to health care. One idea increasingly advocated is granting greater responsibility and independence for the burgeoning population of nurse practitioners (NP). Scope-of-practice laws vary widely by state—from tight restriction to full independence. Physicians opposed to full independence argue, however, that that solution will bring the level of care those patients receive below a tolerable standard.
Is this just a turf battle or a patient safety debate?
Unfortunately, any focus on potential risks posed by mid-level providers (NPs, physician assistants, etc.) detracts attention from their predominately positive role in patient safety. In conjunction with increasing access to care, non-physicians are often able to perform tasks that physicians too short on time simply can’t get to: updating histories, checking medications compliance, listening to secondary complaints, providing education, etc. These activities enhance the quality of care—especially in communities with PCP shortages. Those interactions also reduce the likelihood of miscommunication, missed appointments, fumbled test results, unresolved complaints, and myriad other issues that often presage an adverse event and a malpractice allegation.
Certainly, a patient whose needs exceed the capabilities, comfort level, or authority of a non-physician should be seen by a physician as soon as possible. Establishing and enforcing the criteria for such escalations is essential to protect both patients and providers. Indeed, those criteria are the focus of the debate about whether or not expanding the practice scope of mid-level providers increases their patients’ vulnerability to misdiagnosis or mismanaged treatment.
Whatever rules are in place, not all patients will fully comprehend the capabilities or limits of a non-physician they see in their doctor’s exam room or the Emergency Department or an in-store clinic. Quickly and sincerely addressing the concerns of such patients will help reduce misaligned expectations. Of course, mid-level providers are not immune to being named in malpractice claims, and those who supervise them, generally speaking, will also be held accountable for their care.
CRICO’s data indicate that since 2002, 75 malpractice claims or suits named 83 NPs or PAs as defendants,* a rate of about one defendant per 200 practitioners per year. Analysis of those 75 cases indicates that inadequate supervision of the mid-level providers was identified in 19 (25%). The average incurred loss for cases involving mid-level provider defendants was $330,000.
Supervising physicians are obliged to know (and share) what risks these arrangements may pose to their patients and practice. Mid-level providers without independent access to patient safety-related education will be reliant on their colleagues and supervising MDs for alerting them to common hazards and practice-specific concerns. As with most learning situations, point-of-care guidance and training will have a longer-lasting impact. Physicians and those they supervise who establish in situ opportunities to address known or potential risks will likely fare better than those who leave this to chance or individual motivation.
*Mid-level provider defendants who are employed by a CRICO-insured organization receive the same level of coverage and full complement of benefits afforded to CRICO-insured physicians.