Opinion ID: 1057613
Heading Depth: 1
Heading Rank: 9

Heading: Physician Assistant Standard of Care

Text: We turn now to the central issue in this case: the standard of care applicable to physician assistants. Plaintiff argues in her brief to this Court that the Act establishes that a physician assistant is actually practicing medicine on behalf of the supervising doctor and as the doctor's representative. Given that a physician assistant is practicing medicine, Plaintiff asserts, he or she must be held to the same standard of care applied to his or her supervising physician. This is an issue of first impression in Tennessee. Commentators have advocated for separate standards of care for physician assistants. See, e.g., Cook, supra, at 239 (The Iowa courts should adopt the standard of care of the reasonably prudent [physician assistant] acting under the same or similar circumstances.); McLean, supra, at 261-62 (analogizing that physician assistants are to physicians as paralegals are to lawyers and asserting that a different `measuring stick' needs to be used to evaluate the services provided by each). And, while the cases have arisen in different contexts, numerous courts have analyzed why different standards of care should apply to physician assistants and medical doctors. For example, in Bradford v. Alexander, the Texas Court of Appeals held that, in a medical malpractice case, a physician assistant is not competent to testify about the standard of care to which a medical doctor is held. 886 S.W.2d 394, 397 (Tex. Ct.App.1994). The court reasoned, It would indeed lead to incongruity if we permitted a subordinate to testify as an expert concerning the standard of care to which we hold his or her supervisor, who has greater knowledge and training than the subordinate. We do not allow paralegals to testify about the standard of care a licensed attorney owes his client; a physician's assistant should not be treated with greater deference. Id. See also Paris v. Kreitz, 75 N.C.App. 365, 331 S.E.2d 234, 247 (1985) (recognizing that physician assistants are not subject to the same standard of practice as. . . a medical doctor); Johnson v. Westfield Mem'l Hosp., Inc., 184 Misc.2d 792, 710 N.Y.S.2d 862, 863 (N.Y.Sup.Ct.2000) (recognizing that a physician assistant's standard of care is different than an ophthalmologist's, a specialist, held to a higher standard of care even than an average physician); Land v. Barnes, No. M2008-00191-COA-R3-CV, 2008 WL 4254155, at  (Tenn.Ct.App. Sept. 10, 2008) (recognizing that, [s]ince a physician's assistant may only render diagnostic or therapeutic services under the `supervision, control and responsibility of a licensed physician,' there is considerable doubt that a physician's assistant would be competent to testify as to causation in a medical malpractice case); cf. Philipp v. McCreedy, 298 S.W.3d 682, 687-89 (Tex. Ct.App.2009) (recognizing that a medical doctor familiar with the standard of care for physician assistants may qualify to testify about a physician assistant's alleged negligence). A number of our sister states also have statutory provisions that appear to contemplate a different standard of care for health care providers depending on their specific profession. [18] A persuasive analysis of the reasons for assigning a different standard of care to physician assistants was provided by the Superior Court of Delaware. In Wilson v. James, the plaintiff sued Dr. James, physician assistant Montague, and New Castle Family Care for their alleged negligence in failing to properly diagnose the plaintiff's young son. No. 07C-04-025 PLA, 2010 WL 1107787 (Del.Super. Feb. 19, 2010). Montague filed a motion in limine to keep the plaintiff's expert, a medical doctor, from testifying about the standard of care applicable to a physician assistant because the plaintiff's expert doctor had stated during his deposition that he was unaware of what the `scope of practice of physician's assistants' was under Delaware law, or of how a physician's assistant's training and duties differed from those of a nurse practitioner. Id. at . The plaintiff argued that Montague should be held to a pediatrician's standard of care. The court characterized the plaintiff's contention as bewildering, id. at , and held that the plaintiff's expert's admitted lack of familiarity with the practices of physicians' assistants in Delaware render[ed] him unqualified to articulate the standard of care for a physician's assistant, and by implication he cannot express a competent opinion as to whether Montague violated that standard, id. at . The court explained that it is contrary to Delaware law, which, among other limitations, explicitly prohibits physicians' assistants from performing any medical act which has not been delegated by a supervising physician, except in emergencies or as specifically authorized by statute. Although common sense might provide a quicker route to the same conclusion, the Medical Practice Act's limitations upon a physician's assistant's scope of practice make clear that the applicable standard of care for a pediatric physician's assistant cannot be identical to the standard of care for a Board-certified pediatrician. Id. at  (footnotes omitted). A few jurisdictions have nevertheless imposed on physician assistants the same standard of care as that required of medical doctors. For instance, a Michigan statute provides that [a] physician's assistant shall conform to minimal standards of acceptable and prevailing practice for the supervising physician or supervising podiatrist. Mich. Comp. Laws Ann. § 333.17078(2) (West, Westlaw through P.A. 2010, No. 78 (except 75 & 77), of 2010 Reg. Sess.). Wyoming's Board of Medicine Rules and Regulations provide that a physician assistant is expected to perform with similar skill and competency and to be evaluated by the same standards as the physician in the performance of assigned duties. Wyo. Bd. of Med. R. & Regs., ch. 5 § 4(d) (2009). See also Cleveland v. United States, 457 F.3d 397, 404-05 (5th Cir.2006) (opining that, under Louisiana law, the standard of care applicable to a physician is also applicable to a physician assistant); Andrews v. United States, 548 F.Supp. 603, 611 (D.S.C.1982) (applying standard of care applicable to physicians under South Carolina law to physician assistant). Our close review of Tennessee's statutes, which are similar to those of Delaware, [19] convinces us that the General Assembly did not intend that physician assistants be held to the same standard of care as physicians when administering medical care. Rather, a fair reading of the Act, and the Rules promulgated thereunder, establishes that a Tennessee physician assistant is a medical provider who practices medicine within a specifically circumscribed scope of practice, under the close supervision of a medical doctor, and pursuant to a specific protocol developed with the supervising medical doctor. And, although we recognize that physician assistants exercise a degree of independent judgment in providing medical services, the Act makes clear that physician assistants do not have the same autonomy that is accorded to doctors. Physician assistants are statutorily limited to performing only those tasks that are within the physician assistant's range of skill and competence. Tenn.Code Ann. § 63-19-106(a)(3). Moreover, physician assistants are exposed to disciplinary action for practicing medicine without a license if they render professional services in a manner inconsistent with the Act. Id. § 63-19-108. It is logically inconsistent to impose significant limitations on physician assistants and yet simultaneously hold them to the same standard of care imposed upon their supervisors. As the Wilson court observed, common sense also argues against holding a medical provider to a standard of care he or she has not been educated or trained to meet. As noted above, physician assistants are required only to be graduates of a physician assistant training program and to successfully complete the examination of the National Commission on the Certification of Physician Assistants. Id. § 63-19-105(a)(2). In contrast, before a physician will be issued a license to practice medicine in Tennessee, he or she must have graduated from a medical school and must have completed satisfactorily an approved one-year training program. Id. § 63-6-207(a)(1)(A), (C) (Supp. 2009). [20] Physicians must also pass an examination administered by the Board of Medical Examiners. Id. at (b). Clearly, by both statute and common knowledge, physician assistants and physicians are not equivalent categories of health care providers. See McLean, supra, at 259-60 (discussing the significant differences in education and training between physician assistants and physicians and observing that to conclude that the care rendered by the average physician is the same as the care rendered by the average physician [assistant] is, at best, naive). If physician assistants were as capable of practicing medicine as physicians are, physician assistants would not require the close supervision of physicians. See MacDonald v. United States, 853 F.Supp. 1430, 1438 (M.D.Ga.1994) (observing that a physician's assistant is not an acceptable substitute for a doctor because [t]wo years of study as a physician's assistant does not operate as a sufficient substitute for the extensive study and training required to become a doctor, and recognizing that [i]t is because doctors have undergone this extensive study and training that they have the responsibility to perform adequate oversight over physician's assistants in their charge). Finally, we accord special significance to the Tennessee Board of Medicine's internal rule that a physician assistant's standard of care is established, at least in part, pursuant to the written protocol developed between the physician assistant and his or her supervising physician. Tenn. Comp. R. & Regs. 0880-02-.18(5)(b), (6). This provision clearly implies that the physician assistant's standard of care is not identical to that of the supervising doctor. Given that the profession of physician assistants is distinct from that of physicians, we believe that Tennessee's medical malpractice statute, Tenn.Code Ann. § 29-26-115(a), contemplates that the recognized standard of acceptable professional practice for physician assistants is that of physician assistants, not physicians. Accordingly, we agree with those authorities who differentiate between the standard of care which must be met by physicians and the standard of care which must be met by physician assistants. [21] We hold that a physician assistant must be held to the recognized standard of acceptable professional practice in the profession of physician assistants and any specialty thereof, and not to a standard applied to physicians. This is consistent with Tennessee's longstanding recognition that, in a professional malpractice action, the defendant is responsible for any damage which may result to those who employ him from the want of the necessary and proper knowledge, skill, and science which such profession demands. Wood v. Clapp, 36 Tenn. (4 Sneed) 65, 66 (1856) (emphasis added). Thus, [p]rofessionals are judged according to the standard of care required by their [own] profession. Dooley v. Everett, 805 S.W.2d 380, 384-85 (Tenn.Ct.App.1990) (emphasis added); see also Restatement (Second) of Torts, § 299A (1965) (Unless he represents that he has a greater or less skill or knowledge, one who undertakes to render services in the practice of a profession or trade is required to exercise the skill and knowledge normally possessed by members of that profession or trade in good standing in similar communities.). The profession of physician assistants is distinct from the profession of physicians. Therefore, in order to establish that a physician assistant has committed medical malpractice, the plaintiff must adduce testimony by an expert who is qualified to testify about (1) the standard of care applicable to physician assistants and (2) whether the physician assistant in question exercised `the reasonable degree of learning, skill, and experience that is ordinarily possessed by others of his profession.' Godbee v. Dimick, 213 S.W.3d 865, 896 (Tenn.Ct.App.2006) (quoting Hopper v. Tabor, No. 03A01-9801-CV00049, 1998 WL 498211, at  (Tenn.Ct.App. Aug. 19, 1998)).