A physician of Physician oversight in my practice is a system with four layers: every prescriber uses the same rating scales, written criteria require physician review for defined situations, physicians review charts on a regular cycle, and difficult cases are presented at a cross-office case conference. Candidacy for Deep TMS and Spravato stays with physicians.
When I founded Stedfast Psychiatry in 2021, it was a small practice. Five years later we have 13 offices across Florida and South Carolina, and most of the day-to-day care is delivered by psychiatric nurse practitioners and physician assistants rather than by me or the other physicians. Patients and referring doctors reasonably ask what "physician oversight" means in a practice that size. It is a fair question, and a vague answer is a warning sign. Here is the specific one.
Oversight is a system, not a signature
In Florida and South Carolina, physician assistants practice under a supervising physician, and nurse practitioners in psychiatry prescribe under a written protocol or practice agreement with one. Those legal requirements set a floor. A physician's name on a protocol does not by itself make care better; what makes it better is whether that physician has built a structure in which problems surface early and get handled by the right person.
I think of oversight in four layers: shared measurement, defined escalation, chart review, and case conference. Each one catches something the others miss.
Layer one: everyone measures the same way
Every prescriber in the practice uses the same instruments at the same points in treatment. The PHQ-9 for depression and the GAD-7 for anxiety are completed before every relevant visit, and the scores go into the chart as structured data, not as a note in the narrative. We add disorder-specific scales where they apply and functional goals at the first visit.
This is measurement-based care, and I insist on it for a reason that goes beyond the individual patient. The research is clear that it improves outcomes: Tong Guo and colleagues showed in a 2015 randomized trial in the American Journal of Psychiatry that patients treated with scale-guided decisions remitted more often and faster than patients treated by clinical impression. John Fortney and colleagues, writing in Psychiatric Services in 2017, estimated that fewer than one in five mental health clinicians used standardized measures routinely, and described the gap as the field's biggest missed opportunity.
For a multi-office practice, shared measurement has a second benefit. It lets me see across 13 offices without reading every chart. If a prescriber's panel is not improving at the rate the rest of the practice is, that shows up in the numbers, and I can look at why. Without common instruments, I would be relying on anecdote, which in a practice this size means relying on nothing.
Layer two: escalation criteria that do not depend on judgment
Good clinicians know when to ask for help. Systems should not depend on that. We have written criteria that require a case to be brought to a physician, regardless of how confident the prescriber feels:
- No response after two adequate medication trials, which triggers a review of diagnosis and a discussion of interventional options.
- Any new or worsening suicidal thinking.
- Any question of bipolar disorder before an antidepressant is started or continued.
- Any proposed benzodiazepine or stimulant prescription beyond a defined duration or dose.
- Psychotic symptoms, significant medical comorbidity, or a patient older than 65 on more than a set number of psychotropic medications.
- Any referral for Deep TMS or Spravato, both of which require a physician's assessment of candidacy before scheduling.
The criteria are deliberately conservative. The cost of an unnecessary physician review is 15 minutes. The cost of a missed one is a patient on the wrong treatment for a year.
Layer three: chart review
I and the other physicians review a sample of each prescriber's charts on a regular cycle, with new prescribers reviewed more heavily in their first months. We look for specific things: whether the diagnosis is supported by the documented history, whether medication trials reached adequate dose and duration before being called failures, whether the scores were used to make decisions, and whether the escalation criteria were followed. Feedback goes back to the prescriber in writing and in person.
Chart review is unglamorous and it is where I learn the most about the practice. Patterns show up there before they show up anywhere else: a tendency to under-dose, a habit of renewing a plan that is not working, a reluctance to raise therapy. Those patterns become teaching topics for the whole group.
Layer four: case conference
Prescribers across all 13 offices join a regular case conference by video, where the difficult cases get presented and discussed. The format is structured: history, trials to date with doses and durations, current scores, the question being asked. A physician leads and the group works through it. New prescribers present early and often.
The conference does two jobs. It gets the hard case a second and third opinion. And it teaches, because every prescriber in the room hears how a physician reasons through a diagnostic question or a medication decision. Over time that reasoning becomes the practice's reasoning, which is the point.
What I do not delegate
Some decisions stay with physicians. The candidacy assessment for Deep TMS and Spravato is one; I lead both programs and the clinical oversight is mine. Diagnosis of bipolar disorder before an antidepressant is started is another. So is any decision to continue a controlled substance beyond the defined limits. These are not statements about the ability of our nurse practitioners and physician assistants, many of whom are excellent. They are statements about where the consequences of error are highest and where a physician's training is most specifically relevant.
What this costs and why we pay it
Oversight at this level takes physician time that could otherwise go to seeing patients, and it takes administrative work to maintain the data. A practice could skip most of it and remain within the law. We do not, for a simple reason: psychiatric care delivered without measurement and without structured review drifts. Patients stay on treatments that are not working. Diagnoses go unquestioned. Nobody notices, because nobody is counting.
The ability to count, across 13 offices, is what physician oversight means in my practice. It is a set of instruments, criteria, reviews and conversations designed so that the care a patient receives in Goose Creek, South Carolina, follows the same standards as the care I deliver myself in Jupiter. The protocol signature is the legal requirement. The system is the actual job.
Frequently asked questions
Will I see Dr. Husted or a nurse practitioner?
Dr. Husted sees patients at the Jupiter and Palm Beach Gardens offices and by telehealth across Florida. At other Stedfast offices care is delivered by nurse practitioners and physician assistants working under the practice's physician supervision structure, with defined criteria for physician review.
What is measurement-based care?
Treatment decisions guided by standardized rating scales such as the PHQ-9 and GAD-7, completed at every visit and tracked over time, rather than by general impression. Randomized trials show it produces faster and more frequent remission.
Who decides whether I am a candidate for Deep TMS or Spravato?
A physician. Every referral for either program requires a physician's assessment of candidacy before scheduling. Dr. Husted leads both programs and provides their clinical oversight.
More from Dr. Husted
- Why I measure depression treatment by function, not just mood
- When to consider Deep TMS: how I decide with my patients
- Spravato in practice: what I tell patients before their first session
Educational content and not a substitute for evaluation. If you are in crisis, call or text 988.