I was prompted to look for a mid-level provider because I was overwhelmed with requests for consultations and was unable to meet the needs of patients and referring physicians in this region,” says Kate Queen, MD, a rheumatologist in private practice at Mountain Medical Associates in Clyde, N.C. “I had attempted to recruit a second rheumatologist but had not been successful, and this seemed like a good alternative solution.”
Dr. Queen’s experience echoes the needs of many rheumatologists with overbooked schedules and limited financial resources. As doctors search for ways to deliver high-quality care in an environment of healthcare cost containment, many are embracing a team approach and collaborating with mid-level providers to meet the unique demands of their individual practices.
Research Leader with Versatility
The nature of healthcare delivery is changing to accommodate a decreasing supply of physicians, a trend toward increasing specialization, and an ever-growing number of older and uninsured patients. In many cases, mid-level providers or “physician extenders” bridge the gap between patient expectations and the overwhelming patient care demands placed on physicians—and their utilization is on the rise. In 2005, the U.S. Department of Labor noted that mid-level care delivery was the third-fastest growing profession in the United States, and projected a 53% increase in the hiring of such providers by 2010.
The term “mid-level provider” encompasses both nurse practitioners (NPs) and physician assistants (PAs), but these professions differ in training—and perhaps in outlook. Studies done in the primary care setting suggest that NPs gravitate toward the issues of health promotion and education instilled by the nursing paradigm, while PAs orient toward a diagnose-and-treat practice model. However, their roles in the rheumatology setting are influenced more by the type of practice—whether it’s private or based in an academic center—the practice goals of the supervising rheumatologist, and the individual interests of the mid-level provider.
What attracted Joyce Carlone, MN, RN, to the Emory University Rheumatology Division was the opportunity for job versatility. “I was attracted to this position because it promised to not only allow me to use my practitioner skills, but also to organize a new program that could really make a difference within the organization” she says. “Dr. Conn and I discussed how my job description could also evolve over time and allow me to do a variety of activities since I enjoy diversity.”
As doctors search for ways to deliver high-quality care in an environment of healthcare cost containment, many are embracing a team approach and collaborating with mid-level providers to meet the unique demands of their individual practices.
Doyt Conn, MD, professor of medicine and director of rheumatology at Emory University School of Medicine, initially hired Carlone to help form an early arthritis clinic; after its foundation was in place, they redirected their efforts toward clinical research.
“With Joyce Carlone and her skills, we were able to then get involved in a number of NIAMS [National Institute of Arthritis and Musculoskeletal and Skin Diseases]- and pharmaceutical-sponsored studies in rheumatoid arthritis and then lupus. She helped recruit, educate, and supervise … other research nurses,” says Dr. Conn of their enterprise.
Providing a cohesive link between patient care and clinical trials, Carlone uses her assessment skills to obtain clinically useful data and helps patients maneuver through a potentially overwhelming healthcare system. “I have become well acquainted with the majority of the early arthritis clinic patients and act as their liaison between their doctors, the clinic, and the hospital,” she says. “Grady [Memorial Hospital] is very large, and it is difficult for patients to navigate the system.”
She has subsequently broadened her administrative responsibilities to include 2004 chairperson of the ARHP Meeting Planning Committee. A strong advocate for rheumatologic training at all levels, she endorses adding more mid-level training opportunities to the curriculum of the annual scientific meeting, and her endeavors have evolved into a one-day Clinical Focus Course for NPs and PAs.
Teamwork on Quality
In the non-academic setting, a mid-level provider–physician collaboration may have different goals. Leslie McDowell, ANP, MSN, and Dr. Queen focus on efficiently delivering high-quality care to a large patient population. The result of their collaboration has been the steady growth of Dr. Queen’s practice—she has seen an average of 20 new consults a week for the past 10 years—as well as the development of a computerized medical record. Dr. Queen credits McDowell with finding new ways to deal with the challenges of a busy practice. “She helped me understand things that she could do to lighten my load, and she did free me up in a lot of ways to focus on other challenges,” says Dr. Queen.
Currently, McDowell sees about 15 patients a day, orders labs and diagnostic studies, performs arthrocenteses and joint injections, and teaches patients about DMARD therapy and teriperatide self-injection. She rarely sees new patients and does not initiate DMARD therapy without Dr. Queen’s consent. “It is terribly important that the two individuals have a collegial working relationship and similar philosophies,” says McDowell. “Unless there is mutual respect there will not be success. Communication between providers is also essential. Patients need to know that you are a team in order to have confidence in their care.”
Experience and Certification
The road to becoming an NP may start with a nursing degree, but most NPs have many years of nursing experience before completing the graduate-level NP training program. Their training focuses on learning basic assessment skills, distinguishing normal from abnormal findings, and understanding the limits of one’s own clinical judgement. There is also a clinical component in which student practitioners shadow physicians or certified NPs and assist with history taking, physical exams, and decision-making. NPs must maintain not only state nursing licensure, but also NP recognition. National certification exams are given based upon specialty, and most of these certifying bodies require continuing education or periodic re-examination.
If NPs train under a nursing paradigm, then PAs are educated in a medical school-based model (albeit substantially abbreviated from that which trains physicians). The typical applicant to a PA program has a bachelor’s degree that includes premedical coursework and more than four years of healthcare experience. Their first year of training focuses on classroom and laboratory instruction and includes a research component. The second, or “clinical,” year includes a variety of rotations, including internal medicine. Upon completion of their coursework, graduates must pass a national certification exam. PAs are required to take ongoing medical education classes—at least 100 hours of classroom time every two years—and must retake the certification test every six years to maintain their state licensing eligibility. They do not have to complete a residency or internship, but many do so. PA postgraduate residency training programs are available in internal medicine as well as many other specialties.
Most NPs and PAs get their clinical rheumatology skills from on-the-job training—not their respective training programs. Carlone had no rheumatology experience before she was hired. “When I accepted my current position, I told Dr. Conn that I had no experience in rheumatology and that my knowledge base was sadly lacking,” she says. “Luckily he didn’t find this an impediment. I proceeded to follow our rheumatology fellows and Dr. Conn in clinic, plus I did extensive reading. I really have Dr. Conn to thank for most of what I currently know.”
McDowell was able to do an internship with a rheumatologist during her training, but acknowledged that few NPs have this opportunity. “I attended an adult nurse practitioner program at the University of Florida,” she says. “While there, a rheumatologist/internist recruited me. I did my internship with him during my final year of graduate school and then was employed by him for about two years. There was no formal rheumatology curriculum in my graduate program…Rheumatology training is rarely present during the NP training program.”
Some Reservations Remain
Concerns about mid-level providers’ lack of exposure to rheumatologic diseases, plus their limited general medical training, have prompted some physicians to call for constraints on their utilization. Studies that evaluate the quality of care associated with physician extenders have been performed in the primary care setting, and while end-points of cost-effectiveness and efficacy have been documented, some rheumatologists question whether these results can be applied to their practices.1 Patients with connective tissue diseases may present atypically, be more debilitated, and ultimately have rarer diagnoses, leading to concerns that physician extenders will have a mistaken or missed diagnosis. One group of rheumatologists interviewed for this article found that employing a physician extender created more work for them, as they were now ultimately responsible for the care of more patients. They also expressed concerns about increased liability.
However, many rheumatologists feel that the successful management of patients with connective tissue diseases requires a team approach. “I think almost every rheumatology practice could benefit from a nurse practitioner,” Dr. Queen states, “but I think working collaboratively is most successful when there is a commitment from the beginning to provide training and support so that the nurse practitioner or mid-level provider understands your values and goals, is secure in their ability to evaluate patients and make treatment decisions within their competency, and is always comfortable asking for help when they are uncertain or need guidance.” McDowell says having similar philosophies, mutual respect, and clear expectations has enabled her to form a mutually fulfilling alliance with Dr. Queen, and emphasizes that a collegial working relationship is key.
Though research conducted on the contributions of mid-level providers—particularly in the field of rheumatology—is sparse, there are many successful collaborations, and the market demand for mid-level provider services may outweigh the present concerns. As the landscape of healthcare delivery evolves, these partnerships are likely to be the paradigm on which future healthcare systems are based. “The challenge in medicine today is learning to embrace change and look at change as an opportunity—and an opportunity to do a better job is there,” says Dr. Queen.
Dr. Landis is a rheumatologist and a freelance writer.
Advice from the Experts: Qualities of an Effective Mid-Level Provider in Rheumatology
I think the most important qualities—besides being an excellent clinician—would be having a willingness to work with chronic disease and an ability to teach patients effectively, no matter their educational level. Patients are often scared and confused about their disease process and medications and need information that they can understand.
–Joyce Carlone, MN, RN, CFNP, rheumatology nurse practitioner for 24 years
Some of the important [qualities] for a rheumatology nurse practitioner are curiosity, an interest in long-term relationships with patients [and their families], and the patience and determination to see things through. There are no cures or quick results to be seen in our business.
–Leslie McDowell, ANP, MSN, rheumatology nurse practitioner for 14 years
Reference
- Hooker R, Cipher D, Sekscenski E. Patient satisfaction with physician assistant, nurse practitioner, and physician care: A national survey of Medicare beneficiaries. J Clin Outcomes Manage. 2005;12(2):88-92.
