UP FRONT
Advanced Practice Perspectives
In this column, we will hear from an increasingly represented and crucial
component of hematology/oncology care: advanced practice professionals/
advanced practitioners. In this edition, Todd Pickard, MMSc, PA-C, discusses
how APPs can be better incorporated into hematology/oncology practices.
Help Us Help You:
Enhancing APP Productivity
More than ever, hematology and oncology
practices are relying on advanced practice
providers (APPs; nurse practitioners [NPs]
and physician assistants [PAs]) to fill the
unmet needs created by a growing patient
base and a looming physician shortage.
Of course, staffing your clinic with APPs
doesn’t automatically improve patient care
and productivity. We need to be integrated
effectively into practice and allowed to operate
to the full extent of our skills.
Both NPs and PAs are trained to provide
a wide spectrum of medical service to our
patients; bringing an APP into practice allows
physicians to increase access to care and the
volume of services they provide. So, please,
help us help you.
What Can an APP Do for Your
Practice?
When I talk with physician groups – and even
to physicians within my own institution – I
encounter several misconceptions about the
role of the NP and PA in clinical operations.
The first misconception is that patients will
always want to see a physician for the service
they are receiving, and, when they learn that
they are being seen by someone who is not
a physician, they will be confused. Patients,
it turns out, are not that unsophisticated. A
survey of oncology practices (including those
that collaborate with non-physician practitioners) and their patients showed that patients
not only can tell who they are being seen by,
but were perfectly happy with it: Patients
expressed high satisfaction when they were
treated by non-physician practitioners.1
Second, people believe there is a magic
number for the appropriate ratio of APPs to
physicians, and APPs to patients. I cringe
when people ask me for the “best” number of
NPs and PAs to have in their practice because,
honestly, there is no standard answer to that
question. That “magic number” is something
each practice will have to figure out for itself.
Many practice-level decisions need to be
made based on the patient population being
served, the acuity of care, the type of diseases
being treated, and what local recourses are
available.
Third, physicians may think that they are
liable for anything and everything that an NP
or PA does – putting their own licenses in
jeopardy and making them very fearful about
ASHClinicalNews.org
working with an NP and PA. However, that’s
not the case: NPs and PAs are licensed providers who are primarily accountable for what
they do when they practice.
Physician liability becomes an issue when
physicians recognize inappropriate or dangerous practices occurring and allow them to
happen without correcting them. One example would be if state practice laws dictate that
an NP cannot prescribe opioids, but the physician is aware and allows the nurse practitioner
to do so without correcting the practice.
I encourage physicians to appropriately
structure their practices to make every member accountable under state law. When APPs
are working in an appropriately structured
environment with collaboration agreements,
there is very little risk to the physician.
The only
limitation to how
physicians can
work with APPs
to improve their
practices, from
both a quality
and a productivity
standpoint, is their
imagination.
A Little Knowledge Goes a Long Way
What you are able to accomplish at your
practice depends on your location and the
regulations outlining NPs’ and PAs’ scope of
practice. There are many practice differences
among states, but usually not huge differences.
The variations are fairly nuanced and usually
very easy to understand; depending on the
state, a chemotherapy order may only be filed
by a physician, but even one state over, that
type of rule may not exist. Some states require
that physicians review charts completed by
the APP, or that the APP may not have the
authority to prescribe scheduled medications;
others may not have those rules.
In every state, though, PAs and NPs have
standard responsibilities, including evaluating
and screening patients, perform