9.1.1: Physician Supervision of Other Licensed Health Care Professionals

The physician who provides medical supervision of other licensed healthcare professionals is expected to provide adequate oversight.  The physician must always maintain the ultimate responsibility to assure that high quality care is provided to every patient.  In discharging that responsibility, the physician should exercise the appropriate amount of supervision over a licensed healthcare professional which will ensure the maintenance of quality medical care and patient safety in accord with existing state and federal law and the rules and regulations of the Board.  What constitutes an “appropriate amount of supervision” will depend on a variety of factors.  Those factors include, but are not limited to:

• The number of supervisees under a physician’s supervision;
• The geographical distance between the supervising physician and the supervisee;
• The supervisee’s practice setting;
• The medical specialty of the supervising physician and the supervisee;
• The level of training of the supervisee;
• The experience of the supervisee;
• The frequency, quality, and type of ongoing education of the supervisee;
• The amount of time the supervising physician and the supervisee have worked together; and
• The supervisee’s scope of practice consistent with the supervisee’s education, national certification and/or collaborative practice agreement. 

The above factors outlining the supervisory relationship should be outlined in a written collaborative practice agreement, supervisory arrangement, protocol, or other written guidelines.  
Physicians should only supervise another professional for the diagnosis, treatment, and overall care (including procedures) for which the physician has an appropriate level of education, training, experience, and/or certification.  Physicians should also be cognizant of maintaining appropriate boundaries with their supervisees, including refraining from requesting medical treatment by the physician’s supervisee.*  

Advanced Practice Providers

There are additional requirements and considerations for supervisory arrangements between physicians and physician assistants and nurse practitioners, collectively referred to herein as advanced practice providers (“APPs”).  They include:

• Written agreements and supervisory arrangements between APPs and their supervising physicians should comply with the regulatory requirements provided in 21 NCAC 32S .0213 (physician assistants) and 21 NCAC 32M .0110 (nurse practitioners);  
• APPs are specifically prohibited from prescribing controlled substances for the use of their supervising physician;
• APP-owned practices cannot employ or contract with physicians to provide medical services on behalf of the practice.  However, an APP may enter into a contract with a physician solely to meet legal supervision requirements for APPs; and
• Physicians should exercise caution if using a private company to pair them with an APP-owned practice.  The Board has found that many of these arrangements are correlated with poor and inadequate supervision as well as rule violations.  

*See also the Board’s position statement on “Self-treatment and Treatment of Family Members.”