Over 20 years ago, when I was a hospital administrator, I had a first-hand vantage point to the emergence of physician assistants (PA’s) and nurse practitioners (NP’s) as mid-level providers.
It is easy to understand why business-savvy hospitals started hiring PA’s and NP’s—they are cheaper than physicians. In addition to their cost effectiveness, the general idea is these mid-level providers can handle common, basic illnesses, freeing up doctors to handle more complex diagnoses and conditions.
By educating yourself as a patient, you can make sure that you are comfortable with the level of training of your healthcare providers, and that you are getting what you are paying for.
Mid-level providers have limited independence
As an initial matter, when a physician becomes licensed in Texas, he or she can immediately practice medicine without supervision. Wise patients will always check the training and experience of physicians, including residency training, fellowship training, and board certification.
Unlike doctors, Texas law does not allow physician assistants and nurse practitioners to practice independently. Instead, both PA’s and NP’s require closely-regulated physician supervision.
Since Senate Bill 406 became effective in 2013, Texas has required supervising physicians to enter into a written, signed, and dated “prescriptive authority agreement” with PA’s and NP’s that they supervise. These agreements must include identification of:
(1) the name, address, and all professional license numbers of the parties;
(2) the nature of the practice, practice locations or practice settings;
(3) the types or categories of drugs or devices that may be prescribed or the types of categories of drugs or devices that may not be prescribed;
(4) a general plan for addressing consultations and referrals;
(5) a plan for addressing patient emergencies;
(6) the general process for communication and the sharing of information between the physician and the NP or PA;
(7) if alternate physician supervision is to be utilized, designation of one or more alternate physicians who may (A) provide appropriate supervision on a temporary basis in accordance with the Prescriptive Authority Agreement and Texas law; and (B) participate in the prescriptive authority quality assurance and improvement plan meetings required by Texas law; and
(8) a description a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following: (A) chart review, with the number of charts to be reviewed determined by the parties; and (B) periodic face-to-face meetings between the parties.
Blurring the lines between doctors, NP’s, and PA’s
Recently, I was making an appointment for a family member at a Kelsey-Seybold Clinic in the Houston area. This would be the first time this patient would be seen in this particular department of the clinic, so I looked into the available providers. There were two options, one was a physician, and the other was a nurse practitioner.
Based on the simple nature of what we required, I had no preference. When I called the appointment line, I was told that I could choose between “Dr. X’ and “Dr. Y.” From my own research, I knew that Dr. Y was really a nurse practitioner. I asked the reservationist for clarification and she replied that, “Yes, Dr. Y is a nurse practitioner.”
When arriving at the clinic, the front desk person said, “Dr. Y will see you now.” When we went to the back, I passed by the actual physician, and saw that she was dressed in the same uniform, or scrubs, and the NP.
By the way, I found the nurse practitioner to be highly competent on that visit, so that is not my point here. Rather, do you think that this could get confusing? Do you think that some patients might think that they were being treated by a physician, rather than a NP. I certainly think so.
Pushing the boundaries
With over 10,000 nurse practitioners and physician assistants in Texas, it is not surprising that they have formed powerful lobbying groups to try and expand their scopes of practice. Their stated goal is to change Texas law to allow mid-level providers to provide totally independent, unsupervised care.
According to a recent article in the Journal of the American Medical Association (JAMA), some surgeons are concerned that the lobbying by nurse practitioners groups may effective enough to obtain the rights for NP’s to perform independent surgery in the United States in coming years.
This has already happened in the United Kingdom, where nurses can receive additional training—far less that a physician who undergoes surgical residency and/or fellowship training—to become designated as surgical care practitioners (SCPs).
What you can do
In coming years, I expect that it will become more and more difficult to determine who is behind the mask when it comes to health care. I recommend that all patients do advance research before seeing a health care provider.
For physicians and physician assistants, detailed profiles are available on the Texas Medical Board website, which includes educational and training background, recent disciplinary history, and a list of hospitals where they have staff privileges. If you think that you are going to see a physician and cannot find him or her in the Texas Medical Board website, it should raise a red flag.
https://public.tmb.state.tx.us/HCP_Search/SearchNotice.aspx
The Texas Board of Nursing website is where you can go to verify very limited information about nurse practitioners.
https://www.bon.texas.gov/licensure_verification.asp
We are here to help
If you or a loved one has been seriously injured by medical malpractice by a hospital, doctor, physician assistant, or nurse practitioner, call Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case. Our experienced medical malpractice attorneys evaluate and file lawsuits for patients and their families.
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Robert Painter is a medical negligence and wrongful death lawyer at Painter Law Firm PLLC, in Houston, Texas.
More recently, as a Houston, Texas medical malpractice attorney, I have noticed that the lines between doctors on the one hand, and PA’s and NP’s on the other, have become increasingly blurred.
