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Supervisory Responsibilities

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, from the patient's point of view, it appears 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 if the physician appears to be supervising the personnel.

All school physicians should insist that their supervisory responsibilities be listed and described in a contract with the individual school or the district. This delineation of responsibilities is necessary whether the physician is an employee or a volunteer. The problem of apparent agency is greatest when there is no other physician supervising activities that should be physician supervised. Unless the physician has explicitly declined to supervise such activities, he or she will be held liable as the supervising physician. Explicitly declining to supervise a given activity is not enough. The physician must not become involved with the activity in such a way as to appear to supervise it.

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.

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