In this feature, NCMB presents examples of issues that frequently come before the Disciplinary Committee but don’t often result in public action. Our hope in highlighting these topics is to help licensees avoid problems and ensure they meet appropriate professional obligations.
Problems and misunderstandings with physician supervision of PAs, NPs and other APPs are perennial issues in enforcement cases. It is important to understand that agreeing to supervise in NC is not a mere formality but a commitment to a true collaborative relationship. Over the years NCMB has established a number of detailed administrative rules that spell out in detail the specific requirements for PAs and supervising physicians in supervisory arrangements.
Case Study
After 10 years working as a physician assistant with a large primary care practice, PA leaves to open a solo primary care clinic. PA arranges for a physician she met at a professional meeting to serve as her off-site supervising physician. PA was a trusted provider in her previous practice and many established patients elected to follow her to the new clinic. After one year in successful solo practice, PA decides to expand the scope of services she offers to include cosmetic procedures, primarily Botox and dermal fillers that PA learned to inject at a two-day workshop. PA markets the new services with a print advertising campaign, sending direct mail postcards and even renting a billboard in her town.
A couple of months after launching the cosmetic services, the medical board opens an investigation based on an anonymous complaint that PA is practicing without physician supervision. In her written response, PA states that she does have a supervising physician who works at a different practice location and speculates that the complainant must mistakenly believe that PAs are required to have on site supervision. PA provides the medical board with the name and contact information of her supervising physician.
Upon further investigation the medical board discovers that, upon opening her own practice, PA did not meet monthly with her supervising physician for the first six months as required for PAs in a new supervisory relationship. When asked about this, PA indicates that she did not think this rule applied to her because she has a decade of experience, not realizing that the rule applies to new supervisory relationships and not to new PAs. In addition, PA’s scope of practice and prescribing documents are cursory, and PA is only able to produce documentation for one quality improvement meeting with her supervisor during their entire 13-month relationship. When asked to explain the lack of contact, PA states that she was able to handle all patient care independently and did not need to consult with her supervising physician. After interviewing the supervising physician, who confirms that contact with PA has been minimal, the medical board learns that he is not trained to perform Botox and dermal filler injections and, in fact, has never treated a single patient with the treatments he is “supervising”.
Discussion
North Carolina law currently requires that all PAs have a supervising physician to practice lawfully. State law permits PAs to own their own practices. Provided that the PA and their primary supervising physician follow all applicable rules and policies, on-site supervision is not required. Before performing any medical acts, tasks or functions, the PA must submit an online Intent to Practice form via NCMB’s online Licensure Gateway portal to designate the primary supervising physician. If the supervisory relationship is new – that is, the PA and the supervising physician have not had a formal supervisory relationship before – then the PA and supervising physician must meet monthly for the first six months of the supervisory relationship and keep written documentation of such meetings. After six months, the two must meet at least twice each year for quality improvement meetings, which also must be documented. QI meetings are not required to be held in person, but should be substantive in nature, including discussion of challenging cases and opportunities to improve care. On a day-to-day basis, the supervising physician must be readily available to the PA for consultation, either in person, or by telephone, text or instant message. The PA must also create detailed written documents that outline the PA’s scope of practice and prescriptive authority.
Rules related to physician supervision of PAs are available online. Additional guidance on NCMB’s expectations regarding supervision of PAs and other licensed professionals is provided in
this position statement.
Additional considerations
A key aspect of the supervisory relationship between physician and PA (or any other APP) is that there must be parity between the knowledge and skills of the supervisee and the supervisor. While there is no issue with a physician’s clinical knowledge and expertise exceeding those of the supervisee, it is never acceptable for the supervisee’s knowledge and, more specifically, their scope of practice, to surpass that of the primary supervising physician. It is NCMB’s view that it is not feasible or appropriate for a physician to supervise a procedure or treatment he or she cannot perform competently themselves. In the case study presented above, the supervising physician’s lack of training and experience in administering Botox and dermal fillers made him an inappropriate choice of supervisor. To rectify the situation, the PA has two main options: She could discontinue providing Botox and fillers or, alternatively, she could find a new primary supervising physician who is trained and experienced in those procedures. In either situation, the medical board would also expect the PA to shore up her scope of practice and prescriptive authority documents – by adding more detail about the specific medical acts, tasks and functions she performs and making sure to include the cosmetic procedures. Finally, the PA would also need to comply with at least the minimum requirement for QI meetings with her supervising physician and ensure she is following all other rules. Extra credit: If the PA were to find a new primary supervising physician she should ensure that she removes the previous supervisor using the online Intent to Practice form. This is a step that is too often forgotten.
Conclusion
PAs are NCMB’s fastest growing licensee group, with more than 10,000 licensed PAs and counting. Currently, every PA who practices in North Carolina must have an appropriate supervising physician. Supervision requirements exist to protect patients and to improve quality of care. NCMB asks that both PAs and supervising physicians alike treat the supervisory relationship with the seriousness and integrity it warrants.
