Mr A was a university student enrolled in a PA program. As part of his studies, he was assigned to work in a medical clinic owned by Dr V. During his regular workday at the clinic, Mr A was supervised by Dr V or Ms F, the clinic’s on-staff PA.

Miss K, a 17-year-old adolescent came into the clinic with complaints of intermittent headaches and a “hot” forehead that had been present for 2 or 3 days and managed with ibuprofen. In the examination room, Mr A introduced himself to the patient and her mother as a PA student and advised them that he was on a clinical rotation.

He told them that he would be taking a history and performing a physical examination, with their permission. He then would present the information to his “preceptor or supervising physician,” who would then perform an independent examination and develop a plan for the patient. The patient and her mother agreed that Mr. A could proceed.

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In his chart notes, Mr A wrote that the patient had experienced “throbbing, lateral-frontal headaches 15 times a day.” Each episode would last 15 to 30 seconds. Miss K denied having weakness, paresthesia, fever, chills, weight loss, shortness of breath, neck or back pain, chest pain, nausea, or vomiting. He noted that the patient has type 2 diabetes. Palpation of the head and neck did not elicit tenderness and the patient’s neck exhibited full range of motion. Her lungs were clear. The patient was not in acute distress. Mr A noted a fast heartbeat and possibly a diastolic murmur.

Mr A did not make a diagnosis and instead went to discuss the case with the supervising PA, Ms F. The clinicians discussed life-threatening illnesses that needed to be ruled out, including stroke, brain tumor, aneurysm, brain hemorrhage, and meningitis. After that, Ms F evaluated the patient, who again denied having any nausea, vomiting, or vision problems. Ms F noted that the patient was not distressed, and that her eyes, ears, nose, throat, and neck examinations were normal. Neurologic examination showed no abnormalities.

Ms F checked the patient’s heart and determined that she had a benign venous murmur rather than a diastolic murmur. The chart note was revised, with diastolic murmur changed to venous murmur and “tension headache secondary to stress” added. The patient was told to take acetaminophen as needed and to return to the clinic in a week if the headaches worsened or became constant or she developed nausea, vomiting, photophobia, body aches, or neck pain.

The patient reported feeling better for the next 2 weeks with occasional headaches, which were treated with acetaminophen. Fifteen days after the clinic visit, the patient complained to her mother about light sensitivity for the first time. Two days later she had a fever and her headache worsened. The next day she began seeing double and her mother took her to the emergency department (ED).

The ED physician conducted physical and neurologic examinations, both of which were normal. The physician was about to perform a lumbar puncture when the patient’s pupils dilated and she began having convulsions. It was later determined that she had coccidioidal meningitis. She suffered numerous strokes that caused permanent brain damage and left her paralyzed from the waist down.

Legal Background

The patient’s mother hired a plaintiff’s attorney and sued the original clinic, Dr V, and Ms F. [She also sued other defendants who settled.] The plaintiff alleged that Ms F had negligently failed to diagnose and treat the patient’s coccidioidal meningitis and that Dr V and the clinic were vicariously liable. The plaintiff also alleged that Dr V and his clinic were directly liable for their failure to supervise Mr A. 

The case went to a jury trial. Both sides had medical experts testify. The defense experts commended the PA student’s chart notes, calling them thorough. They believed that the patient’s diagnosis and treatment were appropriate given the facts that existed at the time. The plaintiff’s experts stated that the physician should have conducted an examination, not the PA, and that the patient should have been sent to the hospital. The plaintiff also attempted to introduce expert testimony stating that the standard of care for medical practitioners required Dr V to supervise PA students directly, rather than have another PA provide supervision, but the medical experts were unable to testify as to the legal requirements of student PA supervision. 

The jury found no negligence in the treatment of the patient by Ms F or the student PA and, thus, found no liability.

The plaintiff appealed arguing the common law doctrine of respondeat superior, which holds that an employer can be vicariously liable for the acts of an employee. The appellate court disagreed and noted that since the jury had returned a verdict that Ms F was not negligent in the diagnosis or treatment of the patient, neither Dr V nor the clinic could be held vicariously liable for medical malpractice.

The appellate court also would not entertain the plaintiff’s claim of ordinary negligence, noting that there was only 1 cause of action for negligence, and it was based on an allegation of misdiagnosis. A general negligence cause of action would be redundant, noted the court. The appellate court affirmed the decision of the lower court and found the clinicians not liable.

Protecting Yourself

In this case, the student PA did a comprehensive job examining the patient. Working together, the student and the clinic’s PA ruled out life-threatening conditions based on the patient’s symptoms. Was their diagnosis wrong? Yes. Was it based on solid facts at the time? Also yes.

The reasonable diagnosis was made based on the patient’s condition and symptoms, which changed 2 weeks later. At her original clinic visit, the patient did not demonstrate light sensitivity, neck pain, nausea, or other symptoms that might have been indicative of meningitis. The diagnosis made was reasonable under the circumstances, and neither Ms F nor the student was found to have acted negligently in the treatment of the patient; thus, their employers could not be vicariously negligent.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.