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Role Refinement


Physician assistants (PAs) and nurse practitioners (NPs), which I will refer to as non-physician providers (NPPs), are popular members of hospitalist practices and have a lot to offer. I think HM groups without NPPs should think about whether adding them would be valuable.

My experience suggests there are many different ways NPPs can contribute to an effective practice. But the optimal NPP role, one that is good for patient care, economically sound for the practice, and satisfying for both the NPP and the MD hospitalists, varies significantly from one practice to the next. I’ve worked with a number of practices that fail to achieve all these goals for a variety of reasons, but a common theme is that the MD hospitalists seem to think the NPPs have been provided for free. As a result, the MDs, and perhaps to some degree the NPPs, feel little or no obligation to develop the optimal NPP job description.

This team approach to rounding works well for our group. The hospitalists and NPPs work together to care for a set group of patients. The hospitalist and the NPP meet in the morning to divide the workload based on acuity, geographic location, and urgency. Sharing a common patient load helps with the common hospitalist dilemma of having to be in two places at the same time.

A popular role for NPPs is one very similar to that of the MD hospitalist (e.g., the NPP has a team of patients and rounds and admits daily). That might work well, but for reasons I’ve discussed previously (see “The 411 on NPPs,” September 2008, p. 61), many practices should at least consider other roles for NPPs. One alternative would be to have the NPP work an afternoon-to-night shift (e.g., 3 to 11 p.m.) to handle admissions and “crosscover.” Another option is for the NPP to essentially “own” a component of the practice, such as medical consults for orthopedic patients.

Whatever role is chosen, it must be one that provides the NPP career satisfaction. Over the last few years, I’ve had the pleasure of connecting with Ryan Genzink, PA-C, at various SHM meetings. He essentially is a career hospitalist, and I’ve found him to be a thoughtful guy. At HM09 in Chicago, he and I spoke for a while about NPP roles that provide value and career satisfaction. So I’ve invited him to share his thoughts here.

(Editor’s note: The following is written by Ryan Genzink, PA-C, of Hospitalists of West Michigan in Grand Rapids. He is the AAPA medical liaison to SHM.)

Dr. Nelson correctly observes that while NPPs can be beneficial to HM, there is no “one size fits all” model. However, I think finding the right model for your group sometimes is presented as being more difficult than it really needs to be. Over the years, I have had the opportunity to talk with a number of physicians, PAs, and NPs who work in HM. While models vary, those identified as successful seem to share some common elements.

My story is typical of a lot of PAs working in HM. When I was hired in 2000, my hospital was addressing a workforce shortage. Medical resident workloads were capped, private attending physicians wanted help admitting patients, and the ED was anxious to transfer admitted patients. The hospital was intent on not making our patients wait.

I joined a small group of PAs whose job description included addressing these issues. Like the residents we worked alongside, we took initial calls from the ED, performed histories and physicals, then staffed those with our attending physicians. As a new graduate, I was green and enthusiastic.

The hospitalists were fairly new to working with PAs, too. They had spent years teaching residents, but PAs had joined the group only a year prior. Even so, the group had developed a successful supervision model based on their experiences teaching residents. Patients I saw were cared for by attendings who reviewed the history, asked key questions, performed essential exam elements, and gave the final word on the treatment plan. Teaching naturally flowed from these interactions.

This model continues today. And like the interns who needed less attending input as they transitioned into chief residents, I also required less physician input over time. As our professional relationship grew, the hospitalists became more familiar with my work and exam skills, and I became proficient with our common treatment plans. We functioned together as a team. Of course, this process was no small investment on the part of the hospitalists I worked with. It took time—sometimes with detailed discussions of treatment protocols, or re-examining the patient together to make sure our exams were on the same page. Nonetheless, I think all involved agree the payoff was worth the effort. For our physicians, it made the transition from a resident-based program to one staffed with NPPs favorable. Granted, a residency program has different goals, but because the NPPs don’t rotate off service every six weeks, there is more time to develop collaborative, professional relationships. The investment the attending physicians made stuck.

As work volume increased, PAs in our group expanded into other roles. Our two academic rounding teams, each consisting of one hospitalist and a few residents, added a third team staffed with a hospitalist and a PA. When the residents left, all three teams were staffed with a physician and a PA. NPs later joined the group. And while NPs had slightly different state supervision rules, they functioned in the same roles as the PAs in our facility.

This team approach to rounding works well for our group. The hospitalists and NPPs work together to care for a set group of patients. The hospitalist and the NPP meet in the morning to divide the workload based on acuity, geographic location, and urgency. Sharing a common patient load helps with the common hospitalist dilemma of having to be in two places at the same time. I can see a patient who is ready for discharge (e.g., their ride is on the way), allowing my attending to dedicate his time to another patient’s family conference. In every case, the physician is involved. It is the extent of the involvement that varies. This model gives us flexibility and offers availability to our common patients.

Again, this is one of many successful models. Some, including Dr. Nelson, have suggested that a successful integration model might limit NPPs’ role in the group so that they can have ownership (e.g., post-op consult services). I think there is some merit to this, but this system also has potential unintended consequences.

When we look at what makes hospitalists successful at caring for post-operative patients, we often cite the experience gained from the wide variety of complex medical problems that we address on a daily basis. It is our frequent experience with patients with chronic heart failure that helps us identify the patient in early fluid overload. Our knowledge of diabetic ketoacidosis improves our routine diabetes management.

In my experience, rarely does a patient present with a single, narrowly defined problem. I think that limiting NPPs to the care of specific patient problems will result in limiting their effectiveness and possibly decrease their job satisfaction. I also think HM groups can err on the side of having unrealistic expectations for NPPs. Some groups have them perform the same role as an attending—with an NPP taking the spot of an off-service attending, and vice versa. This can work, if the NPP is experienced. Few would expect a new intern to perform like an attending. Conversely, restricting an NPP to collecting labs and paperwork is not an efficient use of resources.

As Dr. Nelson suggests, successful NPP integration depends on physician leaders being dedicated to the collaborative model and understanding that NPP success is tied to group success. And while admittedly not a perfect test, when in doubt about how an NPP could function in your group, I think asking if a resident would work in the same role is a good starting point. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelson He is co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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