Speaker 1: I've got a paper looking at malpractice suits against PAs and NPs. It's called Physician, Assistant, and Nurse Practitioner Malpractice Trends by Dr. Brock, who has done a number of papers in this regard. This is the most recent look at this problem, and it's in a journal I've never heard of called Medical Care Research and Review. This is a 2017 article. It's unfortunately, virtually impossible to find articles that are looking at, specifically, emergency medicine related cases. That's the case here as well. What did they find? This is from the National Practitioner Database. They found that of these 178,000 medical malpractice or adverse events, adverse events are things where your medical staff basically has restricted your privileges because you did something like maybe you were touching a patient inappropriately or something, so it's not necessarily a lawsuit or some issue of substandard of care. In any case, they reviewed 178,000 malpractice charges or adverse events. 95% of them involved physicians, 3% involved PAs, and 2% involved nurse practitioners. Hold on one second. Here's

Speaker 2: the problem. We're always going to involve the physician. See, we don't know how much interaction there was with the PA or the NP. Maybe they were just a part of the process. Whenever you say, oh, they don't get sued as much, the big gun, the guy at the top, the one with the insurance policy, maybe what we focus on, that doesn't mean there wasn't PA and

Speaker 1: NP input into these cases, Rick. No, I fully agree. They do look at the frequency per 1,000 providers. For every 1,000 physicians, 11 got named in one of these actions to 19, between 11 and 19. On the PA side, it was one and a half to two and a half per 1,000 PAs. That's a tiny fraction. For every 1,000 NPs, there was 1.1 to 1.4 of these malpractice or otherwise events. Interestingly enough, diagnostic-related issues occurred more frequently with PAs. Half the cases involved diagnosis, 40% with the NPs and 32% with physicians. This is not the case. I would bet a dollar if it was limited to emergency medicine because we are about diagnoses. Once we got the diagnosis, we can look up how to treat it. I think that these numbers would not be applicable. I think that in emergency medicine, it is diagnosis, delayed diagnosis, that's it. That's what you get

Speaker 2: sued for. I think, particularly for emergency medicine, Rick, it's going to take us 10 years to find out where this balance is. Over the last 15 years, we've seen PA involvement, independently seeing cases, go from damn near nothing to up to 40% or 50% in some groups. It's going to take a period of time for us to see the trend actually level off and find out where they are. Emergency medicine is a unique process. We should remember that all the time. You are absolutely right about diagnosis. We do two things. We find it and we fix it. PAs in other fields, for example, orthopedic surgery, they get told what to do, putting on casts, that sort of thing. We are the finders and the fixers. Finding it, you either do or you don't, and that really sets the tone for us. Because of all of these

Speaker 1: laws now making it more difficult to sue physicians, over time, this is 2005 to 2014, the average award for a physician case has gone down from 221,000 to 195,000. PA and NP awards have remained pretty much level at about 112,000. In fact, they've gone up a little bit, 112,000 to 120,000. We're going down, they're going up. It's surprising that these awards for PA and NP involvements are not inconsequential, $120,000. That's the trend. It's been going on for a while. I agree 100%. We really have no idea what is current because of the delay in all of these cases. You have to file it. You have to wait half a year to file it, that kind of thing. We don't know what's going on now at all. The idea that a third of patients in emergency departments are being seen by PAs and NPs, there's got to be a lot more interesting stuff going on in the world of malpractice than we know about. Absolutely. We are in the middle

Speaker 2: of history. It's very hard to determine which direction some of this stuff is going in.