LAS VEGAS -- Ignoring legal and regulatory guardrails can damage reputations and lead to job loss and jail time, yet following "the letter of the law" alone isn't enough to avoid medical discipline, warned panelists at the American Academy of Physician Assistants meeting here.
Ethics and patient safety also play a role, said Stephanie Radix, JD, senior director for outreach and advocacy at the AAPA, and Jeffrey Nicholson, PhD, PA-C, who runs a medical-legal consulting firm in Milwaukee.
The two presenters highlighted several legal and ethical challenges faced by physician assistants, many of which were based on questions asked by PAs seeking advice, Radix said.
When a Supervisor Leaves Town
Radix started with the example of a PA who practices as part of a Physician-PA cardiology team in Maryland. The physician on that team planned a trip to Hawaii for a conference. The PA wondered whether to continue practicing in the supervising physician's absence.
In Maryland, where this practice is based, the law requires a physician to be available either in person or via telecommunication to consult with the PA, Radix explained.
While it may be technically legal to continue to practice in that physicians' absence, doing so is "questionably ethical," said Nicholson. If something went wrong, the PA would want a physician there to intervene at a level of care that PA cannot provide, he added.
Pre-signing Prescriptions
A second case study focused on a PA who began a new job while waiting for his DEA registration. The physician, on his way out the door for his daughter's ballet recital, realizes he will miss an appointment with a patient needing a refill of an anti-anxiety medication. The physician tells the PA, "I'll just pre-sign the script," and suggests the PA fill in the details later.
"This is never ever, ever a good idea," said Radix. It's a federal and state law violation, she added. She noted instances of raids on nurses' and doctors' homes that produced stacks of pre-signed prescriptions. In one case, a patient receiving such a script overdosed on opioids and the physician and nurse involved were held responsible.
Questionable Oversight
In a third scenario, a PA working with an orthopedist who also plans to leave town tells a PA that "the podiatrist can collaborate with you while I'm away."
Much to the audiences' surprise, this is legal in a handful of states. In West Virginia, Virginia, and California -- with some exceptions in the latter -- PAs can be supervised by podiatrists.
Again, the presenters advised PAs to consider the ethical ramifications of their decisions and the potential danger to patients. Having a podiatrist supervise a PA -- who knows more about the body and disease outside of the foot and ankle -- is "absurd," Nicholson said in a phone interview.
Even in those states where such supervision is legal, Nicholson advises PAs that finding a supervising physician or osteopath would be more appropriate.
"It would be outside of the podiatrists' purview, in our opinion, to allow them to have any supervisory role for any issue outside of the foot or ankle," Nicholson said.
New Skills
In a final illustration of thorny legal and ethical issues, Radix described a scenario where a newly hired PA is told by a collaborating physician that another PA will train him in using fluoroscopy to insert a PICC line, but the new hire is uncertain of whether PAs can legally use fluoroscopy.
The veteran PA tells the newbie, "I do this all the time."
This last example stumped the audience.
"This is another one of those trick questions ... There is no single way [fluoroscopy] is regulated," said Radix, noting that some states don't regulate it at all. However, having another PA say something is legal, does not justify a lack of caution.
PAs must look at the radiation laws in their states to check whether PAs are named on a list of providers who are exempt from needing a special license to use fluoroscopy.
If PAs are not listed as exempt, the next step is to look for laws that regulate the supervising or collaborative physicians' role in fluoroscopy. Lastly, PAs should look for laws that require PAs to gain more education on using ionized radiation, said Radix.
Expanding Skill Sets
Taking this case a step further, Nicholson noted that PAs in many states -- particularly in rural areas -- are starting to perform procedures that supervising physicians are not always trained to do.
If there is a procedure that PAs are comfortable doing and would like to perform regularly, they should have documentation to show that training, documentation that shows a supervising physician is comfortable with a PA doing the procedure and, where possible, that the physician is also trained in that particular procedure, he said.
"You must document that you are qualified to do [the procedure] and that the liability is shared between yourself and some other knowledgeable person who does the procedure," Nicholson said, noting that that person does not have to be a PA's direct supervising physician.
Without any documentation on file, "you can get in real big trouble if there's a lawsuit."
Parting Words
Both Nicholson and Radix stressed at the start of their presentation that their lecture was not intended to provide legal advice, and that Nicholson is not a lawyer.
But they noted their best advice for when a situation seems fuzzy is to always pursue the most ethical response and the one that's safest for the patient.
"If you treat every patient like your grandmother," Nicholson said, "your chances of being sued are very, very slim."