Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.
It is imperative that physicians know the law of the state they practice in with regard to their relationship with and responsibility for advanced practice providers who are providing urologic care, writes Brianne Goodwin, RN.
Brianne Goodwin, RNAdvanced practice providers (APPs), credentialed as physician assistants and nurse practitioners, have had an increased presence in the work force over the past several years. Combined, there are more than 300,000 of these licensed providers in the United States, and they have made their way into more than half of urology practices (Med Econ 2015; 92:43-5; Curr Urol Rep 2015; 16:62).
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While training of these providers is relatively uniform, what differs dramatically under various state laws are the roles, responsibilities, and relationships between the provider and the physician. It is imperative that physicians know the law of the state they practice in with regard to their relationship with and responsibility for APPs providing urologic care.
There is rarely a malpractice suit where an NP or PA is named, and not a physician. This is due to the inextricable supervisory relationship between the physician and APP. The most common ways collaborating with an APP can land you as a named defendant in a lawsuit are negligent hiring/training of the APP and failure to properly supervise the APP.
Let’s take each one of these separately to highlight where the risk lies and what you, the physician, can do to prevent it.
PA Harwood has been hired for your busy urology practice to assist in procedures including urodynamics and cystoscopies. He interviews very well and seems like the perfect fit for those physicians who will supervise him. He is hired within days and starts within a week.
In the course of evaluating a patient with a history of dysuria and hematuria, Harwood prescribes antibiotics for a suspected urinary tract infection and sends a urine culture. He does not perform a cystoscopy or communicate with the urologist about this patient or the potential need for a cystoscopy. Harwood was written up by his prior employer for “communication issues” with his supervising physicians, but this was not learned in the course of interviewing him.
Negligent hiring or training of an APP is an avoidable claim. It simply requires the physician or office to do their initial homework and then due diligence when taking on a new APP. When deciding to hire an APP, it is critical to thoroughly review the candidate’s résumé, contact prior employers, and verify their education and certification.
A new APP should not “hit the ground running.” Rather, he or she also needs to be trained on applicable policies and procedures of your office, and this needs to be documented to best avoid a failure-to-train claim.
Assume the patient in the above scenario eventually gets diagnosed with bladder cancer and sues for a delay in diagnosis. The physician and PA will not have a strong defense to a negligent hiring claim, as the PA’s communication issues could easily have been discovered. Vetting a potential new APP might seem tedious and time-consuming, but is urged for office managers or administrators that often undertake these activities.
An elderly patient presents to his urology clinic for an annual check-up. His PSA is drawn and reveals an elevated value of 7.21 ng/mL, which had risen from the previous year's PSA of 4.7 ng/mL. The patient sees urology NP Mills in follow-up, who notes the elevated PSA and also notes that the patient's prostate is enlarged. However, Mills believes that the patient's PSA value is within the acceptable range for age-adjusted PSA, a concept that allows for higher PSA values in older men to account for benign growth. The NP recommends no further urologic work-up.
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Five months later, the primary care doctor draws another PSA, which now returns a result of 12.9 ng/mL. The patient returns to the urology clinic to see Mills, who still believes the increase in PSA is the result of benign growth and does not believe a biopsy is indicated. Months later, the patient is diagnosed with Gleason 9 prostate cancer, and he dies within the year.
Scenario 2 is rife with potential problems regarding the NP and her collaborating physician. Did the physician review the charting, documentation, and labs of this patient? Was there a physician physically on site when this patient was evaluated by Mills? Some states require this. Did Mills feel like she could or should speak to a collaborating physician about this patient’s PSA values?
The literature supports that an environment of excessive autonomy for APPs, or one in which there is hesitance to “bother” the physician about a patient, are both dangerous (Med Econ 2000; 77:205-8, 215). Each of these situations results from a lack of communication, which can be disastrous for a physician. Guidelines and limits for APPs need to be clear, and collaborative two-way communication between physicians and APPs is essential to best reduce liability risk.
The AUA Consensus Statement on Advanced Practice Providers further details how to identify the skill level of an APP and consequently the level of supervision one might require (bit.ly/AUAAPPstatement). While all APPs, by law, require some degree of supervision or collaboration, extra caution must be taken with those new to urology.
While the purpose of this document “is to provide guidance for urologists on the integration of APPs into the urological care setting,” it is highly recommended that all administrators and/or office managers who have any role in hiring or vetting APPs or have general clinical oversight responsibilities be familiar with this document to best reduce liability risks for physicians and APPs alike.
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