NPs, PAs Find Home on Hospitalist Teams

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."

Some hospitals, feeling hamstrung by an unwieldy web of federal and state scope-of-practice rules, layer on their own in-house policies to govern just what their nonphysician providers can do. But those days could soon be over as a recent proposal by the Department of Health and Human Services aims to make it easier for hospitals expand their use of physician assistants and nurse practitioners.

On Oct. 24, the agency declared that it wants to "further modernize hospitals’ medical staffing policies" and give them "the clarity they need to explore new and expanded approaches to care giving."

The proposed regulation<http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf> seeks to make clear that hospitals can grant privileges to NPPs to work within the scope of practice allowed under state law, regardless of whether they have been appointed to the hospital’s medical staff. The proposed rule is also designed to help hospitals to address workforce shortages, particularly in medically underserved communities.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader."

Existing rules are a hurdle that "may be unduly limiting access to care and/or delaying treatment for patients and causing undue burden to practitioners (for example, the need to seek out physicians to co-sign orders)," the agency noted.

The regulations are part of a broader initiative created by President Obama to cut red tape and roll back overly burdensome or outdated federal rules.

"More and more people are realizing the value of NPPs," said Dr. David Friar, the CEO of Hospitalists of Northern Michigan, who has integrated NPPs into three of the company’s five hospital medicine programs. He sees the growing use of NPPs in hospital medicine groups as just one part of the natural evolution of the field of hospital medicine.

Though many hospitals are already doing this, red-tape notwithstanding, supporters of NPPs praised the symbolic impact of the government’s proposal.

Tricia Marriott, PA-C, said the take home message from the HHS proposal is that hospitals should apply their state laws, but that creating more restrictive in-house policies for how NPPs operate is unnecessary.

Ms. Marriott said Some hospitals have very restrictive policies about what physician assistants (PAs) can do, allowing them to act only as scribes at the bedside. That means PAs can’t do rounds or independently assess patients, which could limit patient access to care, she said.

One reason that NPPs are being embraced in some hospitals but not others is that physicians and hospital officials just don’t understand what PAs and nurse practitioners can do, Ms. Marriott said.

<[stk -2]>"If people haven’t trained with PAs in their hospital, they don’t know the possibilities," she said. <[etk]>

Ryan Genzink, PA-C, a physician assistant in Grand Rapids, Mich., and the medical liaison between the American Academy of Physician Assistants and the Society of Hospital Medicine, agrees, saying, "The biggest issue is familiarity."

Right now there are many physicians who simply don’t know how NPPs can be integrated into a hospital medicine group. And others may think it wouldn’t work in their system, he said.Mr. Genzink said h He’s optimistic that more people will come around to the idea as they see case studies, success stories, and research on the different NPP models.

For those programs that are willing to give it a try, Mr. Genzink advised getting buy-in from the physicians involved ahead of time. And he stressed the importance of having a physician champion. "When you have a physician who is a champion of the cause and who understands that their success is dependent on the PA’s success, that’s when you have programs that really work well," he said.

"More and more people are realizing the value of NPPs."

<[stk -2]>At the hospital medicine program at Northwestern University, Chicago, which has had NPPs for about 5 years, the challenge was finding a way to integrate a handful of PAs and NPs into a group with 50-60 hospitalists, all of whom had slightly different practice styles. The answer was to find a niche for each of the NPPs, such assigning a PA to work only on the oncology service. That has allowed the NPPs to get to know the practice styles of a smaller group of physicians and for trust to build among the group, said Dr. Nita Kulkarni, assistant professor of medicine and medical director of the PA training program at Northwestern. <[etk]>

The reaction from physicians to working with NPPs has been mixed, Dr. Kulkarni said. For instance, for some attending physicians who are fresh out of their residency training, working with a PA or NP can be a little unsettling because they are still figuring out their own role.

"They sometimes find it difficult to know how to delegate work," she said. "Oftentimes they don’t really know what PAs learn, what PA school is like, how many years is it, and what their learning model is. It takes some education and just experience with working with the NPPs."

Dr. Friar, who was an instructor at a recent "boot camp" for NPPs sponsored by Society of Hospital Medicine, said the NPPs they have worked with have been an asset not just from the clinical side. Their group also has NPPs who sit on hospital boards. They are oftentimes a better fit for this work than the physicians because they possess excellent leadership skills.

"Having an M.D. or D.O. after your name doesn’t magically make you a good business person or a good leader," Dr. Friar said. "That’s something that a lot of providers in a lot of hospitals forget."