Common Mistakes Physician Extenders Make in Their Practices

First of all, for those who may be thinking “what is a physician extender,” a physician extender is a licensed health care provider (not a physician) that provides medical services typically performed by a physician.

Physician extenders include Nurse Practitioners, Physician’s Assistants and other similar positions. The following case study outlines an unfortunate scenario that would most likely end up in a costly medical malpractice suit against a dermatologist. After briefly highlighting the problems within the case study that could lead to a malpractice claim by a patient, we suggest some preventative maintenance steps a physician should take to avoid malpractice claims and costly litigation. After all, an ounce of prevention is worth a pound of cure.

The “Facts”:

A patient went to a dermatology practice for injection of Botox and Restylane, an injectable filler made from hyaluronic acid to reduce wrinkles and create fuller lips. After signing a consent form for the procedure, the patient was escorted into a room and told "the doctor" would be in soon. A Physician's Assistant (PA) came in to see the patient. The PA did not know Restylane was not approved by the FDA for use in the forehead, even though it is commonly used “off-label” in this way, and he was unaware of the risks of necrosis when it’s injected into the forehead. The PA injected Botox and Restylane into the patient’s forehead.

When the patient called three days later reporting several symptoms including a headache, bruising, and swelling, the PA instructed the patient to ice the area. The following day, the patient called again complaining that her eyes were swollen shut and that she had green skin. After several additional calls by the patient and two visits with the PA over the two weeks following the injection, the PA diagnosed infection and prescribed antibiotics and anti-inflammatories. During this time, the PA never consulted with the physician about the patient's condition. Finally, the patient went to her primary care provider and only then was diagnosed with necrosis, too late to save her skin. At that point, her skin had to be removed, causing deep scarring and permanent disfigurement.

The Problems:

  • The patient was arguably misled about the PA's identity and position when she was told “the doctor” would see her for the procedure.
  • The PA was unaware that he was using a drug in a way not approved by the FDA that came with potentially severe side effects.
  • The PA treated the patient over the phone and in person several times, even after the patient's condition continued to worsen.
  • The PA misdiagnosed the patient's condition, which led to a delay in the patient’s proper treatment.

The Fix:

Patients should never be misled about the qualifications of Physician’s Assistants and other physician extenders. Furthermore, consent forms should clearly reflect when a Physician’s Assistant, Nurse Practitioner or other physician extender is working under a licensed doctor. Consent forms need to give more than just the physician extender’s name after the physician's name (i.e. John Doe, M.D./Jane Doe, PA-C). Practitioners should be fully aware of the drugs they are using including their intended uses, applications, side effects and potential complications, particularly when prescribing or using a drug "off-label."

In this case study, if the PA had known of the increased risk for necrosis when injecting Restylane into the forehead, he likely would have caught the complication before it was untreatable. Also, while it may have been appropriate to treat the patient over the phone for the first phone call, when the patient called back the next day, she should have been seen in the office either in conjunction with the physician or at a minimum in consultation with the physician.

In Illinois, a PA practices under a physician's license, and “best practices” dictate routine communication between a physician and the Physician's Assistant. In the case study, the patient's complications may have been avoided if the PA had conferred with his physician early and often. The PA should have consulted with his supervising physician after the first phone call - when the patient first experienced complications – and immediately documented in the patient's chart that he had consulted with a physician about the initial complications.

For more information about this post or if you are interested in litigation prevention strategies and avoiding damaging malpractice claims as a physician, physician extender, or health care practitioner, please contact the author or consult with your lawyer.

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