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Letter to the Editor: Article did not intend to offend NPs, PAs or minimize their value :

June 27, 2016

I appreciate the passionate and thoughtful responses from Jeffrey A. Katz, PA-C, DFAAPA (, and Cathy M. Haut, DNP, CPNP-AC, CPNP-PC, CCRN (, to my recent AAP News article “How to manage liability risks when supervising mid-level providers” (

Various federal government agencies (e.g., Health Services and Resources Administration, Department of Justice Enforcement Administration, etc.) as well as medical liability insurers currently utilize the term “mid-level provider/practitioner,” and most physicians continue to recognize it as including physician assistants (PAs) and nurse practitioners (NPs). I was not aware that NP and PA associations and their members find this term offensive, and for that I apologize.

My article focused on the often misunderstood legal risks to pediatricians who work in collaborative agreement with NPs and those supervising NPs or PAs. It was not meant to discuss independently practicing NPs, where the liability risks are more focused on those practitioners. Many states allow NPs to practice independently; this article did not deal with them or their individual liability.

In no way did I suggest that NPs or PAs are risky hires or more prone to liability awards. The article stated that lawsuits against NPs and PAs are markedly less frequent than physicians (5.8/1,000 provider years vs. 38.2/1,000 years). The table listing average indemnity payments was from a Physician Insurers Association of America 2003-2013 report, which is limited to closed pediatric malpractice claims and thus may reflect the patient population more than the quality of care. The large award cited was especially relevant for practicing physicians because it included punitive damages against supervising physicians who failed to follow their own guidelines for care management.

Many PA and NP students receive specialty training or have long periods of experience with pediatrics. New graduates’ time in training from starting in post-graduate education to hands-on with patients is similar to that of a third-year medical student. Typically, PA students have one or two clinical rotations examining and caring for pediatric patients prior to graduation.

There is an abundance of literature citing higher error rates in clinical medicine in practitioners with less medical or procedural experience. Even given the 2,000 hours of total training cited by Mr. Katz, president of the American Academy of PAs, these training hours fall dramatically below the average pediatric resident graduate's experience.

The American Association of Nurse Practitioners notes that 17 states require a regulated collaborative agreement with an outside health discipline for the NP to provide patient care or limit the setting or scope of one or more elements of NP practice. An additional 12 states restrict the ability of an NP to engage in at least one element of NP practice, thus requiring supervision, delegation or team-management by an outside health discipline (

The Pediatricians and the Law article provided guidance to pediatricians to minimize liability risks in the above defined relationships with NPs and PAs. It was not intended to articulate or alter the Academy’s position on the overall role of NPs and PAs in delivering excellent care to pediatric patients.


                                    James P. Scibilia, M.D., FAAP

                                    member of the AAP Committee on Medical Liability and Risk Management

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