It is no wonder that after the Medicare and Medicaid programs were signed into law on Jul. 30, 1965, under President Lyndon B. Johnson, that a massive expansion in health care ensued and that physician assistants (PAs) came into existence. In 1965 at Duke University, Eugene A. Stead Jr., M.D., established the first physician assistant program.
As of 2005, there were more than 65,000 PAs in practice and 134 PA programs in operation.1,2,3 In addition, more than 1,000 PAs worked in dermatology as of 2002, according to the American Academy of Physician Assistants — a number that is sure to have grown over the last 4 years.
The laws governing employment of PAs greatly vary. In this column, I will discuss the variations from state to state, such as the number of PAs a doctor may supervise, the training a PA can have, and whether a PA can prescribe medications.
In later articles, I will discuss medical assistants, nurse practitioners (NPs) and nurses (other physician extenders), positions whose legal status overlaps with that of PAs.1-10
How Are They Defined?
In the United States, PAs are medical practitioners licensed to practice medicine under a physician’s supervision. PAs can see patients without a physician present, but they must be supervised. The supervision that PAs need takes different forms and does not have to be direct, as I will further discuss.
PAs are different from medical assistants, who do not have the specialized training that PAs possess. PAs have completed an accredited PA education program and (usually a 2-year program) taken the certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA). All states recognize the provision of care by PAs. The PA licensure is independent of supervisory arrangements, and employment registration requires a licensed supervising physician.
By state law, PAs must practice under an agreement with and the supervision of (direct or indirect) a supervising physician.
For example, the Code of New York statute clearly notes that “. . . [m]edical acts, duties and responsibilities performed by a registered [PA] . . . must:
1. be assigned to him by the supervising physician.
2. be within the scope of practice of the supervising physician.
3. be appropriate to the education, training, and experience of the registered physician assistant or registered specialist’s assistant.”10
What does this mean from a practical standpoint? For one thing, PAs cannot practice beyond their level of expertise. That is, there is conduct that can be provided by PAs that when performed under the direction and supervision of a licensed doctor, are legal, but which, without such direction and supervision, are the illegal practice of medicine or surgery subjecting the physician to discipline by the state’s medical board. 1,2
Scope of Practice of PAs
The scope of practice of PAs is wide and includes: taking histories, performing physical exams, ordering and/or performing diagnostic and therapeutic procedures, formulating working diagnoses, developing and implementing treatment plans, monitoring the effectiveness of therapeutic interventions, assisting at surgeries, offering counseling and education, and making referrals.
However, PAs may not perform any medical service, procedure, function or activity that is not approved by the licensing board for PAs and physicians. 1,2
Dermatology PAs specialize in areas such as acne, psoriasis, phototherapy HIV, and cosmetic dermatology. They can perform sclerotherapy, operate lasers and inject Botox. They can also assist during surgical procedures, such as Mohs.
As long as PAs act within their mandate, they can examine, diagnosis and treat patients independently without a physician even being located onsite. Because this supervision, in most cases, need not be direct or onsite, many PAs practice in remote or underserved areas in satellite clinics.
In most states, PAs prescribe medicine, and in some states they have their own DEA number, which authorizes them to prescribe controlled medications such as narcotics. In some states, PAs in surgical practices can also serve as first assistants in surgery. These providers are are reimbursed under Medicare and third-party insurances. 1,2
The scope of activity of PAs is substantial — 44 states allow PAs to prescribe controlled substances. (See Tables 1A -1D for more detail.)
Moreover, nurses must accept appropriate PA orders. In Washington State, a court ruled that nurses were not exposed to increased liability when following the orders of a PA being supervised by a doctor because the supervising physician could not disclaim responsibility for medical orders written by the PAs.8
A Financial Leg up for Practices
In 2000, Clark3 noted data from the National Ambulatory Medical Care Survey (NAMCS) that PAs see many patients (2.8 million) with dermatologic symptoms but that the NAMCS data indicate that most (72%) of these patients are also seen by a physician.
Despite this rate of duplicity, using PAs has clear advantages for cost-effectiveness. Clark noted that in a 1998 survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:13 Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. In addition, PAs can cover satellite offices, allowing for practice expansion.3
Core Laws Governing PAs
The legal doctrine that is the most important in “PA law” is that of respondeat superior (RS), Latin for “let the master answer” — key doctrine in the law of agency. This doctrine provides that a principal (employer) is responsible for the actions of his/her/its agent (employee) in the “course of employment.” That is the physician who employs the PA is liable for harm done by the PA while acting within the scope of his or her agency or employment. 1,2
Other legal principles that are raised in physician assistant-based and usually all medical malpractice cases include: Negligence per se (discussed below), proximate cause (the legal analysis involved with assessment of the professional’s negligence resulted in injury), and res ipsa loquitur. These principles facilitate the demonstration of malpractice without the need for expert testimony.2 An effect of RS can be to shield a PA from actually being the party in a lawsuit. A PA might claim that he or she lacked knowledge that would make a patient rely on him or her so as to make the PA invulnerable to suit, leaving the doctor his “master” to stand as defendant alone.
Szalados assembled cases involving PAs that make for interesting reading and are adapted here. In Central Anesthesia Associates, P.C. v. Worthy, the plaintiffs, a husband and wife, brought a negligence action against defendants, the medical center, anesthesiologists, a student nurse anesthetist, and a PA.7 Worthy claimed that negligent ventilation occurred at the time of induction for a post-partum tubal ligation. Worthy claimed that this inadequate pulmonary support caused the wife to sustain a heart attack with subsequent neurological damage. The women remained in a coma. This horrible series of events happened when a student nurse anesthetist was being supervised by the defendant PA.
Georgia statute7 requires that anesthesia administered by a student must be under the direction and responsibility of an anesthesiologist. The anesthesiologist could not delegate this to a PA. The anesthesiology group retorted that supervision of student nurse anesthetists constitutes a matter that could be properly delegated to a trained anesthesiologist. The appellate court disagreed with the defendant. The appellate court held that a certified registered nurse anesthetist must be under the “direction and responsibility of a duly licensed physician . . .” and therefore a student cannot lawfully administer anesthesia under supervision of a PA. The appellate court gave partial summary judgment (ruling without a trial on the facts) to Worthy under the doctrine of negligence per se.1,2
Negligence per se typically refers to a negligent act that also violates existing statutory law.
The court, in its determination of whether violation of a statute or ordinance constitutes negligence per se used a two-step standard of review. This review consisted of an examination of the purposes of the legislation in question and thereafter is used to “decide:
1. whether the injured person falls within the class of persons it was intended to protect.
2. whether the harm complained of was the harm it was intended to guard against.”13
Szalados1 explained that the judge applied Georgia Statute (O.C.G.A. § 43-26-9). This statute stated that the law existed to “protect patients from the dangers of improperly administered anesthesia by those unqualified by a lack of what public policy regards as minimum education in the field, and by a lack of specified supervision.”
As such, a PA lacking the minimum qualifications as determined by statute, violated statute and constitutes negligence per se and even violates standards for the provision of health care and would be medical malpractice.
A Few Final Caveats
As a supervising physician of PAs in your office, keep in mind the following caveats:
• Be available to answer questions of PAs because you are the “legal master”.
• Be wary of times when you go on vacation and leave your PA in charge because you still remain legally in charge.
• PAs can be integrated into your malpractice insurance with an additional fee (ask your carrier).
• PAs can buy insurance from associations such as the AAPA (e.g. a $100/$300,000 policy).
• If the PA is doing an invasive procedure, then have the consent note from the patient acknowledging that the PA will be performing this procedure.
• Consider having lab coats that clearly identify doctors as doctors and PAs as PAs.
• Confirm PA credentials and training.
•Comprehensively discuss a PA’s responsibilities and prohibited activities.
Benefiting from these Practitioners
Using PAs in dermatology practice is a trend that keeps on growing. Make sure to get the full benefit while incurring the least liability when working with these practitioners.
It is no wonder that after the Medicare and Medicaid programs were signed into law on Jul. 30, 1965, under President Lyndon B. Johnson, that a massive expansion in health care ensued and that physician assistants (PAs) came into existence. In 1965 at Duke University, Eugene A. Stead Jr., M.D., established the first physician assistant program.
As of 2005, there were more than 65,000 PAs in practice and 134 PA programs in operation.1,2,3 In addition, more than 1,000 PAs worked in dermatology as of 2002, according to the American Academy of Physician Assistants — a number that is sure to have grown over the last 4 years.
The laws governing employment of PAs greatly vary. In this column, I will discuss the variations from state to state, such as the number of PAs a doctor may supervise, the training a PA can have, and whether a PA can prescribe medications.
In later articles, I will discuss medical assistants, nurse practitioners (NPs) and nurses (other physician extenders), positions whose legal status overlaps with that of PAs.1-10
How Are They Defined?
In the United States, PAs are medical practitioners licensed to practice medicine under a physician’s supervision. PAs can see patients without a physician present, but they must be supervised. The supervision that PAs need takes different forms and does not have to be direct, as I will further discuss.
PAs are different from medical assistants, who do not have the specialized training that PAs possess. PAs have completed an accredited PA education program and (usually a 2-year program) taken the certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA). All states recognize the provision of care by PAs. The PA licensure is independent of supervisory arrangements, and employment registration requires a licensed supervising physician.
By state law, PAs must practice under an agreement with and the supervision of (direct or indirect) a supervising physician.
For example, the Code of New York statute clearly notes that “. . . [m]edical acts, duties and responsibilities performed by a registered [PA] . . . must:
1. be assigned to him by the supervising physician.
2. be within the scope of practice of the supervising physician.
3. be appropriate to the education, training, and experience of the registered physician assistant or registered specialist’s assistant.”10
What does this mean from a practical standpoint? For one thing, PAs cannot practice beyond their level of expertise. That is, there is conduct that can be provided by PAs that when performed under the direction and supervision of a licensed doctor, are legal, but which, without such direction and supervision, are the illegal practice of medicine or surgery subjecting the physician to discipline by the state’s medical board. 1,2
Scope of Practice of PAs
The scope of practice of PAs is wide and includes: taking histories, performing physical exams, ordering and/or performing diagnostic and therapeutic procedures, formulating working diagnoses, developing and implementing treatment plans, monitoring the effectiveness of therapeutic interventions, assisting at surgeries, offering counseling and education, and making referrals.
However, PAs may not perform any medical service, procedure, function or activity that is not approved by the licensing board for PAs and physicians. 1,2
Dermatology PAs specialize in areas such as acne, psoriasis, phototherapy HIV, and cosmetic dermatology. They can perform sclerotherapy, operate lasers and inject Botox. They can also assist during surgical procedures, such as Mohs.
As long as PAs act within their mandate, they can examine, diagnosis and treat patients independently without a physician even being located onsite. Because this supervision, in most cases, need not be direct or onsite, many PAs practice in remote or underserved areas in satellite clinics.
In most states, PAs prescribe medicine, and in some states they have their own DEA number, which authorizes them to prescribe controlled medications such as narcotics. In some states, PAs in surgical practices can also serve as first assistants in surgery. These providers are are reimbursed under Medicare and third-party insurances. 1,2
The scope of activity of PAs is substantial — 44 states allow PAs to prescribe controlled substances. (See Tables 1A -1D for more detail.)
Moreover, nurses must accept appropriate PA orders. In Washington State, a court ruled that nurses were not exposed to increased liability when following the orders of a PA being supervised by a doctor because the supervising physician could not disclaim responsibility for medical orders written by the PAs.8
A Financial Leg up for Practices
In 2000, Clark3 noted data from the National Ambulatory Medical Care Survey (NAMCS) that PAs see many patients (2.8 million) with dermatologic symptoms but that the NAMCS data indicate that most (72%) of these patients are also seen by a physician.
Despite this rate of duplicity, using PAs has clear advantages for cost-effectiveness. Clark noted that in a 1998 survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:13 Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. In addition, PAs can cover satellite offices, allowing for practice expansion.3
Core Laws Governing PAs
The legal doctrine that is the most important in “PA law” is that of respondeat superior (RS), Latin for “let the master answer” — key doctrine in the law of agency. This doctrine provides that a principal (employer) is responsible for the actions of his/her/its agent (employee) in the “course of employment.” That is the physician who employs the PA is liable for harm done by the PA while acting within the scope of his or her agency or employment. 1,2
Other legal principles that are raised in physician assistant-based and usually all medical malpractice cases include: Negligence per se (discussed below), proximate cause (the legal analysis involved with assessment of the professional’s negligence resulted in injury), and res ipsa loquitur. These principles facilitate the demonstration of malpractice without the need for expert testimony.2 An effect of RS can be to shield a PA from actually being the party in a lawsuit. A PA might claim that he or she lacked knowledge that would make a patient rely on him or her so as to make the PA invulnerable to suit, leaving the doctor his “master” to stand as defendant alone.
Szalados assembled cases involving PAs that make for interesting reading and are adapted here. In Central Anesthesia Associates, P.C. v. Worthy, the plaintiffs, a husband and wife, brought a negligence action against defendants, the medical center, anesthesiologists, a student nurse anesthetist, and a PA.7 Worthy claimed that negligent ventilation occurred at the time of induction for a post-partum tubal ligation. Worthy claimed that this inadequate pulmonary support caused the wife to sustain a heart attack with subsequent neurological damage. The women remained in a coma. This horrible series of events happened when a student nurse anesthetist was being supervised by the defendant PA.
Georgia statute7 requires that anesthesia administered by a student must be under the direction and responsibility of an anesthesiologist. The anesthesiologist could not delegate this to a PA. The anesthesiology group retorted that supervision of student nurse anesthetists constitutes a matter that could be properly delegated to a trained anesthesiologist. The appellate court disagreed with the defendant. The appellate court held that a certified registered nurse anesthetist must be under the “direction and responsibility of a duly licensed physician . . .” and therefore a student cannot lawfully administer anesthesia under supervision of a PA. The appellate court gave partial summary judgment (ruling without a trial on the facts) to Worthy under the doctrine of negligence per se.1,2
Negligence per se typically refers to a negligent act that also violates existing statutory law.
The court, in its determination of whether violation of a statute or ordinance constitutes negligence per se used a two-step standard of review. This review consisted of an examination of the purposes of the legislation in question and thereafter is used to “decide:
1. whether the injured person falls within the class of persons it was intended to protect.
2. whether the harm complained of was the harm it was intended to guard against.”13
Szalados1 explained that the judge applied Georgia Statute (O.C.G.A. § 43-26-9). This statute stated that the law existed to “protect patients from the dangers of improperly administered anesthesia by those unqualified by a lack of what public policy regards as minimum education in the field, and by a lack of specified supervision.”
As such, a PA lacking the minimum qualifications as determined by statute, violated statute and constitutes negligence per se and even violates standards for the provision of health care and would be medical malpractice.
A Few Final Caveats
As a supervising physician of PAs in your office, keep in mind the following caveats:
• Be available to answer questions of PAs because you are the “legal master”.
• Be wary of times when you go on vacation and leave your PA in charge because you still remain legally in charge.
• PAs can be integrated into your malpractice insurance with an additional fee (ask your carrier).
• PAs can buy insurance from associations such as the AAPA (e.g. a $100/$300,000 policy).
• If the PA is doing an invasive procedure, then have the consent note from the patient acknowledging that the PA will be performing this procedure.
• Consider having lab coats that clearly identify doctors as doctors and PAs as PAs.
• Confirm PA credentials and training.
•Comprehensively discuss a PA’s responsibilities and prohibited activities.
Benefiting from these Practitioners
Using PAs in dermatology practice is a trend that keeps on growing. Make sure to get the full benefit while incurring the least liability when working with these practitioners.
It is no wonder that after the Medicare and Medicaid programs were signed into law on Jul. 30, 1965, under President Lyndon B. Johnson, that a massive expansion in health care ensued and that physician assistants (PAs) came into existence. In 1965 at Duke University, Eugene A. Stead Jr., M.D., established the first physician assistant program.
As of 2005, there were more than 65,000 PAs in practice and 134 PA programs in operation.1,2,3 In addition, more than 1,000 PAs worked in dermatology as of 2002, according to the American Academy of Physician Assistants — a number that is sure to have grown over the last 4 years.
The laws governing employment of PAs greatly vary. In this column, I will discuss the variations from state to state, such as the number of PAs a doctor may supervise, the training a PA can have, and whether a PA can prescribe medications.
In later articles, I will discuss medical assistants, nurse practitioners (NPs) and nurses (other physician extenders), positions whose legal status overlaps with that of PAs.1-10
How Are They Defined?
In the United States, PAs are medical practitioners licensed to practice medicine under a physician’s supervision. PAs can see patients without a physician present, but they must be supervised. The supervision that PAs need takes different forms and does not have to be direct, as I will further discuss.
PAs are different from medical assistants, who do not have the specialized training that PAs possess. PAs have completed an accredited PA education program and (usually a 2-year program) taken the certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA). All states recognize the provision of care by PAs. The PA licensure is independent of supervisory arrangements, and employment registration requires a licensed supervising physician.
By state law, PAs must practice under an agreement with and the supervision of (direct or indirect) a supervising physician.
For example, the Code of New York statute clearly notes that “. . . [m]edical acts, duties and responsibilities performed by a registered [PA] . . . must:
1. be assigned to him by the supervising physician.
2. be within the scope of practice of the supervising physician.
3. be appropriate to the education, training, and experience of the registered physician assistant or registered specialist’s assistant.”10
What does this mean from a practical standpoint? For one thing, PAs cannot practice beyond their level of expertise. That is, there is conduct that can be provided by PAs that when performed under the direction and supervision of a licensed doctor, are legal, but which, without such direction and supervision, are the illegal practice of medicine or surgery subjecting the physician to discipline by the state’s medical board. 1,2
Scope of Practice of PAs
The scope of practice of PAs is wide and includes: taking histories, performing physical exams, ordering and/or performing diagnostic and therapeutic procedures, formulating working diagnoses, developing and implementing treatment plans, monitoring the effectiveness of therapeutic interventions, assisting at surgeries, offering counseling and education, and making referrals.
However, PAs may not perform any medical service, procedure, function or activity that is not approved by the licensing board for PAs and physicians. 1,2
Dermatology PAs specialize in areas such as acne, psoriasis, phototherapy HIV, and cosmetic dermatology. They can perform sclerotherapy, operate lasers and inject Botox. They can also assist during surgical procedures, such as Mohs.
As long as PAs act within their mandate, they can examine, diagnosis and treat patients independently without a physician even being located onsite. Because this supervision, in most cases, need not be direct or onsite, many PAs practice in remote or underserved areas in satellite clinics.
In most states, PAs prescribe medicine, and in some states they have their own DEA number, which authorizes them to prescribe controlled medications such as narcotics. In some states, PAs in surgical practices can also serve as first assistants in surgery. These providers are are reimbursed under Medicare and third-party insurances. 1,2
The scope of activity of PAs is substantial — 44 states allow PAs to prescribe controlled substances. (See Tables 1A -1D for more detail.)
Moreover, nurses must accept appropriate PA orders. In Washington State, a court ruled that nurses were not exposed to increased liability when following the orders of a PA being supervised by a doctor because the supervising physician could not disclaim responsibility for medical orders written by the PAs.8
A Financial Leg up for Practices
In 2000, Clark3 noted data from the National Ambulatory Medical Care Survey (NAMCS) that PAs see many patients (2.8 million) with dermatologic symptoms but that the NAMCS data indicate that most (72%) of these patients are also seen by a physician.
Despite this rate of duplicity, using PAs has clear advantages for cost-effectiveness. Clark noted that in a 1998 survey, the ratio of billings generated (production) to gross income for the average dermatology PA ranged from 3:1 to 6:13 Even with inexperienced PAs new to dermatology, this ratio was usually at least 2:1 at the end of the first year. In addition, PAs can cover satellite offices, allowing for practice expansion.3
Core Laws Governing PAs
The legal doctrine that is the most important in “PA law” is that of respondeat superior (RS), Latin for “let the master answer” — key doctrine in the law of agency. This doctrine provides that a principal (employer) is responsible for the actions of his/her/its agent (employee) in the “course of employment.” That is the physician who employs the PA is liable for harm done by the PA while acting within the scope of his or her agency or employment. 1,2
Other legal principles that are raised in physician assistant-based and usually all medical malpractice cases include: Negligence per se (discussed below), proximate cause (the legal analysis involved with assessment of the professional’s negligence resulted in injury), and res ipsa loquitur. These principles facilitate the demonstration of malpractice without the need for expert testimony.2 An effect of RS can be to shield a PA from actually being the party in a lawsuit. A PA might claim that he or she lacked knowledge that would make a patient rely on him or her so as to make the PA invulnerable to suit, leaving the doctor his “master” to stand as defendant alone.
Szalados assembled cases involving PAs that make for interesting reading and are adapted here. In Central Anesthesia Associates, P.C. v. Worthy, the plaintiffs, a husband and wife, brought a negligence action against defendants, the medical center, anesthesiologists, a student nurse anesthetist, and a PA.7 Worthy claimed that negligent ventilation occurred at the time of induction for a post-partum tubal ligation. Worthy claimed that this inadequate pulmonary support caused the wife to sustain a heart attack with subsequent neurological damage. The women remained in a coma. This horrible series of events happened when a student nurse anesthetist was being supervised by the defendant PA.
Georgia statute7 requires that anesthesia administered by a student must be under the direction and responsibility of an anesthesiologist. The anesthesiologist could not delegate this to a PA. The anesthesiology group retorted that supervision of student nurse anesthetists constitutes a matter that could be properly delegated to a trained anesthesiologist. The appellate court disagreed with the defendant. The appellate court held that a certified registered nurse anesthetist must be under the “direction and responsibility of a duly licensed physician . . .” and therefore a student cannot lawfully administer anesthesia under supervision of a PA. The appellate court gave partial summary judgment (ruling without a trial on the facts) to Worthy under the doctrine of negligence per se.1,2
Negligence per se typically refers to a negligent act that also violates existing statutory law.
The court, in its determination of whether violation of a statute or ordinance constitutes negligence per se used a two-step standard of review. This review consisted of an examination of the purposes of the legislation in question and thereafter is used to “decide:
1. whether the injured person falls within the class of persons it was intended to protect.
2. whether the harm complained of was the harm it was intended to guard against.”13
Szalados1 explained that the judge applied Georgia Statute (O.C.G.A. § 43-26-9). This statute stated that the law existed to “protect patients from the dangers of improperly administered anesthesia by those unqualified by a lack of what public policy regards as minimum education in the field, and by a lack of specified supervision.”
As such, a PA lacking the minimum qualifications as determined by statute, violated statute and constitutes negligence per se and even violates standards for the provision of health care and would be medical malpractice.
A Few Final Caveats
As a supervising physician of PAs in your office, keep in mind the following caveats:
• Be available to answer questions of PAs because you are the “legal master”.
• Be wary of times when you go on vacation and leave your PA in charge because you still remain legally in charge.
• PAs can be integrated into your malpractice insurance with an additional fee (ask your carrier).
• PAs can buy insurance from associations such as the AAPA (e.g. a $100/$300,000 policy).
• If the PA is doing an invasive procedure, then have the consent note from the patient acknowledging that the PA will be performing this procedure.
• Consider having lab coats that clearly identify doctors as doctors and PAs as PAs.
• Confirm PA credentials and training.
•Comprehensively discuss a PA’s responsibilities and prohibited activities.
Benefiting from these Practitioners
Using PAs in dermatology practice is a trend that keeps on growing. Make sure to get the full benefit while incurring the least liability when working with these practitioners.
