I think most people expect that they will be seen by a fully trained physician when going to a hospital. Until recently, I think hospitals have generally felt that expectation.
These days, though, it’s important for patients to ask questions and have a clear understanding of the training and credentials of those involved in their healthcare.
Unsupervised trainee physicians
Yesterday, I deposed a hospitalist physician who works at some hospitals in Corpus Christi, Texas. Most hospitalists are trained in internal medicine and have a hospital-based, rather than office-based, practice.
In that case, my client was a patient who presented at the hospital with pleural effusions that were making it difficult to breathe. Pleural effusions are a medical condition where there is an abnormal accumulation of fluid in the pleural space around the lungs. This excess fluid makes it difficult for the lungs to fully expand and, thus, can cause respiratory distress. In some cases, it’s necessary to drain the fluid through a procedure called thoracentesis.
This man went to a hospital emergency room for help because he was having difficulty breathing. He was admitted to a hospital general floor, rather than the intensive care unit. Over the course of a few days, his respiratory condition deteriorated, but no one addressed his need for thoracentesis to relieve the pleural effusion and help them breathe better.
Then one night, the patient’s clinical condition rapidly deteriorated. His blood pressure plummeted. His respiratory rate was abnormally high. He was gasping for air.
From the medical records, it seemed that the hospitalist physician was on duty, along with a resident physician and family medicine. Resident physicians are individuals who have graduated from medical school, but are still completing hospital-based clinical training. According to the hospitalist, though, that wasn’t the case.
This Texas academic/teaching hospital only staffs its medical wards for night shifts (6:00 pm to 6:00 am) with resident physicians. These trainee doctors were “supervised” by a nocturnist (a hospitalist who works night shifts) who was located off site. Sadly, during the night shift when only a trainee physician was physically on site and available, the patient’s respiratory distress declined into respiratory arrest and he died.
Nurse practitioners and physician assistants
I followed with interest a social media topic of discussion called scope creep. Here’s how it works. Nurse aides want to handle licensed vocational nurse work. Licensed vocational nurses want to move into the territory of registered nurses. Registered nurses want to handle nurse practitioner roles. Nurse practitioners, certified registered nurse anesthetists (CRNA), and physician assistants want independent practice authority like physicians.
While each of these different fields has an important contribution to healthcare, the training and experience differs. Here’s my take on the scope creep debate: Things that are different aren’t the same.
We recently filed a lawsuit in Dallas, Texas involving a nurse practitioner who was covering critical care consultations for a hospital intensive care unit (ICU). ICUs are reserved for the most critically ill patients in the hospital. This case also involved a patient who is having breathing difficulties. His respiratory distress, though, was caused by a tension pneumothorax. This is a dangerous medical condition where air is trapped in the pleural space around the lungs. It also causes a mechanical compression on the locket making it difficult to breathe. He needed an immediate needle decompression to relieve the air and then a chest tube placed.
The emergency physician ordered a consultation with the critical care service and a nurse practitioner responded. Even though the nurse practitioner recognized and documented the patient’s dangerous condition, she didn’t do anything about. After seeing the patient in the emergency room, she returned to the ICU and waited around for him to be transported. Meantime, the patient went into respiratory arrest, crashed, and developed a hypoxic brain injury that has left him permanently impaired.
Part of the scope creep debate has led to discussions about practices that some people feel are deceptive.
• A national physician assistant (PA) organization has decided to change the name of physician assistants to physician associates. Some people feel this obscures the fact that PAs are not physicians.
• Some PA school and nurse practitioner schools now offer doctoral degrees in their fields of study, some of which are entirely online. Some recipients of these degrees referred to themselves as “Dr.” in clinical practice, based on having a doctorate degree in nursing practice or from a PA program.
The scope of practice debate is intense and vicious. As a patient, though, you have an absolute right to ask and be told about the credentials of any healthcare provider who seeks to treat you. Is your “doctor” a physician? Or does your "doctor" have an doctoral degree in nursing or a physician assistant field? Is your anesthesia provider an anesthesiologist physician? Or is your anesthesia provider a CRNA? You can ask and you can choose.
If you’ve been seriously injured by poor medical, physician assistant, nurse practitioner, or certified registered nurse anesthetist care in Texas, then contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.
