Uptick in Lawsuits Involving Mid-level Providers in EDs

It will be EP "on the line"

As the number of mid-level providers (MLPs) staffing EDs increases, the number of lawsuits involving them is also increasing, reports Jennifer L'Hommedieu Stankus, MD, JD, a medical-legal consultant, former medical malpractice defense attorney, and a senior emergency medicine resident at the University of New Mexico Health Sciences Center in Albuquerque.

"One area of increasing liability for emergency physicians is being brought into a case that involved an MLP during the patient contact," says Stankus. "This is something that deserves much more scrutiny and thought on the part of EPs."

In 1997, 28.3% of EDs employed MLPs, with 5.5% of patients seen primarily by an MLP, and by 2006, 77.2% of EDs employed MLPs, with 12.7% of patients seen by the MLP.1

Each state has its own requirements for supervision of MLPs, as do individual hospitals, notes Stankus. In general, she says, the MLPs are practicing under the supervision of a physician, and the scope of their practice is limited to their abilities, training, and experience, and to the scope of practice of the supervising physician.

Only a certain percentage of charts must be signed by a physician, usually within a week, for the purposes of quality assurance under Medicare rules, says Stankus. However, most EDs have the doctor sign the charts before the patient leaves or at the end of the shift for billing purposes, she adds.

"If you sign a chart and don't know the patient and don't address problems, you will be crucified in court," says Stankus. "That is one thing you can take to the bank."

If the EP signs a chart of a patient who was seen by an MLP, says Stankus, "you better scrutinize it carefully. As the senior provider, it will be you on the line for mistakes that are made."

Even experienced EPs make a certain number of errors, notes Stankus, "and for less educated MLPs who are probably not trained to think of 'worst first,' as EPs are, that number may be frighteningly higher."

It behooves the EP to know what is going on with any patient whose chart he or she signs, says Stankus. "The EP should see that patient before they leave the department and write a brief note of their own," she says. To reduce risks, Stankus suggests these practices:

• Be sure that any abnormalities in vital signs or labs in the chart are addressed.

• Consider whether the diagnosis fits, or if anything has to be ruled out.

"Bear in mind the framing effect that can occur when someone 'tells' you what a diagnosis is," says Stankus. "It is best to pop your head into the room, get a quick history to make sure it is the same as on the chart, and eyeball the patient."

• Consider whether the studies make sense and whether they accomplish their goal.

For example, you may see that a CT scan is negative in looking for a transient ischemic attack or ischemic stroke. "Does that rule it out? Absolutely not," says Stankus. "Make sure that appropriate follow-up studies are obtained."

• Make sure that the patient really does have follow-up.

"Telling a patient who doesn't have a doctor to follow-up with their primary care provider in a week doesn't quite cut it," says Stankus.


1. Menchine MD, Wiechmann W, Rudkin S. Trends in midlevel provider utilization in emergency departments from 1997 to 2006. Acad Emerg Med 2009;16(10):963-969.


For more information, contact:

• Jennifer L'Hommedieu Stankus, MD, JD, Department of Emergency Medicine, University of New Mexico, Albuquerque. E-mail: jdlhs@hotmail.com.