JHM Review: Scope of Practice for NPs/PAs in the Hospitalist Team

In this week’s blog post, I have the pleasure of interviewing Anand Kartha, MD, MS from the Boston VA who is the lead author on a paper that just came out in the Journal of Hospital Medicine this week, “Nurse Practitioner and Physician Assistant Scope of Practice in 118 Acute Care Hospitals.”  Anand and his research team attempted to look at, in this first study, the scope of practice of PAs and NPs in the inpatient setting.  They also explored outcome measures that could be affected by the presence of PAs and NPs.  This is a great first look at how these practitioners work today and has some potential implications for the workforce of the future in hospital medicine.

1.  Why did the research team decide to study APPs who work in hospital medicine and specialty services all in one bucket?  Do you plan to study them separately? The reason we study them in an inpatient medicine setting is that in all those locations, ward, ICU, and inpatient medical specialties, APPs very often work in a “hospitalist” type role. Unfortunately there really is not much known about how they function in these roles and what the outcomes of care might be.

2.  In the study saw that PAs seem to perform more procedures than NPs in spite of similar training in these procedures.  Why do you think that is the case?  I personally think that’s a super interesting finding. This study doesn’t tell us “why,” but it might be one of two things.  First, it just may reflect local practice at the VA.  We’ve had a long tradition of working with physician assistants, training them, hiring them in many different roles. It might just reflect that the VA is more comfortable using PAs and they have proven themselves in this role and simply continue to expand in this role.  Explanation B: It seems like a lot of PAs are interested in and enjoy the procedural aspect of medicine, whether it’s in general medicine or surgical services. It just seems like they have a natural interest and aptitude and find it professionally satisfying to perform procedures, perhaps more so than other non-physician providers. But again this study doesn’t really give us the answer to that question.

3.  NPs seemed to have a greater association with improved discharge coordination.  Why might this be? I think it really comes down to the fact that, generally, nurse practitioners have a very extensive nursing background and a medical background. Having that dual background helps them better understand all the complexities around the core discharge processes as well as coordinating care.  These are often second career folks too, so both those factors—having a nursing background and then potentially a greater amount of experience in this setting might have led to the finding that better discharge coordination has an association with services employing nurse practitioners.

4.  PAs work more weekends, nights, and holidays. Any idea why? What implications might this have for the staffing models of the future? I think this is a hugely interesting finding for practices that are thinking of incorporating non-physician providers. So I want to be very clear, this study does not tell you why. But I can speculate on why this might be the case. The first explanation might again be local practice at the VA.  We have a long tradition of educating them, hiring them, and are very comfortable with the care they provide. So it just might reflect that the system and hospitalist services are more comfortable having them work on these less supervised hours. The second factor might be that market forces could be at play here. The demand for NPs is so great that they can actually have a choice to work more standard work hour schedules, schedules that are more conducive to a regular lifestyle. This is pure speculation and it would be good to get the opinion of nurse practitioners.  There are several other possible explanations, but these are two that come first to mind.

5.  What next for the research team?  Did this study point you in new directions to investigate further? This paper looked at primarily what non-physician providers or APPs do. It did not really look at the outcomes of care in the clinical setting. We would try to look at the clinical outcomes and the quality of care that is provided by APPs and, again, try to see if there are similarities or differences.

6.  Any last thing you would like readers to know or why they should read your article in JHM? The current exploding clinical demand will not be met by our current physician training system. I am a firm believer that we will need to expand our use of APPs in the inpatient medical setting, not just surgical settings. Therefore it is critical that we actually study what is the most effective and efficient way to integrate them into our hospitalist side of the house. Every practice is hiring them. I don’t think we are actually thinking closely enough about how best to use them.

Thank you, Anand, for taking the time to speak with me about your recent research. I look forward to hearing how others are integrating NPs/PAs into the hospitalist team. And NPs and PAs, what are your preferences for duties? If you work outside the VA system, I’m interested to hear what your preferences in tasks/duties are.

 

JHM CoverThis blog post is part of a new collaborative partnership between The Hospital Leader and the Journal of Hospital Medicine (JHM). Several times a year, one of our bloggers will interview the primary investigator of an article that will be published in JHM and the article will be available ahead of regular publication time for free via The Hospital Leader. To access your online subscription to JHM, please click here.

 

Burke Kealey

Burke Kealey, MD, SFHM is the Senior Medical Director for Hospital Specialties at HealthPartners Medical Group in Bloomington, Minnesota. Dr. Kealey began his career as a hospitalist in 1995 and has worked in medical leadership since 2000. In 2003 he was awarded SHM’s Award for Clinical Excellence. He has Chaired SHM’s Practice Analysis Committee and helped produce several of SHM’s Compensation and Productivity surveys. Dr. Kealey is a past president of SHM’s board of directors and has served as secretary and treasurer in past terms.

Dr. Kealey has a strong interest in ensuring that hospital medicine practices are effectively managed with a strong focus on the triple aim of affordability, great experience, and best health for our patients.

Raised in Texas, Dr. Kealey received his undergraduate degree from Texas A&M University, his medical degree from the University of Texas at Houston, and then moved north for Internal Medicine training at the University of Minnesota Hospitals and Clinics. While in chief residency he met his lovely wife Samantha, a Minnesota native and current Emergency Medicine physician. Together, they have 4 children.

1 Comment

  1. Debbie Fine on September 16, 2014 at 1:15 pm

    I am an Acute Care Nurse Practitioner employed on a Hospitalist team at a large teaching hospital. I am truly working my dream job. With my 25 years of RN experience, most recently in ICU, I knew I wanted to work as a Hospitalist. I work 7on/7off, and since my hospital requires an MD to see the patient every day, I am paired with one doc each week. We carry a higher census since I’m seeing 8-10 of his patients and also doing admissions. My hospital does not yet allow NPs to bill, however they allow NPs to do discharges. Obviously the MD still will review the discharge plan with me so that he can capture the billing. While I love inpatient care and I love internal med, I hope in time we can be more autonomous and this more helpful to the team. I would love to know how other hospitalist groups are using their NPs and PAs. By the way, we also have a NP on night shift that handles floor calls for the entire team (approximately 130-160), thus allowing the Nocturnist MD to focus solely on admissions.

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