The Supreme Court of Tennessee addressed a medical malpractice case involving Melissa Michelle Cox, who alleged injuries due to physician assistant Michael Maddox's failure to accurately diagnose her condition. Cox did not sue Maddox directly but targeted the M. A. Primary and Urgent Care Clinic, owned by Maddox, and Dr. Austin Adams, his supervising physician. The defendants sought summary judgment, arguing that neither Maddox nor Dr. Adams violated their respective standards of care. The trial court granted this motion, but the Court of Appeals reversed, establishing that physician assistants should be held to the same standard of care as physicians.
The Supreme Court reversed the Court of Appeals, confirming that the standard of care for physician assistants is distinct from that for physicians. Consequently, the Supreme Court reinstated the trial court's summary judgment in favor of the defendants and dismissed the case. The opinion was delivered by Justice Cornelia A. Clark, with the agreement of other justices. The factual background indicated that Cox visited the clinic multiple times between 2003 and 2004 for respiratory issues, ultimately leading to a diagnosis of cardiomyopathy after further emergency treatment.
On June 3, 2005, Plaintiff initiated a medical malpractice lawsuit against the Clinic and Dr. Adams, claiming a violation of the standard of care due to a failure to diagnose cardiomyopathy. Plaintiff asserts that a physician/patient relationship existed through physician’s assistant Michael Maddox and Medical Director Dr. Adams, who both allegedly owed a duty of care. The Defendants admitted to the existence of a patient relationship but denied malpractice, asserting that Dr. Adams did not provide medical care to Plaintiff and that he had no physician/patient relationship with her. They claimed that the treatment met the acceptable standard of medical practice for the relevant period in Rutherford County, Tennessee.
In their motion for summary judgment, Defendants presented affidavits from both Maddox and Dr. Adams, with Maddox detailing Plaintiff's history of visits from September 2003 to June 2004. During these visits, she presented various symptoms, including cough, shortness of breath, and other respiratory issues. Maddox conducted assessments, ordered diagnostic tests, and eventually referred Plaintiff to a pulmonologist. The medical evaluations during this period included diagnoses of bronchitis, allergic rhinitis, sinusitis, and indications of chronic lung changes, with no evidence of acute issues found in imaging studies.
On June 27, 2004, the Plaintiff was diagnosed with congestive heart failure at StoneCrest Medical Center after previous care by Michael Maddox, P.A. in 2003 and 2004. Dr. Adams, the supervising physician, affirmed that both Maddox's and his own medical practices adhered to the recognized standards of acceptable professional practice for physician assistants and family physicians in Rutherford County, Tennessee. Dr. Adams stated he was familiar with these standards and confirmed that he did not personally treat the Plaintiff, only supervising Maddox and having minimal phone communication. He opined that Maddox appropriately evaluated and treated the Plaintiff and that there were no injuries resulting from any acts or omissions by either physician. Defendants submitted a statement of undisputed facts asserting that their medical care complied with accepted standards, which the Plaintiff denied, contesting their claims with deposition testimony from Dr. Nelson Mangione, a cardiologist who treated her heart condition, as her sole expert evidence against the summary judgment motion.
Dr. Mangione testified that Michael Maddox’s care of the Plaintiff was below the standard expected of a primary care physician, whereas Dr. Adams, Maddox's supervising physician, met that standard. However, Dr. Mangione admitted he lacked experience with physician assistants and could not comment on their standard of care or the supervising physician's responsibilities towards them. The trial court granted summary judgment in favor of the Defendants, ruling that the Plaintiff did not establish the relevant standard of care or causation. On appeal, the Court of Appeals reversed this decision, asserting that the standard of care for physician assistants is determined by the supervising physician's standards in their community. The Court noted that Dr. Mangione's testimony regarding Dr. Adams' standard of care was adequate to present a genuine issue of material fact under Tenn. Code Ann. § 29-26-115 (a)(2). The appeal raised the question of the applicable standard of care for physician assistants in malpractice cases, a novel issue for the Court. The review of the trial court’s summary judgment ruling is conducted de novo, favoring the non-moving party and disregarding contrary evidence. The excerpt also provides context about the role and responsibilities of physician assistants, highlighting their emergence in the 1960s to address physician shortages and their collaborative role in healthcare teams.
Increasing utilization of physician assistants (PAs) is driven by their ability to reduce healthcare costs, alleviate physician stress, enhance patient satisfaction, and improve care quality through a collaborative team approach. PAs enable physicians to delegate specific medical tasks while being perceived as subordinate to physicians. Since 1985, Tennessee has recognized PAs as medical providers under the Physician Assistants Act, which emphasizes that PAs and medical doctors are distinct professions. PAs are defined as individuals providing diagnostic or therapeutic services that would otherwise require a licensed physician. Tennessee law allows PAs to operate under the supervision of licensed physicians or osteopathic physicians, ensuring that their services are performed under appropriate oversight.
The practice of medicine encompasses diagnosis, treatment, and prescription for physical ailments. PAs must be licensed, which requires graduation from an accredited training program and passing the National Commission on the Certification of Physician Assistants examination. In Tennessee, licensed PAs can only perform selected medical services under physician supervision, which necessitates active oversight without requiring the supervising physician’s constant physical presence. PA education mirrors that of medical students, requiring at least two years of undergraduate courses in basic and behavioral sciences before entering PA programs, which typically last about 27 months and are integrated with medical school curricula.
Students in a physician assistant (PA) program start with a foundational year of medical science courses, including anatomy and pharmacology, followed by a clinical training phase consisting of classroom instruction and rotations through various medical specialties. By graduation, PA students will have completed 2,000 hours of supervised clinical practice. The scope of services a PA can provide is defined in a written protocol developed in collaboration with the supervising physician, outlining potential problems and treatments. PAs may only perform tasks within their competencies and in accordance with the supervising physician's practice scope, ensuring patient health and safety. In emergency situations, PAs can provide necessary medical services under established guidelines until a responsible physician arrives. PAs operate under the control of a licensed physician, who has complete authority over their actions and must ensure proper supervision. Additionally, a committee on physician assistants, composed solely of licensed PAs, is responsible for setting rules necessary for PA practice, including disciplinary actions. PAs licensed under state law may perform specific medical/surgical services as outlined in their protocols, which must be consistent with the supervising physician’s scope of practice, and always under their supervision.
Each physician assistant must have a designated primary supervising physician and is required to inform the Committee of the physician’s name, address, and license number, as well as any changes within fifteen days. The Board of Medical Examiners and the Committee are authorized to discipline physician assistants for gross malpractice, repeated malpractice, negligence, or incompetence, and for violations of specific scope of practice statutes and rules. Although there is no explicit "standard of care" for physician assistants, the Committee evaluates malpractice by the standards applicable to physician assistants, rather than physicians. There is a statutory "standard of care" for orthopedic physician assistants. The Board has established General Rules and Regulations requiring written protocols that outline the applicable standard of care, with the supervising physician responsible for compliance.
In the context of a lawsuit where Maddox, a physician assistant, is alleged to have been negligent, the plaintiff did not sue Maddox directly but rather the Clinic and Dr. Adams. To succeed, the plaintiff must demonstrate a legal basis for holding the defendants liable for Maddox's alleged malpractice. Under Tennessee law, a principal can be vicariously liable for the actions of an agent if those actions occur within the scope of their agency. The existence of an agency relationship is a factual determination based on the agreement or conduct of the parties. Other states have approached the physician assistant-supervising physician relationship through various statutes, with some explicitly designating the physician assistant as an agent of the supervising physician, while others assign liability for the physician assistant’s actions directly to the supervising physician. In Tennessee, a physician assistant is considered an agent when performing medical services under the supervision of a physician.
Dr. Adams served as the supervising physician for Maddox, establishing an agency relationship between them, despite the absence of a written agreement outlining their specific relationship. According to Tennessee law, specifically Tennessee Code Annotated section 63-19-106(b), a physician assistant must operate under the control and responsibility of a licensed physician, who is accountable for the assistant's actions at all times. Various state laws confirm that the supervising physician bears legal responsibility for the medical services provided by the physician assistant, regardless of whether the assistant is employed by a physician or a healthcare facility. Definitions across multiple states, including Massachusetts, Minnesota, Mississippi, Missouri, Ohio, South Carolina, South Dakota, Texas, Virginia, West Virginia, and Wisconsin, consistently emphasize the supervising physician’s role in overseeing the physician assistant's activities and accepting responsibility for their medical services. Additionally, it is noted that physician assistants cannot be self-employed.
An employer of a physician assistant is legally responsible for the medical care provided by the assistant during employment. If the employer is not a licensed physician, they must ensure that a licensed physician supervises the assistant without interference. A supervising physician is defined as one who agrees to be accountable for the medical acts of a board-approved physician assistant. Services performed by the assistant must be under the supervision and ultimate responsibility of a licensed physician. When a physician delegates responsibilities to a physician assistant, the physician remains accountable for the assistant's conduct, establishing an agency relationship where the assistant acts as an agent and the physician as the principal. In this context, Dr. Adams is considered an agency supervisor of Maddox, meaning Dr. Adams could be vicariously liable for any negligence by Maddox.
Regarding the Clinic, it is described as employing Maddox, which may incur liability for Maddox's negligence under the respondeat superior doctrine. Even if hospitals exercise due care in selecting their employees, they can still be held liable for their negligent actions. However, the absence of the required written protocol between Maddox and Dr. Adams leaves the precise scope of their agency relationship and responsibilities unclear. The record does not clarify the legal relationship between the Clinic and Maddox, or between the Clinic and Dr. Adams, including whether Maddox operated the Clinic as a sole proprietorship or in a partnership or corporate structure, nor whether Dr. Adams was an employee or independent contractor. The resolution of these issues is not necessary for the current case but may be important for potential appellate review. Additionally, the Tennessee Attorney General has issued an opinion regarding the legal relationships involving physician assistants, supervising physicians, and their business organizations.
The excerpt addresses the standard of care for physician assistants (PAs) in the context of a legal case in Tennessee. The plaintiff contends that PAs are practicing medicine under the supervision of a physician and should therefore be held to the same standard of care as their supervising doctors. This issue is novel in Tennessee, with arguments presented for distinct standards of care for PAs. Some commentators suggest that PAs should be judged by the standard of a reasonably prudent PA in similar circumstances, akin to how paralegals are compared to lawyers.
Several court cases from other jurisdictions are cited to support the notion that different standards of care should apply. For instance, the Texas Court of Appeals in Bradford v. Alexander ruled that a PA cannot testify about the standard of care for a physician due to their subordinate role, paralleling the treatment of paralegals regarding attorneys. Other cases reinforce the idea that PAs do not follow the same standard as physicians, with distinctions made between the responsibilities and competencies of PAs and physicians, particularly specialists.
Furthermore, the excerpt highlights that many states have statutory frameworks suggesting varied standards of care for different healthcare roles. The Superior Court of Delaware's decision in Wilson v. James is referenced, where a PA was involved in a negligence claim regarding a misdiagnosis. This body of legal discussion indicates a trend toward recognizing a separate standard of care for physician assistants compared to medical doctors.
Montague filed a motion in limine to prevent the plaintiff's medical expert from testifying about the standard of care for physician assistants. The basis for this motion is that the expert's previous statements indicated an unclear understanding of the applicable standard of care. Various state statutes are referenced, emphasizing that in medical malpractice cases, the burden of proof is on the plaintiff to demonstrate that the healthcare provider did not meet the expected standard of care consistent with other providers in the same field. These statutes outline that the standard of care is determined by factors such as licensure, training, and experience, and that an expert witness must have relevant clinical practice or teaching experience to testify on such standards. Overall, the plaintiff must establish that the healthcare provider's actions were negligent and did not align with the established standards within the healthcare community.
A deposition revealed that an individual was unaware of the scope of practice for physician assistants under Delaware law and the distinctions between their training and that of nurse practitioners. The plaintiff argued that Montague should adhere to the standard of care expected of a pediatrician, which the court found perplexing. The court determined that the plaintiff's expert was unqualified to define the standard of care for physician assistants due to his unfamiliarity with their practices in Delaware. It emphasized that Delaware law prohibits physician assistants from performing any medical acts unless delegated by a supervising physician, except in emergencies or as allowed by statute. The court noted that the Medical Practice Act indicates that the standard of care for a pediatric physician assistant cannot be the same as that of a Board-certified pediatrician. While some jurisdictions hold physician assistants to the same standards as medical doctors, Delaware's statutes and regulations suggest otherwise, specifying that physician assistants practice under the close supervision of a physician and within a defined scope of practice. Although they may exercise some independent judgment, physician assistants have limited autonomy and risk disciplinary action for unauthorized practice.
Significant limitations on physician assistants (PAs) cannot logically coexist with holding them to the same standard of care as their supervising physicians. The Wilson court emphasized that it is unreasonable to expect a medical provider to meet a standard of care for which they have not been trained. PAs must graduate from a training program and pass the National Commission on the Certification of Physician Assistants exam, while physicians must graduate from medical school, complete a one-year residency, and pass a Board examination, highlighting the educational disparity between the two roles. Consequently, PAs and physicians are not equivalent healthcare providers. The court referenced McLean to illustrate that equating the care provided by PAs to that of physicians is misguided. Moreover, it was noted that PAs require supervision due to their limited training. The Tennessee Board of Medicine stipulates that a PA's standard of care is partly defined by the written protocol with their supervising physician, suggesting that their standard is not identical to that of physicians. Thus, Tennessee's medical malpractice statute implies that the recognized standard of acceptable practice for PAs is distinct from that of physicians. Ultimately, PAs should be evaluated against the standard of care recognized in their profession, not that of physicians, aligning with Tennessee's historical view that professionals are accountable for the requisite knowledge and skills inherent to their fields.
Professionals, including physician assistants, are evaluated based on the standard of care specific to their profession. To prove medical malpractice against a physician assistant, a plaintiff must provide expert testimony that demonstrates both the relevant standard of care and whether the physician assistant acted within that standard. Notably, the standard of care for physician assistants is distinct from that of physicians, although some cases have assumed they are the same.
In Tennessee, medical malpractice claims are governed by Tennessee Code Annotated section 29-26-115, which outlines the necessary elements for a successful claim. These elements include: (1) establishing the recognized standard of acceptable professional practice in the relevant community; (2) proving that the defendant did not meet that standard through negligence; (3) demonstrating that this negligence directly caused the plaintiff's injuries; and (4) showing that these injuries would not have occurred absent the defendant's actions. Furthermore, competent expert testimony is essential to substantiate these elements, which apply not only to physicians but also to non-physicians like nurses engaged in patient care.
Courts and litigants often refer to the "recognized standard of acceptable professional practice" in healthcare as the “standard of care.” Expert testimony is generally required to establish this standard unless the alleged negligence is so apparent that it falls within the common knowledge of laymen, which is not applicable in the current case. According to Tennessee law (Tenn. Code Ann. 29-26-115(b)), a health care provider must be licensed in Tennessee or a contiguous state and must have practiced in the relevant specialty within the year preceding the alleged malpractice to testify as an expert. This competency requirement applies to both plaintiff and defendant witnesses and can be waived by the court under certain circumstances.
For expert testimony to be admissible regarding the standard of care, the witness must have sufficient experience and familiarity with the defendant's field of practice. Specifically, the plaintiff must present expert testimony establishing (1) the applicable standard of care, (2) how the defendant's conduct deviated from that standard, and (3) how this deviation caused the plaintiff's injuries. An expert witness qualified to testify about a physician assistant's standard of care may include a medical doctor familiar with the relevant practices.
A defendant can challenge a plaintiff's medical malpractice case by filing a motion for summary judgment, which will be granted if there is no genuine issue of material fact, as per Tenn. R. Civ. P. 56.04. The burden of proof rests with the defendant to show there are no material facts in dispute, after which the burden shifts to the plaintiff to demonstrate that such issues do exist.
A defendant seeking summary judgment shifts the burden of production to the plaintiff by either negating an essential element of the plaintiff's claim or demonstrating that the plaintiff cannot prove an essential element at trial. In this case, Defendants supported their motion with expert affidavits from Maddox and Dr. Adams, which negated any breach of the applicable standard of care. This required the plaintiff to provide competent expert proof to show a genuine issue of material fact regarding the breach.
In response, the plaintiff relied solely on the deposition of Dr. Nelson Mangione, who stated that Maddox breached the standard of care for primary care physicians. However, Dr. Mangione conceded that he lacked familiarity with the standards applicable to physician assistants or the supervising physician, leading the trial court to conclude that his testimony did not meet the plaintiff's burden of proof. The court determined that Dr. Mangione was not competent to testify about Maddox's standard of care, and it found no abuse of discretion in this determination.
The court emphasized that in medical malpractice cases, the primary issue regarding expert testimony is the expert's competence under the medical malpractice statute. Since the plaintiff did not present additional evidence to counter the defendants’ proof, the trial court correctly granted summary judgment in favor of the defendants.
Regarding Dr. Adams, although the complaint could suggest a malpractice claim, the plaintiff did not assert that Dr. Adams independently committed malpractice or had direct involvement during the relevant time. Dr. Mangione also opined that Dr. Adams did not breach the primary care physician standard of care. Consequently, summary judgment was deemed appropriate for Dr. Adams as well, with negligent supervision being the only remaining potential liability theory concerning Maddox's negligence.
In Watkins v. Affiliated Internists, the court addressed the issue of negligent supervision by Dr. Adams, which the Plaintiff raised for the first time on appeal. The court noted that this independent theory of liability was not included in the original complaint, thus barring its introduction at this stage. The ruling emphasized that the professional standard of care for physician assistants differs from that for physicians. The Plaintiff failed to provide expert testimony regarding any breach of the applicable standard of care, leading the trial court to grant summary judgment in favor of the Defendants. The appellate court reversed the Court of Appeals' judgment and reinstated the trial court's decision, resulting in the case being dismissed. Additionally, it was highlighted that the competency requirements for expert witnesses in medical malpractice cases are notably distinct, including adherence to the locality rule. Finally, the costs of the proceedings were assessed against the Plaintiff, Melissa Michelle Cox, with provisions for execution if necessary.
