APPs have a growing role in the oncology workforce
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It is well-documented that cancer care in the U.S. is facing an impending workforce crisis.
Due to demographic changes, an aging population and improved cancer survival, the number of patients with cancer and survivors is projected to increase dramatically over the next 10 to 20 years. Growth in the traditional physician oncology workforce is projected to fall far short of the need.
Among the potential solutions to this workforce problem, one of the most frequently cited is the enhanced use of advanced practice providers (APPs).
Meeting the challenge
As an oncologist who has worked alongside APPs in the clinic and on inpatient services for more than 20 years, I am a strong advocate for expanding and enhancing their role in cancer care. But, the journey to acceptance and integration of APPs into academic oncology practice seems to have been slow.
Time is now running out for us to meet the challenge of what’s been called the “silver tsunami” of older patients with cancer and survivors, and we need to look at strategies to fully integrate APPs into our care models in a thoughtful, planned and structured way.
One of the aspects of oncology APP practice I find most surprising is the uncertainty about the size of the existing workforce.
Based on a survey of APPs in cancer care in the U.S., inclusive of all oncology subspecialties, Bruinooge and colleagues estimated that there were between 5,000 and 10,000 oncology APPs. Just over 50% of survey respondents were based in academic oncology practices, and respondents were roughly evenly split between nurse practitioners and physician assistants.
With some variation according to subspecialty and state laws, the APPs reported spending about 80% of their time in direct clinical care, with the remaining time consumed by administrative responsibilities, clinical research, teaching and quality improvement efforts.
In terms of the practice pattern, which varied somewhat by discipline (hematology/oncology vs. radiation oncology vs. surgical oncology), most (around 65%) performed a mixture of shared and independent visits, with 25% having completely independent practice and fewer than 10% involved in practices with shared visits only. The most common determinants of the practice pattern were physician preference, requirements of the health system and state legislation.
Reassuringly, most APPs had a high level of satisfaction with their job. It’s worth noting, however, that in general, the level of job satisfaction trended with the amount of independent practice.
Shared visits
The findings from this survey are consistent with my own anecdotal experience and suggest that although APP oncology practice has grown organically over many years, it’s time to take a more structured approach to the role of APPs from the perspectives of recruitment, training and practice patterns.
I want to emphasize that the following observations are based on my own personal experience (and biases), and not from an exhaustive review of relevant literature and data.
From both a recruitment and practice pattern perspective, physician needs have often been the main driver for the role of APPs in cancer care.
The APP role has been viewed as supportive to a physician, and many faculty recruits have expectations of APP support for their practice from day 1. This has typically driven a practice model in which APPs may evaluate patients, develop a plan and then refer to the primary physician oncologist to “sign off,” which may vary from completely repeating the evaluation performed by the APP, to reviewing the key components or briefly checking in with the patient and, in all of the cases above, leaving most of the documentation to the APP.
Exactly how this is configured can be dictated by state or institutional policy, but whatever the exact model, this practice of shared visits has definite benefits for the physician, particularly one in academic practice who has multiple competing demands on his/her time. The commonly expressed view is that this allows the physician to focus expertise where it really matters — on decision-making, rather than tasks such as documentation, which can be readily performed by others.
Patients may also benefit from having an additional pair of eyes evaluating them, although the flip side of this is sometimes expressed frustration that having both providers involved can create redundancy and repetition.
From the APP perspective, I hear conflicting views from those who feel that shared visits reduce their role to one of a highly paid scribe, to those who feel that shared practice keeps them within their comfort zone.
Overall, my experience has been that shared visits are a dissatisfier for many APPs.
Another layer of complexity to add to the practice model is the issue of billing and reimbursement — our current models of practice can result in competition for Medicare reimbursement relative value units, or RVUs, between physician and APPs, which is a common justification for pushback against APP independent practice.
A successful partnership
These tensions between APP and physician practice have existed to a greater or lesser extent for many years across many institutions and tell us that we need to stop thinking about APP recruitment and practice as a supportive role to physicians and plan around patient needs and the quality of care.
As patient demand and volume grow, we will need independently practicing APPs to help solve access challenges for our patients and to deliver many aspects of care — the role of APP practice in survivorship care and in aspects of surgical practice is already well-established. APP-led acute care clinics are opening in many centers, including our own, and true partnerships between APPs and physicians in which each functions independently but collaboratively within the same patient population result in great patient care and high levels of patient satisfaction.
I have worked in this model of care over many years and, apart from all of the advantages for patient care, it allowed us to double the number of patients we could see in clinic, greatly improving access for our patients. Identifying those patients who are appropriate for APPs vs. physician providers has, in my experience, not been a particular challenge and can be agreed prospectively — the key to a successful partnership is mutual confidence.
Concern of competency to take care of complex cases is another reason I often hear for resistance to independent APP practice.
Historically, training for APPs has been on the job, largely delivered by physicians. This is, of course, essential for APPs to gain insights into the nuances of a particular practice, but more formal, structured APP training programs will be essential. Like other centers, we are developing an oncology APP fellowship program. These programs will be key to developing a well-trained workforce and if, as we are planning, they can be aligned and overlap with oncology physician fellowship training, we can develop not only some efficiencies but also mutual understanding and respect for the complementary roles of each provider.
It’s clear that APPs are a large part of the future of cancer care. Many centers are recognizing this, have established strong APP leadership at the cancer center and system level, and are thinking in a much more strategic way about how to build this highly skilled workforce. This will need to be driven by patient needs.
Widespread physician buy-in for enhanced APP practice will take time and will undoubtedly be helped if we can replace some of the more mundane tasks often performed by APPs with a different workforce. But, this is necessary change and it’s important to keep up the momentum and fully support it.
References:
Bluethmann SM, et al. Cancer Epidemiol Biomarkers Prev. 2016;doi: 10.1158/1055-9965.EPI-16-0133.
Bruinooge SS, et al. J Oncol Pract. 2018;doi:10.1200/JOP.18.00181.
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