—Tracy Cardin, ACNP-BC, University of Chicago
Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.
Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.
Roles and Scope of Practice
NPs and PAs perform myriad clinical and management responsibilities as hospitalists:
- Coordination of admissions and discharge planning;
- Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
- Medication orders; and
- Hospital committee work to improve processes of care.
Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.
To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.
Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.
“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”
Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.