When a PA is a “utility player” in a group practice, it’s easy for individual details to be missed.
Mr. Q, 48, had been a physician assistant for 15 years with a group practice in a state that was popular with retirees. The patient roster included many newcomers to the area. He liked working with different physicians, but a lawsuit showed him that group practices can present problems.
The patient was a 60-year-old woman who visited an internist in the practice for a routine physical six months after her arrival in the area. Because she was a former heavy smoker and still had a “smoker’s cough,” the physician used the clinic’s equipment to take a chest x-ray and read it himself. He noted a “vague density” in the apex of the left lung field and assumed it was a scar, possibly from the woman’s childhood bout with TB 50 years earlier.
He then recommended a CT scan to clarify the location and nature of the mass, noting “exam normal, rec CT scan to follow shadow in L apex” in the chart. This would be a key piece of evidence in the subsequent lawsuit. The woman said she “would think about it” but never followed up.
The internist continued to see the patient for chest infections and other routine medical matters, including hypertension, over the next five years. During this period, Mr. Q saw the woman three times, when the internist was either out of town or otherwise unavailable. He renewed BP medications on two occasions and treated an episode of bronchitis with antibiotics on another.
Mr. Q was not aware of the “shadow” in the upper left lung field. When he reviewed the chart, he never noticed the physician’s CT-scan recommendation. Therefore, he was surprised to learn that another clinic had diagnosed an apical lung mass, which was resected. Pathology showed bronchoalveolar carcinoma, with mixed cell features.
Pretty soon a lawsuit was filed that named Mr. Q and the internist as defendants. In the court papers, the plaintiff’s lawyer assumed that the internist was Mr. Q’s supervising physician, which was not the case.
When the first requests for documents arrived, Mr. Q wondered what some of them had to do with the patient or her illness. The demands included his license number, his master’s program transcript, and a record of his medical-instruction grades. He learned later that plaintiff’s lawyers throw a wide net during discovery, in the hope of catching a big fish that they can use at trial to discredit the defendant.
Depositions got under way about six months later, and Mr. Q found himself trying to explain how he had missed the internist’s note about the “shadow” at the left lung apex. All he could say was that he didn’t have time to review every patient’s entire chart and that he relied on the patients to bring up past issues. The plaintiff’s lawyer beamed at this revelation, as if his case was as good as won.
The internist’s deposition went smoothly—until he was asked why he had never followed up on the recommendation for the CT scan. He answered that he had not believed the shadow to be malignant. He had urged the patient to have the scan when he first discovered the shadow and had dropped the issue when she didn’t take his advice.
When it was her turn to be deposed, the patient swore that the internist had never advised her to get a CT scan. The defense attorney confronted her with the chart entry, but she stuck to her guns. “He may have written it, but he never told me,” she testified.The case came up for trial about six months after the depositions ended and settlement negotiations failed. Mr. Q and the internist sat with their attorney at the defendants’ table, but the patient was absent, too sick to attend the proceedings every day.
When her lawyer called her as a witness, she came to the stand puffing on oxygen. “I think we just lost,” the defense lawyer muttered before she was even sworn in.
The woman’s testimony came down to the assertion that “they never told me” how important it was to have a CT scan to follow up on the lung shadow. The plaintiff’s expert oncologist then testified that the scan would have detected the cancer early enough for a cure by lobectomy.
Members of the woman’s family took the stand next, swearing that neither the internist nor Mr. Q had mentioned the possibility of cancer at any visit they attended. The plaintiff’s lawyer next called a pathologist who testified that the tumor was initially slow-growing but later accelerated, supporting the “curability” argument. With this, the plaintiff’s lawyer rested his case.
The defense opened with the internist, who testified that he had told the patient she should have the scan. As proof, he showed the jury his handwritten entry in the clinical notes.
But on cross-examination, the plaintiff’s lawyer attacked: “When the patient didn’t get the CT scan, you did nothing at all, right? You didn’t call, you didn’t write, you didn’t communicate how important you thought that scan could be…etc.”
The jury got the point and came back with a verdict for $2.5 million against the physician but nothing against Mr. Q, whose testimony had covered only his own clinical encounters with the patient. He staggered out of the dim courthouse into the bright sunlight wondering why he had been sued in the first place.
Although PAs and nurse practitioners often have considerable independence of action, legally speaking a PA practices under a “supervising physician.” Licensing legislation and regulations in most states are vague, perhaps deliberately, about how much supervision is needed. As a practical matter, the standard is flexible and set by a jury at trial.
As a PA or NP you should, ideally, be familiar both with the patients in your practice and with the clinicians who regularly see those patients. In this way, you can minimize surprises. Mr. Q functioned as a “utility player” for the physicians in his clinic. This created a significant risk factor. Often, he was unfamiliar with either the physicians’ individual styles of practice or with the patients and their histories, thus raising the chances for misunderstanding and miscommunication.
When he first saw the woman in this case, Mr. Q was unaware of the chest x-ray findings and the recommendation for a CT scan, although (as the plaintiff’s lawyer pointed out) a review of the chart would have made it apparent. This placed him in a difficult position at trial, where the forceful questioning of the plaintiff’s lawyer suggested that it was his duty to be familiar with the history of every patient that he saw.
Of course, such familiarity is barely practicable in today’s fast-paced clinical environment. However, even in the midst of a time crunch, asking a patient “Is there anything I should know about your medical history?” can produce some valuable information.