The PA-Physician Supervisory Relationship
PAs work in collaboration with a supervising physician by functioning as an extension of the licensed physician(s) they work with. A strong PA/MD relationship is one of mutual respect and understanding, and leads to the delivery of high quality patient care.
PAs are licensed health care providers who are authorized to practice medicine when working with a supervising physician. PAs see and assess patients, order and interpret investigations (xrays, labs, PFTs, CTs, MRIs, etc.), formulating and communicating diagnosis, formulating a treatment plan, performing diagnostic and interventional procedures, prescribe medications, and assist in surgery.
When integrating a PA into practice, the supervising physician is available to guide, mentor and orient the new PA hire to the practice. Over time, the PA becomes intimately familiar with the physician’s preferences for clinical assessments and treatments.
Effective integration of the PA can lead to reduced physician workload, increased capacity to see more patients and reduce wait times, increased a patient’s access to a health care provider, enhanced patient flow and improved efficiencies. Here we outline the building blocks of that synergistic relationship.
The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes only
What is the PA/MD Supervisory Relationship?
The PA/MD supervisory relationship is the working relationship of a PA working in collaboration with a supervising physician (or group of physicians).
The foundation for a successful PA/MD working relationship requires mutual respect and trust, as well as open communication. PAs should have the freedom to ask questions and seek guidance from their supervising physician(s) for complex cases or issues related to practice.
How much supervision do PAs require?
Types of PA Supervision
PA supervision can be direct or indirect:
Direct supervision involves the physician being physically present in the patient encounter.
Indirect supervision means the physician is available by phone or by electronic means (secure internet network, or EMR messaging) to consult and answer questions should any issues arise.
The supervising physician is responsible for ensuring that the PA is adequately supervised, which means access to the supervising physician is reasonable should the PA wish to consult the physician.
An example of inadequate indirect supervision includes when the physician is not accessible by phone, the physician is not in the country (and cannot come in to intervene, or be available to discuss the case should an issue arise). As per the CPSO, the responsibility of the delegated acts falls ultimately on the delegating physician.
Supervision by Experience: a new PA grad vs. an experienced PA
When a PA first begins working, the supervising physician may consider starting with direct supervision first.
This helps establish a working relationship, the physician can gauge first hand the PA’s knowledge and competency with assessment, ordering relevant investigations, assessment and plan, patient communication. It’s also a great opportunity for the physician to provide feedback and guidance on how they prefer assessments and procedures be performed as well as how they prefer their medical documentation for patient encounters. Feedback on observed PA performance can be given in the beginning, and this method is not uncommon for integration of a PA into a new practice (i.e. in the ER, family medicine, etc.).
With time, as the PA becomes more accustomed to the practice and patient population, a more indirect approach may be taken with supervision where physician is on site, available by phone, EMR messaging or electronically.
For PA/MD relationships that are more well established, or perhaps where the PA is more experienced, the PA in many practice settings performs delegated tasks autonomously in an environment of mutual trust and understanding of the strengths and skills that benefit patient outcomes and practices.
Supervision by Practice Setting: A note about Supervision vs. Billing for work delegated to a PA in Ontario
In Ontario, in a family medicine / rostering model, it is not uncommon to have Physician Assistants seeing their own patients, without the physician physically stepping in. The PA would consult the supervising physician for difficult or unusual cases, and the physician would review the PA’s chart, and sign off on those charts and/or each case without having to be physically present in the room to interact with the patient. This supervision is considered indirect, since the physician is available in the building or via phone but not directly in the patient encounter.
In Ontario, a physician in a specialty or general setting that uses a fee for service model requires direct supervision/meaningful participation if they wish to bill for the services (patient assessments, and consults) rendered by a PA (also known as incident-to billing in the US). This Ontario Hospital Association document outlines how physicians are paid in Ontario, it states that physicians cannot bill for delegated tasks (assessments) performed by a PA unless they actively participated in the patient encounter.
Billing generated by integration of a PA can help pay for the overhead for the PA’s salary/compensation package to make the position sustainable.
Other jurisdictions may have different requirements or practices for billing and PA supervision. Please consult your provincial/territorial medical association or college of physicians and surgeons for rules around billing for delegate work of a PA.
PA/MD Communication within a supervisory relationship
Open communication between the PA/MD for all matters related to patient care, treatment protocols, work environment, and professional development is important. Open communication between PA and MD will lead to better patient outcomes, efficiency and benefits for the practice. Communicating expectations is important, and can be formalized through a supervisory agreement that is established at the beginning of a PA’s employment.
PA/MD Supervisory Agreement
A written supervisory agreement which outlines PA guidelines is a good way to formalize the PA/MD relationship. Here expectations of both the PA and MD are outlined. Note: This is different from an employment contract which includes term of contract, salary, benefits, etc. This supervisory agreement may include:
What physician can expect from PA (e.g. ability to handle patient problems routine to practice, willingness to seek physician input, concise case presentations, appropriate medical documentation, and performance follow-up)
What PA can expect from supervising physician (e.g. ready access to supervising physician, learned advice, willingness to accept care of complex or higher acuity cases, introduction of PA as a member of the team to staff and patients, professional development opportunities such as teaching and CME)
PA Scope of Practice (e.g. description of job and role including clinic responsibilities, common procedures, which can be expanded upon in a separate medical directive document)
Locations of Practice (e.g. if PA is expected to be at hospital, at the outpatient clinic, etc.)
Guidelines for when PA should consult with supervising physician (e.g. irate or hostile patients, life-threatening, or unusual cases, at request of patient)
Examples include a few American supervisory agreements from California, Illinois, and North Carolina. The wording in these agreements can be adjusted to reflect rules within your jurisdiction about PA practice
The rewards of a PA/MD relationship
I currently work as an Orthopaedic Surgery PA for the past several years and can attest to the rewards and synergy I experience within the PA/MD supervisory relationship.
My relationship with my supervising physicians have evolved over time, starting as a new grad getting to know the practice, to a respected regular member of staff who plays an important role in keeping the clinic and OR running on smoothly and on time. With time the PAs at the practice have expanded their time to working with other physicians in the same clinic, and now the supervising physicians hesitate to run a clinic without a PA by their side.
During my early years of working, my supervising physician often compared having a PA like a “resident/fellow that would never leave your side” (residents stay on for several months at a time before moving onto another clinic for their next rotation).
During clinic hours when we are seeing patients, I arrange for all referrals and investigations, complete all dictations of patients I see, and am able to help keep the clinic running on time. With tracking EMR data, I learned that with the introduction of PAs into clinic, we were able to more than double the number of patients seen in a clinic day, reduce the amount of time spent in clinic, and the PAs took on medical documentation and completion of forms during the clinic, freeing the physician from catching on paperwork following the clinic.
Outside of seeing patients in clinic, I am able to help my supervising physician take a large workload off their hands, which includes taking time to answer patient/allied health/provider questions, triage referrals, completion of medical legal documents, worker’s compensation forms and other letters required due to illness/injury. The staff often appreciate having easy access to someone who is a “representative of the physician” to answer their questions about patients.
Non-Monetary benefits of hiring a PA
The supervising physician can enjoy non-monetary benefits of a PA, such as more free time that can be used for academic or research endeavours, teaching, seeing more patients, and/or more time for leisure activities and family.
If patient volume is increased while maintaining quality patient care, the PA may also help increase the practice’s revenue to cover other overhead or operational costs of the clinic.
I always asked for feedback and consulted the physician for complex cases. With time, I became extremely comfortable with Orthopedic assessments and treatment plans. I knew all of the surgical procedures he performed, recovery time, and protocol for rehab following all procedures. I learned all the protocols for routine pre-op and post-op visits, as well as what investigations he preferred to order and when to refer. When we had medical learners on with us, I played a role in orientating the student to the clinic but also in teaching Orthopedic Principles which supplemented what the medical learner was getting from my supervising physician.
We developed a lot of patient education materials to reduce the number of questions the administrative assistant would receive on the phone if something was not explained clearly, and I was able to spend time answering patient questions about return to work/activities after an intervention or surgical procedure.
In return, I get a long-term mentor who is very approachable and willing to answer any patient questions, or whom I can consult for complex cases. There are opportunities for continuing medical education (e.g. attending conferences, workshops), as well as direct teaching from my supervising physician and I get time to get involved with teaching and mentoring for PA students as part of my contract.
In the United States, PAs can bill for patients, even with a physician physically present. Due to limitations of billing rules in Ontario, this is not possible and physicians cannot bill for services rendered by a PA in a fee for service model without being actively involved in the patient encounter. This is why we have the physician participate in every patient interaction, however in our instance there is little duplication in work (e.g. asking the history over again, repeating the entire physical exam) as we have an established PA/MD relationship and he has trust in my ability to assess patients and present concisely pertinent details about the patient before he goes in to finish off the interaction.
If the model was similar to the United States, the PAs in fee-for-service setting could run clinics for non-complex patients, and/or routine follow-ups while, for example, the MD is in the operating room. With an established set of medical directives and supervisory agreement, there is a mutually agreed up set of guidelines and understanding of what the PA’s scope of practice and when to refer to the physician as outlined above.
There are PAs in family practice settings in a rostering model that have their own panel of patients, which has allowed easier access to a health care provider and decreased wait times.
Helpful References:
What Factors are Necessary for a Successful PA/MD Relationship?
Ministry of Health and Long-Term Care. (2012). Ontario Physician Assistant Implementation – Report of the Evaluation Subcommittee. p.p. 27
Ducharme, Adler, Pelletier, Murray and Tepper. (2009). Impact on patient flow after the integration of nurse practitioners and physician assistants in Ontario emergency departments. The Canadian Journal of Emergency Medicine, Vol. 5, p.p. 458. Retrieved from: http://www.cjem-online.ca/v11/n5/p455
Being a good supervising physician: it’s more than just chart review. The Dermatologist 17 (6).
