They’re Not a Doctor, What’s the Risk?

Amanda Speier (Partner, Taylor Duma, LLP, Atlanta, Georgia)

Mid-level providers like nurse practitioners (“NPs”) and physician assistants (“PAs”) fill an important gap in the provision of healthcare across America, especially in rural areas.¹ Yet, mid-level providers are performing more and more physician-like tasks, often with very little physician oversight, if any. Given the expanding role of mid-level providers, the risk of litigation increases as well. This article provides a broad overview of the role of mid-level providers in order to highlight the need to insure these providers appropriately.

NPs and PAs are licensed, independent practitioners who practice mostly autonomously, albeit with some physician oversight. NPs are advanced practice registered nurses (“APRNs”) who obtain graduate education at the masters or doctoral level, and obtain board certification. The APRN umbrella also includes certified registered nurse anesthetists (“CRNAs”), clinical nurse specialists (“CNSs”), and certified nurse midwives (“CNMs”). NPs can order tests, render diagnoses, and prescribe medication. To become a NP, one must first obtain a bachelor of science in nursing, typically during a four-year undergraduate program. Once you obtain your BSN, a prospective NP must complete a graduate master’s or doctoral nursing program, which can take anywhere between 18 months to three years to complete. There are also combined programs where one can obtain their BSN and MSN at the same time in approximately three years.² The NP conducting your annual physical, diagnosing your condition, and prescribing your medication may have as little as three years of nursing education.

PAs typically start with a bachelor of science degree from a four-year undergraduate program. PAs must then graduate from a PA program, many of which require a certain number of healthcare or patient experience hours before even applying. PA programs are approximately three academic years, which includes both classroom instruction and clinical rotations.³ The PA developing your treatment plan, interpreting your diagnostic testing, and rounding on you in the hospital likely has seven years of medical education.

A board-certified internal medicine physician, on the other hand, has completed four years of undergraduate education, four years of medical school, three years of residency, and then passed a board exam, for a total of 11 years of medical education.

In some states, the scope of practice description for a PA hardly differs from that of a physician. New Hampshire is one of a handful of states, including Iowa, Montana, North Dakota, Utah, and Wyoming, where a PA is given the greatest independence. In New Hampshire, a PA can provide “any legal medical service for which they have been prepared by their education, training, and experience and are competent to perform.”⁴ This includes ordering, performing, and interpreting diagnostic studies as well as evaluating, diagnosing, managing, and providing medical treatment.⁵ The statute is so broad that it seems to allow any type of medical care by a PA. In order to prove a PA was practicing beyond his or her license would require specific evidence of his or her education, training, and experience.

NPs and PAs are regulated by the individual states, and states differ in the amount of oversight required for each. For example, in Georgia, a delegating physician over a NP is required only to review 10% of patient records unless controlled substances are ordered or an adverse outcome occurred.⁶ That means for 90% of patients, the NP or other APRN is ordering imaging, medications, and pronouncing death without any physician oversight. While nurse protocol agreements set forth the limitations of the NP’s practice, the physician largely determines when he or she requires direct consultation. And, a delegating physician may supervise up to four NPs at one time.⁷ It would be optimistic to think a physician supervising four NPs is actively involved in the care of up to five patients simultaneously at any given time.

As for PAs, 20 states require a certain percentage or number of PA charts to be co-signed by a physician.⁸ In Arizona, supervision does not require the physical presence of the physician at the same place where healthcare is provided by the PA as long as they communicate at least once per week via telecommunication.⁹ After 8,000 hours of clinical practice, a PA in Arizona requires no physician supervision at all.¹⁰ That may be only 3-4 years of practice. And while some states like New York have statutes expressly providing that physicians remain medically responsible for the services performed by the licensed PAs they supervise, many states do not.¹¹

The following case law illustrates the often murky limitations of mid-level scope of practice:

• Lopez v. Ledesma, 46 Cal.App. 5th 980 (2020) (California court determines that the scope of a PA’s practice is defined, not by the PA license itself, but by the scope of the practice of the physician who supervises them. Consequently, the court concludes that a PA acts within the scope of his license if he has a legally enforceable agency agreement with a supervising physician, regardless of the quality of actual supervision).
• Cleveland v. U.S., 457 F.3d 397 (5^th Cir. 2006) (suggesting that standard of care for physicians and PAs is the same because Louisiana law allows PAs to perform most of the same tasks as physicians, frequently without direct supervision).

Because of the blurry line between physician and mid-level scope of practice, the verdicts against mid-level providers in medical malpractice suits can be just as high as verdicts against physicians. For example, in 2022, there was a $18 million dollar verdict against a NP in Pennsylvania who failed to refer a patient for further testing or imaging after finding a lump in her breast that was diagnosed nine months later as an aggressive form of breast cancer, requiring a bilateral mastectomy and chemotherapy.¹² Experts opined a simple lumpectomy could have been performed had the patient been referred for imaging, and therefore, diagnosed, nine months earlier. Recently, in June 2025, a Wisconsin jury returned a $29 million dollar verdict against a CNM who failed to notify a OB/GYN when a baby’s heart rate dropped down to the 60s during labor, warranting an emergency C-section delivery.¹³ The newborn was diagnosed with cerebral palsy and will require life-long care.

In conclusion, mid-level providers perform many of the same medical tasks as physicians, yet many discount their potential liability for patient harm. Jurors will likely hold mid-level providers accountable in the exact same way they would judge the standard of care of a physician. The insurance coverage for these mid-level providers should reflect that risk.