The hospitalists were fairly new to working with PAs, too. They had spent years teaching residents, but PAs had joined the group only a year prior. Even so, the group had developed a successful supervision model based on their experiences teaching residents. Patients I saw were cared for by attendings who reviewed the history, asked key questions, performed essential exam elements, and gave the final word on the treatment plan. Teaching naturally flowed from these interactions.
This model continues today. And like the interns who needed less attending input as they transitioned into chief residents, I also required less physician input over time. As our professional relationship grew, the hospitalists became more familiar with my work and exam skills, and I became proficient with our common treatment plans. We functioned together as a team. Of course, this process was no small investment on the part of the hospitalists I worked with. It took time—sometimes with detailed discussions of treatment protocols, or re-examining the patient together to make sure our exams were on the same page. Nonetheless, I think all involved agree the payoff was worth the effort. For our physicians, it made the transition from a resident-based program to one staffed with NPPs favorable. Granted, a residency program has different goals, but because the NPPs don’t rotate off service every six weeks, there is more time to develop collaborative, professional relationships. The investment the attending physicians made stuck.
As work volume increased, PAs in our group expanded into other roles. Our two academic rounding teams, each consisting of one hospitalist and a few residents, added a third team staffed with a hospitalist and a PA. When the residents left, all three teams were staffed with a physician and a PA. NPs later joined the group. And while NPs had slightly different state supervision rules, they functioned in the same roles as the PAs in our facility.
This team approach to rounding works well for our group. The hospitalists and NPPs work together to care for a set group of patients. The hospitalist and the NPP meet in the morning to divide the workload based on acuity, geographic location, and urgency. Sharing a common patient load helps with the common hospitalist dilemma of having to be in two places at the same time. I can see a patient who is ready for discharge (e.g., their ride is on the way), allowing my attending to dedicate his time to another patient’s family conference. In every case, the physician is involved. It is the extent of the involvement that varies. This model gives us flexibility and offers availability to our common patients.
Again, this is one of many successful models. Some, including Dr. Nelson, have suggested that a successful integration model might limit NPPs’ role in the group so that they can have ownership (e.g., post-op consult services). I think there is some merit to this, but this system also has potential unintended consequences.
When we look at what makes hospitalists successful at caring for post-operative patients, we often cite the experience gained from the wide variety of complex medical problems that we address on a daily basis. It is our frequent experience with patients with chronic heart failure that helps us identify the patient in early fluid overload. Our knowledge of diabetic ketoacidosis improves our routine diabetes management.
In my experience, rarely does a patient present with a single, narrowly defined problem. I think that limiting NPPs to the care of specific patient problems will result in limiting their effectiveness and possibly decrease their job satisfaction. I also think HM groups can err on the side of having unrealistic expectations for NPPs. Some groups have them perform the same role as an attending—with an NPP taking the spot of an off-service attending, and vice versa. This can work, if the NPP is experienced. Few would expect a new intern to perform like an attending. Conversely, restricting an NPP to collecting labs and paperwork is not an efficient use of resources.