Many family physicians will supervise a non-physician clinician (NPC) during their career. You may be more familiar with the terms non-physician practitioner, midlevel provider, or advanced practice provider, all of which are used interchangeably. These terms most commonly refer to nurse practitioners and physician assistants.

Although physician supervision of NPCs has become commonplace, many family physicians are not trained in how to do this effectively. Physicians should understand the requirements of supervision to optimize the relationship and to prevent poor patient outcomes, malpractice claims, and medical board actions. The physician is ultimately responsible for ensuring that each patient receives quality care and may be held accountable if they fail to provide adequate oversight or if an NPC under their supervision makes errors.¹

This article offers 10 tips to help family physicians improve their supervision of NPCs.

1. UNDERSTAND THE NPC'S EDUCATION.

Most nurse practitioner programs require applicants to have a Bachelor of Science in nursing. The programs then require approximately 500 didactic hours (focused on disease prevention and health education as well as assessment, diagnosis, and treatment) and 500 clinical hours of training.² Master's and doctoral degree programs are available. Doctoral programs typically have an administrative focus, so DNPs should receive similar supervision as other nurse practitioners.

Most physician assistant programs require prior health care experience, but requirements vary. The programs then require approximately 1,000 didactic hours (focused on medical science and behavioral and mental health, along with critical thinking and decision making) and 2,000 clinical hours of training.² The programs offer a master's degree.

Both physician assistants and nurse practitioners must pass a national certification exam before being licensed to practice. Physician assistants must take the Physician Assistant National Certifying Examination (PANCE), while nurse practitioners may choose between the American Nurses Credentialing Center (ANCC) exam or the American Association of Nurse Practitioners (AANP) exam. Nurse practitioners and physician assistants must earn continuing education credits and recertify every 10 years (for physician assistants) or every five years (for nurse practitioners).

2. UNDERSTAND YOUR STATE'S REQUIREMENTS.

Supervision requirements for nurse practitioners and physician assistants are highly variable, so check your state laws.

Some states allow nurse practitioners to practice without supervision, some require close supervision, and some require supervision for some areas of practice. For physician assistants, all states require physician supervision, but the level of supervision varies.

Check with your state medical board, nursing board, or physician assistant board (if your state has one) about the scope of practice and supervision requirements. Some states do not allow the NPC to practice outside the scope of the physician (e.g., if the NPC would like to do long-acting reversible contraception but the physician no longer provides this service, the NPC cannot provide it either). Note that your organization may have more stringent requirements than state regulations. For more information about state requirements, see this FPM blog post and this AAFP resource.

State requirements should be considered a minimum requirement. Patient safety often requires far more supervision. Physicians should always provide supervision to ensure patient safety, as well as fulfill any state requirements.

3. MAKE SURE YOU HAVE THE TIME.

Most states do not specify the number of NPCs a physician is allowed to supervise; in the few states that do, the number ranges from two to eight. These guidelines can serve as a starting point for discussions with your employer about how many NPCs you can reasonably supervise. Proper supervision requires time for reviewing charts, being available to see patients when necessary and answer questions, communicating and meeting with the NPC, and providing training and education. How much supervision is required depends on the practice environment, the experience of the NPC, and the relationship between the physician and NPC. Some states also specify requirements (e.g., weekly meetings). It is wise to carefully consider how many NPCs you can safely supervise.

4. HAVE A THOROUGH SELECTION PROCESS.

Ideally, you will have a say in the hiring process for NPCs you supervise. A thorough background check and interview is critical to finding an NPC who meets the needs of your organization. Start by verifying the NPC's education, training, licensing, credentialing, and employment history. Additionally, consider contacting their licensing board and the National Practitioner Data Bank to inquire about any administrative complaints or lawsuits that may have been filed against them.

Next, conduct a face-to-face interview. Some of the questions will resemble those of a physician interview, while others should get at the NPC's desire and expectations for supervision (see “Potential interview questions”). Due to the variability of NPC training and experience, and the breadth of the family medicine specialty, it is also important to determine the candidate's clinical knowledge and judgment. Knowledge assessment can be done by asking clinical questions or having the candidate shadow a physician and answer questions. Sample discussion prompts include the following:

• Tell me about your experience with infants [or other patient populations],

• Tell me how you evaluate a patient who presents with shortness of breath,

• Tell me how you approach a patient with depression.

Before hiring, verify the NPC's professional liability coverage. They should have the same professional liability insurance coverage limits that you have. Check your insurance policy and notify the insurer of the supervision arrangement. Make sure the NPC has their own Drug Enforcement Administration (DEA) number as well.

Finally, do not supervise relatives, close friends, employers, or patients. The supervisory relationship is already complex, and having a personal relationship with the other party can complicate it further.

5. DON'T SKIP THE ONBOARDING.

Hiring an NPC is just the first step. Next, you must orient and train the NPC. Develop a written agreement that clarifies responsibilities and expectations, even if state law does not require it. Be clear about the NPC's role (e.g., will they manage their own panel, or just do acute care?). Include the frequency and type of supervision, your requirements for notification of material changes in the status of patients (emergencies, crises, side effects, etc.), and information to be given to patients about the respective roles of the physician and NPC, as indicated by your state's statutes and rules. The agreement should also include the requirement that the NPC notify you of any changes in professional status, such as an investigation or disciplinary action by their professional licensing board or professional certifying organization, complaints by patients, loss or limitation of license, or change in insurance coverage. Ensure that the NPC is aware of their professional code of ethics.

6. PROVIDE ONGOING SUPERVISION.

Do not make assumptions about the NPC's knowledge. Their training is typically less than a medical student, so supervise carefully, especially if they are a recent graduate. Effective supervision includes being readily available for direct communication with the NPC either in person or electronically.³ Make sure the NPC knows their limits and when to ask for help. You may want the NPC to discuss with you controlled substances, expensive testing, or referrals prior to ordering them. You might also decide which types of patients or problems the NPC can safely see. For example, patients with a higher risk score may need a physician at each visit. Visits for a new problem might be best handled by a physician to determine the diagnosis, whereas follow-up visits may be appropriate for an NPC.

Communication works best when the NPC is in close proximity. The NPC should contact you immediately when there is a significant negative change in a patient's condition. There have been malpractice suits where the NPC made significant decisions without informing the physician, who did not know of any problems until being named as a defendant in the lawsuit. Follow the supervision agreement, which will decrease your risk of liability. Document internal training and continuing education.

Alternate patient visits between the physician and the NPC, as opposed to multiple visits in a row with the NPC. This allows you to stay better informed about a patient's care. Remember, you are ultimately responsible for the patient and must remain involved in their care and document this involvement in the patient's chart. For example, your review of the NPC's note or discussions with the NPC about the patient may be documented.

Consider how frequently to review NPC notes, keeping in mind the education and experience of the NPC. Some physicians start with reviewing every note, and then may decrease over time. Regardless of how many notes you review, you are responsible for the care of each patient.

Have regular, specific times to meet with the NPC. Document your supervision, including the dates of each meeting, the duration of in-person supervision, and an ongoing record of the total number of hours of supervision to date. Have a backup supervising physician when you are not available to supervise. Evaluate the NPC regularly by reviewing charts, assessing referrals made or consults requested, and looking at quality metrics. Document the evaluation.

If you are employed, discuss with your employer what to do if the NPC does not follow your instructions. Performance issues may need to be escalated to a medical director or human resources.

7. KNOW WHAT TO DO WHEN AN NPC MAKES A MISTAKE.

If the mistake creates an urgent situation, do what you can to fix or minimize it immediately. Once the issue is under control, address the concern directly with the NPC. For example, a few years ago, an NPC I was supervising had a patient on warfarin with an international normalized ration (INR) of 8. She did not document whether the patient had any active bleeding and prescribed trimethoprim/sulfamethoxazole. I immediately contacted the patient, asked about bleeding, and changed the antibiotic. I discussed this with the NPC, asked her to read specific articles on supratherapeutic INR and medications that increase INR, and instructed her to review any patients on anticoagulants with me before they left the office. I documented the discussion and training.

Depending on the severity of the mistake, additional steps may be necessary, such as further training, disciplinary action, or ending the supervising relationship. The physician should document the meeting and any actions taken, and may need to consult with the medical director, human resources, or legal counsel.

8. ADDRESS OVERUTILIZATION.

If the supervising physician notes the NPC ordering unnecessary tests, making excessive referrals, or directing patients to the emergency department unnecessarily, the physician should address it with the NPC. The NPC may benefit from more education or a standardized process, such as having all referrals approved by the physician.

9. NEGOTIATE CONTRACTS AND COMPENSATION.

Be cautious when signing employment contracts. Effective supervision of an NPC takes time and should be compensated. Do not sign a contract that requires NPC supervision unless you are comfortable with the terms, including responsibilities, compensation, and your ability to end the supervising relationship. Compensation mechanisms may include a monthly or annual stipend, a share of the NPC work-RVU productivity, profit allocation, value-based compensation, or a combination. Physicians should calculate the anticipated time to effectively supervise an NPC and compare their compensation rate for NPC supervision to their compensation rate for other activities. Monitor the time spent in supervision to confirm that compensation remains appropriate.

10. UNDERSTAND BILLING RULES.

The CPT and ICD-10 codes used in primary care are generally the same for physicians and NPCs. The confusion is typically around when an NPC should bill under their own provider number (for 85% of the Medicare allowable charge) and when they can bill “incident-to” a physician's service (for 100% of the Medicare allowable charge). For more information, see the related FPM article.

CONCLUSION

NPCs are helpful partners in patient care, but the relationship does require time and effort on the part of physicians. Do not feel obligated to accept the minimum standards for any NPC you are asked to supervise, and do not feel pressured to spend as little time as possible. Ultimately, you are responsible for the care of the NPC's patients. Your medical license is on the line with the NPCs who work under your supervision.¹ Advocate for the time and compensation to appropriately supervise. With a thoughtful selection and onboarding process, and careful supervision, an NPC can be a valuable member of the care team and help you provide quality patient care.

Editor’s note: For more information on supervising NPCs, see this AAFP online CME course. See also "Supervising APPs: Extra Work but Worth It" in this issue of FPM.