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Are We Placing Unreasonable Demands on Our Advanced Practice Clinicians?

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I started to do the math … four years of undergraduate training, five years of medical school, three years of Internal Medicine, one year of research with the TIMI Study Group, followed by three years of Cardiology fellowship. That’s 16 years of total medical training to become a noninvasive cardiologist — and even after all of that training, I sometimes feel as if there are certain diseases and conditions that I have had minimal or no exposure to.

Now, if you compare that to the amount of time needed for a physician assistant (PA) degree (an average of 24-27 months) or advanced nursing degree (1-3 years after a bachelor’s in nursing degree), I can’t help but wonder if allowing “APCs” (advanced practice clinicians) to manage patients independently or semi-independently is a reasonable expectation. PAs can elect to do an optional residency after PA school but it is not mandatory. Further, if a PA decides to change from one specialty to another – for example, from Emergency Medicine to Family Practice – additional training is not mandatory, even though the skills needed may be completely different. Although a PA does need a “supervising physician,” the degree of supervision is widely variable by state and the supervising physician is not even required to be present on-site in some cases. Perhaps even more alarming is the fact that in 18 states, nurse practitioners (NPs) can practice entirely independently, opening their own practices and prescribing all medications, including controlled substances.

At a recent BBQ with many of my colleagues from other Denver-area practices, we started discussing the way in which NPs and PAs expedite physician work-flow and improve patient care delivery for straightforward cases. That said, we also all expressed concern about the lack of supervision and excess of autonomy APCs are afforded. It was clear that everyone there felt unanimously that APCs are critical to the success of modern medicine. However, no advance is without its challenges. One colleague brought up an example of a young patient with atrial fibrillation (AF) who moved from out of state, where he had primarily been managed by a nurse practitioner without significant input from a cardiologist. The patient had been simultaneously treated for many years with metoprolol, diltiazem, digoxin, and amiodarone — concurrently — for persistent AF; the medications had been added on sequentially, one at a time, and were all part of the AF treatment algorithm for rate control. However, it was clearly a combination that is seldom used for prolonged periods due to drug-drug interactions, unpredictable effects on AV nodal conduction, and significant long-term side effects, especially in a young otherwise healthy patient. With this example, it was clear that the nurse practitioner (through no fault of her own) was following the “AF algorithm” for treatment but had neglected to appreciate the subtleties of managing complex AF, something that may have been a direct consequence of his/her limited clinical experience and training rather than a direct medical error. In Cardiology, a field full of algorithms and treatment pathways, APCs can serve an important role by improving patient access and providing high-quality face-to-face patient care. (I often have patients who tell me how much they appreciate seeing the NP or PA rather than the physician, whose visit may be more rushed.)

But: when does this model of practice stop improving efficiency and quality of care and instead, paradoxically, compromise the quality of care patients receive? Isn’t there a reason that the length of Cardiology training for MDs is long? Don’t we need 15+ years to be exposed to the subtleties of complex cases and learn to recognize when there are zebras instead of horses? And, if APCs are to have independent practices, shouldn’t their training and supervision be more closely regulated (and lengthened!) to provide them with adequate exposure? 

The original intent of the APC was to improve the efficiency of the physician and improve patient access of care. But just like the Arab’s camel, who slowly took over the tent one inch at a time, the line has been pushed further and further without a concurrent increase in APC training. The increasing demands on the physician have resulted in an increase in autonomy for the APC, which has altered the role of APCs so much that they have, for all practical purposes, started to function as physicians. For perspective, this is analogous to a medical scribe being suddenly asked to write medical notes independently because the physician is unavailable.

I, more than anyone, wholeheartedly support the concept of maximizing efficiency in a practice by using everyone to “the top of his/her medical training” in order to deliver high-quality medical care. But what that means has become increasingly ambiguous. Can 1-3 years of post-college training without a residency and fellowship give enough exposure and experience to care for complex patients, to recognize the boundaries of knowledge, and to understand when the patient in front of you is no longer following the dictates of the algorithm?

What do you think? Do the expectations placed on APCs to independently see and manage patients exceed their levels of training? Is more supervision needed? As their autonomy grows, should their training be more strictly regulated and lengthened? Are physicians utilizing APCs in a way that is improving or hindering the delivery of care?

Payal Kohli, MD is a cardiologist and a 2018–2019 Doximity Author.

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