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Teamwork makes the dream work – maximizing the relationship between physicians and advanced practice providers
Advanced practice providers (APPs; physician assistants and nurse practitioners) play a vital role in the success of an academic or private gastroenterology practice. Partnership with APPs in the clinical setting can improve inpatient and outpatient workflow and complex chronic care management, optimizing downstream revenue from endoscopy, radiology, and motility studies and enhancing physician productivity in research or academic affairs. In an informal AGA Community survey of physicians throughout the United States, 86% of respondents worked with advanced practice providers, 61% of whom had done so for over 5 years. While APPs may fill diverse roles in gastroenterology practice, there are common principles that may help optimize the physician-APP relationship. We surveyed both APPs and physicians to gain their perspective and present a tool kit to optimize the relationship among APPs and physicians.
The APP perspective
In qualitative interviews with 12 APPs practicing gastroenterology in a variety of specialties in Massachusetts, we aimed to understand 1) what APPs felt they brought to GI practice and 2) how APPs can be best utilized and integrated into GI practice and flow.
All interviewees independently noted that improving patient access to care and providing continuity of care were key benefits they brought to their practice, resulting in the possible downstream prevention of unnecessary emergency room admissions. Additionally, APPs felt that they brought significant value by having the time to listen to patient concerns to allow the team to prioritize care (83%), and provide patient education on their disease or medications (92%).
Though APPs are often utilized based on the individual needs of the practice, physician understanding of the APP skillset (83%) and a clear job description with set expectations up front (75%) were two critical elements of practice integration and job satisfaction on qualitative APP surveys. Additionally, APPs felt that strong mentorship with opportunities for career growth could enhance career satisfaction and improve the overall retention of the APP (100%).
The physician perspective
Informed by themes identified from the qualitative APP survey, we posted an informal, anonymous online survey to physicians on the AGA Community Forum. Nearly all physicians that worked with an APP felt that they were beneficial to their practice. Ninety-seven percent of respondents found that APPs improved patient access to the clinic, while 47% found that APPs decreased phone calls and 43% found that APPs improved administrative burden. Other less commonly cited benefits of APPs included increased practice revenue, improved efficiency of inpatient care, and assistance with procedures.
In building relationships and developing trust with their APPs, respondents valued communication (94%), observed or measured competency through orientation or standardized training (55%), and increased time comanaging patients (48%). However, 52% of respondents were concerned regarding the time required to train an APP to their standards, 45% were concerned regarding knowledge deficits, and 48% were concerned regarding risk of turnover and burnout. Though patient satisfaction was noted as a possible benefit of a physician/APP team approach, physicians also noted a potential concern that it may compromise the existing physician/patient relationship.
Despite concerns regarding training and knowledge deficits, only 29% of respondents had a standard orientation for APPs, 26% had a clearly defined job description, and 32% had formal teaching in their specialty content area.
Developing a model for success
Based on the results of these surveys and our practice experience, we present seven recommendations to optimize the APP/physician relationship:
1. Create a clear job description that ensures your APP works to the top of their license and training. This key principle can have a great impact on practice revenue and APP job satisfaction.
2. Develop a plan to train the APP to your standards, whether it be through a dedicated content curriculum or a mentored preceptorship. Most APPs finish formal training with very little gastroenterology specialty expertise, and would benefit from content-based learning in the area of gastroenterology in which they will work. The AGA publishes on-demand webcasts in different content areas, geared toward advanced practice providers (https://www.gastro.org/aga-leadership/initiatives-and-programs/nurse-practitioner-and-physician-assistant-resource-center). The AGA also hosts an annual conference to review GI content and prepare APPs to deliver optimal patient care (https://nppa.gastro.org/).
3. Designate objective criteria by which you will measure competency. Share this model with your APP up front to establish transparent expectations, and meet to review competencies and plans for further training at least annually. This structure presents a model for clinical growth and transparent expectations may enhance APP retention.
4. Establish APP mentorship. Just as for physicians, both clinical and career mentorship are an important part of job satisfaction and retention for APPs.
• Meet regularly. We recommend that mentors schedule weekly meetings with their APPs to review cases, questions/concerns, outstanding clinical work, quality-improvement initiatives and/or research. These regular meetings will keep lines of communication open and may enhance APP retention.
• Provide feedback. Both APPs and physicians benefit from constructive feedback. An annual review should not bring any surprises. Keeping feedback honest and constructive will further strengthen the relationship.
5. Introduce the APP as an integral member of the care team during the initial patient encounter. Whether working in a dedicated subspecialty team (inflammatory bowel disease, hepatology, motility, or hepatobiliary) or as part of a general gastroenterology practice, APPs should be introduced during the initial encounter as a key member of the team to establish rapport. The APP’s name should also be listed in the after-visit summary, on business cards, and on stationary to strengthen the team image. Once a patient is established with an APP and a therapeutic relationship is built, patients often report positive outcomes and maintain follow-up with the APP/physician team. We recommend that the physician see the patient at least every other visit (alternating with the APP) to reinforce the team dynamic and dedication of all members of the team to the patient’s health.
6. Provide a sense of community. Depending on the size of your practice, you can connect APPs within your practice, institution, or at a professional organization level. Belonging to a larger group that understands APP practice provides strong support and APP career satisfaction.
7. Create growth opportunities. In addition to clinical growth, APPs can provide value in leading quality-improvement and research initiatives. Establish goals and timelines for achieving goals up front, and be prepared to protect the APP’s time to achieve these goals. Successful APP growth and development may enhance job satisfaction and lead to reduced turnover. In addition, establishment of APP leaders provides candidates to help design and implement an effective APP program as a practice grows.
The authors wish to recognize research coordinators Casey Silvernale and April Mendez, and Dr. Kyle Staller who assisted with the coordination of the surveys that contributed to this work. Dr. Burke is a gastroenterolgist affiliated with Massachusetts General Hospital, Boston; Dr. Thurler is the Ambulatory Director of advanced practice providers and nursing at Massachusetts General Hospital. The authors had no disclosures.
This story was updated on June 26, 2019.
Advanced practice providers (APPs; physician assistants and nurse practitioners) play a vital role in the success of an academic or private gastroenterology practice. Partnership with APPs in the clinical setting can improve inpatient and outpatient workflow and complex chronic care management, optimizing downstream revenue from endoscopy, radiology, and motility studies and enhancing physician productivity in research or academic affairs. In an informal AGA Community survey of physicians throughout the United States, 86% of respondents worked with advanced practice providers, 61% of whom had done so for over 5 years. While APPs may fill diverse roles in gastroenterology practice, there are common principles that may help optimize the physician-APP relationship. We surveyed both APPs and physicians to gain their perspective and present a tool kit to optimize the relationship among APPs and physicians.
The APP perspective
In qualitative interviews with 12 APPs practicing gastroenterology in a variety of specialties in Massachusetts, we aimed to understand 1) what APPs felt they brought to GI practice and 2) how APPs can be best utilized and integrated into GI practice and flow.
All interviewees independently noted that improving patient access to care and providing continuity of care were key benefits they brought to their practice, resulting in the possible downstream prevention of unnecessary emergency room admissions. Additionally, APPs felt that they brought significant value by having the time to listen to patient concerns to allow the team to prioritize care (83%), and provide patient education on their disease or medications (92%).
Though APPs are often utilized based on the individual needs of the practice, physician understanding of the APP skillset (83%) and a clear job description with set expectations up front (75%) were two critical elements of practice integration and job satisfaction on qualitative APP surveys. Additionally, APPs felt that strong mentorship with opportunities for career growth could enhance career satisfaction and improve the overall retention of the APP (100%).
The physician perspective
Informed by themes identified from the qualitative APP survey, we posted an informal, anonymous online survey to physicians on the AGA Community Forum. Nearly all physicians that worked with an APP felt that they were beneficial to their practice. Ninety-seven percent of respondents found that APPs improved patient access to the clinic, while 47% found that APPs decreased phone calls and 43% found that APPs improved administrative burden. Other less commonly cited benefits of APPs included increased practice revenue, improved efficiency of inpatient care, and assistance with procedures.
In building relationships and developing trust with their APPs, respondents valued communication (94%), observed or measured competency through orientation or standardized training (55%), and increased time comanaging patients (48%). However, 52% of respondents were concerned regarding the time required to train an APP to their standards, 45% were concerned regarding knowledge deficits, and 48% were concerned regarding risk of turnover and burnout. Though patient satisfaction was noted as a possible benefit of a physician/APP team approach, physicians also noted a potential concern that it may compromise the existing physician/patient relationship.
Despite concerns regarding training and knowledge deficits, only 29% of respondents had a standard orientation for APPs, 26% had a clearly defined job description, and 32% had formal teaching in their specialty content area.
Developing a model for success
Based on the results of these surveys and our practice experience, we present seven recommendations to optimize the APP/physician relationship:
1. Create a clear job description that ensures your APP works to the top of their license and training. This key principle can have a great impact on practice revenue and APP job satisfaction.
2. Develop a plan to train the APP to your standards, whether it be through a dedicated content curriculum or a mentored preceptorship. Most APPs finish formal training with very little gastroenterology specialty expertise, and would benefit from content-based learning in the area of gastroenterology in which they will work. The AGA publishes on-demand webcasts in different content areas, geared toward advanced practice providers (https://www.gastro.org/aga-leadership/initiatives-and-programs/nurse-practitioner-and-physician-assistant-resource-center). The AGA also hosts an annual conference to review GI content and prepare APPs to deliver optimal patient care (https://nppa.gastro.org/).
3. Designate objective criteria by which you will measure competency. Share this model with your APP up front to establish transparent expectations, and meet to review competencies and plans for further training at least annually. This structure presents a model for clinical growth and transparent expectations may enhance APP retention.
4. Establish APP mentorship. Just as for physicians, both clinical and career mentorship are an important part of job satisfaction and retention for APPs.
• Meet regularly. We recommend that mentors schedule weekly meetings with their APPs to review cases, questions/concerns, outstanding clinical work, quality-improvement initiatives and/or research. These regular meetings will keep lines of communication open and may enhance APP retention.
• Provide feedback. Both APPs and physicians benefit from constructive feedback. An annual review should not bring any surprises. Keeping feedback honest and constructive will further strengthen the relationship.
5. Introduce the APP as an integral member of the care team during the initial patient encounter. Whether working in a dedicated subspecialty team (inflammatory bowel disease, hepatology, motility, or hepatobiliary) or as part of a general gastroenterology practice, APPs should be introduced during the initial encounter as a key member of the team to establish rapport. The APP’s name should also be listed in the after-visit summary, on business cards, and on stationary to strengthen the team image. Once a patient is established with an APP and a therapeutic relationship is built, patients often report positive outcomes and maintain follow-up with the APP/physician team. We recommend that the physician see the patient at least every other visit (alternating with the APP) to reinforce the team dynamic and dedication of all members of the team to the patient’s health.
6. Provide a sense of community. Depending on the size of your practice, you can connect APPs within your practice, institution, or at a professional organization level. Belonging to a larger group that understands APP practice provides strong support and APP career satisfaction.
7. Create growth opportunities. In addition to clinical growth, APPs can provide value in leading quality-improvement and research initiatives. Establish goals and timelines for achieving goals up front, and be prepared to protect the APP’s time to achieve these goals. Successful APP growth and development may enhance job satisfaction and lead to reduced turnover. In addition, establishment of APP leaders provides candidates to help design and implement an effective APP program as a practice grows.
The authors wish to recognize research coordinators Casey Silvernale and April Mendez, and Dr. Kyle Staller who assisted with the coordination of the surveys that contributed to this work. Dr. Burke is a gastroenterolgist affiliated with Massachusetts General Hospital, Boston; Dr. Thurler is the Ambulatory Director of advanced practice providers and nursing at Massachusetts General Hospital. The authors had no disclosures.
This story was updated on June 26, 2019.
Advanced practice providers (APPs; physician assistants and nurse practitioners) play a vital role in the success of an academic or private gastroenterology practice. Partnership with APPs in the clinical setting can improve inpatient and outpatient workflow and complex chronic care management, optimizing downstream revenue from endoscopy, radiology, and motility studies and enhancing physician productivity in research or academic affairs. In an informal AGA Community survey of physicians throughout the United States, 86% of respondents worked with advanced practice providers, 61% of whom had done so for over 5 years. While APPs may fill diverse roles in gastroenterology practice, there are common principles that may help optimize the physician-APP relationship. We surveyed both APPs and physicians to gain their perspective and present a tool kit to optimize the relationship among APPs and physicians.
The APP perspective
In qualitative interviews with 12 APPs practicing gastroenterology in a variety of specialties in Massachusetts, we aimed to understand 1) what APPs felt they brought to GI practice and 2) how APPs can be best utilized and integrated into GI practice and flow.
All interviewees independently noted that improving patient access to care and providing continuity of care were key benefits they brought to their practice, resulting in the possible downstream prevention of unnecessary emergency room admissions. Additionally, APPs felt that they brought significant value by having the time to listen to patient concerns to allow the team to prioritize care (83%), and provide patient education on their disease or medications (92%).
Though APPs are often utilized based on the individual needs of the practice, physician understanding of the APP skillset (83%) and a clear job description with set expectations up front (75%) were two critical elements of practice integration and job satisfaction on qualitative APP surveys. Additionally, APPs felt that strong mentorship with opportunities for career growth could enhance career satisfaction and improve the overall retention of the APP (100%).
The physician perspective
Informed by themes identified from the qualitative APP survey, we posted an informal, anonymous online survey to physicians on the AGA Community Forum. Nearly all physicians that worked with an APP felt that they were beneficial to their practice. Ninety-seven percent of respondents found that APPs improved patient access to the clinic, while 47% found that APPs decreased phone calls and 43% found that APPs improved administrative burden. Other less commonly cited benefits of APPs included increased practice revenue, improved efficiency of inpatient care, and assistance with procedures.
In building relationships and developing trust with their APPs, respondents valued communication (94%), observed or measured competency through orientation or standardized training (55%), and increased time comanaging patients (48%). However, 52% of respondents were concerned regarding the time required to train an APP to their standards, 45% were concerned regarding knowledge deficits, and 48% were concerned regarding risk of turnover and burnout. Though patient satisfaction was noted as a possible benefit of a physician/APP team approach, physicians also noted a potential concern that it may compromise the existing physician/patient relationship.
Despite concerns regarding training and knowledge deficits, only 29% of respondents had a standard orientation for APPs, 26% had a clearly defined job description, and 32% had formal teaching in their specialty content area.
Developing a model for success
Based on the results of these surveys and our practice experience, we present seven recommendations to optimize the APP/physician relationship:
1. Create a clear job description that ensures your APP works to the top of their license and training. This key principle can have a great impact on practice revenue and APP job satisfaction.
2. Develop a plan to train the APP to your standards, whether it be through a dedicated content curriculum or a mentored preceptorship. Most APPs finish formal training with very little gastroenterology specialty expertise, and would benefit from content-based learning in the area of gastroenterology in which they will work. The AGA publishes on-demand webcasts in different content areas, geared toward advanced practice providers (https://www.gastro.org/aga-leadership/initiatives-and-programs/nurse-practitioner-and-physician-assistant-resource-center). The AGA also hosts an annual conference to review GI content and prepare APPs to deliver optimal patient care (https://nppa.gastro.org/).
3. Designate objective criteria by which you will measure competency. Share this model with your APP up front to establish transparent expectations, and meet to review competencies and plans for further training at least annually. This structure presents a model for clinical growth and transparent expectations may enhance APP retention.
4. Establish APP mentorship. Just as for physicians, both clinical and career mentorship are an important part of job satisfaction and retention for APPs.
• Meet regularly. We recommend that mentors schedule weekly meetings with their APPs to review cases, questions/concerns, outstanding clinical work, quality-improvement initiatives and/or research. These regular meetings will keep lines of communication open and may enhance APP retention.
• Provide feedback. Both APPs and physicians benefit from constructive feedback. An annual review should not bring any surprises. Keeping feedback honest and constructive will further strengthen the relationship.
5. Introduce the APP as an integral member of the care team during the initial patient encounter. Whether working in a dedicated subspecialty team (inflammatory bowel disease, hepatology, motility, or hepatobiliary) or as part of a general gastroenterology practice, APPs should be introduced during the initial encounter as a key member of the team to establish rapport. The APP’s name should also be listed in the after-visit summary, on business cards, and on stationary to strengthen the team image. Once a patient is established with an APP and a therapeutic relationship is built, patients often report positive outcomes and maintain follow-up with the APP/physician team. We recommend that the physician see the patient at least every other visit (alternating with the APP) to reinforce the team dynamic and dedication of all members of the team to the patient’s health.
6. Provide a sense of community. Depending on the size of your practice, you can connect APPs within your practice, institution, or at a professional organization level. Belonging to a larger group that understands APP practice provides strong support and APP career satisfaction.
7. Create growth opportunities. In addition to clinical growth, APPs can provide value in leading quality-improvement and research initiatives. Establish goals and timelines for achieving goals up front, and be prepared to protect the APP’s time to achieve these goals. Successful APP growth and development may enhance job satisfaction and lead to reduced turnover. In addition, establishment of APP leaders provides candidates to help design and implement an effective APP program as a practice grows.
The authors wish to recognize research coordinators Casey Silvernale and April Mendez, and Dr. Kyle Staller who assisted with the coordination of the surveys that contributed to this work. Dr. Burke is a gastroenterolgist affiliated with Massachusetts General Hospital, Boston; Dr. Thurler is the Ambulatory Director of advanced practice providers and nursing at Massachusetts General Hospital. The authors had no disclosures.
This story was updated on June 26, 2019.