APP Controversies and Misconceptions Save

Our weekly review of all things important with advanced practice providers in the month of December. Tonight, we're going to be discussing APP's controversies and misconceptions. Let's begin with our panel. I'm Jack Cush in Dallas, Texas. Lisa?

Yeah, Lisa Carnego from Durham, North Carolina.

Lisa, you a nurse practitioner or a PA?

Yeah, I'm a nurse practitioner for the past ten years in rheumatology.

And Derek?

Hey there, I'm Derek Mueller, PA. I'm out of St. Clair Shores, Michigan near Detroit. PA,

I've

been in practice for six years.

Excellent. All right, so let's get into it. I want to thank our sponsors for this month on APPs. That includes AbbVie, Lilly, Johnson and Johnson, Novartis and Sanofi have been sponsoring this APP campaign where we've got a lot of content up. I hope you've been following that.

It's all about how important APPs can be in practice, what they do, what are the challenges for them. A lot of articles and content written by APPs for APPs and rheumatologists. It's covering all the needs in rheumatology, whether you're an MD provider or an APP provider. As you can see, we have these four weekly Tuesday night rheumatologists. Tonight, it's gonna be controversies and misconceptions about APPs, and we hope to hit on things that are important to you.

I think really important for those of you who are tuning in and watching this live, you can certainly get involved in the conversation by clicking on the Q and A button ask your questions there, and we'll discuss those as they come up throughout this one hour webinar. So to help with the discussion as we have done in the past, we usually send out a one time, one day survey on the topic we're going to cover and use that as a launch point for the discussion. We did a one day survey yesterday. We had overnight 190 responses, about 20% were from nurse practitioners and physician assistants and about 80% from rheumatologists. Again, they sort of have the same distribution, the APPs in the rooms, whether they're in private practice or academic or hospital based.

So an interesting tidbit from the survey, asked one of the last questions was, did you go to ACR or ULA this year? 190 people who responded. And look at this, the far left is everybody answering and 60%, did not go, 40% did go. And I think that's about right. The question is though, when I subsetted the, 20% of APPs versus a rheumatologist, look, they're really the same.

And I think that's encouraging to me. That means that APPs are getting the same education you're getting. If we look at their attendance at ACR, I could ask another question, did you go to a regional meeting or a rheumatology only meeting? And I'm sure we would have gotten the same distribution. Derek and Lisa, what do you see amongst your peers as far as what they go to?

Do they pretty much mirror the rheumatologist or are they on a different educational track? Lisa?

Yeah, so for ACR attendance in my practice, we have about eight APPs and I'm pretty much the only one who goes to ACR but for the smaller conferences like AWARE or some go to RNS and RAP, a lot go to RAP. So I think rheumatology specific but maybe a little smaller than ACR is where my practice typically finds himself.

And I think that's exactly what rooms are doing. Rooms used to be that you weren't really a rheumatologist unless you went to the ACR meeting or you are, but that attendance has gone down over years and people are going to the smaller meetings, RWCS and PRDs got a meeting, the West Coast has got the Pearson conference, there's the Harvard Review Courses Room now live. Well, you know, and people are going to those because the other meetings seems so big and so hard to navigate, you know? Derek, what's your impression?

I think across the board, it seems like APPs in our area don't attend larger national meetings like ACR and I think part of that might be limited because of cost and CME budget, then again taking that time to make that big trip, and a lot of APPs in our state are, you know, there seems to be a lot younger APPs, and maybe there's some intimidation about attending a large meeting like ACR. I hope that can change in the future and APPs feel like that's a meeting they can go to. I went to my first one this past fall and it was a great experience for me.

Not really on our agenda, but I think it's a concern to me as a rheumatologist and maybe an employer in the practice. I'm a little unclear, actually I'm not clear, I'm pretty clear about what to recommend. The APPs that work with me, my recommendation could be that they should go to a good smaller rheumatology meeting, or they could go to a meeting just for APPs like RAP, or they could go to RNS who's trying to also have serve the needs of APPs. Or they could go to ACR where you have the ARP, which has a much more diverse representation. I think this is what's overwhelming to any learner, especially APPs.

And I think if ACR wants APPs to come more to ACR meeting, I think it's up to them to make the content worth their while. Anybody have a different view on that? But I think this is important because every APP I know has always wanted to have a plan for their education. I'm going to publish this week. We did two surveys of APPs and we asked a lot of questions about their education.

The survey responses are really interesting. 80% of APPs have dedicated CME time that they need to use, want to use. And what you both just said is what the results were. Some will go to national meetings, but a lot are going to more regional and smaller meetings. The one thing I found surprising with the nurse practitioner I worked with is sometimes she preferred usually like every other year to go to an APP meeting as opposed to a rheumatology meeting.

Meaning one that's designed for nurse practitioners or designed for physician assistants that may not be a rheumatology meeting, but it's general medicine and whatever, because, and I guess the message I got, those people understand me.

Yeah, Doctor. Cush, if I may butt in. I think when I'm advising other APPs as to which meeting to go to oftentimes it'll be based upon like for me I go to ACR because I do research and I specialize in uveitis and some of the smaller conferences may not have as much knowledge centrally about those topics or be as strongly research centric, whereas some of my more clinical APPs it makes more sense to go to the more clinical conferences. I think it can really be tailored for the individual and where they are in their learning process as well to really support them in that ongoing education. I think that's where I would advise to go.

And as for the APP centric ones, they have a lot of pharmacology specialized CEs, which as a nurse practitioner I need 25 pharmacology hours, which I don't get through grand rounds and other things, and oftentimes at ACR. So that's one thing that I would go to like an AANP or APP specific conference for.

That makes sense. And it makes more sense also, you'll see in some of the survey questions we have here that the number of PAs and nurse practitioners who are involved in specialty care, specialty clinics, I would include in that research like you're doing, it's a minority, it's about 10% or so of the total number out there. And they're gonna probably get more out of the meetings that meet their needs. And that may be instead of going to CCR, I'm gonna go to ACR because it's going to present the new guidelines on whatever. You want to be up to date on it.

Okay. So let's go on and get into this questions. I just put up a few that were covered in our surveys, but I want to ask Derek and Lisa, what other controversies and misconceptions should we be talking about in this webinar? I think the number of rheumatologists or rheumatology practices that don't employ an APP has gone down quite a bit in the last ten years, meaning that they're being hired more and more, but it ranges somewhere between 2035% in my opinion, without anyone knowing the hard number. And some people just feel, why should I spend all that money on an APP when I could spend a little more money and get me a really good rheumatology fellow?

My answer to that is good luck with that. But it boils down to the ROI and we'll discuss that. Should you hire a nurse practitioner or PA? How should the APPs practice? Where do they fit?

What do they do? What's your practice model? Maybe with the ultimate question being can APPs practice independently? Any other controversies or misconceptions that we should probably address in this webinar, Derek?

Well, I think when we're talking about, is it worth hiring our APP? Mean, we have to take into a couple of factors. There's a monetary factor of that APP making their salary and you know, making profit for the practice potentially and what's that investment of time. I think that's one of the big concern is hiring an APP right out of the school. How much time is it gonna take?

There might be some unknown to that, but I'm hoping in our discussion we can kind of clear up why that is definitely worthy of the time and the money it takes to hire an APP. You know, for example, I mean, I just had a patient comment today. I mean, I have a patient who's been in our practice for over a decade before our office had an APPs and said, this is a completely different practice with APPs. I can get in and be seen whenever, you know, I have an acute issue. It's just a totally different change in the practice now that there's APP.

I'm hopefully we can highlight why that is.

Yeah, what do you think Lisa?

Yeah, I think the other one that we continue to grapple with is should APP see new patients, especially in a large academic medical center where things are very complicated and sometimes a tertiary referral center. So I think that's one of the big ones. Is there a specific diagnoses group or a specific diagnosis that you want your APP seeing is probably a secondary question to that.

Right. So certain diagnoses, certain situations, certain types of follow-up, are those prudent in these folks? Let me ask, I think we're going to be kind of aligned here on someone who doesn't employ or work with an APP. I think the best way to get experience with APPs is you don't have to hire them, but if you work in system where other APPs are working, you'll work with them and find out how good they are. I have to say that last week's TNR, where we discussed cases, if anybody is not too clear about, well, what's an APP gonna do for me or how good are they gonna be?

You need to watch or listen to that podcast. Those three APPs on there were constantly bringing up stuff that I hadn't thought of, were spot on with their clinical decisions and their diagnostic opinions and whatnot. And I must say, I only worked with one of those people before, two out of the three I just met for the first time and they were just fabulous. So I think that was the best evidence as to whether you should hire someone or not. But the question, should you hire an NP or a PA?

I like that both of you are representing your camps and it's okay that you can say, I have to move by contract say PA first if you're Derek or NP first, but does it matter for either of you? Lisa, you go first.

I really don't think so. I always recommend hiring for personality and then training for skills and whether that's an NP or PA or a physician or your front office staff, know, I mean that's pretty much across the board for me and I think similar care and the studies would suggest similar care around a year for either of those types of practitioners. Would support Foley either.

Derek, what's your advice?

Yeah, would say hire both. I think it's the right person for the right job. I think that the training differences, I mean there might be some slight differences in program training and how there's recertification of an MP versus a PA and our continuing medical education cycle. To be honest, our education and our potentials for what we can do in a rheumatology office are both quite vast.

Yeah, I like the idea of hiring the personality, the person, but then find out what's their expectations, what is their job? And then that has to sort of match what the job is that you're offering. But if you're a rheumatologist and listening to this and you don't currently employ an APP, your expectations are too low because you don't know what you're doing. If you're someone who's really experienced like John Tesser or Philip Meese or myself, or the people at Duke that Lisa works with, your expectations are really high and would shock the guy that's never or the gal that's never worked with an APP. So realize you should go in with expectations and that they are gonna grow as you and your APP grow together.

So let's get into some of the questions. Should you hire or not? On three of the questions in this survey, asked the question, I gave the option, I don't have an APP. This is the three answers I got. One was almost half, two are around 20%.

Another one I did recently was around 30%. So we really don't know that answer. I was talking to Betsy Kirchner from the Cleveland Clinic recently and I asked for some advice and she gave me this great quote. She says, How would you guys answer this? My physician colleagues always ask me respectfully and with genuine puzzlement, how come I, the physician had to go through residency and fellowship, meaning, seven, eight years of training before I could see patients on my own.

But the APP we just hired twelve weeks ago now has his own panel and schedule. What's going on like that just, that kind of for the inexperience. And that's kind of why I think some people have this hesitancy in doing. So we asked the question, what are the barriers for you in hiring advanced practice provider into your practice? This is one of those questions where second biggest answer was, I don't have an APP, almost 24%.

And I liked that it's really all over the map. Everyone's got different concerns, but return of investment 30%. I don't know if it's worth the investment. 22.5% say education and training. And I think what they mean by that is I'm not sure how to train them or they certainly don't come rheumatology trained.

When I've asked that question in the past, somewhere between 810% of APP hires in rheumatology are pre trained. And if that's been your situation, that's pretty lucky. 15% are confused about role definition. Not many people are concerned about billing issues. So, Derek, these answers surprise you at all?

I think actually that the billing issues being such a small piece of the pie is, I don't, that's a little surprising to me because I feel like there's a ton of questions and confusion about how encounters are billed between providers. That was a little bit surprising to me. And then I think education and training, I think that's, of course, it's a barrier, but I think the office, the rheumatologist, the staff have to have the know how and the drive to train someone for an extended period of time. That can sometimes take a long time to workshop what that is going to look like for an individual person. So I understand that, I think that's part of the investment that has to be taken.

Exactly, anyone who's interested in how you train an APP, listen to our first Tuesday night rheumatology on hiring, onboarding and training. It was very insightful, lots of instruction, a lot of resources, mentoring plans, on the job training that is structured outside formal training through RAP or ACR or a number of different sources that's all out there. And Derek, I was gonna put a question in here, a more detailed question about billing and especially the issue of incident to billing and whatnot. But number one, that's very unique state by state. And it's also unique for Medicare and for Medicaid.

That in itself could be a session that maybe we'll do in the future, but that's why I didn't include it here. Lisa, what do you think?

Yeah, I'm actually surprised that the biggest barrier is seen as return on investment. I guess I struggle with this because all of our APPs are working at the top of their scope and have fairly autonomous independent practices in a parallel model meaning they're practicing around other people, other rheumatologists who do this. So I'm surprised by this. I'm pretty sure I broke even after year one and then you know from there it's just up and up and up. I think I find that rather interesting actually.

And in terms of the education and training, I would say going through the data on this that we don't have any guidance about what is the right education or training for Rheumatology APP. How long does it need to be? What does it need to entail? You know specifics kind of like our fellowships programs that are very regimented and we don't really have that for APPs. At Duke you know we have a fellowship program that's a two year proposition and you know we're bringing new folks in that have experience and not using that at the moment, but figuring out how to train onboard and really educate and continue to train and support APPs is an ongoing issue.

So I can see why that's on here because it's kind of a black box.

Yeah, think Duke and there's an ANOVA that has another fellowship or training program for APPs in Connecticut are the only two formal ones out there. We started with one, gosh, almost twenty years ago at UT Southwestern that ran for a little while, but then sort of fizzled out. And I think you're right, think those are But the ROI, so I actually put some information up on ROI in the next slide. This is a no brainer. Hiring an APP in my practice more than doubled my output and more than doubled the income.

And it did so at less than half the price. So APPs in general are making starting salaries around 130,000. It varies nationwide by state by state or region. And those are the hottest areas of growth and the easiest to hire. Physicians, the starting salary in 2024 are well over 200,000, as high as 260,000 for our new rheumatologists had a fellowship, but their availability, good luck.

So again, to not consider an APP for the issues of ROI just means that you don't know what you don't know and you're afraid to change. I don't know. I think that the idea is to get people to talk about it. To hear other practitioners, I'm always amazed that the comments that I get from, I think one of the rheumatologists on our program in the first or second week said that I know Philip Mies employs three, another one was asking questions, employs seven APPs in their practice, and they just have a few physicians. They have more APPs than physicians.

In a lot of places, the number of physicians is matched by the number of APPs, and they work like in a tandem way. So we have a question from Julie Harrington, who's a Canadian APP. So they have a training program, it's affiliated with the University of Toronto and accredited. It's called the AC PAC program. So that's good.

Americans are welcome up there in Toronto as well. I would ask the question, is your training in the summer or in the winter? But then again, I like hockey, I'll go anytime and as long as I can see the Maple Leafs play on a regular basis. I asked Lisa to come on here because she's written a lot about roles and misconceptions about APPs. I just pulled this one published just this year in Arthritis Care and Research about the state of advanced practice providers in rheumatology.

Elisa, tell us why you did this, tell us what you discussed and what your recommendations from this work.

Yeah, some of my recent work has been around how to integrate APPs into practices. And we've been doing this at Duke for a little while really going through the whole process of interviewing providers and leadership roles and aligning our goals with our system as well as talking to the clinicians who are in practice and finding out what they want and what APPs want and how they want to practice and in what model would they feel most supported. So we came up with a blueprint and that's not the article here on the screen but we came up with a blueprint to kind of guide other practices about how to do this kind of redesign of their models, largely because I found in our practice that people were functioning in all different kinds of models kind of haphazardly based upon where there was clinical space and sometimes just being siloed by location and not really thinking through like, I'm going to put Lisa with Bill and Rex and Rob you know I'm going to intentionally put these folks together who have an interest in uveitis or RA or insert your specialty of choice so that they can support each other.

So I was asked to do this editorial largely just to share my perspectives about integrating APPs and how important it is to really define roles for APPs as we're integrating them and what effective communication may look like. Additionally, thinking about our structured training and what that could look like and in different places it would look differently. So in larger practices like ours, it may be a very large behemoth, whereas in smaller practices, it could be very personal kind of team based approach. But thinking through all of the different things that I've been working on, one of my colleagues, Alison Dimmesdale, who wrote this with me, had originally put forward this model of care and she had done advanced practice work within the health system for quite a while. So this really resonated with me these models.

So thinking about autonomous independent practice APP manages all the aspects of patient care and then collaborates when needed which is really how I'm practicing currently. I happen to work with a rheumatologist as well at times, most of the time actually, in a parallel model. So we do that, he sees his patient, I see my patient, if I have questions we're in the same place I can find him in the hall and ask them questions. And then also specialty specific which is very unique for different practices and then the tandem model which you alluded to earlier, Doctor. Cush, or the kind of like the fellow model, and then the leverage model which is different in different places as well when, but I like to think of it as somebody does a lot of care coordination or does MyChart messages and offloads the burden from the physicians so that they can see more patients is the easiest way to describe that one.

So long story short, this article specifically was talking through some of the issues in our integration with APPs and how important it is and some of the keys to success.

As I listened to you describe this, especially how people end up in different models, I think that sounds to me exactly what rheumatologists have done. Meaning it depends on where you work, who you work with, what the physical and or business structure is of what you're doing, defines who you're gonna be and how dependent, independent, collaborative or not you're going to be. And I think that in one practice, I have been in situations where these different models exist and sometimes they're based on seniority. Sometimes they're based on new hires. Sometimes they're based on who gets paired with who.

But I think that the point is the clinician needs to drive the impetus to learn and the impetus for independence because if they don't, things will just forever be limited. That's what I did in all my situations. I demanded the nurse practitioner be autonomous and always said, Come next door and knock on the door when you want me, when you see a nodule that you're not sure what in the world this is, that kind of thing. And then we'll scratch heads together like, I don't know what that is, what do you think it is? Again, just to be a little bit hyperbolic about this, the nurse practitioner I worked with, in the first year or two, she would present cases to me then I would check out, so to speak.

And as she's presenting the case, I'm going, well, this is clearly a case of calcium pyrophosphate deposition disease. And I'll explain to her in the room the many different causes of this and clinical associations. I go in the room and I greet the patient, I sit at the computer and I look at what she's already written. She's written everything I already thought about what I was going to teach her. I'm thinking, she keeps upping the game on me.

And that's why it wasn't very long before that APP was completely autonomous and really good for the practice and referred by the patients, etcetera. Derek, how your role change in your history where you work?

Well, I think going off of what you were explaining, I think it really is up to us, the APPs to know what we want. If our goal is to see new patients and practice to the top of our scope, then we really have to make that known to who we're working with and push for that, because otherwise if you don't voice that and you don't move forward with that's how you're going to operate, then you're going to be stuck seeing boring follow-up patients. I mean, where you're to do work that you don't really feel like you're practicing to the top of your license. So I think when I first started, was a tandem like approach, fellow attending situation. And then over time, just again, as these presentations of cases became, you know, much more mundane, just, I was kind of off to the races and then more on my own.

And I think that relationship and how that APP operates really changes over time. But again, I think that's really up to the APP to go into it knowing where they want to end up in long term.

Yeah, so I want one more comment on training. Leslie Silver also from Canada talks about the advanced clinician practitioner program ACPAC in Toronto. She finds that some of the questions about training being a holdback in some people. Training is what they do and they have over 140 graduates that are out there in North America that are practicing. And for more details, go to acpacprogram.ca, acpa, rheumatoidacpaprogram.ca.

They're all about competency based training. I think that's really important. Do you have that same principle in place at Duke, Lisa?

Not in that specific kind of formula, so to speak. And I love this that she talks about competency based programs. Actually, anybody wants to reach out to me later with what your competencies are, I'd love to see them. I was actually reaching out to David Leverans just to ask him past week to see if he knew of anybody that would be interested in doing this work.

There's one paper from China about nurse practitioner competencies and whatnot, and I like the structure of it because it gives everybody the assurance. With my people I've trained, I want to know that they are engaged in education on lupus and vasculitis and laboratory testing and biologic management and safety. But I'm not testing it. I think that gets tested every day when we share patients. But I think in a training program, it wouldn't be a bad idea to have competencies or competency evaluation.

So we asked our rheumatologists, 190 respondents, 80% were rheumatologists. How are APPs utilized in your space? Again, they're either doing the same as rheumatologists in a quarter, 20% are doing follow ups on complicated care, and 11% are somewhere between the rheumatology nurse and the rheumatologist. This sounds like a really low bar, right? And then we asked the other question, what are rheumatology APPs best at providing?

Almost 60% said collaborative team care, twenty two percent said chronic and preventative care. Now we have like seven percent each for either specialized care, comprehensive care or basic care. So very few people are doing really basic things. They're doing what sounds like bread and butter rheumatology, especially when it comes to chronic care patients and preventative things. But Derek, does any of this surprise you?

I mean, think when we get to some of the questions later, well, just the answer here how APVs are utilized because I think it's going to kind of depend on the disease state, the individual patients, we'll see later why that is, but yeah, and I think the second polling question just shows that we're all over the map and what people are doing, and I think so much of rheumatology is preventative care and chronic disease management, so you know, that makes sense. But how much is collaborative team care? I mean, that also looks different between how often the physician and the APP are really, you know, having a collaborative ongoing treatment plan with an individual patient. I think a lot of care plans are created and put forth by the APP on an ongoing basis.

Lisa, do you think that a career, choosing a career path for an APP going to rheumatology, should they be encouraged to do specialized disease care or should they be a chronic and preventative care person or should they be part of this collaborative team if those were three separate things or should everybody find their own level?

Yeah, that's a great question. And I think we have a great capacity to do all of those things right when I'm seeing a patient with RA for instance I'm thinking about preventative care as well if I have them on steroids I'm thinking about their bone health I'm talking about immunizations at every visit, you know, so we're cancer screening when appropriate. So I do think that we're doing a lot of the preventative things. We're doing complex care. I think we're doing all of these things to be honest and if an APP would like to do specialized disease care I think that's wonderful.

I know at Duke we have one APP who's specializing in myositis, I specialize in uveitis, we have several others that have an interest in inflammatory arthritities and we really encourage that and we have one that does scleroderma with Doctor. Shah so I do think that it's a great thing and it allows you to really feel competent and like an expert in that really rigorous area that's complicated.

A big issue I've heard this month in talking to so many PAs and NPs is the common practice where they're assigned to the mundane, the routine, the boring, the maddening, the OAs that are not going to change who you can't use pain medicines in, the fibromyalgia who don't follow instructions or hard to manage, and that they're not being challenged to seek their specialty interest or whatever. How do we get out of that rut or what can you? Again, I've always said that I have a vasculitis patient in Room 1 and fibromyalgia in Room 2, and we're picking up charts and I'm picking up the fibromyalgia because I know I need to make my nurse practitioner incredibly happy and incredibly challenged, or I want to find out if she's challenged by vasculitis or a joint injection or lupus or whatever. So what can you guys do to get yourself or your colleagues out of that rut of seeing the mundane patient? Derek, do you wanna tackle that one?

Yeah, I think it's, you know, the onus is on us. I mean, we have to really, take time to educate ourselves about these rare disease states. We have to, you know, impress our colleagues and kind of reason why we should go to educational meetings and you know, learn about things that we're not going to see day to day. I mean, in private practice, you're not seeing a patient with systemic sclerosis or inflammatory myopathy walk through the door every day. Like when those patients do, you know, we have to take that initiative to see them, and we need to keep up on guidelines, keep up on, you know, these disease states that we're not seeing, so when we are encountered with them, you know, we're comfortable in managing them or having that discussion about management with our colleagues.

We have to show that that's what we want to see.

Lisa?

Yeah I think the main thing for APPs is not a lack of desire or wanting to be challenged. Think it's being somewhat scared of getting into the room and not knowing what to do and not having the support to think about that complex patient and having somebody to bounce that off of. So this is something I've really thought long and hard about when I've been thinking about designing teams is really supporting APP so that they can feel confident that they can go into any room, the vasculitis, scleroderma, lupus, wherever, come out and if I have a question and need somebody in the moment I can call, I can find somebody, I can drag you into the room with me to look at this. So I think it's really important that we structure our practices so that we can support each other, whether it's me supporting the physician and saying, yeah, agree, that looks like vasculitis, or the opposite. Know, I think we really have to support ourselves when it gets really complicated.

And then I will add to that too, I think it's important that when we are involved in care of patients who may be more complex, that we're involved in the ongoing follow-up with that patient because if you see one scleroderma patient, a year, you're not going get very comfortable with managing or identifying that disease in general. So I think seeing these patients over time and also having an active role in deciding who are the patients that you follow. You should be able to make that call if you wanna follow some osteoarthritis and fibromyalgia patients, and sprinkle in whatever variety of patients that you feel comfortable seeing, and that would make you a better clinician in the long term.

So I'm sure that you both have seen the information published just last week about the match in rheumatology doing really, really well. Again, rheumatology is, you know, a lot of fellows are going into that and whatnot, and it's become quite competitive. That's all good, well, and fine. Not so good in pediatric rheumatology where there are less than half the spots are matching, and the manpower needs are even greater. There are many states that don't have a pediatric rheumatologist.

So do either of you have much insight into the NPs or PAs going into pediatric rheumatology? I don't.

It's a much smaller number. I believe we have one at Duke that's been in pediatrics for a little while. But to be honest, I don't know that we integrate pediatrics as well, especially APPs as well into larger structures like on the adult rheumatology footprint. And there may be a little bit less support there for advanced practice providers to really integrate. You know, think about APPs going into pediatrics and it can be challenging, right?

You don't want to get it wrong, you really don't want to get it wrong, Right.

Well and I think specifically with pediatric rheumatology, I mean we talk about education and basic training for APPs. Mean, the rheumatology segment is usually quite narrow, but if you think about the education we get in pediatric rheumatology at a basic level, it's a real sliver. So I think maybe that's a barrier for APPs seeking a position specifically in pediatric rheumatology. So, I think that's on pediatric rheumatologists to advertise their field. I think it would certainly be quite attractive to APPs if they just knew more about it.

Yeah, it's a big opportunity and a large unmet need. So I want to describe to you the scope of practice issue that comes up in these two questions and then get asked for your comment. So on the first question on the left, I ask, who treats psoriatic arthritis in your practice situation? Forty two percent said only the rheumatologist. And I chose psoriatic arthritis, it's a little challenging, it's very common.

It's something I think every rheumatologist, every fellow and every APP should be able to easily manage. So forty two percent only rheumatologists, thirty eight percent said either the rheumatologist or APP is fine. Almost eighteen percent, you know, it kind of depends on, the severity of the disease. So they're being a little selective, right? Like how severe do they have to be that's only gonna be a rheumatologist?

I mean, or in my case, how severe do they have to be that they're only gonna see my nurse practitioner because she's better than me. So that's one thing. Now I changed the story. I asked the question, a patient with lupus nephritis is in the hospital and is going to be discharged. So I gave the diagnosis, it's complicated, and they need to get an appointment soon.

Who are they going to see? And now you can see a skewing of how the respondents here look at this. Now sixty percent say it's got to be a rheumatologist that sees the follow-up out of the hospital, especially if it's lupus nephritis. That would not be the case in my clinic. In my clinic, would be, they go to their last clinic provider.

They go back to Doctor. Cush, or they go back to Leilani Law, the nurse practitioner, or whoever's available first. 30% whoever's available next up so that in case it could be either or that's fine. And I think that's a reasonable answer. And then I think last clinic provider is a reasonable answer, but to say, so there is this skewing, like, I think APPs are great, but there's a but.

And the question is, is that you don't know what you don't know? Is that we need research on this to know what's better, and how can we better define it? And right now it's being defined locally by Derek and his coworkers and by Lisa and her coworkers. They define what your panel is gonna look like and whether or not you're seeing new patients. Anyway, what's your feeling on this, Lisa?

Any comments on this?

Yeah, so I'm wondering if the forty two percent that said only rheumatologists are the forty percent that don't have an APP. Because that would make sense to me. Otherwise, really agree with the 38% of folks that said rheumatology, rheumatologist or an APP. And that's how we do that in our practice as well. Severity doesn't factor in at all truthfully.

And then in terms of the lupus nephritis patient, we have a lupus clinic, we're a little lucky. So most of our lupus patients with nephritis are treated in lupus clinics. So they would likely go back there. That being said there are a few out and about in some of our satellite clinics that the APPs will see as well but we have a thing at Duke where usually hospital follow ups are not for the APP.

Okay, so you can go ahead Derek.

I was just gonna say me being in a private practice and a community based clinic, I mean this is a little bit different because you know unfortunately we don't have that you know luxury of lupus clinics unless you know, you're going to a university center like University of Michigan. But when it comes to hospitalized or discharged lupus nephritis patients, I mean, a lot of that visit, that follow-up is just tracking down hospital records, it's damage control, it's you know, we need to figure out what happened in this hospitalization, at least get a game plan going. And generally that patient's going to be back again for a very short interval follow-up thereafter if we're dealing with lupus nephritis. So I think that's a really perfect role for an APP to get in there, look at the hospital course, get a game plan set up and if they need the physician to jump in then it's perfectly set up either for that visit or maybe like a very short interval follow-up. So that's usually how that situation would work with us.

Think the real answer, the right answer here is depends on what you're doing before the patient went in the hospital. Is your APP taking care of the lupus patients and patients with psoriatic arthritis or patients with Behcet's or not? And if they are, I don't see what the problem is and then coming out. If there's a glitch, they can always have a consult with their peers. So we asked the question, before I get into independence, thankfully, Susan Shanoi, who's a fabulous pediatric rheumatologist from the University of Washington, good friend has been listening in and she says, thanks for talking about peds and pediatric rheumatology.

There are more and more APPs being hired into practice and it's a very hot topic. They in the pediatric rheumatology department just hired an APP, but there is no clear indication what's going on nationally with this issue. While we do know nationally, there's an unmet need in training and we only have the positions being filled. It'd be nice to know if APPs are going be taking up some of that slack and what is the effort to actually address that issue. The question is, what are you doing with your APPs?

On the right, I asked the question, is your APP engaged in any of these specialty things like a telemedicine 23%, that's pretty good. A disease specialty clinic nine percent like Lisa's involved in a uveitis clinic. Satellite clinics is less than 5%. Health maintenance is really nobody's doing a health maintenance clinic. And the bottom line is 60% are not involved in any kind of niche areas or specialty clinics.

And I don't know if that's an opportunity that's missed. I can tell you that I've worked with nurse practitioners who were exclusively involved in research, who ran a loop or worked in a lupus clinic. But most of the ones I've worked with saw everything that I saw. And the question is, I already indicated that I'm fully behind autonomous and independent. In your practice, how independent is your NP or PA?

The answer of autonomous and independent was only about eleven percent. In another survey I did recently, it was as high as seventeen percent. But that was a survey of, I believe, nurse practitioners. So there's little bit of a skew there. The main answer was that they were mostly independent, meaning they saw patients and they were supported with backup IMDs when needed.

So that's kind of the independent, but they always have an MD and they're encouraged to do that. Autonomous, I could almost think of as someone who's got their own satellite clinic in a rural environment, and their only to an MD supervisor may be by phone or meeting once a week or something. The next most common answer was mostly dependent. They co manage, that could be like tandem care, which I don't think is very efficient. Maybe good in the beginning, but I don't think it's very efficient.

And then, as we said earlier, really specialized people, specific diagnoses, specific kinds of follow-up 8% full time oversight required. That would be like a first year fellow in the first month of activity in the clinic, that kind of thing. So I assume a lot of those are either very worried employers or very new employees. So let me move on. The question is, Lisa and I were talking about this earlier, who should APPs not be seen?

Or the big question is, I don't know why I'm hidden there. Let me go back and actually make this go away, send it back. Should they be seeing new patient consults? This responded group said number one, no, they shouldn't be seeing new patient consults in thirty eight percent of situations. Twenty percent said no to severe or difficult disease.

Twenty percent said patients with complications should not be seen by APPs. And only twenty percent are doing what I do, what APPs can see all patients. They're smart enough, they're good enough. Again, the APP I've been working for over twenty six years. So I have far less concern about her than a new rheumatologist I've been working with three years.

There are many factors here, but does this surprise you, Lisa?

I don't think it is surprising. And I think as APPs in rheumatology are fairly new, we have a lot of young APPs in our practice even. We have a few senior and but we have a lot more new APPs. So I do wonder if this is just the trajectory of learning and supervision needed to really train and onboard an APP all the way up to fully independent. So I think this could be on a continuum because when I think about my practice, I started off in this tandem and then progressed to parallel and then started my own uveitis for a multidisciplinary clinic off by myself in the eye center.

And you know now I have a parallel model because I have a friend, I have enough patients that I have a friend rheumatologist up there with me. So I think it just depends on where you are in your training and your education and that may be reflected in these results.

Again, hesitancy maybe to hire an APP might be concerned over what their roles might be, might be some real aversion to this idea of them being independent. I think you really addressed that well. Derek, what do you think about this next question where we ask the respondents, what do the study show about patient satisfaction with APPs or outcomes with APPs against rheumatologists? And they got it right in my opinion that sixty one percent said that there's high satisfaction rates comparable to MDs. And only a few fifteen percent say that patients refuse to see APPs if given a choice of APPs or MDs.

The fifteen percent have said there are no studies about this or need to go and look at the studies. Are actually a lot of studies about this showing that. Derek, what do think of these results?

Yeah, I think it's interesting. I mean, I think the survey show anecdotally studies show that patients have incredibly high satisfaction with APPs, you know, that's throughout medicine. I think that anecdotally that seems to be very true in rheumatology as well. I can't tell you how many patients are appreciative of our PAs and NPs at our office for being there to help them and take the reins on their care. Patients are very comfortable with us.

Patients are very used to working with PAs and MPs in all different fields of medicine. It's really no different in rheumatology, and I think that's probably out of anything we're reviewing today, this is probably the most clear thing we know is patient satisfaction with APPs. It's very seldom that, you know, it seems, again, in my experience that a patient has refused to see an APP and they want to follow-up with us long term.

And I'm doing a survey, not survey, I'm writing an article now getting input from multiple APPs about give me your clinic pearls, your things that you would want to teach other APPs or maybe even young practitioners about. And there's a dominance of the responses I've gotten. We got a lot of responses that talk about time to talk, time to listen, time to take their questions. And I think that's really distinctive. What I can say from my own experience is hiring an APP is not like hiring you.

Even though you may train them to practice like you, they are not gonna be like you, the doctor. They're bringing a totally different skill set and their training, how they were trained is different than the way you were trained. You're all about getting it right and spewing the statistics. A 42% chance you could get a deadly infection and like they don't need to know all those facts, they want someone they can trust. So I think you're right, Derek.

I think that the evidence here is quite overwhelming. Let's end with this issue of retention and how can APPs be retained in the practice? What should they be asking for? Or what should the rheumatologist be putting on the table to entire already told you what I do. I go into Room 1 and I send my patient into the more interesting Room 2 with the vasculitis patient.

But this table says, offering education, effective mentoring, limiting the number of doctors they work with or scenarios they work in, having dedicated feedback time and conversation time, and being competitive salary and incentive wise. Lisa, what do you think are the key factors here? You work with a lot of them and I know why they stay because number one, there's a lot of them there. And you have a bunch of doctors who really are very APP avid and friendly and supportive. And it's got a great academic environment.

But what works in your opinion?

Yeah, so I think at the base we have to pay well. We need to have bonus structures similar to our physician colleagues. I do think that one thing that we could benefit from is having a dedicated period of time like at the end of the week or over lunch, you know where we go over complicated cases just to you know continue to create that team environment where we can continue to learn and continue to have that communication that's open and honest and where I can say you know I don't know I'm not sure what this is. What do you think it is? You have to have those relationships in place where you feel like you can say, I don't know.

And in rheumatology, I feel like there's a lot of gray. So have to be comfortable with the I don't know in the gray to do rheumatology. That supportive effective mentoring is another piece as well so continuing to have mentoring from your APP colleagues who may be in a practice for a while as well as mentoring from physicians who believe in you and think that you can do all of those things. I think those are the biggest things.

I often tell people that the success of RheumNow is number one, I'm curious, most of what I do, because I want to know and we share that. But I figured out from a number of years that I'm in the confidence and excellence business. I put up things that make me confident about what I'm doing. I try to get to black and white uncertainty, and it all builds a better rheumatologist and a better nurse practitioner, better APP in general. I think that if you provide that as a mentor, and if you're not actively seeking that you're going to make them better in what they do, then yeah, they're gonna be leaving.

Derek, what's your advice?

Yeah, think similar to what Lisa mentioned, I think that APPs, especially early on in the training course need to feel like they have that room to grow. I think when things go awry, it's when the APP is being pressured, you know, start seeing a bunch of patients all the time. And if that's what the APP wants to do, if they want to have a procedure clinic and make bonuses, a whole different situation. But I don't think, yeah, we need to have that nurturing time to be able to feel comfortable to work through these cases mentally and even just have the time to spend with patients explaining things. And then being explained how various systems work.

I mean, that's just so important in the very beginning. And I think that's where people can get burnt out easy when they just get thrown to the wolves.

All right, that's take us to the top of the hour. I wanna thank our speakers. I wanna thank those of you who tuned in to this great webinar. I wanna acknowledge the ACT PAC program. And if you want training in rheumatology, you can go to the Duke fellowship program, you can go to Inova in Connecticut as a program and up in Toronto, they have the acpacprogram.ca for training.

I want to acknowledge them and the great work that they're doing as well. Derek and Lisa, thanks so much for sharing your time and excellence with the audience.

Thank you.

Thanks for having me.

Everyone, be sure to tune in next week, our final week, Tuesday the twenty third, we're talking comorbidity and health management with three APPs who've got a lot to say on this subject. Good night, everyone.

We hope you enjoyed this TNR podcast devoted to advanced practice practitioners. This podcast was sponsored by AbbVie, Eli Lilly, Johnson and Johnson, Novartis, and Sanofi.