Many family physician practices include non-physician clinicians (NPCs) including, but not limited to physician assistants, nurse practitioners and nurse midwives. Family physicians have been at the forefront of innovation in practicing with NPCs, especially in underserved communities. The American Academy of Family Physicians (AAFP) supports a wide variety of efforts by policy makers to improve access to health care services in underserved communities with innovative staffing models that include NPCs.
The increasing variety of situations in which NPCs practice, the emphasis on practice teams, and the growing tendency of health policy makers to identify NPCs as a means of improving the availability of health care services raises important issues regarding the appropriate relationship between NPCs and physicians. The AAFP believes NPCs should always function under the direction and responsible supervision of a practicing, licensed physician even in states where practitioners and physician assistants have independent practice authority.
These guidelines are intended to serve as a set of general principles with which physicians, NPCs and policy makers can assess the role of NPCs in providing patients accessible, high quality care.
It is important to note that an extremely varied set of laws and regulations defining the legal relationship between physicians and NPCs has been adopted by the federal government and all 50 states. There are major differences in state scope of practice statutes among nurse practitioners, nurse midwives and physician assistants. Physicians and NPCs are urged to fully comply with all federal, state and local laws and regulations regarding health care delivery. Health insurance plans and practices which include NPCs should provide information to members/patients regarding the possibility of being seen by a NPC and if care provided by an NPC includes physician oversight
Such information should be stated in clear terms in plan/practice advertisements and communications, the information should be made known to the patient at the time their appointment is made. The credentials of the NPCs should be clearly and easily identifiable by the patient at the time of the visit.
The central principle underlying physician supervision of NPCs is that the physician retains ultimate responsibility of the patient care rendered when so required by state law. In these cases, physician supervision means that the NPC only performs medical acts and procedures that have been specifically authorized by the supervising physician.
It is useful to conceptualize state NPC supervision laws as providing physicians with the authority to delegate the performance of certain medical acts to NPCs who meet specified criteria and who function under certain legal requirements for supervision. Accordingly, the tasks delegated to the NPC should be within the scope of practice of the supervising physician. The physician remains responsible for assuring that all delegated activities are within the scope of the NPC's education, training, and experience. The physician must afford supervision adequate to ensure that the NPC provides care in accordance with accepted medical standards
It is the responsibility of the supervising physician to direct and review the work, records, and practice of the NPCs on a continuous basis to ensure that appropriate directions are given and understood and that appropriate treatment is rendered consistent with applicable state law. Supervision includes, but is not limited to: (1) the continuous availability of direct communication either in person or by electronic communications between the NPCs and supervising physician; (2) the personal review of the NPC's practice at regular intervals including an assessment of referrals made or consultations requested by the NPCs with other health professionals; (3) regular chart review; (4) the delineation of a plan for emergencies; (5) the designation of an alternate physician in the absence of the supervising physician; and (6) a review plan for controlled substance prescribing and formulary compliance. The circumstance of each practice determines the exact means by which responsible supervision is accomplished. The supervising physician should be reasonably able to afford the service time to adequately supervise the assigned NPC(s).
Employed physicians should ensure all respnsibilities for the supervision of NPCs are outlined in the terms of their employment contract along with reasonable compensation.
It is the responsibility of the physician to ensure appropriate directions are given, understood, and executed to ensure patient safety. These directions may take the form of pre-approved written protocols, in person patient reviews, over the phone consultations, or by some other means of electronic communication as appropriate, per state and licensure guidelines.
Protocols developed by the supervising physician to be carried out by the NPC should include guidelines describing and delineating NPC roles and responsibilities. Protocols should be as specific in their guidance as the physician and NPC require for their practice. Many states and employers require that the physician and NPC develop detailed written protocols, and, in some instances, these protocols must be submitted to and approved by the state or governing medical board. As a practical matter, it is not possible to cover all clinical situations in written protocols. Nonetheless, there must be a clear understanding between the physician and NPC regarding the actions that may be undertaken by the NPC in all commonly encountered clinical situations and, especially, under what circumstances physician consultation is to be immediately obtained. The physician and NPC must regularly review protocols to ensure consistency with the physician's scope of practice, the range of tasks that have been delegated by the physician and the evolving standards of medical practice.
The supervising physician must develop and carry out a plan to ensure NPC quality of care. This plan must comply with all applicable laws and regulations. The supervising physician must regularly review the quality of medical services rendered by the NPC by reviewing medical records to ensure compliance with directions and standard of care. The minimum frequency with which such review takes place is, in some instances, specified in federal and state law. In establishing the frequency and extent of record review, the physician may consider the scope of duties that have been delegated, the NPC's education, training, experience, and patient load.
In principle, supervision should recognize the diversity of practice settings in which NPCs practice. As a practical matter, the efficient utilization of a NPC will at times involve off-site physician supervision. Generally, off-site supervision of a NPC involves a physician-NPC team that has previously established a working relationship. The supervising physician or a designated alternate physician of the same specialty must be available in person or by electronic communication at all times when the NPC is caring for patients. There should be documented transportation and backup procedures for the immediate care of patients needing emergency care and care beyond the NPC's scope of practice. As with on-site supervision, the appropriate degree of off-site supervision includes oversight of the NPC's activities including a regular review of patient records; and periodic discussion of conditions, protocols, procedures, and patients. (1992) (October 2023)