Jeffrey G. Nicholson’s Dissertation


Jeffrey G. Nicholson

A dissertation submitted in partial fulfillment of
the requirements for the degree of
Doctor of Philosophy
(Educational Leadership and Policy Analysis)
at the


This study investigated the growing field of physician assistant (PA) medical practice.
With a relatively short professional history, PAs represent a fast-growing segment of the U.S.
health care continuum (AAPA, 2007). From its military beginning in the 1960s, to its fullfledged,
recognized status as a medical profession, PA practice represents an expanding form of
primary medical care in this country. PA practice is not immune to the concerns of health care
quality, access, and cost. PA practice has brought health care access to thousands of Americans
in health care professional shortage areas (HPSAs) by providing medical services at hospitals
and primary care clinics in these areas (Shafrin, 2006a). However, with the expansion of PA
practice also came the unpleasant issues of liability and lawsuits, thus raising the question: are
PAs safe providers of care?

To answer this fundamental question, the study analyzed growing trends in PA practice,
investigated the medical practice liability of PAs, and compared and contrasted those findings
against similar markers (e.g., lawsuits and licensure actions) for the two provider groups with
whom PAs are commonly compared: physicians and advanced practice nurses (APNs). The
reader is cautioned to bear in mind that the liability and malpractice risk of these three provider
groups are different because each group provides care that varies in complexity and risk of
undesired outcome. This study did not intend to assess or quantify the inherent differences in
malpractice risk between these three provider groups, it simply reported and compared outcome
markers of unsafe medical practice. Physician and APN data was presented for comparison
because these providers are the most similar to physician assistants in medical practice scope and
training, and also because the comparison provides a context for quantifying safety.
This study also presented the implications of its findings for educational leaders, health
care policymakers, and researchers. It reviewed the extent of both pre and in-service education
currently provided in clinical practice safety, risk management and medical malpractice, and
made recommendations for educational leaders and education policymakers based upon its

Statement of the Problem
The American health care system is under constant scrutiny from the public, health care
providers, the government, and multiple regulators (Hooker & Cawley, 1997). Enacted as a
means for increasing healthcare delivery, after 40 years of deployment PAs are entwined into the
complexity of this system. Even with multiple levels of oversight and ongoing research efforts, a
number of authorities and the media continue to point out the shortcomings of America’s health
care system (Sultz & Young, 2006; Pozgar, 2007). Former President Bill Clinton and his wife,
Senator Hilary Clinton, attempted to make health care reform a national priority during their
political campaigns and terms in office. Chief among the shortcomings cited were the lack of
medical practitioners, the spiraling cost of healthcare, and the increasing number of Americans
who lack insurance to pay for their health care (Sultz & Young, 2006). Growing out of similar
concerns that originated in the 1960s, the PA profession was founded to address these very

Many observers of the health care system, including government regulators, hospital
administrators, and consumers, consider these issues to be at crisis proportions (Hooker &
Cawley, 1997). Many hospitals, especially in low-income and/or HPSAs of the country, have
closed because they were unable to collect reimbursement for their services from an uninsured
population, government programs that changed participation requirements, and because they
lacked medical professionals to staff their facilities (Sultz & Young, 2007). Health care
policymakers, politicians, service providers and health care consumers are exploring the use of
physician extenders such a physician assistants and advanced practice nurses to augment the
number of the nation’s physicians and provide quality, cost-effective medical care (Hooker &
Cawley, 1997). Indeed, over the first 40 years of the PA profession’s existence, PAs have
expanded into nearly every medical specialty (AAPA, 2007).

As stakeholders turn to the PA profession to help meet the needs of a health care system
in crisis, there is a need to analyze data from researchers on the quality, cost-effectiveness, and
safety of physician assistant medical practice. A paucity of information is available regarding the
PA profession. Thus, this researcher sought to provide baseline data and a foundation for future
researchers to compare and contrast PA practice to that of physicians and APNs. Of primary
concern is patient safety. Little aggregated data exists that synthesizes liability issues for the PA
profession. Thus, this current study is groundbreaking research that will be of value to multiple

Background for the Study
The PA profession has a relatively short history in the U.S. The profession originated in
the 1960s as a response to the national need for health care services in the wake of physician
shortages and maldistribution of physician services (Carter, 1992). Dr. Eugene Stead, a North
Carolina Duke University Medical Center physician, is credited with creating the first class of
PAs in 1965 (Physician Assistant History Center, 2007). The first class was comprised of
experienced Navy corpsmen that already possessed military medical training and experience
serving in a medical capacity during the Vietnam War. Dr. Stead based this first program on the
fast-track training method used for medical doctors during World War II (Physician Assistant
History Center, 2007).

This fast track approach was that of a physician extender, whereby individuals would be
trained in a relatively short period to provide basic medical care under the general supervision of
physicians. From the humble beginning of four ex-Navy corpsman graduates at Duke
University’s new PA training program in 1967, there are now over 63,000 certified PAs working
in clinical practice as of January 2007 (AAPA, 2007).

The nursing profession was initially approached to take on the PA model of medical care
in the 1960s. AMA leaders were exploring options for training health care professionals – nurses
among them – for advanced clinical role. However, the AMA and American Nursing
Association’s (ANA) dialogue on the PA was often characterized by sharp language and strong
debate over the new profession. Ultimately the ANA rejected the AMA proposal of the PA
concept on two occasions (Hooker and Cawley, 2003). Despite this initial rejection, the nursing
profession since moved forward with advanced practice nurse training in multiple specialties.
Unlike PAs who are trained as generalists and have one national credentialing authority, nurses
choose from a number of advanced practice training designations and certifications such as nurse
midwifery, nurse anesthetist, clinical nurse specialist, women’s health specialist or family nurse
practitioner. Much APN practice, including family nurse practitioner, women’s health nurse
practitioner and geriatric nurse practitioner is identical in scope to PA generalist practice. For
this reason, and because the two provider types have similar histories and timelines, PA and
APN practice is often compared in the research literature. The current study continues this

For a number of reasons, physicians are critical stakeholders with regard to physician
assistant hiring and utilization (Hooker, 1997). Physicians are legally bound to a supervisory
relationship with their physician assistants and as such are liable for the medical decisions and
actions of their PAs. The quality of their daily interactions and relationship has an impact on the
success of their partnership. Some factors impacted by that relationship include the quality and
quantity of care provided to patients, efficiency in the provision of care, enjoyment of their
chosen professions, and the quality of life of both physician and PA (Manion, 2005). The quality
of life effects are especially noteworthy as many physicians hire PAs for the purpose of reducing
their workloads (Manion, 2005).

Physicians are also stakeholders with regard to the utilization of PAs because physician
assistants have proven their ability to provide similar care to that of physicians at a much reduced
cost (Roblin, 2004). Physicians therefore have a motivated interest in monitoring the number of
physician assistant graduates and their scope of practice. The perception of the physician
assistant profession by physicians may therefore play a significant role in determining the
number of physician assistants hired and utilized. Physician assistant utilization in turn has an
impact on the availability of health care services, especially in medically underserved areas, and
among the medically uninsured or underinsured (Larson, 2003).

However, physicians are not the only stakeholders with regard to physician assistant
utilization, nor are they the only employers. Other stakeholders that are impacted by PA
utilization include organizations that provide health care services: hospitals, clinics, health
maintenance organizations, insurance companies, the federal government, and the health care
consumer (Larson, 2003). If the physician assistant profession is perceived as an instrument that
can provide high quality, cost-effective and safe medical care, all of these entities will be
impacted by PA utilization. An examination of the historical trend in hiring practices indicates
that many of these stakeholders are demonstrating increased interest in PA utilization. The
number of PAs employed in the U.S. increased from 40,000 in 1992 to over 50,000 in 2005, and
is projected to be 80,000 by 2010 (AAPA, 2006).

Rationale and Significance of the Study
Existing studies (e.g., Hooker, 1997; Shafrin, 2006a, 2006b) on the physician assistant
profession focus on a number of issues important to the health care system. These include PA
cost effectiveness, patient satisfaction, PA specialization, provision of care in medically
underserved areas, and PA job satisfaction. But no recent published studies exist that examine
the malpractice of physician assistants. This study was intended to fill the void, as it examined
the scope of malpractice that exists in the PA profession and compared it to that of physicians
and other health care professionals.

The PA profession is the third fastest-growing health care discipline in the United States
according to the U.S. Bureau of Labor Statistics (Medical News Today, 2004). Projections call
for the PA profession to grow by 49 percent by 2012. According to AAPA estimates,
approximately 192 million patient visits were made to PAs in 2003, up from 183 million patient
visits in 2002. Of the other health care professions making the top ten for fastest-growing
occupations, the PA profession requires more postsecondary education to enter the field and is
the only health care profession classified in the top quartile ranking by the Occupational
Employment Statistics in annual earnings (Medical News Today, 2004).

The utilization of PAs in the health care workforce has made social, political, and
economic impacts on health care consumers, providers, and delivery systems. Health care
policymakers need to determine whether the expansion of the PA profession and increased
utilization of physician assistants across medical specialties is good for the nation’s citizens and
health care systems. While the federal government has historically supported the expansion of
the PA profession through Title VII training grants to PA educational programs in meeting the
health care needs of Americans who are medically underserved (Shafrin, 2006a), a central
question that still needs examination is whether PAs are safe medical practitioners? Further, are
PAs at least as safe as their physician colleagues and mentors?

Attorneys, insurance companies, state and federal governments, health care policymakers
and health care consumers are all stakeholders in the safety of care provided by physician
assistants. Published data on the safety of physician assistant medical practice are nearly nonexistent.

To date, only two studies (i.e., Brock, 1998; Cawley, Rohrs, & Hooker, 1998), have
investigated the safety of PAs by comparing data sets found in the National Practitioner Data
Bank (NPDB). Brock’s work, based on data collected from 1991 to 1996, found that physician
claims reported to the NPDB were 420 times that of PA claims (100,750 for physicians and 240
for PAs). He noted that since the NPDB began collecting data, total physician payments were
946.6 times the total for PAs. 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

Purpose of the Study and Research Questions
The purpose of this study was to research PA liability and malpractice issues to determine
if PAs are a safe choice for health care provision. This study reviewed the literature on PA
practice and litigation trends, investigated national practitioner databases, examined the
professional organizations that govern PAs to determine the viability and future of PAs and
explored issues related to safety for health care consumers. The intent of this study was to
determine whether the practice of medicine by physician assistants is 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? Based upon an
analysis of the data, recommendations were made to health care policymakers and researchers on
PA utilization and to educational leaders in the PA profession on the provision of pre and inservice
education regarding PA practice safety.

Assumptions and Limitations
There were several assumptions regarding this research study. The researcher assumed
that PA practice will continue forward, building on its current success as a significant factor in
health care delivery. The research undertaken was believed to provide a solid, more
comprehensive and updated foundation for the profession to integrate as it considers patient
safety, quality, and medical care efficacy. For the purpose of the study, it was assumed that PAs
within the data set are practicing within their legal scope of practice and physician supervisory
requirements as defined by state regulations and state medical examining boards. It was also
assumed that civil courts generally hold PAs liable for their medical practice decisions and
actions independently of their supervising physicians. Additional assumptions included that an
analysis of the data can be used to accomplish the following: (a) to predict malpractice and
adverse action trends of provider types; (b) to determine the likelihood of malpractice payments
and disciplinary actions of providers during their careers; (c) to reveal the effectiveness of states
or jurisdictions in sanctioning providers with malpractice payments and therefore provide one
indicator of the effectiveness of states and jurisdictions at protecting patients; and (d) to provide
recommendations to PA, physician, and APN training programs and professional organizations
on the most appropriate type and amount of education to reduce professional liability and
promote patient safety.

Liability and Specialty Differences
This study of PA practice and currently observed liability issues also has limitations. No
comparison of malpractice incidence across disciplines is fair without an understanding of the
liabilities undertaken by each discipline. While this study demonstrated differences in
malpractice incidence, payment amounts, and adverse action incidence between PAs, APNs and
physicians, the reader is cautioned and reminded that each of these medical provider groups is
comprised of a different compilation of medical practice specialties with a subsequent difference
in malpractice risk. The data set utilized did not allow for direct comparisons across the three
provider groups by specialty of practice. Only APN midwives and anesthetists were reported
separately and only because they are certified separately from other APNs.

Role Differences
Additionally, physician assistants at their founding were designed to be dependent
practitioners, working alongside physicians as their assistants rather than as their substitutes.
Although PA practice has become more autonomous than its founders may have anticipated in
the 1960s, it is generally recognized that PAs are not expected to possess the full medical
knowledge base of physicians nor are they expected to manage the most complicated of patients
without assistance from a supervising physician. Likewise, licensing and regulatory agencies
recognize that APNs do not possess the same degree of training as physicians and therefore
require a collaborating physician for APNs in much the same manner as a supervising physician
is required for PAs.

The reader is therefore cautioned to bear in mind is that PAs and APNs may not as a
whole take on the same level of malpractice risk as physicians. It is not the intent of this study to
determine what that difference in risk is between these provider groups. The study is not
intended to determine, define or quantify the differences in liability or malpractice risk between
PAs and physicians or PAs and APNs. It is solely intended to analyze available data and report
the differences in actual malpractice incidence, payments and other known outcome markers of
safety over a 17 year period.

Autonomy Differences
In order to assess the inherent differences in malpractice risk and liability between
physicians, PAs and APNs, one would need to both quantify the differences in autonomy
between PAs, APNs and physicians and to account, compare and proportion the variety of
medical specialties of each provider group, each having its own inherent risk. These tasks are
complex and well beyond the scope of this study. The question of autonomy differences alone is
difficult to quantify because the level of autonomy of a PA or APN is determined by multiple
factors and may vary greatly not only from one specialty to another but from one employer,
employment setting or supervising physician to another. The amount of autonomy of a PA or
APN is largely determined by the provider’s own confidence and comfort with the level of care
being provided. Since these two practitioner types were founded on the principle of extending
physician care as much as possible, state regulations have been written broadly to allow
physician extenders to push their training, knowledge and skills to its limits. Physicians, rather
than envisioning their role as delegating minor tasks or acting as gatekeepers of physician
extender practice, have allowed mid-level practitioners to set their own limits of care within the
supervising physician’s practice specialty. State regulations state simply that PAs may not
practice outside the scope of their supervising physician’s board specialization. The PA or APN
approaches the supervising or collaborating physician for assistance on an as-needed basis.
Autonomy may also vary by employment setting or employer guidelines. For example,
some emergency room physician groups require their PAs to discuss or “staff” every patient seen
by the PA, while others more commonly prefer that the PA only come to the supervising
physician when questions in care arise. Some emergency physicians allow PAs to see any patient
in line for service without regard to patient acuity or level of care, while others restrict their PAs
to seeing only “minor” emergencies or “urgent care.” The difficulty in generalizing or in
quantifying the autonomy issue has been an obstacle to research in this area. While there is some
limited research on the tasks that PAs perform as compared to physicians, there is no literature
on the level of autonomy in performing those tasks or the inherent malpractice risk in performing
those tasks.

Other Limitations
Other limitations include that the research was confined to available data. These data may
not be representative of all current malpractice or liability cases that involve PAs. It is possible
that many cases involving malpractice or liability with regards to PAs: (a) have never been
reported; (b) were settled outside of the courts or regulatory agencies; or (c) are reflected in a
supervising physician’s record instead of the PAs or APNs. While the NPDB staff has made
assurances that PA and APN reporting has always been requested separately from supervising
and collaborating physician reporting, there will always be human error in interpretation of
reporting instructions and even attempts by reporting agencies to underreport or misrepresent
data in order to minimize the appearance of poor outcomes. Another limitation of the study was
that not all adverse action categories were required reporting elements for PAs and APNs. Many
states voluntarily reported these data, but reporting was not required by the act of Congress that
established the NPDB. For those particular adverse actions categories, caution is advised about
drawing conclusions from the comparative data.

Definition of Key Terms
As with any study, there are several key terms and phrases that must be identified to
provide clarity and define the study’s scope. Those key terms include:
American Academy of Physician Assistants (AAPA) is the professional organization that
represents PAs in the U.S. (AAPA, 2007).

Advanced Practice Nurse (APN), also known as Advanced Practice Registered Nurse (APRN,) is
a registered nurse with advanced education, knowledge, skills, and expanded scope beyond that
of a registered nurse. APNs include the subcategories of Certified Nurse Midwife (CNM); Nurse
Practitioner (NP); Clinical Nurse Specialist (CNS); Advanced Practiced Nurse Prescriber
(APNP); and Certified Registered Nurse Anesthetist (CRNA). All advanced practice nursing
credentials require specialized training, continuing education and certification. Most APNs have
a master’s or doctoral degree in nursing (Bryant-Lukosius & DiCenso, 2004).

Adverse action is a broad term with many meanings. For the purposes of this study, this term
refers to (a) any action taken against a practitioner’s clinical privileges or medical staff
membership in a health care entity, or (b) a licensure disciplinary action (NPDB Guidebook,
2007). This term also refers to an action of any entity, including a governmental authority, health
care facility, employer or professional organization. Actions include revocation, suspension,
censure, reprimand, fine, required continuing education, counseling or monitoring
(Massachusetts Board of Registration in Medicine, 2007).

Clinical privileges refer to privileges, membership on a medical staff and other memberships
(including panel memberships) in which a physician, dentist, or other licensed health care
practitioner is permitted to furnish medical care by a health care entity (NPDB Guidebook,

Health care entity is a (a) hospital; (b) an entity that provides health care services and follows a
formal peer review process for the purpose of furthering quality health care; or (c) a professional
society or a committee or agent thereof, including those at the national, state, or local level, of
physicians, dentists, or other health care practitioners, that follows a formal peer review process
for the purpose of furthering quality health care (NPDB Guidebook, 2007).

Health care practitioner is an individual other than a physician or dentist (a) who is licensed or
other wise authorized by a state to provide health care services, or (b) who, without state
authority, holds himself or herself out to be authorized to provide health acre services (NPDB
Guidebook, 2007).

Health care quality is a broad-based term derived from both operational factors and from
measures or indicators of quality selected and the value judgments attached to them. Previously,
quality was defined as “the degree of conformity with present standards” and encompassed all of
the elements, procedures, and consequences of individual patient-provider encounters. However,
the notion of health care quality has moved to measurements and outcomes looking toward peerreview, accrediting bodies, and ongoing credentialing and auditing (Sultz & Young, 2006).

Liability refers to any legal responsibility, duty, or obligation. This term also relates to damages,
or an obligation one has incurred or might incur through a negligent act (Pozgar, 2007).

Licensure disciplinary action is (a) revocation, suspension, restriction, or acceptance of surrender
of a license; and (b) censure, reprimand, or probation of a licensed physician or dentist based on
professional competence or professional conduct (NPDB Guidebook, 2007).

Malpractice refers to professional misconduct, improper discharge of professional duties, or
failure to meet the standard of care required of a professional that results in harm to another
person; the negligible or carelessness of a professional person (Pozgar, 2007).

Medical malpractice payment is a monetary exchange as a result of a settlement or judgment of a
written complaint or claim demanding payment based on a physician’s, dentist’s, or other
licensed health care practitioner’s provision of or failure to provide health care services, and may
include, but is not limited to, the filing of a cause of action, based on the law of tort, brought in
any sate or federal court or other adjudicative body (NPDB Guidebook, 2007).

Medical misconduct generally includes obtaining a license fraudulently; practicing a profession
fraudulently, beyond its authorized scope, with a gross incompetence; practicing a profession
while impaired by alcohol, drugs, physical disability or mental disability; refusing to provide
professional services to a person because of that person’s race, creed, color, or national origin;
permitting, aiding, or abetting an unlicensed person to perform activities requiring a license; and
being convicted of committing an act constituting a crime (Pozgar, 2007).

The National Practitioner Data Bank (NPDB) was created by Congress through the Health Care
Quality Improvement Act of 19896 as a national repository of information related to medical
practitioners. The NPDB’s primary purpose is to facilitate comprehensive reviews of physicians’
and other health care practitioners’ credentials (Pozgar, 2007). The Health Care Quality
improvement Act of 1986 was intended to improve the quality of medical care by encouraging
hospitals, state licensing boards, and other health care entities, including professional societies,
to identify and discipline those who engage in unprofessional behavior; and to restrict the ability
of incompetent practitioners to move from state to state without disclosure or discovery of the
practitioners’ previous damaging or incompetent performance (NPDB Guidebook, 2007).

Practitioner safety refers to the extent of protection of the public and individual patients from
harm by medical care providers (Sultz &Young, 2006). For the purposes of this study, the term
refers to ensuring quality care to meet community standards of patient care.

Physician is a doctor of medicine or osteopathy that is legally authorized to practice medicine or
surgery by a state, or who, without authority, holds himself or herself out to be so authorized
(NPDB Guidebook, 2007).

Physician Assistant (PA) is a U.S. designation for non-physician clinicians licensed to provide
medical care. PAs may use the post-nominal initials of PA, PA-C, RPA, or RPA-C where the C
indicates “Certified” and the R stands for “Registered.” PAs generally have a master’s degree in
medical studies from an accredited university along with a national certification. PAs are
specially categorized as mid-level practitioners with the authority to prescribe medications. The
scope of PA practice encompasses nearly all medical specialties including primary care, surgical,
and orthopedic (AAPA, 2007).

Standard of care is a description of the conduct that is expected of an individual in a given
situation. It is measured against which a defendant’s conduct is compared (Pozgar, 2007).
Supervising Physician is a legal or regulatory designation defining the relationship between a
physician assistant or other non-physician provider (NPP) and a physician. The defined
relationship commonly includes a delegation of services agreement that delegates medical
practice actions and prescription writing authority to the NPP (American Academy of Family
Physicians, 2008).

Supervision means to coordinate, direct, and inspect on an ongoing basis the accomplishments of
another, or to oversee, with the power to direct, the implementation of one’s own or another’s
intentions. The supervising physician must have the opportunity and the ability to exercise
oversight, control, and direction of the services of a NPP. Accordingly, it is the responsibility of
the supervising physician to direct and review the work, records, and practice of the NPP on a
continuous basis to ensure that appropriate directions are given and understood and that
appropriate treatment is rendered. Supervision includes, but is not limited to: (a) the continuous
availability of direct communication either in person or by electronic communications between
the NPP and supervising physician; (b) the active overview of NPP activities including direct
observation of the NPP’s ability to take a history and perform a physical examination; (c) the
personal review of the NPP’s practice at regular intervals including an assessment of referrals
made or consultations requested by the NPP with other health professionals; (d) regular chart
review; (5) the delineation of a plan for emergencies; and (6) the designation of an alternate
physician in the absence of the supervisor. The circumstance of each practice determines the
exact means by which responsible supervision is accomplished (American Academy of Family
Physicians, 2008).

Chapter I provided an introduction to the PA profession and the current issues of liability
and malpractice related to medical care provision. This chapter outlined the study’s purpose,
research questions, significance, and defined key terms. The PA profession has become a
significant factor in the nation’s health care workforce. And while PA practice safety is
tantamount to both the quality and cost-effectiveness of PA medical practice, no comprehensive
research exists that examines how PAs compare with physicians and other similar medical
practitioners in terms of their safety record. The need for research on PA safety is clear, and
research results will impact whether and how PAs are utilized in the future. In Chapter I the
reader was cautioned to bear in mind that the liability and malpractice risk of these three provider
groups are different because each group provides care that varies in complexity and risk of poor
outcome. The reader was reminded that the study did not intend to assess or quantify the inherent
differences in malpractice risk between these three provider groups, it simply intended to report
and compare outcome markers of unsafe medical practice. Physician and APN data was
presented for comparison because these providers are the most similar to physician assistants in
medical practice scope and training.

The next chapter, Chapter II, investigates the current literature germane to this study.
Chapter II provides the historical underpinning of the PA profession, examines the impact of the
PA profession on health care delivery in the U.S., analyzes risk management issues related to the
PA profession, and investigates the current state of medical misconduct and malpractice of PAs.