Chapter 19: Integrating Advance Practice Providers into Care Teams; Training Program for Physician Assistants

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Chapter 19: Integrating Advance Practice Providers into Care Teams; Training Program for Physician Assistants

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Dr. Rodriguez talks about the increasing reliance on advance practice providers in medicine and in oncology. She notes that, at MD Anderson, General Internal Medicine is a hold out. She sketches what an APP can bring to a care team. She talks about her own experience working with a Physician’s Assistant. She explains why she shares oversight of Advanced Practice Nurses with the Division of Nursing. Next Dr. Rodriguez talks about the Physician’s Assistant Oncology Fellowship Program, started in 2008. She sketches differences in the education of MDs and PAs and explains the need for an oncology fellowship. She talks about the impact of the program and an e-course developed for fellows at a distance.

Identifier

RodriguezA_03_20150501_C19

Publication Date

5-1-2015

Publisher

The Historical Resources Center, Research Medical Library, The University of Texas Cancer Center

City

Houston, Texas

Topics Covered

Building the Institution; The Administrator; Building/Transforming the Institution; Multi-disciplinary Approaches; Institutional Processes; MD Anderson Culture; Professional Practice; The Professional at Work

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey A. Rosolowski, PhD:

I have, I mean, I’m about ready to shift topics right now, if that’s OK.

Alma Rodriguez, MD:

Sure.

Tacey A. Rosolowski, PhD:

OK. Because I had on my list a couple of other things I wanted to ask you about; one was the survey, it was the 2014 BIG survey, but I didn’t want to jump to that if there were other initiatives within Medical Affairs that you wanted to make sure you got on record.

Alma Rodriguez, MD:

Well, the other domain within Medical Affairs that I think needs to—it’s also a major—has been evolving again slowly and organically, over the last twenty years, really, but has taken off really dramatically over the last ten years is the expansion of the physician practice to include Advanced Practice Providers, to include Physician Assistants and Advanced Practice Nurses. And initially, when this work model was introduced, it was mostly the surgical services that embraced it because the model of Physician Assistants in surgery was established in the military during the major wars in the twentieth century, and so it is was not so alien to the surgical specialties. But what has been very, if you will, culture-changing has been their integration widely, now, into the medical oncology practices. There are still—and amazing to me, there are still a few holdouts within the organization; not in medical oncology, but in internal medicine where the Physicians feel very threatened by the medical providers.

Tacey A. Rosolowski, PhD:

Why is that?

Alma Rodriguez, MD:

By the Advanced Practice Providers. I have no idea. I’m trying to wrap my head around that one. I really don’t understand. I just got an email from one of the chairs, one of the departments, saying, “We have no comprehension of why at MD Anderson you think that the mid-level providers can give care of equal competence to the Physicians,” or something to that effect. I was stunned, because everybody works with mid-level providers here, except, like I said, very few focus groups.

Tacey A. Rosolowski, PhD:

Now, tell me how a mid-level provider would be integrated into a care team.

Alma Rodriguez, MD:

They are. (laughs) They are part of the team—

Tacey A. Rosolowski, PhD:

No, meaning just—no, I mean—

Alma Rodriguez, MD:

They just are.

Tacey A. Rosolowski, PhD:

—not to convince me, but what do they do? How do they operate?

Alma Rodriguez, MD:

They do everything the physician does.

Tacey A. Rosolowski, PhD:

OK.

Alma Rodriguez, MD:

Under the physician’s direction, with some exceptions, of course. They cannot initiate the decisions for surgery or chemotherapy, but they assist us in the delivery of that care. They do physical examinations, they do procedures, they call patients, they interface with external providers. They interface with each other. They help us to facili—they help the patient and us to facilitate getting certain things done on time. They essentially are an extension of our brains and our hands. I mean, two hands are not enough to get the work done in a day, bottom line.

Tacey A. Rosolowski, PhD:

So what’s the difference between an Advanced Practice Provider and an oncologist, or--?

Alma Rodriguez, MD:

Well, they are not physicians, first of all. They’re not physicians, they don’t have the training we do. So their privileges are granted only under the approval of the Physician, number one, and secondly, they are limited to what we call the more basic performance of responsibilities, being doing the physical exams, eliciting symptoms from the patients, and driving certain therapeutic interventions. I mean, they can order hydration. They can order electrolyte replacements, they can order transfusions, they can order—I mean, they can order tests. But they cannot generate the oncological care plan for the patient. They cannot write chemotherapy orders. They can help us write the orders, because the orders are already preformatted in our order sets. I mean, essentially, once I make the decision, you are going to get Protocol A—in the clinic, my mid-level provider helps me. He pulls up Protocol A, and he says, oh, this, do you want to give all the drugs? Do you want to delete some of the drugs? I go, “OK, we’re going to do full dose everything today, for starters.” OK, he can help me calculate doses, because our current system doesn’t have the dose calculation capability. But in the future, the future an Electronic Health Record is even going to calculate that. So, will I necessarily have to have assistance from them? Probably not. But anyway, we have two-person check requirements in the calculations. So my mid-level provider has to help me—he does his calculations, I do my calculations, we compare. Did we get the right dose? So that’s how we work together. On the in-patient service, we make rounds. We go over the problems for the day, I say, OK, it looks like the patient needs electrolytes. They need this, they need this, they need this, let’s start to plan for the discharge. Please call the case manager, please call the social worker. Please blah blah blah—they take care of all that.

Tacey A. Rosolowski, PhD:

So tell me about the growth of how this office has worked with developing APPs within the Institution.

Alma Rodriguez, MD:

So we—they report, the Physician Assistants program reports to my office because they’re licensed through the same mechanisms as Physicians, through the Texas Medical Board. So if you go to the Texas Medical Board Website, you will see Physician Licensing, Physician Assistant Licensing, and Acupuncture Licensing. So acupuncturists also report to the Texas Medical Board. Pharmacists have their own board, and nurses have their own board. But the Physician Assistants reside within the domain of the governance of Physicians. So there is a bit of—so the Nursing Advanced Practice Providers do not report to me. They report to Nursing, which is confusing to the Advanced Practice Providers who are nurses, because actually, their practice, as Advanced Practice Providers, their practice really resides under the oversight of Physicians. There’s a huge—and it’s been—in Texas, this is a big political issue. In other states, the Advanced Practice Nurses can set up their own practice. In the State of Texas, they have to have oversight by a Physician.

Tacey A. Rosolowski, PhD:

Interesting. Huh.

Alma Rodriguez, MD:

Yeah. So in any event, I sort of have a co-oversight with the Division of Nursing, but the Physician Assistants report to me directly; their Directors report to me directly.

Tacey A. Rosolowski, PhD:

Now, am I correct, in 2008, this office started an oncology fellowship program for Physicians Assistants?

Alma Rodriguez, MD:

Yes, it did. Yes.

Tacey A. Rosolowski, PhD:

Tell me about doing that.

Alma Rodriguez, MD:

Well, again, so Physician Assistant programs, our Physician Assistant’s education parallels that of Physicians in that the first year of the Physician Assistant’s education is exactly as first-year students, have the same curricula, you know, you have to have anatomy, physiology, pharmacology, etc., etc. Where it deviates is that Physician Assistants immediately move into clinical rotations their second year, whereas physicians don’t until about their third or fourth year, actually fourth year. So physicians have a much longer didactic training period than the Physician Assistants. And furthermore, we are required to do residency programs, training, you know, and some of us even do fellowship programs which are beyond—so for us, our training lifespan is about ten years, if you count starting medical school and residency education and fellowship education. It’s very long, and for some surgical specialties, even longer. Whereas the Physician Assistants, immediately after one year of didactics and one year of what is called clinical rotations, they’re sent off to the job. And so they basically are more in the apprenticeship model. They learn on the job to do what they do. So many of the Physician Assistants who are going into oncologic practices really felt a bit lost. And we’ve done our own analysis. When we take in Physician Assistants that we hire either fresh out of school or from other primary care practices, it takes them six months to a year to really get up to speed on what they’re doing here. They require very, very close oversight and supervision. So we thought, why would we not prepare Physician Assistants to be more competent in the job force as oncology trained. There is a precedent in that there are, for example, emergency room fellowships for Physician Assistants, where they spend a year in the emergency room as part of their training, and therefore they are competent at, very competent at working in emergency rooms. There are some that are surgical, so once they’ve done their year of surgery fellowship, they’re very competent in the surgical environment. So we felt, let’s do—why do we not train oncology—why do we not train PAs [Physician Assistants] out of school in the oncology environment for a year? So at the end of that year, because it’s how long it takes us anyway, if we hire them.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

And we consider that a fellowship; they’re not obligated to work for any one physician. We will expose them to various rotations throughout the hospital. They will do some surgery, they will go to radiation, they will also do medical oncology, hematology practices and see what they like best. So there is an American Academy of Physician Assistant education; they do have criteria for credentialing programs. We were the—and most of their experience had to do, like I said, with emergency medicine, and surgical programs, we kind of an outlier group for them. So it took a while for us to get through that entire process of accreditation as a program. We had to develop curriculum, we had to identify instructors within the organization, or preceptors, rather, within the organization. So Maura Polanski is the lead Director of Education in that program, and I’m the designated Medical Director of the program. Because again, because it’s—because their training is under the guidance of a physician, they have to have a Medical Director for their program.

Tacey A. Rosolowski, PhD:

So that was formed in about, well, about eight years ago. So what are the effects that you’ve seen? Are there many of these fellows who decide to stay at MD Anderson? What’s been the impact of the program?

Alma Rodriguez, MD:

Yes. The impact has been that, you know, some of the best fellows we’ve had have, fortunately, stayed with us, and some of them have gone to really—most of the ones that have not stayed with us have gone to excellent programs in the nation. Dana Farber Memorial and other programs, simply because, you know, family or interest of the individuals leads them to those locations.

Tacey A. Rosolowski, PhD:

Right. Right.

Alma Rodriguez, MD:

We wish that more programs would do this. We’ve had lots of—we’ve been asked by the American Society of Clinical Oncology, our Director, Todd Pickard, has been a member of a committee at the national level for the American Society of Clinical Oncology, because many of the community oncologic practices are beginning to realize we need to have help. And how are we going to do this, and who is capable of doing—who is competent to do it, how do we get people trained to do it? So we’ve developed, actually, an online course for—precisely for those people who cannot physically be here. Because we can’t—of course, we don’t have the funds to have, you know, 100 fellows at MD Anderson. Let me see if I—I used to have a little flyer here for that program. Let me see if it’s still here. Oh, yeah, here it is.

Tacey A. Rosolowski, PhD:

Oh, neat!

Alma Rodriguez, MD:

We have an e-Learning course.

Tacey A. Rosolowski, PhD:

Oh, how neat! Could I take this?

Alma Rodriguez, MD:

Sure.

Tacey A. Rosolowski, PhD:

That would be great.

Alma Rodriguez, MD:

Let’s see if—yeah, Maura Polanski and I.

Tacey A. Rosolowski, PhD:

Neat!

Alma Rodriguez, MD:

And we’ve updated it a couple of times. It requires, you know, when you have online learning courses, you have to—they expire, they have a life span, because knowledge, of course, keeps accumulating, so you have to update them periodically in order to be certified.

Tacey A. Rosolowski, PhD:

And is that the same kind of—I mean, does the person come out with the same kind of status of approval, as if they were coming here?

Alma Rodriguez, MD:

No.

Tacey A. Rosolowski, PhD:

No.

Alma Rodriguez, MD:

Not really. I mean, this is didactic information—

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

It’s not the same as the—

Tacey A. Rosolowski, PhD:

Not the apprenticeship.

Alma Rodriguez, MD:

Yes. It’s not the same as having your roots on the ground and face-to-face with the patients’ situations, and learning from, again, face-to-face from experts who can explain why this is different than that, and so on. So no, of course a live person-to-person experience always is richer than— But nonetheless, I think, we think that this provides an incredibly rich—this is an incredibly rich source of knowledge that can inform people on how to get themselves prepared, or at least have a basic and working knowledge of why there is a difference between this category of disease and that category of disease; what kind of side effects might you expect from this kind of chemotherapy drug, versus this other drug, and so on. What might be some of the more common complications of surgery, you know, in patients who have had a mastectomy versus a renal removal, or versus a cystectomy, a bladder resection, and so on. So just some very basic understanding, so they are not going into their jobs completely unprepared. Right.

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Chapter 19: Integrating Advance Practice Providers into Care Teams; Training Program for Physician Assistants

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