Opinion ID: 1057613
Heading Depth: 1
Heading Rank: 5

Heading: Physician Assistants

Text: According to one commentator, physician assistants were introduced in the United States during the mid-1960's to fill the gap in primary health care services created by a physician shortage. James H. Cook, Note, The Legal Status of Physician Extenders in Iowa: Review, Speculations, and Recommendations, 72 Iowa L. Rev. 215, 215 (1986) (footnote omitted). Physician assistants generally work under the supervision of or in close relationship with physicians as part of a multitiered health care team and perform numerous routine clinical procedures, thereby freeing physicians to concentrate on complex medical problems. Id. According to the United States Bureau of Labor Statistics, physician assistants take medical histories, examine and treat patients, order and interpret laboratory tests and x rays, and make diagnoses. They also treat minor injuries by suturing, splinting, and casting. [Physician assistants] record progress notes, instruct and counsel patients, and order or carry out therapy. [Physician assistants] also may prescribe certain medications. Bureau of Labor Statistics, U.S. Dep't of Labor, Occupational Outlook Handbook, 2010-11 Ed., Physician Assistants, on the Internet at http://www.bls. gov/oco/ocos081.htm (last visited June 21, 2010). In 2008, physician assistants held almost 75,000 jobs. Id. Another commentator explains, [t]he rationale behind increasing utilization of physician [assistants] is that [they] `lower [the] cost of providing health care, reduce physician stress, [provide] higher levels of patient satisfaction, and improve quality of care resulting from the team approach.' Thomas R. McLean, Crossing the Quality Chasm: Autonomous Physician Extenders Will Necessitate a Shift to Enterprise Liability Coverage for Health Care Delivery, 12 Health Matrix 239, 257 (2002) (quoting Patrick Knott & Kathleen Ruroede, One Solution for Managing Risks During Cutbacks in Residency Training Programs, 11 Risk: Health, Safety & Env't 35, 39 (2000)). Dr. McLean observes that physician assistants enable doctors to delegate certain health tasks and that society views physician [assistants] as subordinate to physicians. Id. Since 1985, Tennessee has recognized physician assistants as medical providers pursuant to the provisions of the Physician Assistants Act, Tenn.Code Ann. §§ 63-19-101 to -115 (2004 & Supp.2009) (the Act). [7] In passing the Act, our legislature indicated clearly its recognition that physician assistants and medical doctors are members of distinct professions. A physician assistant is defined under the Act as an individual who renders services, whether diagnostic or therapeutic, that are acts constituting the practice of medicine or osteopathic medicine and, but for the provisions of § 63-6-204 [8] and § 63-9-113, [9] could only be performed by a licensed physician. Tenn.Code Ann. § 63-19-102(5) (footnotes added). The practice of medicine is defined as the treatment, diagnosis, operation upon, or prescription for, any physical ailment or any physical injury to or deformity of another. Id. § 63-6-204(a)(1) (Supp. 2009). Physician assistants must be licensed, id. § 63-19-105(a), and licensure is generally available only upon graduation from an accredited physician assistant training program [10] and successful completion of the examination of the National Commission on the Certification of Physician Assistants. Id. at (a)(1), (2). Licensed Tennessee physician assistants are statutorily authorized to perform only selected medical services as follows: (a) A physician assistant is authorized to perform selected medical services only under the supervision of a licensed physician. (1) Supervision requires active and continuous overview of the physician assistant's activities to ensure that the physician's directions and advice are in fact implemented, but does not require the continuous and constant physical presence of the supervising physician. The board and the committee shall adopt, by September 19, 1999, regulations governing the supervising physician's personal review of historical, physical and therapeutic data contained in the charts of patients examined by the physician assistant. (2) The range of services that may be provided by a physician assistant shall be set forth in a written protocol, jointly developed by the supervising physician and the physician assistant. The protocol shall also contain a discussion of the problems and conditions likely to be encountered by the physician assistant and the appropriate treatment for these problems and conditions. . . . (3) A physician assistant may perform only those tasks that are within the physician assistant's range of skills and competence, that are within the usual scope of practice of the supervising physician, and that are consistent with the protection of the health and well-being of the patients. (4) The physician assistant may render emergency medical service in accordance with guidelines previously established by the supervising physician pending the arrival of a responsible physician in cases where immediate diagnosis and treatment are necessary to avoid disability or death. (b) A physician assistant shall function only under the control and responsibility of a licensed physician. The supervising physician has complete and absolute authority over any action of the physician assistant. There shall, at all times, be a physician who is answerable for the actions of the physician assistant and who has the duty of assuring that there is proper supervision and control of the physician assistant and that the assistant's activities are otherwise appropriate. Id. § 63-19-106(a), (b). The Act also provides for the creation of a committee on physician assistants (the Committee). Id. § 63-19-103(a). Each member of the Committee is required to be a licensed physician assistant. Id. The Act charges the Committee with the duty to promulgate rules reasonably necessary for the performance of the duties of the physician assistants, including, but not limited to, rules that specify the acts and offenses that subject the license holder to disciplinary action by the committee. . . . Id. § 63-19-104(a)(1). In compliance with its statutory duty, the Committee has promulgated the General Rules and Regulations Governing the Practice of a Physician Assistant, Tenn. Comp. R. & Regs. 0880-03-.01 to -.24 (2009) (the Rules), including the following provision: A physician assistant who holds state license in accordance with T.C.A. § 63-19-105 may provide selected medical/surgical services as outlined in a written protocol according to T.C.A. § 63-19-106, and when such services are within his skills. The services delegated to the physician assistant must form a usual component of the supervising physician's scope of practice. Services rendered by the physician assistant must be provided under the supervision, direction, and ultimate responsibility of a licensed physician accountable to the Board of Medical Examiners or the Board of Osteopathic Examination under the provision of T.C.A. § 63-19-109. Tenn. Comp. R. & Regs. 0880-03-.02. Further, (1) The range of services which may be provided by a physician assistant shall be set forth in a written protocol, jointly developed and signed by the physician assistant and the supervising physician and maintained at the physician assistant's practice location. (2) A physician assistant is authorized to perform the services outlined in his or her protocol under the supervision of a supervising physician who complies with all the requirements of [Tenn. Comp. R. & Regs.] 0880-02-.18. [11] (3) Each physician assistant shall have a designated primary supervising physician and shall notify the Committee of the name, address, and license number of his/her primary supervising physician and shall notify the Committee of any change in such primary supervising physician within fifteen (15) days of the change. Id. 0880-03-.10 (footnote added). Significantly, the Rules authorize the Board of Medical Examiners and the Committee to discipline a physician assistant for, among other things, [g]ross malpractice, or a pattern of continued or repeated malpractice, ignorance, negligence or incompetence in the course of practice as a physician assistant  and for [v]iolation of the scope of practice statutes T.C.A. §§ 63-19-106 through XX-XX-XXX and Rules 0880-03-.02 and 0880-03-.10. Id. 0880-03-.15(1)(d), (1)(s) (emphasis added). Although neither the Act nor the Rules contains an explicit standard of care applicable to physician assistants, [12] it is clear that the Committee determines whether to discipline physician assistants for malpractice by reference to the practice of physician assistants and not by reference to the practice of physicians. In addition to the Rules, the Board of Medical Examiners has promulgated the General Rules and Regulations Governing the Practice of Medicine, which include a specific section dealing with the supervision of physician assistants. See Tenn. Comp. R. & Regs. 0880-02-.18 (2009). That section provides that written protocols are required and that they shall outline and cover the applicable standard of care. Id. at (5)(b). The section also provides that [t]he supervising physician shall be responsible for ensuring compliance with the applicable standard of care under (5). Id. at (6).