The risky role of physician assistants and nurse practitioners in neurosurgery
Some neurosurgeons turn over too many responsibilities to less-trained mid-level providers
If you have had any type of surgery in a hospital setting in recent years, the chances are that a mid-level provider, like a nurse practitioner or physician assistant, has played a significant role in your care.
Most surgeons are in a race to see more and more patients every day in order to maintain their income level, which has taken a hit because of Medicare and insurance cuts. To that end, surgeons and their practice groups frequently hire mid-level providers to assist with the workload.
A position paper entitled, “Team-Based Care in Neurosurgery,” published by the American Association of Neurological Surgeons and Congress of Neurological Surgeons, illustrates the balancing act in medicine between health care provided by fully-trained doctors versus that provided by mid-level providers.
After investigating many negligence cases, as a Texas medical malpractice lawyer, I have seen what can happen when hospitals and surgeons rely too much on nurse practitioners and physician assistants in surgical care.
To compare the quality of care that can be delivered by neurosurgeons versus mid-level providers, we will first take a look at their training and experience.
Training and role of neurosurgeons
A neurosurgeon is a physician trained in surgery on the nervous system, particularly the brain and spinal cord. Like all medical doctors, neurosurgeons have to go to college and complete four years of medical school.
After that training, doctors who want to become neurosurgeons have to be accepted into and complete a hands-on residency-training program. There are 99 such programs affiliated with hospitals and medical schools in the United States, with an average length of seven years.
To add it up, the typical neurosurgeon has 11 years of education and training after receiving an undergraduate college degree, or 15 years after high school.
According to the American Association of Neurological Surgeons and Congress of Neurological Surgeons position paper, a neurosurgery residency includes training on the anatomy and physiology of the nervous system; how to perform a neurological assessment, meaning how to determine if something is wrong; intracranial pressure dynamics; cerebrospinal fluid dynamics; cerebral blood flow and metabolism; how to interpret CT scans, MRI scans, and other neuroradiographic films; spinal biomechanics; and management of situations like fluid and electrolyte balance, respiratory problems, venous thromboembolism, seizures, infections, and nutrition.
Neurosurgeons are trained to handle all types of neurosurgical emergencies, and have expertise in formulating a diagnosis, making clinical decisions, developing treatment plans, the initial stabilization of patients, performing procedures at the patient’s bedside, performing surgery in the operating room, providing post-surgical critical care, post-operative care, and follow-up care.
Some of the emergency medical conditions that neurosurgeons are equipped to deal with include intracranial infection; cranial, spinal, and peripheral nerve trauma; ruptured intracranial aneurysm; stroke; hydrocephalus; shunt malfunction; spontaneous cerebral hemorrhage; brain and spinal tumor; and spinal cord compression from ruptured disc, hematoma, or infection.
Training and role of mid-level providers
Physician assistants (PAs) receive their training in programs that have varying admission and training requirements. Some schools require a bachelor’s or associate’s degree for admission, while others only require completion of a college courses in chemistry, physiology, anatomy, biology, and microbiology. Some schools also require past medical experience, whether as a paramedic, emergency medical technician (EMT), certified nursing assistant (CNA), or nurse. Once admitted to physician assistant school, the entire program of classwork and clinical rotations takes three years, resulting in the award of a master’s degree. Depending on the specific PA program requirements, a physician assistant will have three to seven years of education and training after high school—less than half of the training of neurosurgeons.
A nurse practitioner (NP) is a registered nurse who holds a bachelor’s degree and then has completed a master of science in nursing (MSN), which typically takes two to three years to complete. Many MSN programs allow nurses to complete most of the degree requirements online. Depending on the specific NP program requirements, a nurse practitioner will have four to seven years of education and training after high school—less than half of the training of neurosurgeons.
The American Association of Neurological Surgeons and Congress of Neurological Surgeons position paper recognizes that PAs and NPs can participate in the care of neurosurgical patients, after additional training by a neurosurgical team.
These mid-level providers can perform neurological assessments, write orders, and assist neurosurgeons during procedures or surgeries.
Neurosurgeons often rely on NPs and PAs to perform some bedside procedures independently, including inserting intracranial pressure monitors, ventricular drains, and lumbar drains. The position paper even recognizes that NPs and PAs can be used to perform the initial assessment and management of neurosurgical emergencies.
When the team approach fails
In my experience as a Houston medical malpractice attorney, I have seen an increasing trend where hospitals and neurosurgeons use physician assistants and nurse practitioners to provide essentially all of the care outside the operating room.
Many clients and family members have told me that the first time they met their neurosurgeon is when they walked into the hospital room for a few minutes to introduce themselves, announce a diagnosis, and recommend a surgical procedure—without ever even seeing, talking to, or examining the patients. This means that 100% of the information that the neurosurgeon is relying on is coming from an assessment and testing results conducted, ordered, and managed by a mid-level provider with less than half of the neurosurgeon’s training.
Clearly, sometimes—perhaps most of the time—this system works, particularly for patients who present to the hospital with common brain, spine, or nervous system conditions. But what about the patient whose signs and symptoms are outside the box? Does a less-trained nurse practitioner or physician assistant have the training and experience to make the right calls and recommendations to the neurosurgeon, who, by habit, only spends a few minutes with a patient before taking him or her to surgery?
In cases that I have handled for clients injured by neurosurgery malpractice, over reliance on mid-level providers led to a misdiagnosis, the wrong treatment, and a corresponding delay in implementing the correct treatment. For neurosurgical patients, this can be life-threatening or can lead to paralysis, paraplegia, or quadriplegia, if something is compressing the brain or spinal cord.
Similarly, I have handled a number of cases where nurse practitioners and physician assistants handled care for the neurosurgery team after surgery, in the post-anesthesia care unit, intensive care unit, or on the floor. In one case that I handled in Plano, Texas, for example, I recall that the patient woke up from spine surgery and was unable to feel or move any of his extremities. He repeatedly informed the mid-level providers, who assured him that everything was fine. By the time he was seen by the neurosurgeon, it was too late to correct the spinal cord compression that the patient had, rendering him quadriplegic for life.
What can you do?
Nurse practitioners and physician assistants are valuable parts of the health care team, but be aware that sometimes they are assigned to do things beyond their training and capabilities.
If your initial evaluation for a neurosurgical condition is by a nurse practitioner or physician assistant, be sure to provide a thorough history of what brought you to the hospital, any abnormal symptoms that you have noticed, and any pre-existing conditions that you have, as well as medications that you are taking.
If it is not an emergency situation where they want to rush you to surgery immediately, when the neurosurgeon comes to see you, share the same information that you told to the mid-level provider.
After a neurosurgery, you may find that the follow-up care is being provided by mid-level providers, rather than the neurosurgeon. When your recovery is going smoothly, this arrangement may work fine, where there is one layer between you and the neurosurgeon who should be making the final decisions regarding your care.
If you start to show signs of an infection, like a fever, notice a change in nerve sensation or being able to move part of your body, or have a change in mental status or behavior, then it is time for the neurosurgeon to see you immediately. Because you, as the patient, may not notice some of these changes, it is a good idea to have someone with you who can describe the problem and request that the surgeon come and see you.
We are here to help
If you or someone you care for has been seriously injured as a result of negligent care related to a neurosurgery, then call 281-580-8800, for a free consultation with an experienced medical malpractice attorney at Painter Law Firm.
Robert Painter focuses his legal practice on representing victims of medical negligence, including people who have been seriously injured from poor neurosurgical care, or in other types of surgery, including surgical malpractice, anesthesia errors, and medication overdoses. Robert Painter is a medical malpractice lawyer at Painter Law Firm, in Houston, Texas, where he frequently writes and speaks on topics related to medical errors and the law.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes [...]read more
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine [...]read more
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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