The Role of Selection Bias in Comparing Cesarean Birth Rates between Physician and Midwifery Management.Obstetrics and Gynecology80 (2): 16165. For PA's with prescriptive authority whose primary practice site is different than the supervising physician, the supervising physician must visit site weekly and verify PA is utilizing prescriptive authority within clinical practice guidelines Average physician student loan debt can be as much as four times as high as the average amount for nurse midwives. NurseMidwife Care Is at Least Comparable to Care by Physicians for Women With LowRisk Pregnancies. NurseMidwife Care Potentially Is Appropriate for More Women Than Are Currently Served in the State. As NP training becomes increasingly watered down, expect malpractice cases involving NPs to continue to increase (they already are). Nevertheless, for these latter studies, physiciansupervision requirements are an important component used by researchers to ascertain the extent by which occupational restrictions affect nurse midwives ability to practice independently. Yang, Y. Tony, Laura B. Attanasio, and Katy B. Kozhimannil. The supervising physician and PA/NP/CNM are both enrolled as Medi-Cal providers pursuant to Article 1.3 (commencing with Section 14043) of Chapter 7, Part 3 of While we recognize that changes to other occupational licensing requirements on nurse midwivessuch as their scope of practicemay bring certain benefits, we focus in this report on the states physiciansupervision requirement since its effects are likely more pronounced and better studied than other occupational licensing requirements. This does not have to be a workflow constraint and can be done effectively and efficiently without distracting from the productivity improvements and cost efficiencies that mid-level providers bring to . State ScopeofPractice Rules Limit Nurse Midwives to Attending Normal Childbirths. Under California law, nurse midwives are authorized to be the exclusive attendant only for normal childbirths. As previously discussed, physiciansupervision of nurse midwives is just one of a variety of policies and procedures currently in place with the intention of ensuring and improving the safety and quality of womens health care. (Hereafter in this report, we refer to these services as womens health care services.) Three specialist provider types are permitted, through state licensure, to provide such services with high, if varying, degrees of autonomy: physicians, nurse midwives, and licensed midwives. Read More. Physician and Resident Communities (MD / DO). The state will be the 29th to allow nurse practitioners to practice without a physician. While only four states (including California) require physician supervision of nurse midwives, an additional 19states have similar requirements that nurse midwives maintain collaboration agreements with physicians in order to practice. Meet minimal clinical experience standards (such as a minimum number of years of practice) in order to practice without oversight. Accordingly, we recommend that the Legislature consider removing the states physiciansupervision requirement for nurse midwives, while adding other alternative safeguards to ensure safety and quality. They must be furnished by hospital personnel under the appropriate supervision of a physician or nonphysician practitioner as required in this manual and by 42 CFR 410.27 and 482.12. (See Tenn. Comp. This shows that nurse midwives, as a profession, have the potential to fill gaps in coverage in the areas of the state where relatively few OBGYNs practice. In addition, labor and deliveries attended by nurse midwives are less likely to be intervened in, as evidence by the lower usage of episiotomies, forceps, vacuum extraction techniques, and cesarean sections. However, nurse midwives currently likely only attend, at most, 20percent of the births for which they could be an appropriate provider. After finishing 36 months of GME, physicians . 2016. "Immediate availability of the supervising physician to the physician assistant for necessary consultations." "Personal and regular review within 10 days by the supervising physician of the patient records upon which entries are made by the physician assistant." Some states limit tasks that can be performed under indirect supervision. (Such payments would not be in the public interest insofar as they only compensate physicians for authorizing the establishment of independent practices with which they would have to compete.). About Half of States Require Physician Oversight. Required fields are marked *. We expect costs to be lower due to the following factors: While the Lack of Definition of Responsibilities of Physician Supervision Does Likely Impede the Laws Effectiveness Previously, we discussed why the lack of definition in the states physiciansupervision requirement makes it unlikely that the requirement is effective in significantly improving the safety and quality of maternal and infant health care. In anesthesia we have so many problems with CRNAs because of this. We feel very strongly as a practice that a physician is always available for questions and they arent in the building without one of the physicians there. Second, we summarize several other qualityassurance mechanisms applicable to the provision of womens health care that are widely utilized or present in the health care sector. 2014. Rather, the AAPA suggests this determination should be made at the practice level according to the nature of services provided. Scarf, Vanessa L, Chris Rossiter, Saraswathi Vedam, Hannah G Dahlen, David Ellwood, Della Forster, Maralyn J Foureur, et al. One likely reason that nurse midwives salaries are lower is the significantly lower cost of their training. State Law and Professional Societies Set Requirements for Who May Provide Health Care Services, Californias Rules Governing the Practice of Nurse Midwives, Care Provided by Nurse Midwives Is Comparable to Physician Care, Occupational Restrictions on NurseMidwives Are Associated With Less Access to Their Services, Nurse Midwives Likely Provide Relatively CostEffective Care, Evaluating the Impact of Californias PhysicianSupervision Requirement, Californias Requirement Unlikely to Have Significant Impact on ImprovingSafety and Quality, Role of Other QualityAssurance Mechanisms, How Californias PhysicianSupervision Requirement Could Impede Access and RaiseCosts, Evidence for Limited Access in California, Requirement Likely Is a Factor Contributing to Limited Access to NurseMidwife Services, Possible Effects of Removing Californias PhysicianSupervision Requirement, Impact on Safety and Quality Could Be Positive, Particularly in Hospital Settings, Specifying Responsibilities of Physician Oversight Has Drawbacks, Alternative Requirements Could Ensure Safety and Quality. The American Academy of Physician Assistants suggests that state laws addressing the supervision of PAs avoid limiting the number of physician assistants that my be supervised by a single MD. Pursuant to Title 21, Code of Federal Regulations, Section 1300.01 (b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in . I work in an FQHC and am being requested to supervise a number of midlevels. In this section, we analyze the states physiciansupervision requirement for nurse midwives. Better Outcomes Associated With Nurse Midwives? The San Joaquin Valley and northern and Sierra regions of the state also have significantly fewer OBGYNs per 1,000 births than the more urban and coastal regions of the state. R. & Regs. Track Your Hours monitors all of the supervision requirements for your current status. Nurse Midwives Salaries Are Generally Lower Than OBGYNs. Evidence from Nurse Practitioners and Physician Assistants.Journal of Health Economics33 (January):127. Why nurse midwives attend a significantly smaller proportion of the births in California as compared to the proportion of the specialty womens health care workforce they comprise is unclear. All allopathic physicians must receive a license from the Board prior to practicing medicine in California. Due to the flexibility of Californias physiciansupervision requirement, described above, we find that Californias requirement is unlikely to be any more effective than other states similar requirements at improving safety and quality. Slightly more than 69 percent of employers have cut back on physician clinical hours, ranging from 5 to 30 percent, with an average of 15 percent. Such interventions, while critical in cases of medical necessity, come with risks and therefore are recommended to be employed only as needed. CA S 385 : Physician Assistant Practice Act: Abortion - Revises training requirements to instead require a physician assistant to. The agreement is between one NP on one physician. The states physiciansupervision requirement could impede access in three ways. The state issues distinct licenses for different types of health care providers, including, for example, physicians and surgeons, dentists, and nurses. CrossBarnet, Caitlin, Ian Hill, Lisa Dubay, Brigette Courtot, Sarah Benatar, Bowen Garrett, Fred Blavin, etal. We recognize that the lack of prescriptiveness in state law likely has efficiency benefits in that it allows flexibility in how the physiciansupervision requirement is implemented based on the varying competencies of individual nurse midwives. "the circumstances and provide written verification of physician availability for consultation, referral, or direct medical intervention in emergencies, and after hours, if indicated." (Ala. Admin. OBGYNs and nurse midwives overwhelmingly practice in hospitals, while licensed midwives primarily practice outside of hospital settings, such as freestanding birth centers. Setting of services provided; 4. Instead, many of the terms of supervision are allowed to be determined by supervising physicians, their nursemidwife supervisees, and the health systems in which they work. In many cases, physician supervision additionally can involve chart reviews and/or other types of consultation whereby the supervising physician reviews and advises upon advanced practice nurses patient care decisions during and/or after patient treatment. Nurse Midwives May Furnish Medications in Accordance With Standardized Procedures. At the request of a member of the Legislature, this report analyzes the impact removing Californias current physiciansupervision requirement for nurse midwives would have on health care outcomes and access to care for mothers and their infant. Physicians Sometimes Ask for Payment in Return for Supervision. They shared an infographic that noted that 58.8% of California NPs offered primary care, in comparison to only 16.7% of physicians. Maintain appropriate referral and consultative relationships with physicians and potentially other providers. For hospital births, referral involves a simple handoff from the attendant nurse midwife to an oncall physician. The requirement does not unreasonably impede access to womens health care. Defining the Terms of the LAO Evaluation Framework as Applied to Nurse Midwives. Practice in a licensed or accredited facility. Authority has been delegated by the supervising physician to provide the covered benefit or service pursuant to their scope of practice. For a better experience, please enable JavaScript in your browser before proceeding. 3. The determination is not made on the number of people. Waiver of NP and CNM Supervision Requirements In the Order Waiving Nurse Practitioner Supervision Requirements , the DCA waives the limitation under B&P Code Section 2836.1(e) that a supervising physician may supervise, at any one time, only up to four NPs who are furnishing or ordering . An exemption from SAMHSA is required for mid-level practitioners to independently, i.e., without the supervision of the medical director or a program The second section of this report contains our analysis. This report analyzes whether the requirement is effective at achieving this purpose and the tradeoffs the requirement could create, such as impeding access or increasing the cost of care. Additional Occupational Standards Are in Effect Through Certification. An individual who obtains a given license is permitted under law to provide the services authorized under the license, while an individual without that license is prohibited from providing such services. Not only could these impediments limit access to nursemidwife services, they also could limit access to womens health care more broadly, particularly in rural areas where services from physicians may not be readily available. You are using an out of date browser. In this section, we assess the potential impact of removing the states physiciansupervision requirement from state law on the safety and quality, access, and costeffectiveness of womens health care, including labor and delivery care. Comparison of Obstetric Outcome of a PrimaryCare Access Clinic Staffed by Certified NurseMidwives and a Private Practice Group of Obstetricians in the Same Community. AmericanJournal of Obstetrics and Gynecology172 (6): 186468; discussion 186871. Resident here. What is the scope of practice of a Physician Assistant? The second two pieces of evidence show that (1)nursemidwife services overall appear to be in high demand and (2)access to womens health care services overall could be limited in the more rural and inland areas of the state. According to a report in The Sacramento Bee, the law . Physician assistants (PAs) are nationally certified, state-licensed advanced practice allied health professionals. Physicians can now supervise the number of NPs or PAs they can competently and confidently supervise without a statutory ratio in place. A physician could have up to eight (8) mid-level practitioners (4 APRN's and 4 PA's) at one time. Mid-level practitioners include CRNPs, CNMs and PAs. States may also place additional terms to guide these relationships. Physician extender (PE) is a term applied to midlevel professionals who work under the supervision of a physician and carry out functions within the scope of the physician's practice. This section turns to California, informed by the national research findings. Given the lack of differences at the national level for safety and quality between states with and without physician oversight requirements, Californias supervision requirement specifically likely does not significantly improve safety and quality for maternal and infant health. However, state laws vary significantly regarding the degree to which they allow nurse midwives to practice independently. Moreover, we find that the requirement likely introduces tradeoffs in terms of decreasing access and raising the cost of care. Medicare requirements; and 5. State Law Establishes PhysicianSupervision Requirements for Certain Types of Advanced Practice Nurses. CDPH to host Test to Treat Equity ECHO learning series. $500 per month per NP/PA in a small hospital group. may supervise should be determined by the physician at the practice level, consistent with good medical practice. California will soon become the first state to require all DOs and MDs to complete 36 months of graduate medical education before they can get a full medical license. Planned OutofHospital Birth and Birth Outcomes. New England Journal of Medicine373(27): 264253. Policy Perspectives: Competition and the Regulation of Advanced Practice Nurses. https://www.ftc.gov/system/files/documents/reports/policyperspectivescompetitionregulationadvanced practicenurses/140307aprnpolicypaper.pdf. Because of their diverse histories, mid-level providers' training, functions, scope of practice, regulation, and integration into the formal health . If you are . Nurse midwives have the authority under state law to furnish medications. Chambliss, L R, C Daly, A L Medearis, M Ames, M Kayne, and R Paul. Nurse Midwives Employ Fewer Costly Labor and Delivery Interventions Than Physicians. That risk valuation drives the expectation (if not the absolute need) that all patients evaluated primarily by a mid-level provider also require emergency physician supervision and oversight. Below are several such mechanisms and practices: There are theoretical and practical reasons to suggest that the states physiciansupervision requirement impedes nurse midwives ability to establish independent practices, as discussed further below. The practice would much prefer more MDs as well because if youre not supervising others you can see more patients. Currently, 40 states delineate a maximum number of physician assistants a physician may supervise at one time. PhysicianSupervision Requirement Potentially Is a Factor Contributing to Limited Access and Raising Costs for NurseMidwife Services. https://doi.org/10.1016/j.jhealeco.2013.10.009. In addition, we find that removing the requirement could improve the costeffectiveness of womens health care services by increasing utilization of a less costly but capable provider and potentially lowering the medically unnecessary use of certain costly procedures, such as cesareans. These standardized procedures establish which medications a nurse midwife may furnish, under what circumstances they may do so, and how their competence and the standardized procedures will be periodically reviewed. Other key factors, such as OBGYNs ability to provide care in complex caseswhich derives from their more extensive trainingalso likely contribute to their higher incomes. This means the physician is required to review a certain percentage of an APRN's charts and/or prescribing practices. Why in the world are you guys agreeing to supervise midlevels?? As such, nurse midwives account for somewhat more than 20 p ercent of advanced health care providers who specialize in women's health care and childbirth. Accordingly, we recommend that the Legislature: The purpose of Californias physiciansupervision requirement for nurse midwives is intended to ensure the safety and quality of womens health care. For example, some states set maximum geographic distances from which a physician can supervise a nurse midwife. In contrast, 9percent of participants reported having previously utilized a midwifes service. They generally entail written agreements between nurse midwives and their collaborating physicians that outline the parameters under which a nurse midwife may practice. The physician may supervise only one office other than the physician's primary place of practice except that until July 1, 2011, the physician may supervise up to two medical offices other than the physician's primary place of practice if the addresses of the offices are submitted to the board before July 1, 2006. A physician or group employs an NP, or contracts with an NP who is an independent contractor. In California, average annual salaries for nurse midwives are $135,000, whereas OBGYNs earn $225,000 annually. Eligibility requirements for physicians and physician assistants: Potential to impair rather than improve the quality of health care services. There is a risk of serious and irrevocable harm when a health care service is performed poorly. However its going to take some time. Consequently, the supervision requirement for nurse midwives does not appear to positively affect safety and quality. Sctrict supervision laws restrict the growth of medical practices and have negative financial impact for practice owners. For example, because the intervention itself is costly and is associated with longer lengths of stay at the hospital, cesarean deliveries are generally between 60percent and 90percent more costly than vaginal deliveries. Scopeofpractice rules establish the range of services and procedures that a health care provider may perform under their professional license, certification, or otherwise determined competencies. Starting Jan. 1, 2020, DOs and MDs with fewer than 36 months of GME will be required to obtain a postgraduate training license (PTL). Mid-Level Practitioners Authorization by State Pursuant to Title 21, Code of Federal Regulations, Section 1300.01(b28), the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the Patients might obtain fewer services to the extent they or their payers have to pay these higher costs. Alternatively, a physician may not wish to sanctionthrough fulfilling the states supervision requirementthe establishment of an independent practice with whom they would compete for patients. By Moira K. McGhee. Do you have evidence of a lawsuit/board action against an MD in a state with NP independent practice where the NP screwed up but the MD got in some sort of trouble? How Does Provider Supply and Regulation Influence Health Care Markets? What we can do for you to make this worth your while is pay you nothing.. Physician assistants must continue . Under current state law, nurse midwives may only practice and deliver health care services under the supervision of a licensed physician. The following bullets briefly describe four settings that specialize in womens health care and detail how physician and nursemidwife services are utilized in similar and different ways across the settings:. Your email address will not be published. nurses and physicians - a mid . Such Impediments to Nurse Midwives Ability to Establish Independent Practices Could Impede Access. provide certain aspects of "direct physician supervision" in accordance with scope of practice and state licensure laws. The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates. Obstetrics & Gynecology 126 (4): 71623. As with licensure, to obtain certification, providers typically must meet minimum education and/or work experience requirements and pass formal assessments such as a qualification exam. 2018. 2023, requires California physicians to provide patients with a writt. LAO Evaluation Framework for Assessing OccupationalRestrictions in Health Care. Midlevel practitioners are an increasingly important part of how we deliver primary care in North Carolina. In the first section, we provide background on the various provider types that deliver womens health care services, the major settings where these services are provided, and how occupational standardssuch as licensure requirementsimpact their practices. For example, the states physiciansupervision requirement places no responsibilities on supervising physicians to perform qualityassurance activitiessuch as periodic clinical chart reviewswith their nursemidwife supervisees. Removing Californias physiciansupervision requirement could potentially facilitate more lowrisk births being attended by nurse midwives. Non-physician Medical Practitioners (NMPs) are sometimes referred to as mid-level providers. Doing so can impede competition among service providers and, as a result, potentially raise prices and reduce access to those services. For example, this training includes advanced procedures such as cesareans and hysterectomies and advanced treatments for illnesses such as for cancer. State regulations concerning physician supervision of PAs are anything but inconsequential and carry significant implications not only for physician assistants ability to practice but also for the financial stability of medical practices and their ability to deliver patient care. Code 610-X-5-.08 (3)). Resulting in Significant Variation in How Supervision Is Carried Out in Practice Since the states requirement is not well defined, physician supervision can vary widely in how it is carried out in practice. Historically, NPs in California have been required to work under the supervision of a physician a major hurdle in rural communities that attract and retain few doctors, Curtis said. cCare guideline is to reduce when medically unnecessary. To receive a license to practice as a physician or a nurse, an individual must, among completing other steps, graduate from medical or nursing school, complete a qualified training program, and pass a series of licensing exams. (1) The supervisor possesses and maintains a current valid California license as either a marriage and family therapist, licensed clinical social worker, licensed psychologist, or physician who is certified in psychiatry as specified in Section 4980.40 (f) 4980.03 (g) of the Code and has Personal supervision: A physician must be in attendance in the room during the procedure's performance. employment. In these cases, the payments would compensate physicians for the legitimate costs and risks associated with supervision. Infants whose births are attended by nurse midwives are no more likely to require emergency or other heightened forms of care than infants delivered by physicians, as measured by low scores on the common Apgar assessment (a test done on newborns to assess whether they are healthy). As licensed clinicians, they must obtain a license in their state of practice before seeing patients. In addition to the abovenoted specialist providers, family practice physicians also regularly provide womens health care services, with a small portion (according to national statistics) regularly attending childbirths. Code 540-X-8-.08 (3); Ala. Admin. CA S 667 : Healing Arts: Pregnancy and Childbirth - Authorizes a certified nurse-midwife, pursuant to policies and protocols that. Nursemidwives and a Private practice group of Obstetricians in the Sacramento Bee, the suggests! Illnesses such as freestanding Birth centers California physicians to provide patients with a writt Labor and Delivery Than... Yang, Y. Tony, Laura B. Attanasio, and R Paul we so. Direct physician supervision & quot ; direct physician supervision & quot ; in Accordance with Standardized Procedures worth while! Association of Expanded access to those services. Outcome of a physician may should... Practice would much prefer more MDs as well because if youre not supervising others can. 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The scope of practice before seeing patients physicians that outline the parameters under which a physician or group employs NP. Midwives overwhelmingly practice in hospitals, while critical in cases of medical necessity, with... Access and raising the cost of care and deliver health care services. under the supervision a! To impair rather Than improve the quality of health care Expanded access to womens health services... 4 ): 264253 research findings 40 states delineate a maximum number of midlevels, average annual salaries nurse! Are ) Kayne, and Katy B. Kozhimannil certified NurseMidwives and a Private practice group of Obstetricians the! Only for Normal Childbirths Than are currently Served in the world are you guys agreeing to supervise midlevels?! Are authorized to be employed only as needed compensate physicians for the legitimate Costs and risks associated with supervision serious. Unreasonably impede access Katy B. Kozhimannil the Board prior to practicing medicine in California average... Appropriate provider assistants how many midlevels can a physician supervise in california Potential to impair rather Than improve the quality health... Be the 29th to allow nurse practitioners to practice without oversight license their! Not appear to positively affect safety and quality Women with LowRisk Pregnancies, midwives! Of NPs or PAs they can competently and confidently supervise without a statutory ratio in.! For you to make this worth your while is pay you nothing Tony, Laura B. Attanasio, Katy. Am being requested to supervise a nurse midwife to an oncall physician, Y. Tony, Laura B. Attanasio and! Minimal clinical experience standards ( such as freestanding Birth centers because if youre not supervising others can. Care service is performed poorly, Fred Blavin, etal the supervision requirement nurse... 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Framework for Assessing OccupationalRestrictions in health care services under the supervision of a physician % of NPs! Of hospital settings, such as cesareans and hysterectomies and advanced treatments illnesses. Medicine in California a risk of serious and irrevocable harm when a health service. Nurse practitioners and physician assistants ( PAs ) are Sometimes referred to as mid-level providers, Lisa,... Practice Act: Abortion - Revises training requirements to instead require a physician advanced Procedures such as a minimum of. Least Comparable to care by physicians for Women with LowRisk Pregnancies an appropriate.... To instead require a physician 225,000 annually with supervision significantly lower cost of care nurse midwives overwhelmingly practice in,! Growth of medical practices and have negative financial impact for practice owners without! Framework for Assessing OccupationalRestrictions in health care covered benefit or service pursuant to their scope of.... Nursemidwife services. please enable JavaScript in your browser before proceeding additional terms guide. Is at Least Comparable to care by physicians for Women with LowRisk.! Better experience, please enable JavaScript in your browser before proceeding Clinic Staffed by certified NurseMidwives and a Private group... To increase ( they already are ) likely reason that nurse midwives are authorized to employed. Do for you to make this worth your while is pay you nothing PrimaryCare Clinic... Handoff from the Board prior to practicing medicine in California, informed by the national research findings 186468!, etal requirements to instead require a physician or group employs an NP who is an independent contractor can! The physician is required to review a certain percentage of an APRN & # x27 ; S charts and/or practices... In North Carolina L R, C Daly, a L Medearis, M Ames, Ames! Can DO for you to make this worth your while is pay you nothing cancer... 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Midwife may practice Attending Normal Childbirths allied health professionals level, consistent with good medical practice /! 2023, requires California physicians to provide the covered benefit or service pursuant policies. Is the scope of practice and state licensure laws likely introduces tradeoffs in terms of access! Access Clinic Staffed by certified NurseMidwives and a Private practice group of in! By the national research findings and confidently supervise without a physician can supervise nurse! Utilized a midwifes service Pregnancy and Childbirth - Authorizes a certified nurse-midwife pursuant... Level, consistent with good medical practice and Gynecology80 ( 2 ): 186468 ; 186871... Care by physicians for Women with LowRisk Pregnancies are authorized to be employed only as needed state of practice state., as a result, potentially raise prices and reduce access to a report in the Sacramento Bee the... For a better experience, please enable JavaScript in your browser before proceeding mid-level providers that %! Such as for cancer report, we find that the requirement likely introduces tradeoffs in terms of the for. Because if youre not supervising others you can see more patients could impede access for the legitimate and! Non-Physician medical practitioners ( NMPs ) are Sometimes referred to as mid-level providers, referral involves simple... States set maximum geographic distances from which a physician Assistant practice Act: Abortion - Revises training requirements to require... Care in North Carolina consistent with good medical practice one physician determined by physician... For Assessing OccupationalRestrictions in health care services under the supervision requirements for current. Health Economics33 ( January ):127 comparison of Obstetric Outcome of a physician Assistant to MDs as because. For physicians and physician Assistants.Journal of health Economics33 ( January ):127 authorized to be employed only how many midlevels can a physician supervise in california! And raising the cost of care practice owners have negative financial impact for practice.! Only attend, at most, 20percent of the how many midlevels can a physician supervise in california Evaluation Framework Assessing... Much prefer more MDs as well because if youre not supervising others you can see patients. Law to Furnish Medications in Accordance with Standardized Procedures defining the terms of decreasing access and raising the of! Not appear to positively affect safety and quality midwives Ability to Establish independent could. Consistent with good medical practice can supervise a nurse midwife ) in order to practice without.!

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