Advanced Practice Providers are here to stay. Let’s help them succeed.
The comments section of practice-management articles are littered with physician-readers bemoaning the encroachment of advance practice providers (APPs) into historically physician roles.
With the shortages projected in physician workforce, APPs will be standing in the gap, whether or not organizations and their physician colleagues are prepared for this transition. APP training pathways are shorter than physicians by at least 5-10 years, depending on specialty, in the United States. Organizations are increasingly hiring APPs because of the difficulty of recruiting and cost of the physician workforce, particularly in primary care. Though I sincerely doubt that physicians will become obsolete, APP roles have and will continue to change as a team-based approaches to medicine grow. APPs can train to perform at a high level, including management of complex patients and procedures. However, there are specific challenges to early practice for APPs. Schools are quickly churning out APP graduates into the workforce with a highly variable skill rate. Regardless of the oft-opined inadequacy of their preparation level, they are being hired to fill critical gaps in the healthcare workforce. Physicians working in such organizations shouldn’t wait for someone else to step in to help new APPs succeed. Instead of complaining about it, physicians and leaders need to act intentionally within their own healthcare organizations to create clear structures that will facilitate the best care of the patient by maximizing the team approach. When we work to nurture and grow those around us, everyone, including the patient, benefits.
Understand the APP’s training background and co-develop expectations and structures with the APP for their first years in practice. As we hired new APPs into our family practice, I learned insights (sometimes the hard way) that are worth sharing. New APP graduates especially benefit from structures to guide them through the first two to three years of practice. Here are some of the issues and how to navigate them:
Understand their educational background, what domains may need greater support, and then prepare to invest in supporting those needs. Many NP and PA schools require students to find their own rotations, creating huge variability in training, and they may have very little pre-graduate school clinical experience. Finding a preceptor to take students can be difficult, and rotations may consistent primarily of shadowing with very little hands-on care, or training to one physician’s way of doing things without exposure to broader practice styles within a specialty. NP and PAs also may not have managed the flood of administrative work as students often required in office-based practice, such as coding, relaying test results, patient phone calls, and reviewing refill requests, experience which one would obtain in a physician residency program. Procedural training is variable.
Be an informed hirer by asking new graduates for a list of their rotations and detailed questions about their level of patient management or previous work experience that pertain to your practice. For example, ask them to tell how many complex chronic disease patients they have managed, or their capabilities with the administrative tasks of with patient care, or how many of a specific procedure they have performed independently.
Not all physicians want or know how to be teachers for new graduate APPs. If there is a mismatch between a supervising physician and an APP, typically the APP is going to lose. For physicians that want to teach but feel ill-equipped, provide tools or point them to trainings on how to teach (e.g. how to give feedback, a chart review tool).
For those in procedural roles, use skills workshops and formal check-offs similar to residency case-logs to help with quality management.
Provide graduated levels of responsibility. APPs may need a different schedule/template than a new physician, with more time to look up conditions and ask more questions. This also means the supervising physician is going to feel the time-squeeze. In our practice, we created margin in the physician’s schedule when paired with a new graduate to answer questions. Consider non-clinical training such as inbox management and coding. A curriculum or milestone requirements may be helpful.
Monitor referral patterns and diagnostic test ordering. In our system with limited specialist access, it’s important the specialists focus on appropriate referrals. Utilizing e-consults or having a supervising physician review referrals with the new APP can help before sending.
Provide clear expectations of the role. Is the APP acting as someone’s primary care provider with a panel? Or are they providing support to a physician panel? It can be confusing for patients too, without clarity of roles. Also, don’t assume APPs see their first two years out of school as a physician’s residency where 80 hours a week is the norm; although they expect a steep learning curve, their expectations are different than interns.
If APPs have their own panel, define the panel size. New graduate APPs are unlikely to be able to take on as many complex patients as a typical physician graduate. The higher the percentage of complex patients on a panel, the smaller their relative panel size should be. New graduate pattern recognition and processing is less well-developed, so complex patients take longer and more effort to review. In a group practice, give APPs the ability to recommend transfer of complex patients to a physician panel, have a consultative visit with a physician in the group, or be on a shared panel.
If you are utilizing shared panels, ensure that the physician and APP understand and agree to their respective roles and practice styles. Mutual trust development is vital in shared panels. For example, is the APP helping manage the inbox for both providers? What are the expectations around controlled substance prescribing? How do patients understand the shared role? Not all physicians want to “share” their patients and some patients may resist this model as well. Schedulers should book patients to maximize continuity within the dyad, including asynchronous vacations. In my role as clinical director, it was very helpful to have an APP partner I could trust, which helped me instill confidence in the patient on their care even when I didn’t have the appointment space to see them myself.
If APPs are hired for specific roles such as post-op visits, wellness visits, home visits, or urgent needs only, beware of boredom setting in. APPs want to learn; giving increasing responsibility as they progress may help with retention.
Patients can form deep, meaningful relationships with APPs just as well as physicians, and patients often see their APP as their ‘doctor,’ under a different title. We should not diminish the power of that relationship, even in the context of different training or roles.
Know your state laws around supervision, including limits on the number of supervisees, scope of practice, and any specific supervisory requirements. Even if supervision isn’t required by law, organizations should still consider supervision of new graduates specifically. In my previous institution, NPs were in collaborative agreements with a physician in the same way as PAs even though Washington law didn’t require it. Chart reviews requirements also may vary by state. We centered the responsibility of formal monthly chart reviews on the medical director, while other physicians provided more verbal day-to-day case support, with the medical director as back-up.
Adjust compensation models
Recognize that supervising APPs does come with risk and for new graduates, a significant effort on the part of the physician. Adjust compensation models to account for these aspects.
Shared panel compensation, if based on panel size, can be unfair unless providers are able to effect panel sizes. For example, early in practice I was paired with an APP at 0.25FTE with a very small panel, and thus I received lower compensation even though I had no capability to affect it and it required a similar level of supervision.
Be careful about providing compensation only for those officially ‘supervising,’ but then expecting all physicians to be available to answer questions. In our practice we worked towards a culture where everyone could ask anyone a question, and made an across-the-board stipend to physicians for APP supervision, with some specific supervisor duties falling to the medical director who was compensated additionally for administrative time.
To incentivize supervision, if a physician did a joint visit with the APP by physically seeing the patient or did a procedure with them, the physician documented a shared-visit attestation and received the RVU credit in an RVU-bonus model of compensation.
Organizations who plan to have APPs in the practice should create structures to invest and grow them, with adequate compensation and support for their supervising physicians. Although turnover for new graduates is common, my observation is a well-supported team member is more likely to stay in the practice. The challenges are navigable, and APPs can prove to be vital members of the patient care team, making the investments worthwhile.
