Physician Supervision of Nurses: It’s All About Safety

Doctors can train for as long as 15 years before they are allowed to treat patients without supervision – because extra years of training can mean the difference between life and death. A nurse’s’ training is considerably shorter – which makes their supervision by a physician critical to patient safety.

For this reason the Coalition supports continued physician supervision of nurses and opposes SB 695.

Medical Training

Medical school is a rigorous, full-time, four-year program consisting of classroom work as well as thousands of hours of clinical training. After graduation, MDs enter into a residency program that ranges from 3-7 years of additional training. In some instances, fellowship training may also follow, adding 1-2 more years to the process.

Physicians train for at least a decade – some for much longer – before
they are permitted to practice without supervision.

The years required to become a physician are essential, ensuring that physicians of all specialties – from primary care to neurosurgery – obtain the knowledge and skills necessary to safely practice.

Nursing School

Nurses obtain their certifications in a variety of ways. However, no matter their training pathway, nurses do not undergo the level of training necessary to independently diagnose and treat complex medical conditions.

Even advanced practice nurses may only complete an additional
2 years of education and training after college.

The extra years of training that physicians receive can mean the difference between life and death. For this reason the Coalition supports continued physician supervision of nurses and opposes SB 695.

NC Electrolysis Examiners Propose Changes to Physician Supervision

The North Carolina Board of Electrolysis Examiners have filed proposed rules to take effect on August 1, 2015. Among other regulations, these proposed rules would make changes to the requirements for physician supervision of electrolysis providers.

PUBLIC HEARING: Sunday, April 26, 2015, 9:30 a.m.-1:30 p.m.

Trinity Oaks, 728 Klumac Road, Salisbury, NC 28144

The North Carolina Board of Electrolysis Examiners will accept public comment regarding proposed rules changes found here. The rule change proposes to clarify provisions regarding applications for licensure, school and instructor certifications, fee increases, continuing education, and agreements with Supervisory Physicians.

New language would specify that agreements with supervising physicians include an acknowledgement that current guidance from the North Carolina Medical Board with respect to laser hair removal and laser surgery by non-physicians will be observed and monitored. The new rules would also require attestation that the supervising physician will be readily available and able to respond quickly to patient emergencies and questions by those performing electrolysis procedures under the physician’s supervision.

Comments can be directed to:

Susan Magas, 2 Centerview Drive, Suite 60, Greensboro, NC 27407, phone (336) 856-1010, or

Comment period ends: June 1, 2015

Protect Patients OPPOSE SB 240

Legislation has been filed in the NC Senate that puts patients at great risk. Senate Bill 240proposes to eliminate the requirement of physician supervision of nurse anesthetists (CRNAs). North Carolina law has always required physician supervision of nurse anesthetists providing anesthesia medical care. Unfortunately, this important patient safety standard is under attack.

Physician supervision is, and should remain, the law.

The North Carolina Medical Board has always required physicians to supervise nurse anesthetists providing anesthesia services – this helps ensure the safety of services provided. Physician anesthesiologists complete almost double the education and more than ten times the clinical training of nurse anesthetists.

In 1998 and again in 2005, the N.C. Attorney General concluded that North Carolina law requires “the anesthesia care of a patient [must] be under the supervision of a physician.”

In 2005 the N.C. Court of Appeals rejected a lawsuit by nurse anesthetists by finding that “physician supervision of nurse anesthetists providing anesthesia care . . . is a fundamental patient safety standard required by North Carolina law.”

The requirement of physician supervision is supported by multiple academic studies suggesting that physician involvement in anesthesia care improves patient outcomes. Additionally, every hospital in the state requires the supervision of nurses providing anesthesia services.

North Carolina law has always required physician supervision of nurse anesthetists. It should remain that way. We value the important contributions of CRNAs, but a physician-led care team provides the most effective — and safest — care for patients.

* Training Chart Courtesy of ASA “When Seconds Count”

AARP Educates Patients: Physician v. Nurse Training

Patient education is key when it comes to understanding the roles of various healthcare providers as well as the risks posed by medical treatment not overseen by a physician. A 2015 AARP Magazine Infographic provides patients with the fundamentals of physician office roles, calling attention to the dramatic differences in training between physicians and nurse practitioners.

The graphic reads, “The physicians are still the ones in charge — and those with the most training, as indicated by the length of their white coats, the longest of any health care professionals. MDs have 3 to 7 years of training after med school.”

View the graphic on the AARP website here.

Scope of Practice 101: How the NCGA Protects Patients

What is Scope of Practice?

Professional scope of practice refers to a set of parameters placed into state law to define what acts a licensed healthcare provider may, or in some cases, may not perform.

As a result, the law does not limit what medical acts a physician may perform. The North Carolina Medical Board provides oversight to physician practice, ensuring the public is protected from any potentially harmful behavior.

Non-physician health care providers have a legislated scope of practice that places limitations on their practice. This may appear in one of many ways.

  • As a definition in statute. For example 90-143 defines Chiropractic as the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.” As a result activities outside of this defined scope are prohibited without legislative authority.
  • As a specified list of permitted activities. For example 90-722 lists 5 categories of practice that a polysomnographic technologist may engage in. This list if further broken down into a very specified list of tests that may be performed by these practitioners.
  • In the form of physician supervision. Physician assistants and advanced practice nurses are not limited by a definition of practice or list of tasks. However, each must practice with a supervising physician’s approval.

How is Scope of Practice Determined?

In North Carolina the legislature specifies the scope of practice of various healthcare providers within Chapter 90 of the General Statutes. These decisions are often based on the level of training of the healthcare provider, balanced with the potential for harm to patients.

Can a Licensing Board Make Changes to Scope of Practice?

Not in North Carolina. Statute often allows licensing boards to write rules to clarify acceptable practice guidelines. For example, the Medical Board and Board of Nursing have rules in place to determine what information must be included in a supervisory agreement between the two providers. However, a licensing board cannot allow its licensees to practice outside of the legislated scope of practice or eliminate the requirement for physician supervision.

Why Do Providers Need a Scope of Practice?

It is important that these permissions, and in some instances limitations, are specified within state law in order to protect patients from harm. Just as state law describes who can operate motor vehicles, it is also tasked with determining who is qualified to provide medical care.

Naturopath Licensing Bill Reappears at NCGA

Almost every year the NC General Assembly is faced with proposed legislation to license naturopaths to practice medicine in North Carolina.  This session is no exception with Senator Stan Bingham filing SB 118 – Naturopathic Licensing Act, last week.

During past debates illegally practicing naturopaths have offered their services as a form of “primary care” – a thought that is troubling to our members. Many patients fail to ask questions regarding the qualifications of their health care provider.  If naturopaths are able to use the title of doctor or physician when practicing this could further confuse the public, presenting the false perception of medical training.

Additionally, licensure of naturopaths as physicians is troubling because:

  • ineffective naturopathic treatments may delay necessary or needed medical services and put patients at risk
  • the lack of ethical standard for naturopaths could lead to patient exploitation through sales directly to patients of “naturopathic remedies”
  • this bill places no limitations on naturopaths when it comes to providing mental health care, treating children, or even diagnosing cancer.

For these reasons the Coalition opposes SB 118 as introduced.

Focused on Safety in 2015

The new legislative session will be incredibly busy and one full of important issues – especially those related to health care. The primary goal of our organization is to keep North Carolinians safe from harm when receiving medical advice and services.

The North Carolina Coalition to Protect Patients is a non-profit, 501(c)4 organization, comprised of a dozen member organizations:

  • North Carolina Academy of Family Physicians
  • North Carolina Chapter, American College of Physicians
  • North Carolina Dermatology Association
  • North Carolina Medical Society
  • North Carolina Obstetrical and Gynecological Society
  • North Carolina Orthopaedic Association
  • North Carolina Neurological Society
  • North Carolina Psychiatric Association
  • North Carolina Society of Anesthesiologists
  • North Carolina Society of Otolaryngology and Head and Neck Surgery
  • North Carolina Society of Pathologists
  • North Carolina Spine Society

Together, our organizations work to conduct research and provide educational materials regarding the growing importance of physician leadership in healthcare. The Coalition supports the development of team-based models of care, rather than further fragmentation of care by providers who seek to practice independently. This includes those who wish to expand their scope of practice to a level that exceeds their training, as this could harm patients and their families.

When it comes to protecting North Carolina patients, there’s no sense arguing over who can provide the highest quality of care. The best solution is for healthcare professionals to continue working together under the leadership and supervision of a trained physician.

You can learn more and stay up to date by following the organization on Twitter, @PatientSafetyNC. If you have any questions or would like additional information please contact us at

SC Out-of-Hospital Birth Ends in Tragedy

For the second time since 2013, South Carolina officials are investigating the Carolina Community Maternity Center in Fort Mill after an attempted delivery ends in tragedy.  CCMC is staffed by Certified Midwives, including those who would not qualify for licensure in North Carolina. NC law wisely requires all licensed midwives to obtain advanced nursing degrees and to be supervised by physicians.

While the cause of death has yet to be determined, the York County Coroner has confirmed that there were no signs of injury to cause the death of a South Carolina infant.  The state’s Department of Health and Environmental Control is currently investigating the center for possible violations of state regulations.

Tragic outcomes as these are often avoidable when qualified individuals manage the care of both mother and child with physician supervision – and deliveries are attempted in a hospital setting.

Study Reveals Nurse Practitioners Order More Diagnostic Imaging than Physicians

According to a new study published in the November 24thJAMA Internal Medicine, nurse practitioners order more costly diagnostic imaging examinations than primary care physicians do in order to evaluate similar patients. Advanced practice clinicians, including Nurse Practitioners, order imaging be performed for 2.8% of their patients following an office visit compared to 1.9% for primary care physicians. While this percentage may seem small, when states, governments, or other payers are seeking to lower costs and maintain quality for a population of patients – these numbers equal real dollars.

“… efforts to expand access to care by simply substituting advanced practice clinicians for physicians without careful imaging appropriateness mechanisms may further elevate health care costs and potentially increase unnecessary radiation exposure…”

 Learn More:

JAMA Intern Med. Published online November 24, 2014. Abstract; Read more at Medscape.

Utah Midwife Charged with Manslaughter Following Failed Home Birth of Preemie Twins

Last week a lay midwife in Utah was ordered to stand trial on charges of second-degree felony manslaughter for her responsibility in a series of events that led to the death of premature baby. The midwife, Vicki Dawn Sorensen, allegedly refused to take a mother, laboring with premature twins, to the hospital for more skilled treatment and delivery.  The midwife is also accused of falsifying emergency medical information.  Reportedly, the lay midwife even attempted to stop the hemorrhaging mother from leaving a home-based birth center in an ambulance. One of the two premature twins died as a result of the home birth, the second would be delivered via emergency C-section at the hospital.

According to reports by the Salt Lake Tribune, the same midwife may have been responsible for other infant deaths following home births gone wrong.  Police documents indicate that the midwife and her daughter, also a midwife, may have buried infant remains in secret.

Licensure is available for lay midwives in the state of Utah, however, Sorenson chose to practice without a license. A trend that is not uncommon for lay midwives that prefer a lack of regulation.  Among the many catastrophic events of the day, Utah authorities allege the following in their charges against this lay midwife:

  • Utah law prohibits lay midwives from delivering twins; Sorensen proceeded with an attempted delivery of twins more than one month premature.
  • When it was suggested that the family be transferred to the closest hospital, Sorenson stated that she “did not like” that hospital and would deliver the infants at her birthing center.
  • The midwives at the birthing center had no device on hand to force respiration of the distressed infant – a simple piece of equipment that could have potentially saved his life.
  • Emergency medical technicians that arrived at the scene reported that the midwives were attempting infant CPR on the baby boy, using a technique that was “12 years out of date.”
  • When asked for medical records to accompany the infant to the hospital, the midwife claimed to not have been present during the delivery and to have no knowledge of the baby’s gestational age, or the mother’s medical history.  Instead, Sorensen claimed that the mother “walked in off the street for help with the delivery.”

Also involved in the treatment of this family was a naturopath who allegedly tried to stop the hemorrhaging mother’s labor with an IV of magnesium. Court documents indicate that the naturopath was “unaware of how to administer the substance and had to call the hospital to ask how, and to ask the amount.”

Doctors at nearby hospitals have stated that the first born twin would have had “a 100 percent chance of survival” had he been born in a hospital.

North Carolina does not currently offer licensure to lay midwives. Instances such as this devastating delivery in Utah further demonstrate the disparity between the skills and training of lay midwives v. physicians.  With lives on the line – home birth with an unskilled provider simply isn’t worth the risk.