Resources & Information


When everyone is supervising, is anyone? More PAs listing multiple primary supervising physicians

The NC Medical Board has noticed that an increasing number of licensed physician assistants are designating five or more physicians as their “primary” supervisors. The NCMB has had at least one documented case in which a PA had as many as 17 primary supervising physicians. The Board is concerned that PAs and physicians in these types of practice arrangements may not be meeting the Board’s requirements with regard to supervision. The Board voted at its meeting in March to ensure that, effective January 2012, PAs with five or more primary supervising physicians are included in the NCMB’s PA site visit program, which verifies compliance with supervision rules.

The Board recognizes that it may be desirable for a variety of reasons to have multiple physicians share the responsibility of acting as a midlevel practitioner’s primary supervisor. The Board does not consider this situation optimal, even if it is possible for multiple primary supervising physicians and their supervisee(s) to be in compliance with supervision rules. Designating a large number of physicians to act as primary supervisors may, in fact, prevent the midlevel practitioner from developing a meaningful clinical partnership with his or her primary supervisor(s), which is the Board’s ultimate goal.

For example, administrative rules require PAs to have detailed written scope-of-practice agreements that clearly state the medical duties and tasks to be delegated by each primary supervising physician. When a large number of primary supervising physicians take responsibility for a single PA, practices may be more inclined to use prepared, generalized documents to meet this requirement. In the Board’s view, using pro forma documents decreases the quality of the supervision because the PA and his or her primary supervisor(s) are less likely to carefully consider each practitioner’s skills, training and experience and create individualized documents that state the medical tasks that may be safely delegated.

On another note, the Board expects each primary supervising physician to hold regular, meaningful quality improvement meetings with each midlevel practitioner under his or her supervision. In an established supervisory arrangement, rules require that a PA meet with each primary supervising physician at least once every six months. A PA with 17 primary supervising physicians would need to participate in, at minimum, 34 QI meetings a year. Even if a PA could manage to attend such a large number of meetings, the Board questions whether the quality of theses interactions would meet its expectations for meaningful quality improvement.

There is no specific restriction that requires PAs to limit the number of physicians they designate as primary supervisors. However, the Board prefers that PAs structure their practice arrangements such that they have an opportunity to develop close working relationships with their primary supervisors. This is most likely to occur when there is one primary supervisor. In a situation where that is not feasible, the Board believes it is best when supervision is shared among the smallest number of primary supervising physicians possible. If other physicians in the practice wish to have a role in supervising midlevel practitioners, they may participate as back-up supervising physicians.

  • Proof of licensure and registration

  • Statement of supervisory arrangement with each primary supervising physician (This document provides a detailed description of the PA’s scope of practice)

  • Signed and dated record of Quality Improvement meetings between each primary supervising MD and PA relevant to clinical problems and QI measures

  • List of all back-up supervising physicians, signed and dated by MDs (primary and backups) and PA

  • Written prescribing instructions to include written policy for periodic review of these instructions by each primary supervising MD

  • DEA registration and pharmacy permit, if applicable

Learn more: View NCMB rules for PAs