Supervising APPs: Extra Work but Worth It

It always amazes me how much we do in medicine that we often have very little training for — i.e., the “see one, do one, teach one” mentality. Even with simulation labs and artificial intelligence, we are still, to a degree, doing things to our patients with relatively little experience and oversight. To those not in health care that might sound scary, but those of us who've gone through it understand.

I felt this way when I first graduated from residency many years ago and joined a practice where I was expected to supervise two physician assistants (PAs). I had never worked with advanced practice providers (APPs) before, and it was intimidating. The nature of residency is that there's always some degree of built-in supervision: The intern supervises the medical student, the resident supervises the intern, and so forth. However, there are quite a few other supervisors in the chain of command, so I never felt the same sense of personal responsibility.

Then there I was, not even 30 years old and suddenly legally responsible for the medical decision making of someone I just met. Thankfully, the APPs I worked with were seasoned and conservative. They had no problem coming to me with concerns, they discussed cases with me, and they expected feedback. Fast-forward 20-plus years and I'm still working with APPs and find it very enriching.

The other day one of my patients was discharged from the hospital and needed a follow-up appointment with me. I'm about a week away from vacation (a “staycation” to rebuild my deck, in case you are interested) and my schedule has been packed. I could have tried to get creative and move patients around, or worked through lunch, but instead we put the patient on the PA's schedule. That's one of the advantages of supervising APPs.

To be clear, the patient absolutely had a choice — if they had requested to see me personally, I would have made that happen. But my patients know I work with APPs and understand the situation: I'm always available to see them, but the APPs are an extension of me, and ultimately the treatment plan is mine. In this instance, having the patient see the APP worked out really well, because the day before the visit the PA came into my office and we were able to have a five-minute clinical discussion about the patient, their hospitalization, and the goals of the next day's hospital follow-up appointment.

After the visit, the PA came to me for a debrief. The patient was doing very well and had no new complaints. In fact, the PA was able to get the patient to agree to some additional palliative care services — something I had been talking to them about for a while but never had been able to find the right words to convince them to accept. Maybe it was a third-party effect, or maybe the PA just did a better job explaining it. Regardless, the outcome was good for the patient: They were seen in a timely manner following a complex hospitalization and got plugged into some additional resources, all while keeping me in the loop.

In this edition of FPM, Dr. Mary Krebs offers some great advice on working with APPs. The key is knowing your limits, and especially their limits. In another article in this issue, Betsy Nicoletti explains some coding concepts that can help ensure your practice is getting paid properly for the work of the APPs you supervise.

I'm a big fan of team-based care and believe APPs can be valuable members of the care team when used correctly. When used incorrectly, the arrangement can lead to bad outcomes. Hopefully, this issue of FPM will give practices more tools to maximize these working relationships. In my career, I've been fortunate to work with clinically strong APPs who understand their training and welcome supervision. It's extra work for me, but worth it.