Optimizing APP s in a Residency Training Program Gary E. Lemack, MD Program Director, Urology and FPMRS UT Southwestern Medical Center
Agenda Why APP s in Urology Training APP s in Urology Making the numbers work Functioning in a Urology training program Pitfalls
Why APP s? Growing population Aging population Insufficient # urologists in practice Urologists are aging/planning to retire Insufficient training programs to address the need
A growing need population growth 310,232,863 282,171,957 249,438,712 227,224,681 205,052,174 180,671,158 152,271,417 132,122,446 123,076,741 106,461,000 93,863,000 50,000,000 100,000,000 150,000,000 200,000,000 250,000,000 300,000,000 350,000,000 2010 2007 2004 2001 1998 1995 1992 1989 1986 1983 1980 1977 1974 1971 1968 1965 1962 1959 1956 1953 1950 1947 1944 1941 1938 1935 1932 1929 1926 1923 1920 1917 1914 1911 https://www.google.com/fusiontables/datasource?dsrcid=225439
An aging population = increased urological needs In the US the population 65 and older will double from 2000 2030 from 35 to 71 Million
The State of the Urology Workforce AUA Survey 2015
The State of the Urology Workforce AUA Survey 2015 4000 3500 3000 2500 Number of Urologists 2733 2747 2642 3337 About 50% are older 30 than 55 years 25 20 Percent of Total (11,989) 22.8 22.9 22 27.8 2000 15 1500 1000 500 530 10 5 4.4 0 <34 35-44 45-54 55-64 >65 0 <34 35-44 45-54 55-64 >65 https://www.auanet.org/common/pdf/research/census/state-urology-workforce-practice-us
The Impending Shortage and the Estimated Cost of Training the Future Surgical Workforce Williams et al Annals of Surgery Volume 250, Number 4, October 2009
PA workforce is growing Public Health Rep. 2011 Sep-Oct; 126(5): 708 716.
A growing need for APP s Population growth Aging population No increase in urology trainees Urologists are aging Reimbursement remains a question Increasing number of PA s in practice
Integration and Mentoring Integration may pose difficulties at various levels: Identify opportunity in the practice Search and recruit Interview candidates Assure acceptance by MD providers/ partners Assure acceptance by nursing staff and office assistants Mental block: MD and midlevel provider generate revenue, other staff member aid those who can in generating that revenue In AMC: acceptance by fellows and residents Acceptance by other specialty MD providers Can be particularly challenging for in-hospital services consulting services provided by midlevel providers
Integration and Mentoring Mentoring also poses its challenges: Midlevels fresh out of school have limited urology knowledge Midlevels who already have on the job experience may have skills you wish they would not have There is no ready-made of the shelf curriculum available Different practice settings require different skill sets from the midlevel Expectations as to the scope of practice may differ In practice: concept of an apprentice is unfamiliar In AMC: used to having residents and fellows with different baseline knowledge and skill sets Different levels of comfort required before allowing independent practice
PA s job outlook https://www.bls.gov/ooh/healthcare/physician-assistants.htm
Occupational Employment Statistics https://www.bls.gov/oes/current/oes291071.htm
NP s job outlook
How to find the right person Contact local PA/NP program & offer your practice site as a clinical rotation site This essentially can turn into a month long job interview for multiple candidates This month of free training does not really have any direct cost to the practice Over time word gets out at the PA/NP program that your practice site offers good training http://www.arc-pa.org/accreditation/accreditedprograms/
New Graduate vs Experienced Midlevel Every practice is different and unique; there will be an integration period regardless of level of experience Recent graduates offer a substantial knowledge advantage Graduates who have worked in family practice, rural small practices etc, may struggle in procedure-oriented practice Prior urology experience is a double edged sword: bad habits are difficult to break! New graduates are plentiful, about 21,000 PA/NPs per year
How to train APP s in Urology Post-graduate training (fellowships) On the job (mentoring and integration)
Post-graduate fellowship (UTSW) 12 months, financially supported training 6 months of outpatient rotations Double scrubbing for bedside assist Second 6 months: Start own supervised clinic Observe (PA/MD), then perform procedures New patients Follow-up existing patients
Mentoring Model at UTSW Midlevels are expected to attend all conferences if possible Grand Rounds Journal Club M&M conference Pre-op conference Weekly lecture series Active participation is encouraged Case presentation Discussing of literature
Mentoring Model at UTSW - CLINIC Newly recruited midlevels will rotate with MD provider in different disease areas: Oncology Reconstructive urology/prosthetics FPMRS Stone disease Neurourology Voiding dysfunction For variable periods of time they will shadow MDs Expectation is to read parallel to this apprenticeship material relevant to the different disease areas Supervised office procedures: cystoscopy, TRUS biopsies, MRI TRUS fusion biopsies, gold seed placements, Testopel implantation, PTNS
Mentoring Model at UTSW - Hospital New hires also provide other hospital functions Floor consults, ER consults Over time, assume increasing levels of responsibility in the OR: ALL robotic cases double scrub with current PA s Prostatectomy, Sacrocolpopexy, Partial Nephrectomy, Cystectomy Typically NOT doing any other cases at present
Mentoring becomes Integration Often during the initial clinical rotation an interest is identified in a particular disease area This lends itself to a natural selection of practice type Midlevels are maximally effective when working in loose collaboration with MD providers Seeing new patients prior to MD Seeing patients with MD Seeing follow up patients stable in their disease or postoperatively Sub specialization of midlevel provider in our AMC practice is the norm, not the exception!
Expectations It is important to set realistic expectations at every step Expectations clearly articulated create accountability for both parties Provide feedback early and often nothing worse than giving it too late only to hear could you not have told me that earlier Be transparent in your feedback Be transparent in terms of finances, wrvu, billed charges, and collections as this in the end is what has to work out Don t allow anybody to not be clear as to the relationship between work, charges, collections and salary
Professional Growth and Satisfaction Professional growth is the key to job satisfaction Encourage growth and development from the beginning Make learning of new skills a habit Provide educational opportunities Printed material Online material In AMC: participation in conferences etc In private practice: discuss key journal articles prompted by cases Allow travel to meetings (AAPA or NP, AUA meeting) Encourage academic productivity
So What do Our Midlevel Provider Do? Work incident to MD provider (infrequently) Work independently Seeing follow up patients Evaluating and treating new patients within certain disease categories Refer appropriate surgical cases Independently perform procedures Do ALL Penile injections, Pessary Fitting
Collections by year of service
How can APP s benefit a residency training program? Enhance resident learning Improve compliance with duty hours Improve speed of delivery of care Alleviate some of the non-learning service obligations Help train residents in OR
How do our PA s interact with residents? Split duties seeing inpatient consults Review each consult with chief resident See ER consults when residents unavailable Review disposition with residents and staff Primary bedside assist all robot cases Approximately 700 robotic cases in 2017 Teach technique to junior residents Residents > 5 required prior to console time
What to avoid Things that will hinder successful integration of midlevels into a practice: use them for H&Ps use them for postop visits only use them for cognitive services only Ask them to bill only incident to Don t provide opportunity for professional development Expect a new hire to be fully functional as a urology provider and/or know your preferences
Conclusions APP s can improve financial productivity of AD APP s can succeed academically Patients are HAPPY to see APP s APP s help compliance with duty hours APP s can improve experience of trainees