The expanding role of nurse practitioners and physician assistants in Texas surgical groups

Many people think of surgeons as medical heroes. They mend broken bones, remove cancerous tumors, and repair vital organs, among many other things. They thrive in the intense, high-stakes environment of the operating room. They sometimes deal with life-and-death emergencies.

In my experience, there are two broad types of medical malpractice involving surgeons.

The first category of common surgical negligence involves the technical mistakes and complications that occur during surgeries from time to time. Another way of looking at it is these are things that happen in the operating room. Here are some common examples:

• Operating on the wrong patient, performing the wrong procedure, or performing the right procedure but on the wrong site. These are sentinel or never-event errors that could be easily avoided when the surgeon and operating room team comply with the universal protocol, or surgical timeout, for beginning the surgery.

• Lacerating, cutting, or injuring an unintended structure during surgery. These injuries have become more common with the advent of laparoscopic surgery. During an abdominal procedure, the laparoscopic equipment can cause a bowel perforation, among other injuries. Most surgical experts agree that the bowel perforation itself is not a deviation of the standard of care or negligence, so long as the surgeon recognizes the complication and addresses a timely.

• Making a technical mistake in the surgical procedure itself, which is a violation of the standard of care and negligence. For example, we represented a family in a medical malpractice wrongful death lawsuit where a surgeon didn’t resect (cut out) an adequate amount of tissue around a colon cancer tumor. This allowed the cancer to continue to grow and ultimately took the patient’s life.

The second category of common surgical negligence involves post-operative care. We see a substantial amount—maybe a majority—of surgical malpractice cases in this category.

In thinking about why that may be, I think some of this may be from the way surgeons are wired. They like to swing in like Tarzan to do a surgical repair and then swing out of the operating room to leave the clean-up and follow-up care to junior physicians or other providers.

In many surgical practices, it’s common to have follow-up care and even post-operative appointments handled by nurse practitioners (NP) or physician assistants (PA). These mid-level providers function with a certain degree of autonomy, but under Texas law must be supervised by a licensed physician.

As a former hospital administrator, I think NPs and PAs are great health care provider resources when utilized in the right way, And the right way means practicing within their education, training, and experience. From the many surgical cases and lawsuits that we have handled at Painter Law Firm, we believe that many surgeons give assignments to NPs and PAs that exceed their competence. This can spell disaster for patients.

The mid-level provider professional groups and lobbyists robustly push for more and more independence. Their goal is for nurse practitioners, physician assistants, and certified registered nurse anesthetist (CRNA) to function completely autonomously with no physician oversight. They tout the benefits as helping with important issues including medical scarcity and cost savings, and in a fuzzy way sell a story that the quality of care is the same whether it’s provided by non-physicians or mid-level providers.

For example, in California, there’s a current bill that would loosen practice regulations and restrictions on nurse practitioners. This quote from an opinion piece is typical of this school of thought: “Nurse practitioners are fully licensed and board certified and lead the nation in high quality, high value care. . . . Study after study demonstrates that nurse practitioners have patient outcomes as good or better than doctors and save health systems money in so doing.”


As much as I respect competent mid-level providers, I vehemently disagree that they provide the same level of care as physicians, and surgical practices easily demonstrate this point.

Many hospitals and surgeons rely on nurse practitioners or physician assistants to conduct rounds and see post-operative patients. In some cases, surgeons don’t do rounds or see post-operative patients at all, but rather rely exclusively on mid-level providers. The same is true for follow-up office visits.

The hours and days after a surgery may be significant if there is a problem or complication. A surgeon is fully aware of the technical and other operations of the procedure that was performed. A surgeon is in the best position to interpret and act upon signs, symptoms, and other comments provided by patients. Mid-level providers don’t have the same degree of training and experience and sometimes overlook them.

That’s what happened in the case that we’re currently working on in the Dallas Fort Worth area. A trauma patient had an abdominal surgery. On the first night after surgery, the nursing staff reported to a physician assistant that the patient had low blood pressure and that he also couldn’t move his legs. The physician assistant focused only on the patient’s low blood pressure in order to administration of blood products, thinking that he continued to have abdominal bleeding.

For around 12 hours, the physician assistant didn’t notify the surgeon of the fact that the patient couldn’t move his legs. The PA didn’t see the patient to evaluate this serious neurologic issue and, based on a lack of notification or awareness, neither did surgeon. By the next morning, when the trauma team rounded, the patient’s symptoms were even worse. He is now coping with permanent paralysis that could have been entirely avoided with proper surgical or physician follow-up care.

You can help improve your post-operative safety by comprehensively sharing your signs, symptoms, and complaints with mid-level providers to visit you, but by additionally asking the nursing staff, PA, and NP to request an in-person visit by the attending surgeon or physician you insure your best option for post-operative safety.

If you’ve been seriously injured because of poor surgical, hospital, or medical care, then contact a top-rated Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.