Notes from the field: My personal journey of collaborative practice with APPs
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This month’s featured roundtable on the evolving and broadening role of advanced practice providers in rheumatologic care is a timely discussion, and I give a big thanks to Carrie Beach, BSN, RN-BC; Jeffrey Curtis, MD, MS, MPH; Amanda Mixon, PA-C; Kenneth G. Saag, MD; and Christine Stamatos, DNP, ANP-C.
I certainly agree with their thoughtful comments on both the challenges and the opportunities to grow and strengthen the rheumatologist-APP alliance. As Ken Saag notes, “we are not cranking them (rheumatologists) out fast enough,” which tells us that ignoring the need and potential for collaborative care is really not an option.
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The discussants highlight many of the hurdles to creating successful care models and I agree with virtually all of them. Although I have little to add regarding quick solutions to remedy the workforce crisis, I do have some personal reflections I would like to share with you on this topic. I have been practicing with an APP for virtually my entire career, which I think makes me a statistical outlier considering I have been doing this for more than 4 decades.
At the beginning of my practice in the early 1980s, much of my time was spent caring for patients with HIV who had a new disease surrounded by many more questions than answers. This was new territory for all of us and the medical needs were great given the paucity of therapies that we had. It was at this time that I was first confronted with so many dying patients, many of whom were my own age, as well as the social backlash against those both afflicted by the disease and those who are merely at high risk.
Working in the lab and confronted with a growing HIV population with an unpredictable future, while at the same time trying to develop a rheumatology practice, I needed help. During the next decade, I hired and worked with two wonderful practitioners, a physician assistant and a registered nurse, who were not APP certified nor trained as such — and it was an adventure. They both had skills and strengths, but their learning curve was steep and ultimately both moved on for good reasons.
Then, nearly 25 years ago, I found myself looking to hire another practitioner to meet my growing needs. By then, I had a growing and complex rheumatology practice along with my HIV/ID practice and I knew it would be impossible to find someone with a skill set that stretched across all of these domains. That is when I met Betsy Kirchner, MSN, CNP, DNP, a freshly minted MSN with HIV floor experience who was waiting to take her NP boards. It was immediately clear that she was the right person at the right time, and we bonded. Later, Betsy attested that the main reason I hired her on the spot was that I was impressed by the combat boots she wore to the interview, which was an instant match for my persona at the time.
Over the ensuing years, life changed as it always does. Her family grew, my practice became more complex, I increased my academic output of research, education and publications, and Betsy stepped up every step of the way. Most importantly, we trained her in rheumatology at a time when there was no model for such — and she excelled. Over her career she became a leader in her field, having served as an important founding member of both the Rheumatology Nurses Society and the Rheumatology Advanced Practice Providers association, having published and lectured extensively, and ultimately earning her DNP, all while raising a beautiful family and continuing to work.
All that said, I want to close on the most important aspect of our collaborative practice, which in my mind is the cultivation of an atmosphere of respect and trust. In fact, I consider this aspect of the APP-physician dyad to be the most critical factor in all practice settings regardless of specialty.
To me, having mutual trust with an APP assures that if the going gets really tough, a given APP will reach out at any time to ensure quality care. We euphemistically refer to these as “red light” moments, usually arising in serious diagnostic or therapeutic dilemmas. All collaborative practices, in our estimation, must have this open-door policy to ensure quality care. This trust also has a humanistic side. On more than a few occasions, Betsy has told me what I must do to comfort a patient or family we have cared for — some of whom for a virtual lifetime — in a time of need. I like to say that, when successful, the APP-rheumatology collaborative practice enhances both care and the caring that all patients need.
Betsy now has a far more busy and independent practice, and I do not see her on most days of the week, but on Tuesdays we still work together either individually or, often, in unison for complex patients.
Finally, I close by echoing one of the comments I hear ever more often by my long-term patients when I am alone in clinic, when after our greeting there is a pause and they wistfully say, “Where’s Betsy?” Enough said.
That my take, what’s yours? Please share your thoughts with me at calabrl@ccf.org or at rheumatology@healio.com.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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