Keep an Eye on Them

Physicians Must Supervise Nonphysician Practitioners

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Law Feature - November 2006  

By  Erin Prather
Associate Editor

The patient came to the physician's office with a list of problems that a nurse practitioner (NP) diagnosed as an upper respiratory infection. She wrote him a prescription, but the patient soon returned with other issues. Again, she prescribed medication. This time, she failed to document the patient's medical history or the medications she prescribed. Later, the patient asked her to call in a controlled substance prescription he said had helped him in the past. She complied. A few days later, the patient overdosed and was treated at a nearby hospital.

The physician for whom the NP worked soon found himself in front of the Texas Medical Board (TMB). Although he did not know about the controlled substance prescription, the board ruled the physician was responsible because he did not oversee the patient's treatment and did not supervise his NP. The board also faulted the doctor for not maintaining an adequate patient medical record. The NP was fired, and the doctor agreed to TMB's disciplinary actions.

While this is a worst-case scenario (the patient's health was placed in jeopardy), similar situations have been reported to TMB, which has the authority to cancel, revoke, or suspend the license of any physician guilty of not adequately supervising persons acting under his or her supervision.

The board sanctioned five physicians for violating supervision requirements last year. Disciplinary actions ranged from a physician being placed under observation by a monitor designated by the board, a physician having to take additional continuing medical education courses, a doctor losing the right to supervise or delegate prescriptive authority to a nonphysician, and a physician being required to take the Medical Jurisprudence Examination given by TMB.

"We take this very seriously. Physicians need to be mindful that they have a very wide delegation privilege, but they are also responsible for training and supervising those delegatees. When we receive complaints about improper supervision and find violations based on those complaints, those physicians will have to answer to us," said TMA Executive Director Donald Patrick, MD, JD.

Texas Medical Association Associate General Counsel Lee Spangler, JD, says it is legal for physicians to delegate medical tasks to trained nonphysicians, but doctors should not allow them to exercise independent medical judgment beyond their training.

"A physician can assign a task to a nurse practitioner, physician's assistant, or other medical assistant so long as that person has the training and skills to carry out what's being delegated and if the physician retains supervision and control of the patient's care. Problems arise when nonphysicians make choices without the physician's delegation or consultation," Mr. Spangler said.

He points out that in clinics treating a medically underserved population, including rural health clinics, a physician can delegate tasks to nonphysicians without being at the practice site personally. However, nonphysicians still must be adequately supervised.

Physicians must periodically review the services provided to patients, visit the practice site at least once every 10 business days, and be available through direct telecommunication. The physician also must receive daily status reports on any problems or complications that arise.

The same type of delegation may be performed at an alternative or second practice site where similar services are provided. The alternative practice site must be within 60 miles of the delegating physician's primary site. 

Not Sure? Ask a Lawyer

If you decide to use nonphysician practitioners, make sure you're aware of the care they're providing. TMB rules are not intended to restrict physicians from delegating tasks. They are guidelines for delegating tasks to qualified nonphysicians.

"Texas physicians should carefully review with an attorney of their choice the relationship they have with nonphysicians employed by their practice," Mr. Spangler said. "At the end of the day, a physician is the one who is legally responsible for acts performed by others within their practice."

TMA's Office of the General Counsel has posted an article detailing what you need to know about delegating authority to nonphysicians on the TMA Web site at  www.texmed.org/npp. Although TMA attorneys cannot provide legal advice to TMA members, they can offer general legal information.

It's also a good idea to check the TMB Web site,  www.tmb.state.tx.us, for updates on rules and policies.

Erin Prathercan be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at  Erin Prather.  

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