Only the largest school health programs employ physicians to deliver direct patient care. In most programs, the primary role of the school physician is to supervise nonphysician personnel: school nurses, dietitians, coaches, and trainers. In some smaller districts, the school physician also may need to oversee food sanitation in the lunch room and zoonosis problems in vocational agriculture classes.

Most states require nurses, child health associates, physicians’ assistants, and other such personnel to be supervised by a physician. If the school employs personnel (or uses volunteers) who may not practice without physician supervision, the duty to supervise these personnel will flow to any physician who is nearby. The legal theory for this responsibility by proximity is called ostensible agency. This means that if it appears to the patient that the physician is supervising the personnel, the law will hold that physician responsible. Since ostensible agency is judged from the patient’s perspective, a contract between the physician and the school to exclude such supervision will not obviate the physician’s responsibility. Explicitly declining to supervise a given activity may not be enough. The physician must not become involved with the activity in such a way as to appear to supervise it. For this reason, all school physicians should have their supervisory responsibilities listed and described in a contract. The contracts should provide for the supervision of all personnel who may require it under state law to protect both the physician and the other personnel.

The school physician has a duty to ensure that all the medical professionals that he or she supervises are competent, adequately trained, and practicing within the limits of the law. Disciplining a nurse may be difficult if the nurse reports to a nursing supervisor or other administrator who is not responsible to the physician. If a supervising physician has reason to believe that a nurse is practicing in an incompetent or illegal manner, the physician must stop the practices or resign. The physician cannot defend improper supervision by blaming nonphysician administrators.