Our current system of healthcare delivery needs to change if it is to accommodate the influx of millions of newly insured patients and a looming physician shortage of massive proportions. There are about 1 million physicians currently practicing in the U.S. In addition, there are 200,000 advanced practice RN’s, 100,000 physician assistants and 55,000 CRNAs. This non-physician group is sometimes referred to as mid-levels, which is a term not well received by these practitioners and not exceedingly descriptive. The correct blend of these providers and the response to pending shortage of providers will be integral to the success of our healthcare delivery.
The integration of physicians and the advanced practice providers has not been smooth. True integration only started about 35 years ago. This was mostly in the Anesthesia area with Anesthesiologists and CRNAs. To this day, it is still contested as to who can do what with their respective societies being constantly at odds. Much of this is related to a changing scope of practice and who can do what procedures. I worked as an Anesthesiologist and Critical Care physician for 33 years, training and working with physicians and advanced practice providers (AP). What I saw as the biggest problem was the constant comparison of the advanced practice provider to a physician. The only real way to be a physician is to be schooled and trained as one. This constant comparison, in some ways, downplays the advanced practitioners’ very well defined and excellent skills. The pride should be in what their role is, and not what it is not. The advanced practice provider is said to be able to do 80% of what a physician does. Early in my career I found this to be true in both the OR and the ICU. The overlapping of skill sets is what needs to be the focus of the working relationship. This was the linchpin that allowed me to concentrate on the unknowns of the sickest patients, all the while being confident that my partners in care, the advanced practice providers, were working beside me, sorting out daily issues. As time went on, the concept of a team formed. Patient care was optimal, due to ongoing discussions about the patients between the physician and advanced practitioners. Topics of interest were presented by both physicians and advanced practitioners.
The clearly defined roles of the physicians and advanced practitioners are imperative to the success of their relationship and healthcare delivery. In this regard, the defined roles cannot be related to changing finances of an institution. It should be very apparent that they are not in competition, but have more of a collaborative relationship. The degree of physician oversight and how flexible this is must be clear and establishes a path to any needed resolutions. The team model for care has had many success stories and emphasizes the strengths of both physicians and advanced practitioners, leading to sustained job satisfaction. Providing ease of access to healthcare is the established goal, with access to the physician provided through the team.
As the shortage of physicians becomes more and more prominent, the areas that advanced practitioners are focused will change and be added to. There will always be some resistance from physicians who have not worked with advanced practitioners in the past. This is why there are several standard guidelines to use when integrating advanced practice providers.
1) AP’s are there to collaborate and free the physician for the most complicated patients.
2) The expectation of the AP should match their skill set and experience
3) Competencies for skills are set and renewed periodically
4) Communication between providers is encouraged
5) Mentor relationships increase job satisfaction.
There are three basic models for the advanced practitioners to work within a system.
1) They are set up specifically in a specialty area such as a diabetic clinic or ambulatory clinic. Though this can focus a skill set and provide great care, the burnout rate can be quite high for the AP.
2) The AP is integrated within a care team as an extension of a physician. This, I believe, gives healthcare and the providers the best match. There can be a high level of satisfaction by the AP and the physician. It also gives the AP more latitude in the diversity of the patients they care for as they grow with the physician and the practice.
3) Here the AP is a solo, independent practitioner. On the surface this may seem to be a good scenario, but it leaves the AP with the possibility of little interaction with colleagues and seeming isolation. Pressure from administrators for APs to practice outside their comfort zone has more than normal potential. This is the least popular model from the physician’s viewpoint.
In summary, the team approach is a good model for continuing professional interaction, education, and job satisfaction. The few things that can derail it are lack of clearly defined pathways for conflict resolution and lack of respect for each other’s defined roles. It is a great way to grow the combined practitioner’s knowledge base by sharing interesting and difficult patients. The team approach maintains a collaborative environment. I hope as training programs evolve for physicians and advanced practice providers, they can naturally learn the process of working together. This can only help one group in particular—the patient.
