Every few days, a doctor on our physician communities will post a question about a proposal (or even a requirement) to be a ‘supervising physician’ or a 'collaborating physician.' This is not surprising, as the number of individuals, companies, and employers who are seeking physicians to provide supervision to non-physician healthcare professionals is increasing daily. Many states do not allow clinicians such as NPs or PAs to practice independently, stating that they can only practice under the supervision of a physician.
As a physician, these requests to accommodate others practicing under your license should be approached with caution and adequate due diligence. Although these positions are often marketed as low lift roles where you can make easy money simply by being available for questions or periodic chart reviews, it is not that simple. There are larger implications for patient care, the physician profession, and professional and personal liability that must be considered before putting your name and license on the line. Below, we’ll take a deeper dive into things you should be considering and questions you should be asking if you are asked to perform this role, appropriate compensation if you choose to accept a role, liability concerns, and more.
Disclaimer: Our content is for generalized educational purposes. Please do your own due diligence before making decisions based on this page. Nothing on this page constitutes formal or personalized legal or financial advice. Laws and taxes vary based on location and while this information is accurate to the best of our knowledge, it may not be up to date or apply in your location or personal situation. We are not formal financial, legal, or tax professionals, and you should consult these as appropriate. To learn more, visit our disclaimers and disclosures.
Article Navigation
Why is there an increasing need for physician supervisors for non-physician clinicians?
As the aging population increases and physician shortages amplify, there has been a need to expand the healthcare team to improve access to care, particularly in underserved communities. As such, the usage of physician assistants (PAs) and nurse practitioners (NPs) as physician extenders within both physician groups and hospital systems has increased dramatically, and the number of PA and NP training programs has also significantly increased.
Traditionally, these clinicians have worked under physicians as part of a healthcare team, and are directly supervised in their responsibilities.
In the past decade, however, many professional groups for these fields have advocated for, and successfully won, the ability to work more independently. In many states throughout the country, these non-physician clinicians can now practice independently without the supervision of a physician. Some of these clinicians have opted to be employed directly by hospital systems or physician groups, while others have pursued opening their own practices or side gigs.
Whether they have independent practice rights or not, many state, employer, or company policies still require physician oversight for all or certain responsibilities. This may be because of concerns for patient safety and/or for the need to have access to more medical expertise if a patient’s needs are beyond the education or expertise of the non-physician clinician.
Long story short, as hospital systems and companies look to cut costs and fill needs, and as more and more non-physician clinicians pursue their own practices or their own side ventures, there are increasing requests for physicians to take on a supervisory role. Some employers are even requiring it of their physician employees.
The point of this article is not to focus on scope of practice issues, but rather to focus on how physicians should look at roles and responsibilities, as well as liabilities, that come along with being a supervising physician before agreeing to take on a supervisory position.
What are some examples of positions that doctors are being asked to take as “supervising physicians,” “medical directors,” or collaborating physicians?
Depending on who’s asking (a non-physician clinician, an employer, a healthcare company such as a startup or telemedicine company, or a corporation), these roles can vary significantly, and it’s important to understand exactly what your role will entail before deciding if you’d like to participate.
How hospital systems tend to need supervising physicians
The traditional care model involves physician led teams which utilize the NPs or PAs to expand their capabilities. The NPs and PAs may perform initial consultations, gather a history and perform an initial physical examination, or round on patients. They discuss their findings with the physician and come up with care plans. In these cases, the physician is also seeing the patients and the patient is admitted under their service. Physicians are generally supportive of this team based model.
However, these days, hospital employers are increasingly asking physicians to be the supervising physician for nurse practitioners or PAs hired by the hospital system who are functioning more independently. Various responsibilities for the physicians may include:
Being available for consultation for complex cases for a NP or PA run clinic
Being the prescribing physician for prescriptions written by the NP or PA
Signing off on notes written by the nurse practitioners or PAs
Taking on patients that require a level of service or expertise that the non-physician clinician can not provide or does not feel comfortable providing
Physicians may or may not be compensated for their responsibilities in these situations. It’s important to realize that the liability from any negative outcomes often falls on the physician regardless, as they are ultimately responsible for any work “performed under them.”
We have also seen many reports of non-physician clinicians getting added onto a physician’s license as the supervising physician without their knowledge or permission, so it is becoming increasingly important for employed physicians to check and see if this is the case at a regular cadence.
Additionally, employed physicians should make sure that supervision responsibilities (or ability to decline supervision responsibilities if not comfortable) and relevant compensation are clearly outlined in their contracts. Not having these responsibilites outlined is one of our red flags to watch out for in a physician contract, as you don't want to be blindsided or forced into an arrangement that you aren't comfortable with or are not compensated for.
How corporate healthcare companies, telemedicine companies, or others in healthcare innovation are using supervising or collaborating physicians
Some of the roles of the supervising or collaborating physician in these settings overlap with those above. However, many companies looking to scale in healthcare are looking to employ non-physician practitioners to save on costs and increase profit margins, and therefore only employ a bare minimum number of physicians to comply with regulatory requirements. Some examples include:
Being a supervising physician for NPs or other healthcare professionals who are seeing patients in person in a corporate clinic
Being a supervising physician for NPs or other healthcare professionals via telemedicine
Being a physician who signs off on prescriptions recommended by others seeing the patient
Being a medical director for a company where others are practicing under your license for home visits, chronic care management, or similar
Responsibilities may include:
Occasionally performing a chart review of randomly selected charts to ensure quality
Signing off on encounter notes and the assessment and plan
Putting into place protocols for patient safety and workflow
Teaching non-physician clinicians about updates or new developments in the field
Signing off prescriptions for patients seen asynchronously via telemedicine by a non-physician clinician
Being available as backup on complex cases
If you are a physician, it’s important to note that when these clinicians are practicing under your license, you are liable for work that is done both with and without your input. In many of these scenarios you don’t have input into the hiring of the practitioners that will be working under you, and may not know their qualifications to perform the scope of work that is being asked of them. This is very different than a NP or PA who you’ve trained and work with daily in a hospital system, and this is where members of our communities often raise their eyebrows at the cost-benefit analysis of liability versus potential for compensation, and potential patient safety issues that may arise when those clinicians are compensated based on volume but don't have to take on the ultimate liability associated with their care.
If you’re considering a telemedicine position where you’ll have other members of the healthcare team working under your supervision, you’ll want to review this dedicated article on things to ask before accepting a telemedicine position.
How NPs, PAs, and other clinicians may ask you to be their supervising physician, partner, or serve as a medical director
As more and more nurse practitioners and physician assistants enter the field, like many physicians, many of them are encountering burnout or are bitten by the entrepreneurial bug that we encourage amongst our physician colleagues on Physician Side Gigs. Many NPs or PAs are looking to start their own practices or businesses, many of which are cash pay services that can be quite lucrative, thus increasing the allure. If they are in a state that requires physician supervision or has other regulatory requirements about ownership in certain types of businesses, they may need a physician to either partner with them, serve as their medical director, or be their supervising physician, in order to turn their business idea into reality.
Some examples here include:
Starting their own insurance based primary care clinic or telemedicine practice
Opening a med spa that offers lasers, Botox and fillers, and other cosmetic procedures or wellness services
Having a Botox or aesthetics side gig (Botox parties, etc.)
Opening an IV hydration clinic
Opening ketamine clinics
Starting a telemedicine practice in weight loss medications, hormonal supplements, or other popular areas
Providing emergency services to events that need medical staffing
These clinicians will often reach out to physicians to help them to pursue these endeavors. Often times, these positions are marketed as a low lift responsibility that is only necessary to comply with requirements, and easy money for the clinicians. On the surface, it can seem like a great physician side gig that allows you to make some extra money without having to build your own side business.
HOWEVER, as physicians, we need to understand that ultimately, the reason that these clinicians need a supervising physician is for patient safety and access to physician level expertise. No matter how trivial a procedure such as Botox or administration of IV fluids may sound, you are still ultimately responsible for any complications. Additionally, without you being physically present on a daily basis, it’s hard to keep tabs on what is going on. There have been several high profile lawsuits in situations where things went horribly wrong and the physician was held liable for large sums of money. In some of these cases, the physician did not even know that certain services were being performed under their license.
Additionally, know that many physicians are being asked to be medical directors for activities that are being conducted in a different state, including across the country. It’s important to think about how sympathetic a jury will be if there is a complication from a procedure, and you were the supervising physician from multiple states away that was powerless to help out but took on a role as a supervising physician.
Questions physicians should ask themselves before considering a role as a supervising physician
Conversations on our phyiscian communities can get quite heated when supervisory roles are discussed, as physicians understandably place a lot of value in the education that they’ve received, and worry when others with less education and experience want to use the physician license to practice medicine without having the same training or liability.
Are you providing true supervision to this NP or PA, or are you just signing off on charts, prescriptions, or procedures without knowing about the encounters?
This is one of the scariest aspects of some of the supervisory agreements out there. There is a lot being done under your name and license on a daily basis, and you won’t know much about the clinical interaction, how it was conducted, what was seen on the physical exam, whether the appropriate clinical history was asked about, etc. In general, our communities are more comfortable with supervisory agreements where you are truly overseeing each interaction.
Is the liability you take on worth the amount you're getting paid?
In many cases, the amount of money that is offered for this responsibility is trivial, such as a few hundred dollars a month. If you’re an employed physician, you may not get paid at all. This is where our physician communities jump in to warn their colleagues that undertaking that level of responsibility for patient safety and the risk of liability for things that go wrong is not worth the money.
Remember that you spent many years becoming a board certified and licensed physician, and that expertise has worth. It’s not about the time that the responsibilities take, it’s about how long it took to get that license, and you want to be compensated appropriately for your expertise as well as the risk you take on whenever anybody is providing medical care under your license.
How well do you know this NP’s or PA’s practice patterns and fund of knowledge that you feel comfortable with how they're going to manage patients under your name?
Remember that you will be responsible for all decision making for any clinician practicing under your license that’s hired by the company or who approaches you personally. In the case of corporate roles, often times you won’t even personally know that person or their qualifications, or have had a chance to observe their clinical skills. Most times you’ll have no say in whether they are hired or not, or whether they should be fired or need remediation. And yet, you’ll take all the liability for what they do.
Do the clinicians working under you acknowledge the boundaries of their scope of training and recognize when they should ask for help or a second opinion, and will they contact you on the things that you prefer to be contacted about?
As physicians who have gone through the hierarchy of medical training and residency, we all can cite examples of medical students, interns, residents, and even fellows who should have let the team know about something that they didn’t realize was important that ended up in a misdiagnosis or even a negative result for the patient. We know that it’s not intentional - they simply didn’t know what they didn’t know or felt confident about something that they didn’t have the experience to navigate skillfully. Considering this, how will you judge whether these clinicians (who usually have less years of formal training than residents and fellows) are appropriately involving you in decisions or procedures?
Similarly, even if they do have the confidence and expertise, your own personality may dictate that you want to be made aware of certain decisions before they are acted on. You'll want to make sure that the clinicians working with you are okay with you overseeing their work in this way, even if they don't think it's necessary.
Do YOU have the expertise necessary to supervise the activities that they are going to be performing under your license?
Many physicians receive cold outreaches for supervisory positions from companies or individuals that just need a physician name for paperwork purposes. They may not actually care about your credentials. However, as the physician, you should have relevant expertise if you are going to supervise someone. If you are a radiologist supervising a nurse practitioner running their own primary care practice, how well can you supervise them or serve as a resource for them? Will you know when something is being done outside of the standard of care?
Similarly, if you’re a non-procedural physician supervising someone doing Botox and fillers, are you going to be able to help out if there’s a complication? Do you know how to do the procedures yourself?
What are the implications for patient safety and for our profession when we allow other non-physicians to practice under our licenses and accept the liability?
Many physicians worry about patient safety, as well as the implications for our profession, if we allow those without the same experience to practice in the same way that physicians do. It’s important to note that this isn’t about protecting turf, but potentially devaluing the important role that a physician’s experience plays in delivering healthcare and healthcare related services safely. When entering a supervising role, you should really believe that your patient's will be getting the level of care that they need and deserve.
The training pathway for other members of the healthcare team differs significantly from physicians. Physicians go to college for four years, then medical school for four years, and then residency for a minimum of 3 years. Residency programs can be 7 years or longer depending on things like research requirements. Additionally, many physicians will go on to do a fellowship after residency that could be up to another 3 years. Some physicians will do more than one fellowship.
Conversely, taking med spas and aesthetics as an example, some training programs for learning how to do injections can be as short as a weekend. It's hard to imagine that these can adequately teach the anatomy, how to handle complications, alternative treatment options that may be better for patients, etc. Even with more extensive programs, it's unlikely that these programs provide the level of knowledge that a dermatology or plastic surgery residency would provide.
All of these years of experience are what allow physicians to practice medicine safely and think beyond algorithm based care, tailor individual solutions that take into account the patient’s complete medical history and personal situation, and know what to do when things go wrong. If there is no incentive for individuals to get that level of training but still be able to practice medicine in the same way as a physician, we risk decreasing the number of people in the system that have the appropriate level of training to handle complex cases, complications, and more.
Have you looked into lawsuits against physicians for work that was done under their license by NPs and other health professionals, where the doctor took the fall or paid heavier fines than the person who was actually involved in the patient's care?
Last but not least, make sure you understand the extent of potential liability before you take on a side gig as a supervising physician and are comfortable with the risks. There have been several high profile cases in the news in the past few years where a physician either had a judgment placed against them in a lawsuit or was even arrested for actions being performed under their name that they were not aware of. All of these things can have consequences for your medical license, your ability to practice medicine long term, reporting to the National Practitioner Data Bank, and more. Many of these consequences will affect not just you, but your loved ones.
Think seriously about whether the benefits that you get from the (likely relatively small) compensation that you get for undertaking this liability are worth potential issues.
Conclusion
As the number of PAs and NPs looking to practice more autonomously increases and as companies and healthcare systems look to scale their operations, there are more and more requests or requirements for physicians to ‘provide supervision’ to non-physician healthcare professionals. Physicians cynical of this model point out that this is often for little to no pay, and simply in order to meet legal requirements to have a physician at the head of the medical team and/or to limit liability for those without a medical license. Adding to the skepticism is that it is often marketed as a low lift role that is easy money, whereas digging deeper, there are a lot of implications for the physician profession for allowing others with less expertise to practice medicine by renting out the license of a board certified physician and leaving the physician with the liability for anything that goes wrong.
Accordingly, while there may be situations where supervision is provided in a completely appropriate manner, any doctor asked to participate as a supervising physician should first do their due diligence into potential downsides and ask if the cons of this side gig or mandated responsibility are worth the money and risk.
Additional resources for physicians seeking side gigs
Explore related PSG resources: