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3 Ways to Tame Tensions Between Physicians and APCs

Analysis  |  By Debra Shute  
   November 30, 2017

Advanced practice clinicians are crucial to helping health systems ensure patient access, but numerous factors can undermine team-based care if left unchecked. 

Despite health systems' essential need to embrace team-based care, physicians aren't always crazy about working with advanced practice clinicians, and vice versa. Clinicians rarely complain out loud, however, and often enter into collaborative contracts when they'd rather be in charge.

Ignoring that elephant in the room comes at a cost, says Liana Orsolini PhD, RN, ANEF, FAAN, care delivery and advanced practice system consultant at Bon Secours Health System in Marriottsville, MD.

For starters, when tensions get bad enough that a nurse practitioner or physician assistant quits (often with a mere two weeks' notice), it costs roughly $150,000 to recruit and hire a new APC, says Timothy Willox, MD, chief medical officer for Bon Secours Virginia Medical Group.

Related: Hard-Nosed About Physician Teamwork

To help promote better teamwork from the get-go, consider the following steps:

1. Clear a Landing Spot

Part of physicians' reluctance to work with APCs is generational. If a physician has worked on his own for 30 years, notes Orsolini, changing the model may be a tough sell. "And you've got to respect that," she says.

Rather than waiting for problems to arise, identify any animosity or discomfort upfront, says Willox. "You've got to work through that before you even bring in an APC."

This task is twofold. "Breaking down the barriers is part helping physicians understand the value of the APC, but it's also identifying the right provider, the right practice, and the right environment to bring that APC in," Willox says.

To that end, Bon Secours' nascent onboarding committee involves both APCs and physicians to help make sure both sides are comfortable in their roles, they have what they need, and they're comfortable in their environment, he says.

Related: 4 Steps to More Satisfying Clinician Onboarding

2. Ensure Role Clarity

Likewise, healthcare organizations must set and communicate clear expectations for APCs and physicians, including the circumstances under which they'll work independently or collaboratively.

But don't stop there. The rest of the staff, as well as patients, need the same information. For example, the appointment scheduler in a medical group should be well-versed in what types of visits are appropriate for an NP vs. a PA vs a physician.

This step may not be as obvious as it sounds, notes Orsolini.

"There's so much ubiquitous role confusion—and that's not talked about either," she says.

She recalls a situation at one practice in which an NP was seeing just eight patients a day, simply because the scheduler didn't understand what the NP did. "Once the NP finally asked what was going on and explained to the person making the appointments what she did, she got to see more patients," Orsolini says. "We as a health system can't afford for an NP to see eight patients a day."

3. Ease the Transition

Physicians' concerns about APC competency can also lead to pushback, says Willox.

"For example, we just introduced NPs into our hospitalist program. They are some very, very sick patients, and it takes a little while for that NP to have the experience and the ability to be able to manage those patients by themselves," he says. "Physicians have to be comfortable with the skill level of an APC before they let them loose."

One way Bon Secours is working to build competency among new APCs is by piloting a transition-to-practice residency.

"It's the kind of program where a new NP who doesn't really feel comfortable jumping in and taking their own panel may have a yearlong transition where they rotate through specialties and primary care, and gradually as they go through the program they're empowered to take on more and more of their own patient responsibility," Willox says.

"At the end of the program we all feel much more comfortable allowing them to transform into an independent provider in a practice."

Bon Secours has hired almost all graduates of the program, he adds. "And they've all turned out to be superstars."

Debra Shute is the Senior Physicians Editor for HealthLeaders Media.

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