CHAPTER V
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS
Introduction
Chapter V discusses the study findings in a systematic fashion with reference to the tables
and figures presented in Chapter IV. Questions are raised where appropriate, limitations are
expressed throughout and conclusions are drawn where possible. Where conclusions are
uncertain or based upon assumptions, appropriate questions are raised and recommendations
made for further research. The end of the chapter contains a final summation of study findings
and discusses study implications for education policy and health care policy, practice and
research. Finally, recommendations are provided specifically to educational leaders, the PA
profession, training programs and to future researchers of the physician assistant profession and
patient safety.
Discussion
Malpractice and Adverse Action Incidence
The summary data presented in Tables 6 and 7 indicated statistically significant
associations in malpractice payments and adverse actions between physicians, PAs and APNs.
Table 6 revealed that physicians had the highest number of malpractice payments and adverse
actions. PAs had more adverse actions, but less malpractice payments than APNs. Caution must
be taken when interpreting the total of adverse action reports because three of the five categories
of adverse actions studied were voluntarily reported for PAs and APNs (each adverse action
category will be discussed separately). Table 7 displayed the number of payment reports,
providers involved, and ratio of providers per report. The number of providers involved was
higher than the number of malpractice payments because multiple providers were involved in
some payments. For example, a physician and PA or physician and APN could be involved in the same payment. Physicians had 1.10 reports per provider, PAs had 1.24 reports per provider and
APNs had 1.26 reports per provider. This means that 10%, 24% and 26% of each provider group
respectively had another provider involved in the malpractice payment. It is reasonable to note
that PAs and APNs had a greater percentage of other providers involved in payments because
they would frequently be named along with their supervising or collaborating physician in
malpractice litigation. Interpreting the data in this way, if we assumed that the other provider
involved was the supervising physician, 76% of PAs and 74% of APNs had malpractice
judgments or settlements when their supervising/collaborating physicians did not. However, it is
possible that the supervising/collaborating physicians also made a malpractice payment for the
same case as a mid-level provider but was reported separately. If the difference were known,
then it would be possible to estimate the frequency that PAs and APNs are found negligent when
their supervising or collaborating physician is not.
Average Age of Provider and Time in Practice at Time of Report
Table 8 revealed the average age in years of the three provider types at the time of the
malpractice report or adverse action. Physicians were older at the time of these events than both
PAs and APNs. This may be due to the age affect of the practicing population of these provider
types. Since both APNs and PAs are graduating at a much higher rate and are proportionately
younger than physicians, the age difference is not surprising. A more revealing assessment was
the mean year of practice at the times of these events as reported in Table 9. Table 9 revealed a
statistically significant difference in mean years in practice at the time of the malpractice
payment between physicians and PAs and physicians and APNs, but not between PAs and APNs.
Physicians were in their practices longer on average than PAs or APNs, with mean of 25.2 years.
PAs were in practice an average of 15.1 years and APNs 18.7 years. We might conclude that
physicians are less likely to be sued early in their careers than PAs or APNs. However, if the
total workforce mean years in practice is greater for physicians, so will its mean years in practice
for any benchmark or activity. Conversely, a larger proportion of PA and APN total workforce
has been in practice a shorter length of time.
Durations Between Payment and Adverse Action and Between Litigation and Payment
A second observation from Table 8 was the difference in years between malpractice
payments and adverse actions for all three provider types. There was a five, four and two year
age difference respectively for the provider types between the time of the adverse action and
malpractice report. This may be explained if there is an association between malpractice incident
and adverse action. If we assume that a malpractice payment was justified and that an association
exists between payment and adverse action taken by a licensing board or professional society, it
is reasonable to conclude that time is required for review of provider conduct and for disciplinary
action to be taken by reporting entities.
Table 14 revealed a statistically significant difference in the duration between litigation
and malpractice payment between all three provider types. It suggested that it may take years
from notice of suit to settlement or judgment. The average duration between these events was 4.2
years for physicians, 3.6 years for PAs and 3.8 years for APNs. The mean duration for all three
provider types was 3.9 years. Since the NPDB requires reporting of payments only, not sits filed,
this information is helpful in interpreting the data and analyzing trends.
Payments by Patient Age and Gender.
Table 10 revealed a statistically significant association in patient age and gender across
the three provider groups in malpractice claims for the period 1/31/2004 - 12/31/2007. Data for
other years was not available. These data may be interpreted to reveal a difference in the
probability of litigation by gender. There were 47,457 patients involved in malpractice payments
by physicians, including 26,483 females (56%) and 20,974 males (44%). Physician assistants and
advanced practice nurses were involved with less than 2% of patients relating to malpractice
payments. For PAs, 303 (48%) of female patients and 223 (52%) of male patients were involved
in malpractice payment reports. For APNs, 536 (59%) of female patients and 359 (41%) of male
patients were involved in malpractice payment reports. If we combine the three provider types,
females comprised 56% of the total. These data may indicate that women are slightly more likely
to litigate than men against their health care provider. However, it is also possible that women
are more greater consumers of health care. A greater number of visits by women would skew the
data towards more lawsuits from women patients. A more revealing study would be the gender
difference in malpractice payments per health care provider encounter. This would control for
patient gender. As the greatest difference between gender payments occurred with APNs who are
predominantly women, it is also possible that women have a higher expectation or are more
likely to litigate against fellow women. This possibility is also raised when we see that less
women than men litigated against PAs who were predominantly male during the study period.
According to the AAPA census reports, the proportion of actively practicing women PAs did not
surpass male PAs until 2000. Another possibility to explain the high number of female patients
involved in APN payments is that APNs have proportionately more women patients. The
inclusion of nurse midwives in the APN data and a high proportion of nurse midwives in the
APN data would support this explanation. Further exploration of the differences in malpractice
litigation by women against female and male providers would make an excellent follow up
study.
Reason for Malpractice Payment
Tables 11 and 12 reported medical malpractice payments by reason for payment and
provider type. These tables may be interpreted to demonstrate the main reasons for malpractice
payments. The analysis revealed a statistically significant association across the three provider
types. The top five reasons reported for malpractice payments among physicians were diagnosis
(33.9%), surgery (27.1%), treatment (18.0%), obstetrics (8.6%), and medication related (5.5%). The top five reasons among PAs were diagnosis (55.5%), treatment (24.6%), medication related
(8.5%), surgery (4.6%), and miscellaneous (3.1%). For APNs, the top five reasons for payments
were anesthesia (38.7%), obstetrics (22.2%), diagnosis (14.8%), treatment (10.5%), and
medication related (4.8%). Anesthesia and obstetrics were higher ranking reasons (first and
second) for payments among APNs. This is likely due to the greater proportion of APNs than
PAs employed in these areas. If these two reasons were excluded, the ranking of the top four PA
and APN reasons for payment would be the same: diagnosis, treatment, medication, and surgery.
Anesthesia and obstetrics ranked seventh and eighth for PAs as few PAs work in anesthesia and
obstetrics compared with APNs. According to the 2007 AAPA census, only 0.3% of PAs were
employed in anesthesia and 2.4% in obstetrics/gynecology (AAPA, 2007).
The issue of differences in litigation and malpractice payments with specialty becomes
apparent in this table. It is not currently possible to control for specialty with data from the
NPDB. The best comparison of malpractice incidence and payments between provider types
would be made by comparing the incidence between providers working in the same medical
specialty.
Medication-Related Payments by Reason for Payment
Table 13 revealed medication-related medical malpractice payments by reason for
payment for the data dates available, January 1, 2004 - December 31, 2007. The most common
type of medication errors were the same for all three provider types. In order of frequency these
were: a) improper management of medication regimen and; b) improper technique. Other
common errors were consent issues, failure to order appropriate medication, wrong medication
ordered, wrong dosage of the correct medication and consent issues. Administration of
medication errors was ranked third for PAs and APNs and a distant eighth for physicians. This
may reflect the fact the PAs and APNs administer medication orders themselves more frequently
than physicians. Physicians historically delegate the administration of medications to nurses.
Malpractice Payment and Gender
Table 15 displayed the mean and median payment for malpractice reports by gender for
the full 17 year study period. These data were provided separately by the NPDB staff and is not a
part of the public use data file. The data showed that female providers, regardless of type of
provider, had larger malpractice payments on average than male providers. Female providers
also had higher median malpractice payments for physicians and APNs. Median malpractice
payment was slightly lower for PAs. Both the average and median payments for female
practitioners was higher than that for males when provider types were combined. Not only were
women patients more likely to litigate against women providers as noted in Table 10, we now
see that the amount of malpractice payment made by women providers was also higher on
average than their male colleagues. Gender has been revealed as factor in these findings and
should be further explored in future studies. Speculation as to why women providers make
higher payments might include a greater willingness than men to admit medical errors or fault
and a lack of desire to prolong litigation. Either of these dispositions could lead to higher
settlements. The researcher cautions that these comments are speculation and that further
research on this topic is in order.
Rate of Malpractice and Adverse Action Incidence
Table 16 and Figures 4-15 reveled a statistically significant association in malpractice
reports and adverse action reports by year for all three provider groups and presented the percent
change in reports by year from 1991-2007. While percent change is useful, given the small
numbers of PA and APN reports compared to physicians, both percent and absolute number
changes were reported. The year with the largest number of physician malpractice reports was
2001. Physician malpractice reports remained fairly consistent between 1991 and 2003 and then
saw a decrease from 2003 to 2007. Physician malpractice reports were also seen to be on a
steady downward slope from 2003-2007. The overall slope of physician malpractice incidence
reports between 1991 and 2007 was flat (-0.2% change in number of reports per year). The
number of PA malpractice reports saw a continual increase peaking at 135 in 2004 with a jump
from 81 in 2001 to 123 in 2002. PA reports have decreased from 2004 to 2007. However, the
overall slope of PA malpractice incidence reports from 1991 to 2007 indicated an average
change of 12.13% per year, indicating an upward trend. The number of APN malpractice reports
was fairly consistent from 1991 to 2000 hovering between 90 and 140 but then saw a large
increase from 111 in 2000 to 183 in 2001and increased again in 2004, 2005, and 2006 (from 168
in 2003 to 264 in 2006). The overall slope of APN malpractice incidence reports from 1991 to
2007 indicated a 7.42% average increase in reports per year, showing an upward trend similar to
PAs. The slopes for PA and APN malpractice incidence should not be over-interpreted as the
actual number of reports was comparatively small to that of physicians.
The largest percent change in malpractice reports for physicians was a decrease in 1995
of 11.4%, for PAs was an increase in 2002 of 51.1% and for APNs an increase in 2001 of 61.3%.
The comparison in physician malpractice reports between 1991 and 2007 was a decrease of 1900
reports or 14.2%. The average number of reports for the 17 year period was 14,512. The
comparison of PA malpractice reports between 1991 and 2007 was an increase of 80 and the
average number of reports over the period was 72. The comparison in APN reports between 1991
and 2007 was an increase of 137 and the average number of reports for the period was 153.
The analysis was clear that litigation and malpractice payments for PAs and APNs from
1991 to 2007 have been rising overall, and for both provider types especially since 2000. In
contrast, the number of physician malpractice reports has been steady overall and has been on a
downward slope since 2003. The overall slope for the provider types combined is flat but skewed
by the comparatively large number of physician reports.
This researcher believes there are two main probable explanations for the increase in total
number of PA and APN malpractice payments. First, there are many more mid-level providers
entering the workforce. The number of active mid-level providers has increased at a rate over
this time period that approximates the rate of increase in malpractice payments. The workforce
of PAs and APNs increased significantly from 1991 to 2007. The number of active PAs went
from 20,628 in 1991 to 68,124 in 2007, a 230% increase (AAPA, 2008). Extrapolation from
nursing survey reports conducted by the U.S. Health Resources and Services Administration
(HRSA) in 1992 and 2004 indicate that the number of APNs in the workforce rose by
approximately 143% between 1991 and 2007, from 118,761 to 288,960 (U.S. HRSA, 1992;
2004). Combined, the increase in PA and APN practitioners from 1991-2007 was 156%. The
overall increase in malpractice payments for PAs and APNs from 1991 to 2006 was 176% (123
in 1991 to 340 in 2007). This figure is close to the 156% percent increase in the PA and APN
workforce. According to data from the U.S. Bureau of Labor Statistics (U.S. BLS), the number
of physicians increased by only 14.8% between 1991 and 2006 (U.S. BLS, 2008). This helps
explain why the incidence of malpractice reports for physicians has remained comparatively
steady. Second, if the slopes for PA and APN malpractice incidence were increasing compared to
physicians, it could be attributed to the fact that PAs and APNs are being held more
independently accountable for their provision of medical care as the professions mature. As
mentioned in the literature review, treatment of PAs by the courts as separately liable from their
supervising physicians is evolving. Only recently have some states adopted regulations requiring
peer review of malpractice claims against PAs and NPs.
It is unknown why PA malpractice payments have seen a decrease since 2004 in 2005
and 2007, although this is consistent with the downward physician slope in that time period. PAs
are more closely tied to their supervising physicians than APNs in that a PA’s supervising
physician is indisputably liable for their PAs actions, and they commonly share the same
malpractice insurance policy. PAs and physicians are inextricably linked by practice regulations
and state laws. This does not hold true for APNs whose legal relationship with and liability of
collaborating physician are not as clear and which vary by state.
Regarding adverse action reports, the year with the largest number of physician adverse
actions was 1998 with 4971 reports. Physician adverse action reports were fairly consistent
between 1991 and 2007 with an overall flat slope. The number of PA adverse action reports was
fairy inconsistent but did show an overall upward slope peaking in 2003 with an overall decrease
from 2003 to 2007. The number of APN adverse action reports saw low numbers of one to seven
reports from 1991 to 2002 but then a large increase in 2003 and 2004 with a peak of 21 in 2004.
The APN reports increased from 5 in 2002 to 21 in 2004. The number decreased in 2005, 2006
and 2007. The largest percent change in adverse action reports for physicians was a decrease in
2007 of 11.6%, for PAs was an increase in 1997 of 175% and for APNs an increase in 2001 of
133% followed by increases in 2003 of 120% and 2004 of 90%. The total change in physician
adverse action reports from 1991 to 2007 was an increase of 235 reports or 6.7% and the average
number of reports was 4,315. The total change in PA adverse action reports from 1991 to 2007
was an increase from 6 to 14 or 133% and the average number of reports for the period was 18.
The total change in APN reports from 1991 to 2007 was an increase of 1 to 8 or 700% and the
average number of reports was 106.
Similar to malpractice payments, the number of adverse action reports for PAs and APNs
has seen an increase over the 1991-2007 study period while physician reports have remained
fairly steady. This researcher believes the same reasons noted above are responsible for this
difference. Also similar to malpractice payments, since 2003 the number of adverse actions has
seen an overall decrease to 2007. However, that decrease is true for APNs as well as for PAs and
physicians. Speculation for this decrease in recent years would include a less government
intervention, less federally regulated approach to health care by a Republican presidential
administration. Assuming a lag time between malpractice payments and adverse action reports
similar to the lag time between litigation and payment report as noted in Table 14, the decrease
in adverse actions since 2003 is consistent with the November, 2000 change in executive branch
and political party administration. Another explanation might include a changing climate of
health care reform where the vital role of health care providers may be more greatly appreciated.
Malpractice Payments and Adverse Actions by State of Practice
Table 17 revealed a statistically significant association in the number of malpractice
payments and adverse actions by state of practice (work state) for the period 1991-2007 for all
three provider types. The table was sorted by physician malpractice payment rank. The states
with the highest number of malpractice reports for physicians were those with the largest
populations and number of physicians: New York, California, Pennsylvania, Florida and Texas.
The number of adverse action reports however, was not as connected to population. The states
with the highest number of adverse actions in order of frequency were California, Texas, Ohio,
Florida, and New York. Pennsylvania ranked much lower in its number of adverse actions even
though it had the third highest number of malpractice payments.
The states with the highest number of malpractice payments for PAs were New York,
Florida, Texas, California, Michigan and North Carolina while for APNs those states were
Florida, Texas, New York, Pennsylvania and California. The states with the highest number of
adverse action reports against PAs were New York and North Carolina while for APNs were
Texas and Florida.
One might expect a correlation between the number of malpractice payments and the
number of adverse actions taken against health care providers. That is, it is reasonable to
hypothesize that providers who were found to be unsafe through the marker of malpractice
payments would also have their ability to practice restricted in some way as observed through the
incidence of adverse actions. The ratio of adverse action reports to malpractice payment reports
may give an indication of states’ effectiveness in protecting the public from unsafe providers.
This ratio was provided in Table 18. The previously discussed duration between malpractice
payments and adverse actions against providers (lag time from payment to disciplinary action)
extrapolated from Table 8 provided another indication of the validity of this correlation.
Ratio of Malpractice Payments to Adverse Action Reports
Table 18 provided the ratio and percentage of adverse action reports to malpractice
payments by state over the 17 year study period. It compared the number of adverse actions
taken against providers’ ability to practice to the number of malpractice payments over the same
period. This may be interpreted as an indication of how states are performing in restricting high
risk or unsafe provider’s ability to practice and in promoting patient safety. The table was
displayed in rank order from highest percentage of adverse actions to malpractice payments to
lowest. Averaging all states, the ratio of adverse action reports to malpractice payments was
4.4:1. Described another way, adverse action reports occurred 23% as frequently as malpractice
payments. Some smaller jurisdictions and military jurisdictions had more adverse actions than
malpractice payments, and two had no adverse actions at all. It is interesting to note that some of
the states with the largest number of malpractice payments had lower than average adverse
action sanctions. Pennsylvania and New York in particular had adverse action percentages that
were three times lower than the average. This may indicate that they are not performing as well
as other states in sanctioning unsafe providers.
Malpractice Payment Amount – Inflation Adjusted to 2008 Dollars
Table 19 displayed the inflation adjusted mean, median and total malpractice payments
for the three provider types over the 17 year study period in 2008 dollars. The results revealed a
statistically significant difference between all three provider types. The total malpractice
payments for the 17 years for all providers exceeded 75 billion dollars. Physician assistant
payments comprised 0.3% of the total and APN payments comprised 1.2% of the total. It is
interesting to note that the mean and median malpractice payment of APNs was higher than that
for physicians. This may reflect that a higher proportion of APNs on average work in higher
liability specialties than their PA and physician colleagues. Once again specialty comparisons
would be appropriate if available.
The average and median APN payments were the highest at $350,540 and $190,898. The
average and median physician payments were $301,150 and $150,821while the average and
mean PA payments were $173,128 and $80,003. The physician adjusted mean payment was 1.74
times higher than PAs but only 0.86 that of APNs. The physician adjusted median payments
were 1.89 times that of PAs but only 0.79 that of APNs. It is speculated that APN mean and
median payments are higher than that of physicians and PAs because the proportion of APNs
who work in the specialties of anesthesia and obstetrics is higher. The proportion of malpractice
payments for nurse anesthetists (47%) and nurse midwives (25%) was 72% of total APN
payments. Additionally, these two specialties have a higher incidence of mortality when errors
occur, and mortality judgments are higher than morbidity judgments. That is, when something
goes wrong in these specialties, it is more likely to result in death, and judgments or settlements
in cases of death are generally higher than results of injury alone.
Table 20 displayed the mean, median and total malpractice payments by year for the
study period for all three provider types adjusted for inflation to 2008 dollars. Statistical
significance was preserved by year. Figures 16-26 demonstrate the trends in average, median
and total malpractice payment amounts for the 17 year study period adjusted for inflation to 2008
dollars. Total, average and median payment amounts increased throughout the study period for
all three provider groups. As previously noted the average and median payment amounts of
APNs were higher than that of physicians and PAs. Physician payments comprised 98.9% of
total payments for the three provider groups during the study period. Physician total payment
amount peaked in 2001 and 2003 and then declined each year since. PA total payment amount
also peaked in 2003 and in 2006 but declined in 2007. APN total payments amount saw its first
peak in 2003 but then continued an overall upward slope peaking again in 2005 and 2007. There
were spikes in median payment for APNs in 2002 and PAs in 2003. Median payments for PAs
and APNs have been decreasing overall since 2003.
Payment amounts must be viewed with reference to the number of malpractice reports.
The decline in total physician and PA payment amounts from 2003 to 2007 is consistent with the
decrease in the number of malpractice reports for that period. Possible explanations for the
decrease in payment incidence have been discussed. The increase in APN total payment amount
over the last several years is also consistent with increased APN malpractice incidence over
those years. However, variability exists because the amount of malpractice settlement or
judgment can vary widely depending on the severity of determined patient harm by attorneys or
courts. A useful follow up study would be to examine the extent of malpractice related regulation
or reform by state over the study period. Many states have been active in limiting the amount of
damages awarded to patients for personal injury, others have instituted state funds to pay
damages in excess of insurance limits. According to the NPDB Associate Director of Research
and Disputes, there are currently ten states that have excess compensation funds (R. Oshel,
personal communication, June 11, 2008). Yet other states have legislated that state governments
themselves as defendants when damages exceed certain amounts, typically for judgments in
excess of three million dollars.
More useful observations were made by looking at the trends in mean and median
malpractice payments for the three provider groups over the 17 year study period. This was
displayed in Figures 16 and 17. When the slopes of mean malpractice payments were compared,
physicians had a lower increase in inflation adjusted payments per year than PAs and APNs.
Physician mean payment increased by $5620 per year over the study period while that of PAs
increased by $8993 and APNs by $8706. While APN mean malpractice payments are higher than
physicians and PAs, the payment amounts were increasing at a similar rate to that of PAs over
the study period. When median payments are examined (Figure 17), the slope of the physician
median payment is noted to be greater than that of PAs and APNs. Physician median payments
demonstrated an annual increase of $6004, the median annual increase for PAs was $4611 and
APNs $3065. The annual increase in median payment for APNs was the lowest of the provider
groups over the study period.
Malpractice Payment Amount – Adjusted to 1991 Dollars
Table 21 displayed mean and median malpractice payments adjusted to 1991 dollars for
the full 17 year study period. Average payment differences between Physician and PA, Physician
and APN, PA and APN were significant with p-value <0.05 level using Scheffe’s method. Dollar
amounts for 1991 were chosen to make similar comparisons to the 1998 studies of Brock and
Cawley discussed in Chapters II and V. As mentioned in Chapter II, Cawley’s group, examining
six years of data from the NPDB, found that the average malpractice payment of PAs was
$55,241 while that of physicians was $139,581. Average physician payment was 2.53 times
higher than that of PAs. The current study, examining 17 years of data, indicated that physician
payments are still higher on average than PA payments, but only 1.75 times higher when
adjusted to 1991 dollars. The median payment for physicians was 1.90 times higher adjusted.
Average adjusted PA payments were $108,246 while average physician payments were
$189,278. Median adjusted payments were $94,845 for physicians and $49,924 for PAs. The
narrowing of the gap between average payments between physicians and PAs from Cawley’s
study to the current one may be attributed in part to the larger number of PA payments now in
the dataset. Only 24 payments were in the dataset in Cawley’s work. The current study included
1,222 PA payments. It may also reflect that PAs overall are being held more accountable for
their provision of care in the years subsequent to the earlier study. This is a reasonable
assumption in that the courts have been gaining experience with the PA profession and defining
PA level of accountability over time.
APN mean and median payments were higher than both physicians and PAs. The mean
and median ratio of payment amounts adjusted for APNs to physicians were 1.16 and 1.25. The
ratio of adjusted payments for APNs to PAs was more than double, 2.04 and 2.39. Again this
may be explained by the larger proportion of APNs employed in specialties where mortality is
high when errors occur.
Brock’s work, based on data collected from 1991 to 1996, found that physician-related
claims reported to the NPDB were 420 times that of PA-related claims (100,750 for physicians
and 240 for PAs). The current study, examining 17 years of data, indicated that physicians now
have only 200 times more claims than PAs (245,267 payment reports for physicians and 1,222
for PAs). This difference is attributable to the larger proportion of PAs in the workforce and a
dataset that is more than twice as large, spanning more than twice the number of years.
Brock also noted that total physician claims in dollars from 1990-1996 were 946.6 times
the total for PAs. The current study indicated that the total physician dollar claims paid (in 1991
adjusted dollars) is only 312 times that of PAs for the full 17 year study period ($46,376.24
million for physicians and $148.2 million for PAs from Table 21). Again the difference in total
payments is attributable to the increased proportion of PAs in the health care workforce
compared to physicians and longer study period. It is also due to the fact that the average dollar
amount of payments in the current study for PAs is much higher than it was in the earlier Brock
study as noted above. However, if we look at the average malpractice payment amount we
calculate similar slopes for physicians and PAs. The average PA payment is not increasing at a
greater rate than that of physicians (Figure 16). We would therefore expect PA average payments
to remain less than average physician payments into the future as long as the slopes remain
similar. Additionally, when we compare the slopes of median payments between physicians and
PAs (Figure 17), we note that the slope of PA median payments is less than that of physicians.
This is further indication that PA average and median payments are not likely to reach of the
level of physician payments in the near future.
Ratio of Payments by Provider Type
Table 23 displayed the ratio of malpractice payments per total number of providers in
2006 for each provider type. Average payment differences between Physician and PA, Physician
and APN, PA and APN were significant with p-value <0.05 level. The most recent year that
demographic data were available for all three provider groups was 2006. The ratios were 1:62,
1:563 and 1:1016 respectively. The number of malpractice payments does not necessarily equate
the number of providers with payments because some providers may have had more than one
malpractice payment in 2006 and more than one provider may have been identified with a single
payment. If we could control for multiple payments by a single provider, the result would be a
better approximation of malpractice payments per provider. Nevertheless, this table can be used
to provide the payment to provider ratio in 2006 with that limitation noted. The data indicated
that in 2006 PAs had a probability of making a malpractice payment that was 9.1 times less than
physicians, and APNs had a probability that was 16.4 times less. Please note that the APN
demographic data included both active and non-active practitioners. Therefore the ratio of
payments to APN may be misleadingly low. Also please bear in mind that physicians may
assume inherently higher malpractice risk than PAs or APNs because of role differences and
differences in autonomy. We may not conclude that PAs and APNs are safer providers of care
than physicians with this analysis, only that they appear to have a lesser probability of making
malpractice payments in 2006.
Table 24 provided the number of malpractice payments over the 17 year period per
average number of active providers within the 17 year study period. This provided an estimate of
the probability of malpractice payment by provider type in the 17 study period. Average payment
differences between Physician and PA, Physician and APN, PA and APN were significant with
p-value <0.05 level. The average number of active providers was calculated by averaging the
number of active providers in each year of the study period. The estimated number of providers
for years in which a survey was not taken was calculated by determining the annual difference
between closest known years. There was one payment report for every 2.7 active physicians, one
for every 32.5 active PAs and one for every 65.8 active and non-active APNs. In percent, 37% of
physicians, 3.08% of PAs and at least 1.52% of APNs would have made a malpractice payment
over the 17 year period. The analysis assumed one malpractice payment per provider. Again
please note that the APN demographic data included both active and non-active practitioners.
Therefore the ratio of payments to APN may be misleadingly low. Also please bear in mind that
physicians may assume inherently higher malpractice risk than PAs or APNs because of role
differences and differences in autonomy. We may not conclude that PAs and APNs are safer
providers of care than physicians with this analysis, only that they appear to have a lesser
probability of making malpractice payments over the 17 year study period.
Basis for Adverse Action Report
Table 25 displayed the most common bases for adverse action reports since reporting
began in 11/22/1999 to 12/31/2007. The most common basis for action by reporting entities by
far was a licensing action by federal, state or local licensing authorities for physicians and PAs.
This was followed by unprofessional conduct, alcohol and other substance abuse, criminal
conviction and narcotic violation. Since licensing actions may also themselves have occurred for
reasons listed, it would be prudent to look at them independently of licensing actions. As such,
the most common bases for action in order were unprofessional conduct, alcohol and other
substance abuse, criminal conviction and narcotic violation. Unprofessional conduct is generally
determined by state medical boards or state boards of nursing. Although not technically illegal,
unprofessional conduct may include inappropriate relationships with patients, abuse in
prescription writing, abuse of authority and any other actions that professional boards may deem
inappropriate or unprofessional.
State and Medical Board Licensing Actions
Five adverse action types were reported to the NPDB; state and medical board licensing
actions, clinical privileges actions, professional society membership actions, practitioner
exclusions from Medicare and Medicaid programs, and D.E.A. actions. Tables 26 and 27
displayed state and medical board licensing actions for the 17 year study period. Of the five
adverse action types taken against the three provider types, state and medical board actions
represented the largest proportion (67%) of all actions taken. Using the 2006 active provider
census data, 5.7% or 1 of 17.5 physicians had state and medical licensing board actions taken
against them in the 17 year study period. Unfortunately, since data was only voluntarily reported
for PAs and APNs, that data was excluded from this study so no comparisons may be made at
this time.
Table 28 displayed state and medical licensing board actions by state for the 17 year
study period. The states with the largest number of actions taken against physicians were
California, Texas, Ohio, Florida and Arizona. However, the states with the most adverse actions
against physicians were not necessarily those with the most malpractice payments. New York
had the highest number of malpractice payments, but ranked fifth in state and medical board
licensing actions. Likewise Pennsylvania ranked third in malpractice payments but 20th in state
and medical licensing actions. Table 29 compared the rank by state of the top twenty physician
malpractice payments and medical licensing board actions. Arizona stood out as a state that
ranked high in licensing board actions (fifth) compared to malpractice incidence (fifteenth).
Pennsylvania stood out as a state that ranked low in licensing actions (twentieth) compared to its
rank in malpractice incidence (third). The differences between frequency of malpractice reports
and state and medical board licensing actions may be interpreted as an indicator of how well
state licensing and medical boards are monitoring their physicians and sanctioning unsafe
practice. This has already been discussed in the section examining total adverse actions.
Clinical Privileges Actions
Table 30 displayed clinical privileges actions for the 17 year study period. Clinical
privilege actions were the second most common type of adverse action taken against providers
constituting 22.3% of all adverse actions in the dataset. There were 14,547 actions reported
against physicians constituting 1.9% of all active physicians in 2006. No comparisons may be
made for PAs and APNs since that data were not a required reporting elements. Clinical privilege
actions are distinct from state and medical licensing board actions in that they occur at the
hospital or clinic level. Health care professionals are not only regulated and monitored by state
boards but also by their local work settings. In theory this should add a second level of protection
for the public as consumers of health care.
Table 31 displayed clinical privilege actions by year for each year of the study period.
The number of physician actions displayed a mild downward trend from 1991 to 1998, a mild
upward trend from 1998 to 2004, and then a more moderate downward trend from 2004 to 2007.
The number of PA actions has been quite small, not exceeding seven through 2002, but then
reaching a high of 12 in 2006 with eight in 2007. There appeared to be an upward trend for PAs
beginning in 2002, though the total numbers are small. Similar to PAs, the number of APN
actions was quite low never exceeding 5 through 2002. A large increase occurred in 2003 and
2004 with drops again in 2005, 2006 and 2007. The numbers of PA and APN actions is too small
to make any generalizations or conclusions. For physicians, however, the drop since 2003 is
reflective of the drop in total adverse actions for this same time period and may reflect the
political climate and similar reasons outlined above.
Table 32 displayed clinical privilege actions by state for the study period. California had
the most clinical privilege actions for physicians. It also had 41% more actions for all providers
than the next highest ranking state of New York and 44% more than Texas. The top five clinical
privilege actions against physicians by state is similar to the top five state and medical board
licensing actions with the exception of Arizona ranking fifth. As mentioned, Arizona’s state
licensing board may be a stronger regulatory body and patient advocate compared to its
counterparts in other states. Arizona also ranked high in clinical privilege actions at tenth. It is
possible that Arizona’s state licensing board reputation and/or actions has encouraged the state’s
hospitals and clinics to be more aggressive with their own clinical privileges actions. PA and
APN data was excluded because is was only voluntarily reported.
Professional Society Membership Actions
Tables 33-35 displayed professional society membership actions. Only physician data
were required for reporting. The number of actions against physicians decreased from 1991
through 1999 but has been increasing on average since then. High numbers of membership
actions were expected for the larger states, but Oklahoma stood out as third ranking in number of
actions. This suggests that Oklahoma has active and strong physician professional societies. No
conclusions may be drawn for PA and APN actions since these were not required for reporting.
Exclusions from Medicare and Medicaid Programs
Table 36 displayed practitioner exclusions from Medicare and Medicaid programs. This
was a reporting requirement for all provider types, and statistically significant differences were
revealed with p< 0.0001. Exclusions from Medicare and Medicaid programs constituted 9.9% of
all adverse actions reported in the database. There were 6,311 physicians excluded from
Medicare and Medicaid Programs in the study period, or 0.81% of the active physician
population of 2006. There were 219 PA exclusions or 0.34% of the active PA population of
2006. The physician and PA exclusions followed a similar longitudinal pattern over the study
period. While 219 PAs were excluded from these federal programs, no APNs were. Discussion
of the zero value for APNs in this category with NPDB staff, one probable cause mentioned is
that Medicaid and Medicare exclusions for APNs may have been reported under the nursing data
fields rather than APN fields. Exclusions from these federal programs is normally a consequence
of billing irregularities. Physician assistants generally do not perform their own encounter and
procedure coding upon which billing is based. It is possible that at least some of the PA
exclusions from these programs were based upon the PA’s supervising physician exclusion.
APNs are allowed more independent practice and billing than PAs in most states. The fact that
no exclusions were reported raises the question of whether APNs were erroneously reported
elsewhere in the database.
Table 37 displayed practitioner exclusions from Medicare and Medicaid programs by
year for the full study period. For both physicians and PAs, the number of exclusions had an
overall average increase till 2001 and 2002. In 2001 the number of physician exclusions from
Medicare and Medicaid programs began to decline dramatically through 2007. PA exclusions
declined dramatically in 2003 from 23 to an average of less than ten for the subsequent four
years. The large decline in exclusions for both provider types from 2001-2003 follows a similar
pattern for all adverse actions. Since Medicare and Medicaid programs are federally
administered, it is reasonable to hypothesize that these declines may reflect a change in
administration policy or political climate. This analysis was consistent with earlier findings and
earlier comments are validated.
U.S. D.E.A. Actions
Table 38 displayed U.S. D.E.A. actions for the 17 year study period. Reporting of D.E.A.
actions was required for all provider types, but the low proportion of total actions reduced
statistical significance. Of the 1,355 total D.E.A. actions were 2.1% of all adverse actions for the
period. There were 1,352 D.E.A. actions against physicians in the period which constitutes
0.17% of the number of active physicians of 2006. There were two PA and one APN actions in
the 17 year period. The number of D.E.A. actions is quite small compared to all other actions.
The concerns of the D.E.A. are also concerns of the state and medical licensing boards, medical
staffs, professional societies and privilege committees of hospitals. It is quite likely that D.E.A.
actions are comparatively small because actions had already been taken against the offenders
through these other monitoring and regulatory bodies. Another likely explanation is that APNs
and PAs are not required by many states to maintain their own D.E.A. registrations. Although
new pharmacy software requires D.E.A. numbers in order for prescriptions to printed with the
PA or APN’s name on the label, some mid-level providers may still prescribe using their
supervising or collaborating physician’s D.E.A. registration number for controlled substances.
Table 39 displayed D.E.A. actions by year for the full 17 year study period. The data
revealed two peaks with the largest number of actions occurring in 1994 and 2004. The actions
decreased to a low in 1998 and the again from 2004 to an all time low in 2007. There were two
actions against PAs, one in 1999 and one in 2004. There was one action against an APN in 2004.
Once again the pattern of decreased actions in the last four years is noted for physicians. This is
another indication of the probability of a change in federal policy or political climate, and is
consistent with a change in federal administration in the year 2000 and expected lag time to
adverse action reporting. However, caution is advised in interpretation since n-value is low and
statistical significance is not met.
Table 40 displayed D.E.A. actions ranked by state for the 17 year study period. The state
with the largest number of D.E.A. actions was California, with more than double or 131% more
than the state with the second most actions, Texas. Part of the high California D.E.A. actions
may be attributed to its large physician population, but other factors must also be at work. Either
California indeed had the greatest number of D.E.A. violations or its other regulatory venues did
not do as good a job as other states in monitoring or disciplining providers with D.E.A
violations.
Adverse Actions Summary by Provider Type
Tables 41 and 42 displayed a summary of the absolute number of adverse actions for
each provider group from 1991-2007 and also as a percentage of the total number of providers in
that group in 2006. The tables suggested that the largest number and proportion of adverse
actions for physicians were state and medical licensing actions. Practitioner exclusions from
Medicare and Medicaid programs most affected PAs. No program exclusions were reported for
APNs even though this was a required reporting element. The staff of the NPDB believes that the
lack of Medicare and Medicaid program exclusions for APNs reflects a reporting error
(exclusions were reported as nurses rather than as APNs). The number of actions against PAs
and APNs was too low to draw conclusions based on comparisons between the provider groups.
Summary and Conclusions
It was not the intent of this study to determine, define or quantify the differences in
liability or malpractice risk between PAs and physicians or PAs and APNs. An undertaking of
that sort would require a system for analyzing and quantifying role differences between the three
provider groups and full spectrum variations in the level of autonomy PAs and APNs are
provided when working with supervising or collaborating physicians. This study was solely intended to analyze retrospectively markers of unsafe medical practice and compare PA findings
to those of physicians and APNs to determine if PAs are safe providers of medical care, or at
least as safe as physicians and APNs based upon those markers.
Unless otherwise specified, statistically significant associations were found for every
variable studied between PAs and physicians, APNs and physicians, and between PAs and
APNs. The intent of this study was to answer the following questions: is the practice of medicine
by physician assistants as safe as the practice of medicine by physicians and advanced practice
nurses? Specifically, research questions for this study included: (a) Do PAs negate their cost
effectiveness through the costs of malpractice?; (b) Is the rate of malpractice for physician
assistants at the same trajectory as that of physicians and advanced practice nurses?; (c) Is the
ratio of malpractice claims per provider the same for physician assistants, advanced practice
nurses and physicians?; and (d) Are the reasons for disciplinary action against PAs and APNs the
same as those for physicians?
Answering the Study Questions
Based on the 17 year comparison of physician and PA malpractice incidence and average
malpractice payments, it appears that PAs do not negate their cost effectiveness through the costs
of malpractice when compared to physicians and APNs. Statistically significant differences
existed between PA to physician and PA to APN malpractice incidence to provider ratios. The
data suggested that the ratio of malpractice payments to PA was 1:32.5 while that to physicians
was 1:2.7 and to APNs 1:65.8 over a 17 year period. In 2006, those ratios were 1:563 for PAs,
1:62 for physicians, and 1:1016 for APNs for that single year. Statistically significant differences
were also found between PA and physician and PA and APN mean and median malpractice
payments over the 17 year study period, adjusted for inflation to 2008 dollars. The mean
physician payment was 1.74 times higher than the mean PA payment and the median payment
was 1.89 times higher. The mean APN payment was 2.02 times higher and median payment was
2.40 times higher. These findings suggest that PAs may be a factor in malpractice cost savings
for the health care industry.
The rate of malpractice incidence for PAs and APNs is increasing while the rate for
physicians is flat, neither increasing nor decreasing as viewed over the 17 year period. This has
been explained by the more than doubling in the number of PAs and APNs entering the
workforce over the study period and by the comparatively minor increase (14.8%) in number of
active physicians during this period.
The reasons for disciplinary action against PAs and APNs are largely the same as for
physicians. The three most common reasons included: a) licensing actions by federal, state and
local licensing authorities; b) unprofessional conduct; and c) alcohol and/or other substance
abuse. Additionally, all three provider groups received adverse actions reports of clinical
privileges actions, narcotics violations and U.S. D.E.A actions. Practitioner exclusions from
Medicare and Medicaid programs were reported for physicians and PAs.
This study has provided a comprehensive review of the data available in the National
Practitioner Databank regarding physician, PA and APN malpractice incidence, malpractice
payments and adverse actions that restrict or sanction clinical practice. It has updated and
exceeded in scope the only studies previously undertaken in 1998 by Brock and by Cawley, et al.
Those studies were limited not only by the few years of data available at the time but also in
scope. The number of adverse actions was too small at that time to draw any meaningful
conclusions. While adverse action numbers were still comparatively small for PAs and APNs
and some actions were voluntarily reported, this study was able to identify trends in adverse
actions and make trend comparisons between provider types.
This study also went beyond the studies of Brock and Cawley to include data on APNs, a
similar yet competitive discipline to PAs, and a discipline to which PAs are often compared.
APNs stood out in the study as having higher average malpractice payout amounts than PAs and
even physicians. It was hypothesized that this was due to the high proportion of APNs in the
dataset that are nurse anesthetists and midwives. APNs also stood out in that PA and physician
total malpractice payouts have been decreasing in the last four years while APN malpractice
incidence and total monetary payouts have been on the rise. However, average and median APN
malpractice payout amounts, while still higher than physicians, have been on the decline in the
last few years. That is, there are more APN payouts, but the average and median payout amounts
are declining.
The study revealed gender differences in litigation incidence and amount of malpractice
payment. Through data available only from NPDB staff, this study suggested that female health
care providers make larger malpractice payments on average than their male colleagues. It also
suggested that female providers are slightly more likely than their male colleagues to be sued.
There is also indication that more women bring malpractice claims then men, but this could be
simply a factor of women as greater consumers of health care services. Although inconclusive,
these findings suggest the need for further research on issues of gender in health care provision
and patient safety.
A statistically significant difference was found in the number of years in practice before a
malpractice payment was made between physicians and PAs and between physicians and APNs.
Physicians were involved in clinical practice ten years longer on average than PAs and six years
longer than APNs before making a malpractice payment. This may be largely a function of
provider group average workforce years in practice.
There was an average of 3.9 years between malpractice payments and adverse action or
disciplinary sanction by reporting entities.
Anesthesia and obstetrics were higher ranking reasons (first and second) for malpractice
payments among APNs. This is likely due to the greater proportion of APNs than PAs and
physicians employed in these areas. If these two reasons are excluded, the ranking of the top four
PA and APN reasons for payment were the same: diagnosis, treatment, medication, and surgery.
The issue of differences in litigation and malpractice payments by clinical specialty became
apparent in this study. It was not possible to control for specialty with data from the NPDB as
specialty reporting was not required, so other research tools and data are necessary. This is an
area where further research is recommended.
The number of malpractice payments and adverse action reports for PAs and APNs has
seen an overall increase during the 1991-2007 study period while physician reports have
remained fairly steady. This can be explained by provider demographics. However, malpractice
payments and adverse actions since 2003 have seen a an overall decrease for all three provider
types. It was hypothesized that a change in government policy or political climate may be
responsible. Further exploration of this possibility is recommended. Decreases in Medicare and
Medicaid program actions as well as decreases in D.E.A. actions since 2003 support the
hypothesis that the overall decrease in adverse actions since 2003 may reflect a change in
government policy or political climate.
Comparing to Brock’s data, the study revealed that the per provider ratio of total
malpractice payments between PAs and physicians is narrowing over time. This is explained by
demographic factors.
The study indicated a statistically significant difference between physician and PA mean
and median payments each year throughout the study period. Regarding trends, the study
suggested that physician average payments over the 17 year period, in 2008 dollars adjusted for
inflation, are 1.74 times higher on average than PA payments, and median payments are 1.89
times higher on average. The study also suggested that the average PA payment is increasing at a
faster rate than that of physicians over time, but the median PA payment is decreasing over time
compared to physicians. The slopes of the average physician and PA payments over the 17 year
study period indicate that physician average payment increase each year is less than that of PAs
(a $5620 rise in average payment per year for physicians and $8993 rise per year for PAs), but
the slope of median physician payments is greater than that of physicians ($6004 for physicians
and $4611 for PAs). We therefore may expect that PA average payments may eventually
intersect that of physicians, but median payments may continue to diverge. Since average and
median payments appear to be headed in opposite directions, we cannot draw a definitive
conclusion. Examination of the next several years of data will provide the answer.
States with the most adverse actions against physicians were not necessarily those with
the most malpractice payments. Pennsylvania and New York, while ranking high in malpractice
incidence, were found to have adverse action ratios that were three times lower than the average.
That is, while states on average had about one adverse action for every 4.4 malpractice
payments, these states had about one in thirteen. This could be an indication of their
ineffectiveness at sanctioning unsafe providers.
Arizona stood out as a state that ranked high in licensing board actions (fifth) compared
to malpractice incidence (fifteenth). Pennsylvania stood out as a state that ranked low in
licensing actions (twentieth) compared to its rank in malpractice incidence (third). The difference
between frequency of malpractice reports and state and medical board licensing actions may be
an indicator of how well state licensing and medical boards are monitoring their physicians and
sanctioning their practices. Arizona and Pennsylvania are opposites in this regard.
Oklahoma stood out as third ranking in number of professional society actions against
physicians. This finding suggests that Oklahoma may maintain active and strong physician
professional societies.
The state with the largest number of D.E.A. actions was California, with more than
double the amount of Texas, the state with the second most actions.
Implications and Recommendations
Education of PAs, Physicians, and APNs
The introduction to this study referred to a nation in a health care system crisis due to
spiraling costs, practitioner maldistribution, predicted practitioner shortages and insurance
disparities with 40 million Americans who are uninsured. This study purports that the costs of
malpractice are a significant contributing factor to the problem. This study has suggested that
more than $74 billion (in 2008 dollars) have been spent on malpractice claims against
physicians, PAs and APNs alone in the past 17 years. The costs of medical malpractice in the
U.S. have underscored the need for improved medicolegal education for practitioners at all levels
of training and experience. Training should begin with the development of a strong foundation in
medicolegal education during the didactic portion medical education programs for all
practitioners. While currently there is no data on medicolegal education in PA Programs with the
exception of what is required by the accreditation standards, 124 medical schools report
providing an average of 25 hours of instruction on "medical ethics" during the 4-year curriculum;
no additional information is available regarding whether this includes specific medicolegal
content (McAbee, Deitschel and Berger, 2006). The Committee on Medical Liability and Risk Management of the American Academy of Pediatrics (AAP) has begun to study the medicolegal
education of physicians and has found it lacking. The author of the current study, having twelve
years of PA program administration experience, concurs that medicolegal education of PA
students falls short a desired emphasis, despite the implementation of the medicolegal
accreditation standards discussed in the literature review. The author of this study agrees with the
recommendations of the of the AAP committee that a formal dedicated course in medical
jurisprudence is desirable. Such a course should include topics such as principles of medical
malpractice including the expert witness process; informed consent and refusal of care; overview
of regulatory issues (e.g., Health Insurance Portability and Accountability Act of 1996,
Occupational Safety and Health Administration regulations, Emergency Medical Treatment and
Active Labor Act, Americans With Disabilities Act, Clinical Laboratory Improvement
Amendments); fraud and abuse; good-Samaritan laws; patient incompetence; third-party
liability; criminal prosecutions of health care providers; elder law; and issues related to genetics,
reproduction, and technology. In addition, the procedural aspects of how a lawsuit develops (e.g.,
summons and complaint, discovery, deposition) are important to initiate students to the workings
of the legal process. This alone can help start to assuage the fear that students have about the
legal process. The effectiveness of such a course can be accentuated with lectures in relevant
bioethics. If feasible, a mock trial could be implemented for introducing students to the
operational aspects of a malpractice trial.
An AAP 2004 survey of graduating pediatric residents found that 76% of residents
reported no instruction in expert-witness testimony; 76% reported no instruction in vaccine
injury liability; 65% reported no instruction in the malpractice crisis; 57% reported no instruction
in medical malpractice litigation; 54% reported no instruction in medical liability insurance; 50%
reported no instruction in risk management/loss prevention; and 36% reported no instruction in
risk communication (McAbee, 2006). The author of this study concurs that recent PA graduates might report similar results. Therefore recommendations are also in order for medicolegal
education during the clinical components of physician, PA, and APN training. For physicians,
this would occur during residency, for PAs during the typical twelve-month period of clinical
“rotations,” and for APNs, during their clinical modules. Competencies for the clinical education
portion of training should include risk management, informed consent, professional behavior,
quality of care improvement, billing and coding, documentation, the use of technology in a
medical practice, substance abuse prevention and management, and patient communication
including apologizing for errors. The current study’s review of the most common bases for
adverse actions and malpractice claims supports these curriculum recommendations. Since
medicolegal issues are complex, it is recommended that each educational program appoint a
faculty member to oversee the curriculum for all phases of training.
Recommendations are also in order for practicing clinicians. Practitioners should
encourage state professional organizations, hospitals, and medical schools to sponsor legal
medicine seminars that are relevant to everyday practice. As previously described, the American
Academy of Physician Assistants provides didactic sessions on medicolegal and risk
management topics each year at its national continuing medical education conferences. State
medical, nursing, and PA association chapters can also be invaluable in offering didactic
medicolegal topics to its membership. As with all medical education, independent self-study
should take place at all levels of experience. Malpractice insurers often provide a reduction in
premiums for completion of risk-management courses. One valuable source for lecturers for both
pre-service and in-service education includes hospital, malpractice insurance company and
community attorneys, and risk-management specialists. This researcher is acutely aware of the
challenges that program directors have when faced with adding topics to an already-expanded
and concentrated PA curriculum. However, the importance of this issue must be acknowledged
and better addresses because of the personal and professional impact that legal issues have on
practitioners.
Practitioners should be willing to share malpractice experiences with students and
colleagues. Since law is based on precedent; lawsuits will be filed if attorneys are aware that
suits on specific issues have been successful. Providers must be willing to share their
experiences, because we all can learn from the mistakes of others. Disclosure may decrease the
chance of litigation and result in smaller awards if litigated and improve patient safety.
It is recommended that educators, whether faculty at academic institutions or community
practitioner mentors, elevate the importance of, and increase their efforts in, medicolegal
education. Future practitioners must be better prepared for practice, not only to reduce their own
practice risk but to promote patient safety. If the focus of malpractice/risk management education
is placed within the context of what is best for the patient, as are most other issues in medical
education, the topics will be much better received and retained.
This study has provided essential information for the education of PAs, physicians and
APNs. Training programs should incorporate study findings into their required medicolegal
curricula. The study validated the decision of the Accreditation Review Commission on the
Education of Physician Assistants to incorporate quality assurance, risk management, legal
issues of health care and professional liability into the required standards of PA training
programs. The American Academy of Physician Assistants, state PA professional chapters and
their corresponding physician and APN colleague organizations would do well to disseminate the
results of this study to their members, to employers, government agencies, and all stakeholders in
the safety and cost effectiveness of medical care. These groups should incorporate study findings
into their continuing medical education programs and publications. Also, practicing clinicians
may now make better informed, research-based decisions on the necessity and amount of their
malpractice insurance coverage.
Health Care Policy
The observations and conclusions from the analyses should be of value to a variety of
stakeholders regarding patient safety and the delivery of safe medical care by physicians, PAs
and APNs. Analyses of the data suggested that the utilization of physician assistants is and
remains a safe choice for the provision of medical care when compared with physicians and
APNs. Also when compared with physicians, the study found that utilization of PAs may
actually decrease the costs of medical malpractice as indicated by lower PA malpractice
incidence and average malpractice payments.
The study suggests that the cost of medical malpractice exceeded $74 billion (in 2008
dollars) in the last 17 years for physicians, PAs and APNs alone. Although the PA portion of this
amount was the smallest, the study finding of $245 million in PA malpractice payments and the
public concern of patient safety should provide ample cause for hospitals, clinics, government
regulatory agencies to implement and maintain strong risk management and quality assurance
programs. Professional societies have further indication of the importance of monitoring
members and assisting those with competence and substance abuse issues.
Given the costs and risks to patients, disciplinary sanctioning or retraining of unsafe
providers should be given high priority by health care policymakers. Additionally, government
agencies and state professional societies need to examine why some states are doing a much
better job than others at sanctioning unsafe providers. A further recommendation to
policymakers is to include the comparatively young PA and APN professions in the mandatory
reporting requirements of the NPDB. Three of five categories of adverse actions, including the
most common type of adverse action affecting physicians, were not reporting requirements for
PAs and APNs. Only through mandatory reporting of all categories for all three provider types
can accurate comparisons be made across these disciplines in all categories.
Research
This study has provided benchmarks for future researchers on the safety of physician,
physician assistant and advanced practice nurse medical practice. It has made unique
contributions to the fields of medicine, education, and law. No previous study of medical
malpractice had comprehensively examined 17 years of data contained in the NPDB. No
previous study had examined the effectiveness of states in sanctioning unsafe providers through
a review of the frequency of actions intended to restrict the practices of providers with
malpractice histories. No previous study had compared malpractice and adverse action data
across three similar but distinct provider groups. And, no previous published study had noted
gender differences in malpractice incidence and average amount of malpractice payments. This
study has contributed fresh research on PA practice, as well as on physician and APN practice. It
has provided new knowledge about the comparative safety of PA medical practice and
benchmarks for future research. Through its numerous findings, some anticipated, some not, it
has provided a solid research foundation for health care and education policy. Through its
unexpected findings and limitations, it has raised a number of new questions, providing a basis
for further exploration. Some questions this study has raised for future researchers include: Why
do PAs appear to have lower malpractice incidence and payments than physicians and APNs?;
What can be done to test the validity of these findings?; Is there a way to control for confounding
factors such as variable role delineation and assumption of risk?; Why do female providers make
higher malpractice payments than their male counterparts?; What are some states doing which
make them appear more vigilant in taking adverse actions against unsafe providers?; Why does
there appear to be an overall downward trend in malpractice and adverse action incidence since
2003?; and What is currently being done and what more can be done in the education of
physicians, PAs and APNs to reduce malpractice incidence and increase patient safety?
