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Progression of clinical exposure, understanding key to advanced practice provider onboarding
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Editor’s note: HemOnc Today’s regular columns for advanced practice providers (APPs) tackle common issues APPs face, discuss day-to-day practice and regulatory concerns, and share research advances. To contribute to this column, contact Alexandra Todak at stodak@healio.com.
Those of us who have worked in hematology/oncology knowingly embrace the realization that this is a multifaceted subspecialty, and that effective patient management requires not only an extensive knowledge regarding the presentations of malignant diseases, but also management of toxicities, comorbidities, recognition of emergent situations and an empathetic demeanor as we guide our patients through an often-difficult path.
I have often defended my choice of specialty throughout the years after being asked, “How do you do what you do? It is so sad.” Each time I am faced with summarizing my decision to work in this field of medicine, I do stop to ponder the “why” for myself. Patients who come to our offices do so because one of their worst nightmares came true, and we are charged with assisting them to fully understand their disease, regardless of whether the endpoint is a cure or the outcome is the frank realization that they are likely to succumb to their disease.
On the contrary, advancements in many cancer treatments also have happily moved many patients’ potential for survival forward, often turning the curve for chronic management into a distinct subspecialty for many patients and practices. This has a separate set of challenges, not the least of which is the sheer volume of patients to manage within a practice, further setting the stage for the need to maximize the optimization of APPs in the cancer arena.
To serve our patients well, we must have a command of knowledge, and a combination of empathy and confidence so our patients can move forward with dignity and with perhaps one of the most important mental preparations — that of a positive attitude.
Development strategies
APPs have been successfully integrated into hematology/oncology subspecialties for many decades now — my own experience being more than 30 years. The challenge of fully developing the individual APP’s ability to function at the top of their scope of practice and expertise on the multidisciplinary team while developing the strategy to vet competency is a realistic and complex necessity.
Many APPs are not fully utilized in the provider pools of cancer medicine. Part of this, I challenge, has been because of the lack of formal development strategies for APPs working in hematology/oncology. During my many years of precepting APP students and onboarding APP hematology/oncology employees, I have come to the realization that a formalized pathway of expected vetting of clinical and procedural skills is paramount to the success of the larger mission. The goal is to create an expert team integrated in such a way that all members complement each other to facilitate the care of their patients.
In my clinical practice, steeped in the research arena of literally hundreds of conducted clinical trials, the formalization of a “transition-to-practice” model represented a steadfast way of both vetting the competence of and infusing support for the APPs. That has now become a backdrop for developing a medically sound and emotionally mature hematology/oncology APP with the expertise for increasing autonomy as team members.
I remember a long-ago mentor of mine saying “the most important thing for you to know is what you know.” He meant that the application of core medical knowledge and the confidence to know normal physiology is paramount to learning pathophysiology. To ground oneself with confidence in core knowledge is the first, and perhaps most important, step. We will never know everything; perhaps the most dangerous clinician is one who makes assumptions regarding something they don’t know.
Knowledge base
There is still much lacking in understanding the knowledge base of a particular APP, even for those who have worked with APPs. To that end, knowing the basics inside and out is paramount for the hematology/oncology APP. So, what are they?
To develop this theme, I will first focus on a few key features of review for any APP onboarding into the hematology/oncology arena as a backdrop:
- Blood counts and laboratory studies: Knowing the norms; how to qualify, grade and trend abnormal labs; when corrective actions are warranted; and when lab abnormalities are critical and/or life threatening, thus requiring immediate corrective actions, as well as developing an eye for subtler, but important, trends. Spending the time and detail-oriented focus on basic blood counts and normal labs comparatively will set the stage of knowledge, regardless of whether the APP will be primarily managing hematology patients or those with solid tumors. Application of common lab pathologies that align with disease states makes much more collective sense when applied to the comparison against clinical norms and grading of abnormalities. One can then delve deeper into the typical abnormalities of a particular disease state or toxicity profile of drugs used in treatment for certain patient populations.
- Organ function: Drive first with a review of the physiologic normality of organ function as a backdrop to pathology states, the grading of abnormal organ functions, and how the disease states and/or systemic therapies impact organ function. An excellent example is the causation of “itis” scenarios from biologic therapies, consistent with overstimulation of immune responses in sometimes multiple organ functions. Ground every new clinician with the summary of grading an abnormal, using “tools of the trade” — such as Common Terminology Criteria for Adverse Events, ECOG/Karnofsky scales, etc — as tools upon which to build expertise. When one is faced with an abnormal, knowing the severity — or grading — and application of appropriate descriptors of such is the backdrop to understanding the impact of the particular disease or treatment on normal organ functions.
- Pathology and imaging: Exposure to complex cellular pathologies and less common imaging studies is typically absent from the didactic and clinical training of APPs in their core curriculum. To become familiar with diagnostic and surveillance studies of both types, setting aside block time to spend with a pathologist and/or radiologist who reads interpretive studies is a unique and necessary strategy to understanding the interpretations more fully, and to better apply the information clinically. Most of us would agree that repetitive visualization weighs heavily in the learning process. Although having the final interpretation is necessary, the process of knowing which study will best answer the clinical question, and also understanding the visualization of study interpretation, is even more important for the development of expertise in this field of medicine.
Additional cancer-specific presentations, workups, treatments, toxicity management, surveillance/long-term survival monitoring can then be specifically added in as curriculum in subspecialty clinics. The key is progression of both clinical exposure and understanding followed by, as a result, a mechanism for vetting of competence and autonomy as a team member.
Impact on patient care
A step-wise reproducible strategy to develop the hematology/oncology APP expertise in practice should be used as a tool to maximize the function of the collective team in the charge of cancer medicine.
Ongoing shortages of hematology/oncology-trained faculty and increasing survival trends all point to the benefit of fully developing APP expertise as part of the provider pool, and will afford better patient outcomes, APP retention and expertise as drivers for significant assets to overall patient care.
For more information:
Janice Shipe-Spotloe, PA-C, MS, DFAAPA, CPAAPA, is director of the Office of Advanced Practice Professionals at West Virginia University School of Medicine and a HemOnc Today Editorial Board Member. She can be reached at 3040 University Ave., Suite 1250 Box 8133, Morgantown, WV 26505; email: shipespotloej@wvumedicine.org.
Disclosure: Shipe-Spotloe reports no relevant financial disclosures.