Published in the September 2012 issue of Today’s Hospitalist
WITH PHYSICIAN SALARIES on the rise and a finite supply of hospitalists, it’s no secret that group leaders are looking to nurse practitioners and physician assistants to help carry some of the load. Hiring more midlevels is one way to provide more services without bankrupting hospitals, David A. Friar, MD, said in a session at this year’s Society of Hospital Medicine meeting in San Diego.
For more on hiring midlevels, check out our September 2017 article, Building your team with NPs/PAs.
Dr. Friar’s group, Hospitalists of Northern Michigan in Traverse City, has been successfully using nonphysician providers (NPPs) for more than 12 years. But many hospitalists “and allied professionals “have legitimate concerns about that working arrangement.
Part of the problem, Dr. Friar said, is that both groups keep hearing several myths about each other. He, along with two nurse practitioners, debunked some of the myths surrounding inpatient collaboration.
Myth #1: NP/PAs take too long to hire and train
It typically takes three to six months to hire a good NP or physician assistant (PA), said Dr. Friar, a time frame he said is reasonable. “You want to find somebody who fits your program,” he explained. “It’s no different than hiring any other member of your team.”
But because midlevels’ inpatient experience can vary dramatically, on-the-job training can take as long as 12 months. That’s what groups should expect for an NP or PA who has no hospital experience or is hired right out of school.
Even midlevels with inpatient experience should train at least three months. Every program is different, and it takes time to get new hires up to speed on your group’s workflow and processes. And larger groups will need to spend more training time because midlevels have to learn each doctor’s specific approach.
Dr. Friar and his colleagues have found that putting only a few physicians and NPs in charge of educating newly hired midlevels is effective. The new hires go through an orientation period where they don’t carry the triage pager, for example, until approved by the lead educator. The group also selects its educators carefully and tries to give them protected time for training.
On the flip side, some NPPs worry about joining hospitalist programs because they fear they won’t get the training they need to do the job well. According to co-presenter Tracy E. Cardin, ACNP-BC, an NP who works with the hospital medicine section at the University of Chicago Hospital, every training program needs to include a process for getting constructive criticism and feedback from allied professionals along the way.
Myth #2: All doctors/midlevels are the same
When making hiring and training decisions, Dr. Friar said it’s key to take each person’s skills into consideration and place each appropriately. His group runs five different programs in four hospitals, and each has a different philosophy. Midlevels who function spectacularly in one program won’t necessarily do well in another. “Likewise,” he said, “what we expect the NPPs to do in one program isn’t always the same as in the other program.”
Doctors need to figure out what they need in a particular situation and decide if a specific clinician would fit that need. A midlevel who’s worked for the past 12 years with orthopedic surgeons “may not be a great choice for our small program,” Dr. Friar said, “but he could be a wonderful choice for our bigger program.”
If you have a small program with limited training capabilities and need an employee to get up to speed quickly, hire someone with hospital experience. By the same token, assigning a midlevel with little experience to a geographically-based unit may be helpful in that he or she would be dealing with only a limited number of staff and one group of patients.
Just be aware, Dr. Friar pointed out, that such an assignment could affect long-term satisfaction. “I don’t want to get stuck on the ortho ward for the rest of my career,” he said. “Make sure that you don’t consign an NPP to eternity on the cardiology or ortho ward.”
According to Ms. Cardin, newly-trained NPPs should work with only a limited number of physicians at first. And because midlevels come with so many different skill sets, groups should standardize their clinical practices as much as possible, coming to a consensus, for instance, on what type of anti-hypertensive group members want to use.
Groups should also try to standardize NPPs’ daily roles. “It’s not fair to have one who only admits patients or only does discharge follow-up while another is the primary provider,” said Dr. Friar.
That kind of disparity will affect job satisfaction, added co-presenter Jeanette Kalupa, DNP, national director of NP/ PA services and clinical practice director for Eagle Hospital Physicians and chair of SHM’s NP/PA committee. “Most NPs and PAs want to be involved with patients through the continuum of their care,” Dr. Kalupa said.
Myth #3: Hiring NPs/PAs will increase my liability
Though some physicians cite concerns about liability, research shows that allied professionals get sued far less often than physicians “and usually for smaller amounts. According to Dr. Friar, his group has “never had to make a payoff based on any behavior by an NPP, whereas we’ve certainly made payouts for things physicians have done.”
Having midlevels on board may even prevent lawsuits because they bring a second set of eyes and ears to very complicated patients, said Ms. Cardin. “Further, there is another person communicating with the patient and the family, and we know the genesis of many lawsuits is simply poor communication,” she noted.
And NPPs often have an edge in communicating because they typically have more time to spend with patients than do physicians.
Myth #4: Midlevels (or doctors) will just slow me down
Every practitioner’s time is valuable and needs to be respected. Part of not wasting each other’s time is learning to trust the other’s clinical judgment.
“When one of the NPs calls and says, ‘I have a pneumonia. It’s straightforward pneumonia. Don’t worry about it. See the patient sometime in the next six hours,’ I know I can trust her,” Dr. Friar said. “If she calls and says, ‘Dave, this guy is really sick,’ I know I’ve got to stop what I’m doing and go down there.”
But even doctors who trust their NP/PA partners sometimes feel they can do better alone. Dr. Friar pointed to one group member who was convinced that adding midlevels would break his “extremely efficient” stride.
The physician found, however, that partnering with an NPP allowed him to see 26 patients a day vs. only 20. That raised his productivity bonus and still allowed him to make it home for dinner each night.
Midlevels have the same concern: that physicians will only slow them down. “An NPP does an admission and calls the attending and says, ‘OK, I’m finished,’ and the attending says, ‘I’ll meet you there in 20 minutes,’ ” Ms. Cardin said. “But we know that turns into a ‘hospital’ 20 minutes, which has an exponential factor of three or four, depending if it’s a Monday or a Friday.”
Instead, she noted, groups need expectations that respect both parties’ time. “I’ll call and give you the salient points about this admission, but then I’m off and running to see more patients,” she said. “You have to develop processes that allow for maximum admissions.
Myth #5: Treating NPPs as colleagues will muddy boundaries
Medicine is full of stories of midlevels who are not invited to the company party or included in lunch outings, or who don’t receive the same CME allowance as doctors. In fact, said Dr. Kalupa, research shows that about half of NPs and PAs get between $1,500 and $2,500 a year for CME, which is far less than most physicians.
“Some institutions justify this by saying, ‘Well, they’re only half a physician,’ ” said Dr. Friar. “But the catch is that they still need the same education if they’re going to do the same job you do. So the ‘half a physician’ thing doesn’t really cut it.”
Moreover, NPPs need to be treated as full team members if you want to build a culture that values openness and good internal relationships. According to Dr. Friar, many PAs and NPs have taken pay cuts in exchange for positions that offer them more autonomy and a voice in group decisions.
“It’s not the typical medical hierarchy that a lot of physicians are taught,” said Ms. Cardin. “It’s a team. For retention, you really have to treat your NPPs just like you would another doc.”
She left a previous job with a pulmonary critical care group, she said, in part because the doctors and their spouses sat at one set of tables during the holiday party, while she and her spouse had to sit at another.
Myth #6: Conflict means things just aren’t working
But doesn’t adding more members to the team just create more potential conflict?
“You can’t actually have an authentic working relationship with trust without conflict,” said Ms. Cardin, who pointed out that NPPs often interpret conflict as a lack of support from physicians. “You have to sometimes say and hear the difficult things.”
Dr. Friar agreed. “Conflict is unavoidable,” he said, noting that clinicians are always coming at clinical issues from different angles: enoxaparin vs. heparin, which antibiotic to choose, or if and when to use sequential compression devices. It’s the same kind of disagreement, Dr. Friar noted, that he may have with a night doctor. To resolve such disagreements, both parties must sit down and talk collegially.
To manage conflict or arrive at consensus, it helps when both doctors and NPPs are part of the same group. One audience member pointed out that midlevels who are employed by a hospital while hospitalists are part of a private group may have “all kinds of supervisory steps and processes that they can move through that physicians need to be aware of.”
“The more closely aligned everybody is in terms of incentives,” Dr. Friar said, “the better off you are.” By the same token, he added, it’s a good idea to incentivize the performance of both doctors and midlevels on the same quality measures. Investing the time and money it takes to work well with NPPs, he added, is a win/win situation for everyone.
“If I can get a physician to see two extra patients every day,” Dr. Friar said, “the hospital saves a lot of money. Physician time is becoming more and more expensive.”
Ingrid Palmer is a freelance health care writer based in Evergreen, Colo.
Survey says: What NPs and PAs earn
HOW MUCH do nurse practitioners and physician assistants who work with hospitalist groups earn? Jeanette Kalupa, DNP, who’s national director of NP/PA services and clinical practice director for Eagle Hospital Physicians, is also chair of the NP/PA committee for the Society of Hospital Medicine (SHM). At a presentation held at SHM’s annual meeting in San Diego, she presented some data from an SHM survey of midlevels held in late 2011.
The sample size was small “fewer than 100 nonphysician providers (NPPs) responded “so researchers weren’t able to make definite conclusions about what type of schedule those clinicians preferred to work. But survey results did turn up the following trends:
- More than 80% of respondents earned between $80,000 and $119,000 a year. “The number of respondents again is very small,” Dr. Kalupa says, “but the salaries are trending upward.”
- While many hospitalists receive signing bonuses and relocation reimbursement, that’s not the case for most NPs and PAs. And while most receive only a base salary, some are eligible for quality bonuses.
- Many NPPs responding to the survey worked in the Northeast, while others were in the Midwest and South. “Laws vary from state to state and bylaws vary from hospital to hospital,” explained Dr. Kalupa. “States that have more restrictive practices may have fewer NPPs working in hospital medicine.”
- Midlevels’ roles and census vary widely. “We looked at a typical NPP workload and found anywhere from six to 15 encounters a day,” Dr. Kalupa said. The survey also asked how many patients each NPP started the day with.”This was an important question for us because in some places, NPs and PAs are admitting machines or discharge machines,” she said. “It’s our opinion that being one or the other is not a job satisfier. So we were happy to see that many NPs and PAs did start with a census every day, though some were pretty high.”
- Most midlevels are billing shared care for their services. “NPPs can bill independently at 85% of the Medicare rate,” Dr. Kalupa pointed out. “But if they bill in partnership with the physician and the necessary documentation is there, they can do shared visits and get 100% reimbursement.”