Exploring Professional Anticipatory Socialization: Who Are the Messengers Influencing Future Physicians' Perceptions of Advanced Practice Providers?

PURPOSE: Evidence exists that physicians in training and practice often do not understand advanced practice providers (APPs) and their roles in professional practice. This study asked the question: What are the messages and messengers during the anticipatory professional socialization period that potentially influence how residents perceive APPs? METHODS: Semistructured interviews were conducted with 15 residents in one academic setting. Transcripts were analyzed using an inductive approach to coding to identify the messages and sources of those messages (messengers) that had influenced how residents perceived APPs. RESULTS: Participants reported limited exposure to APPs before medical school, although most had heard of APPs from family, friends, or advisors or through their own experience in a clinical setting. The messages that participants received were related to how physicians and APPs compare in their training and clinical roles, and how APPs and physicians (and the people who pursue these professions) differ based on their presumed personal attributes. Some messages appeared to support biases against APPs. CONCLUSION: While interprofessional education in medical school aims to prepare physicians to collaborate across professions, attention to anticipatory professional socialization occurring before medical school may also be important to mitigate professional biases that interfere with effective teamwork.

Describing the landscape of integrated clinical educational programs for PAs and NPs.

PURPOSE: Postgraduate clinical training (PCT) has been available to PAs since the 1970s and to NPs since at least 2007. Some programs now enroll PAs and NPs. Although this new training model appears to be expanding, little data about integrated PA/NP programs are available. METHODS: This study examined the PA/NP PCT landscape in the United States. Programs were identified from membership rosters of the Association of Postgraduate Physician Assistant Programs and the Association of Post Graduate APRN Programs. Data (program name, sponsoring institution, location, specialty, accreditation status) were identified from programs' websites. RESULTS: We identified 106 programs at 42 sponsoring institutions. Various specialties, most commonly in emergency medicine, critical care, and surgery, were represented. Few were accredited. CONCLUSIONS: PA/NP PCT is now common, with about half of the programs accepting PAs and NPs. These programs represent a unique form of interprofessional education involving full integration of two professions in the same program and are worthy of further investigation.

Which learning experiences support an interprofessional identity? A scoping review.

In recent years, health professions researchers have suggested that a dual identity that includes both a professional and interprofessional identity is essential to interprofessionality. This scoping review sought to describe the learning experiences that may support the development of an interprofessional identity, providing direction for future research. A scoping review was conducted to identify papers published between 2000 and 2020 that provided empiric evidence to support the impact of planned or spontaneous learning experiences involving two or more healthcare professions that fostered the development of an "interprofessional identity," or a sense of belonging to an interprofessional community. Twelve papers were identified for inclusion. Articles varied regarding both the professional groups studied and the developmental levels of their participants. A wide variety of learning experiences were described in the identified studies, including designed activities and programs, as well as those occurring spontaneously in authentic clinical environments. Examples of longitudinal and integrated programs were also identified. The construct of an interprofessional identity and its potential impact on interprofessional practice has yet to be sufficiently studied. The results of this scoping review suggest that a variety of experiences that occur throughout the professional development trajectory may foster an interprofessional identity. Longitudinal, integrated interprofessional learning programs may result in a more long-lasting impact on interprofessional identity and these types of programs should be the focus of future research.

Exploring residents' perceptions of PA and NP roles and barriers to collaboration.

OBJECTIVE: Developing competencies for interprofessional collaboration, including understanding other professionals' roles on interprofessional teams, is an essential component of medical education. This study explored resident physicians' perceptions of the clinical roles and responsibilities of physician assistants (PAs) and NPs in the clinical learning environment. METHODS: Using a constructivist grounded theory approach, semistructured interviews were conducted with 15 residents in one academic setting. Transcripts were analyzed using an iterative approach to inductive coding. RESULTS: Participants typically perceived PAs' and NPs' roles as being "like a resident," less commonly as independent clinicians, and rarely as collaborators. Barriers to understanding PA and NP roles and perceiving them as collaborators included the lack of preparatory instruction about PAs and NPs, the hierarchical structure of medical education, and inadequate role modeling of interprofessional collaboration. CONCLUSIONS: This study suggests that barriers in the clinical learning environment and the structure of medical education itself may impede residents' learning about PAs and NPs and how to collaborate with them.

Establishing and Evaluating an ASCO Learning Cohort: a Longitudinal Project Assessing the Learning Needs and Behaviors of Oncology Professionals.

BACKGROUND: In 2013, the American Society of Clinical Oncology (ASCO)'s Continuing Education Committee recommended establishing an interprofessional, longitudinal cohort pilot project. The main goals of the cohort were to gain feedback from oncology providers on how they use resources to address their learning needs and gain insights into the utility of different ASCO educational activities. METHODS: The ASCO Learning Cohort Pilot Project included 49 ASCO members that were representative of the overall Society membership demographics and ran from November 2015 through August 2016. Participants documented monthly learning needs and completed monthly feedback activities focused on specific ASCO educational resources. RESULTS: The Learning Cohort Pilot Project proved a viable and innovative cohort model for analyzing the learning process for oncology healthcare professionals. The development, operations, and compliance required unique infrastructure to accomplish this project. Relationships between participant demographic variables and learning preferences are reported elsewhere. CONCLUSION: The ASCO Learning Cohort Project is a unique educational project that demonstrated feasibility and has met its goals. This paper outlines the processes of establishing a learning cohort, including participant selection, project design, and participant feedback. We evaluate the project model as a means to better understand the learning needs and behaviors of oncology healthcare professionals.

Quantitative Assessment of Learning Behaviors for Oncology Providers.

How health care providers select topics and activities for learning is key to meeting their needs. The goal of this study was to investigate how oncology providers identify knowledge gaps and choose learning activities. An online focus group within a larger longitudinal study was conducted between November 2015 and August 2016. Participants were chosen by convenience and stratified random sampling of diverse types of oncology providers. Providers were asked monthly to identify learning needs, explain how they identified those needs, and describe the learning activity they chose to meet those needs. Thirty-two oncology providers recorded 201 learning needs via online journal entries (mean 6 entries per person). Needs were associated with practice setting and professional role (p < .05). Colleague recommendation predicted learning needs for advanced practice providers (APPs) (p = .003). Patient cases drove > 50% of identified learning needs across groups. Learning activity preferences were associated with practice setting (p < .05). Choice of learning activity was associated with practice setting, professional role, and geographic location. Colleague recommendation was important for APPs (p = .025). Over 75% of learner responses identify convenience and content quality as important factors in choosing an activity. This study represents a quantitative assessment of learning behaviors for oncology providers and shows that identification of learning needs and activity selection differ by provider demographics. Limitations include small size and underrepresentation of some groups. Our findings should be confirmed with larger samples. Future research should focus on assessment of cohort versus individual needs and learning priorities.

The Impact of Advanced Practice Provider Staffing on Emergency Department Care: Productivity, Flow, Safety, and Experience.

OBJECTIVES: We examined emergency department (ED) advanced practice provider (APP) productivity and how APP staffing impacted ED productivity, safety, flow, and experience. METHODS: We used 2014 to 2018 data from a national emergency medicine group. The exposure was APP coverage: APP hours as a percentage of total clinician hours at the ED-day level. Multivariable regression was used to assess the relationship between APP coverage and productivity outcomes (patients/clinician hour, relative value units [RVUs]/clinician hour, RVUs/visit, and RVUs/salary-adjusted hour), flow outcomes (length of stay and left without treatment), safety (72-hour returns, incident reports), and experience (Press-Ganey scores), adjusting for patient and facility characteristics. RESULTS: In 13.02 million patient visits in 105,863 ED-days across 94 EDs from 2014 to 2018, nurse practitioners and physician assistants managed 5.4 and 18.6% of visits independently, 74.6% by emergency physicians alone, and 1.4% jointly. APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED-day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = -0.15 to -0.10) and lower RVUs/clinician hour by 0.4 (95% CI = -0.5 to -0.3). There was no impact of increasing APP coverage on RVUs/salary-adjusted hour or RVUs/visit. There was also no effect of increasing APP coverage on flow, safety, or patient experience. CONCLUSION: In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.

Quantitative Analysis of Oncology Professional Learning Preferences.

PURPOSE: ASCO is the premier and largest global professional society for oncology care professionals. In 2015, ASCO launched a longitudinal Learning Cohort Pilot Project to catalog and better understand the learning behaviors and preferences of oncology health care providers. A secondary goal was to assess learner preferences and utilization related to ASCO's portfolio of educational resources. METHODS: The Learning Cohort Pilot Project was conducted between November 2015 and August 2016 with 49 ASCO members. Participants were selected via convenience sampling and stratified random sampling to generate a cohort that mirrored the demographic distribution of overall ASCO membership. Participants completed a different ASCO resource-specific feedback activity each month, which measured professional educational needs, sources sought, and preferences for educational resources. Responses were organized by demographic variables in our participant pool to identify trends in provider learning preferences. Fisher's exact test was used to assess the association between participant demographics and practice setting and responses. Holm's procedure was used to adjust for multiple testing. RESULTS: The Learning Cohort Pilot Project revealed statistically significant relationships between participant demographic variables and learning preferences. Age and practice setting were the demographic variables most consistently associated with the different preferences explored throughout the targeted activities. CONCLUSION: The results of this pilot cohort reinforced the hypothesis that oncology care providers have different professional educational needs and preferences that can be potentially anticipated and met with tailored resources. Delivering solutions to meet these needs represents an opportunity for further research and resource development.

Advanced Practice Provider Critical Care Boot Camp: A Simulation-Based Curriculum.

The demand for advanced practice providers (APPs) is increasing across the United States to meet necessary provider staffing requirements including in intensive care settings. Currently, participation in formal postgraduate training programs, or residencies, for APPs is not required for clinical practice, such that most of the APPs immediately enter into the workforce following completion of their initial graduate-level training. Consequently, this results in a supervised training period until APPs develop the necessary competencies to practice more autonomously. Educational programs that support specialty competency development may facilitate the transition of APPs into clinical practice, allowing them to be credentialed to perform essential procedures as quickly as possible. The goal of this boot camp was to provide training for APPs in common critical care, high-risk procedures, and to provide leadership development for high-risk cases to expedite their orientation process. The following manuscript describes our experience with the development, implementation, and short-term evaluation of this training program.

Exploring the effect of PAs on physician trainee learning: An interview study.

BACKGROUND: Physician assistants (PAs) often have been embedded in academic medical centers to help ensure an adequate patient care workforce while supporting compliance with work-hour restrictions for residents and fellows (also called trainees). Limited studies have explored the effect of PAs on trainee learning. This qualitative study explored, from the perspective of physician faculty and PAs, how PAs working in the clinical learning environment can enhance or hinder trainee learning. METHODS: Using purposive sampling, 12 PAs and 12 physician faculty members in one US teaching hospital were selected for semistructured interviews. Data collection and analysis were characterized by an iterative process. Data analysis was informed by principles of conventional content analysis. RESULTS: Participants identified various ways in which PAs may affect trainee learning, intrinsically linked to the roles PAs assume in the clinical learning environment: clinician, teammate, and clinical teacher. Trainee learning may be enhanced because learning time can be optimized by having PAs in the clinical learning environment. Trainees can learn about PAs and how to collaborate with them, and PAs can enculturate and provide clinical instruction to trainees. Trainee learning may be hindered if learning opportunities for trainees go to PAs, trainees feel intimidated by experienced PAs, or trainees become too dependent on PAs. CONCLUSIONS: Our findings demonstrate enhancements and hindrances to trainees' learning linked to three key roles PAs perform in the clinical learning environment. These findings can inform how PAs are integrated into teaching services. Further investigation is needed to understand how PAs can balance their professional roles to foster effective collaborative practice and learning.

Specialty certification and clinical flexibility.

The ability for PAs to easily move from one specialty to another without additional formal training is a unique feature of the profession that is valued by PAs and their employers. Specialty certification has been viewed as a threat to this flexibility, yet 73% of PAs are in specialty practice. How can the desire to preserve flexibility be balanced against the desire of specialized PAs to distinguish themselves in their chosen specialty? This article reviews the issue of specialty certification in the context of contemporary PA practice and concludes that although specialty certification remains a threat to the flexibility of the PA model, it may be appropriate in some situations. In particular, specialty certification may be appropriate as a means for promotion within healthcare systems so long as it is not used as a requirement for entry into specialty practice, credentialing, or third-party reimbursement. A portfolio model may give stakeholders an alternative way to assess the experience and competencies of PAs in specialty practice areas.

Advanced Practitioners: Collaborators in Radiation Oncology.

Advanced practitioners (APs), including physician assistants (PAs) and nurse practitioners (NPs), are medical professionals with advanced training, degrees, and certifications that qualify them to diagnose and treat medical conditions in a wide variety of health-care settings. As such, APs have been collaborators in radiation oncology practice for decades to complement the role of radiation oncologists. In 1999, Kelvin and Moore-Higgs first reported data on how APs participated in radiation oncology practice. Over the 20 years since that publication, more articles have described how APs have been collaborators to varying degrees in nearly all aspects of radiation oncology practice. However, significant legislative, regulatory, and educational barriers may limit the optimal practice of APs in radiation oncology. In order to mitigate projected shortages of radiation oncology services while maintaining high levels of patient satisfaction, enhanced collaboration with APs in radiation oncology practice is needed.

Cancer education in physician assistant programs.

PURPOSE: The purpose of this study was to describe the current state of oncology education provided by physician assistant (PA) programs. METHODS: This is a descriptive, cross-sectional study of PA programs using a web-based survey. RESULTS: The response rate was 22%. All programs reported dedicated curricular hours to address cancer: genetics, prevention/screening, diagnosis, and general treatment and counseling regarding delivering "bad news." The majority of programs provided 2 hours or less of content related to the evaluation and management of acute cancer treatment effects, oncologic emergencies, and symptoms of cancers/palliative care. Most common content areas without any dedicated time were management of patients with long-term sequelae of prior treatment or undergoing cancer surveillance and identification/management of cancer survivors. The most commonly used instructional format is lecture, interaction with preceptors, and direct patient care. Other forms of learning such as case-based learning and team-based learning are less commonly used. Most programs report the most common cancer patient encounters occur during internal medicine/primary care rotations. Although typically available, few students participate in oncology elective rotations. Data regarding faculty perception of cancer education, teaching resources, and barriers to teaching were also collected. CONCLUSION: Cancer prevention and initial diagnosis are the primary foci of instruction by PA schools. Instruction is typically by classroom lecture and clinical encounters during primary care rotations. Given the challenges faced by PA programs to provide a generalist's education for students, novel means of enhancing cancer education during PA school and continuing medical education following primary PA education will be essential to expand PAs' competencies in cancer care.

The advanced practice professionals' perspective: keys to a good working relationship between advanced practice professions and physicians.

A strong working relationship between advanced practice professionals (APPs) and supervising oncologists is essential for reducing medical errors, retaining employees, and improving work environments. Although there is rather limited data on the unique relationship of the APP and physician, fundamental communication skills-including open communication, mutual respect, establishing expectations, and working with mutual purpose-should be the foundation of these relationships. This paper addresses various aspects of relationship building between APPs and physicians with suggestions for establishing successful working relationships.

Postgraduate clinical education of physician assistants.

PURPOSE: Physician assistant (PA) postgraduate clinical training programs have existed since 1971. There are anecdotal reports of increasing numbers of programs available in the United States, although a reliable means of identifying and tracking such programs has not been available. The purpose of this study was to describe the current state of postgraduate, clinical educational programs for PAs based on defined criteria for study inclusion and to propose the use of these criteria for use by future investigators to determine trends in program development. METHODS: All programs potentially meeting the study criteria for postgraduate PA clinical programs, including programs actively enrolling PAs and that provide didactic and clinical instruction of 6 or more months duration, were contacted to participate in an online survey. RESULTS: A total of 49 programs (42 nonmilitary) programs were included with 22 nonmilitary programs opening for enrollment in or after 2008. Most programs enrolled one or two PAs annually. All respondents of nonmilitary programs indicated that a certificate of completion was provided and no academic credit or degree was offered. A variety of didactic and clinical instructional methods were used. Most sites also provided clinical rotations for PA students, and many required PA residents to participate in student teaching. Although few programs have been accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), most programs are pursuing, or plan to apply for, accreditation. CONCLUSIONS: The results of this survey provide an up-to-date report on the status of PA postgraduate clinical training programs. The investigators recommend future studies use the same criteria for inclusion to establish future trends in program development.

Strategies for workplace learning used by entry-level physician assistants.

PURPOSE: Physician assistants (PAs) play an increasingly important role in medicine. While PAs have strong basic science and clinical training in school, typically they don't participate in postgraduate training and are expected to expand their generalists' competencies through continuing professional education. The purpose of this study was to investigate the methods PAs use during their initial phase of workplace learning and determine which methods are deemed most effective by PAs. METHODS: This large, cross-sectional study of PAs within the first 2 years of practice consisted of a survey of PAs investigating the methods used for assessment of educational needs, instruction, and assessment of learning. RESULTS: The results revealed that PAs generally found that employers are well aware of their learning needs and their supervising physicians play an essential role in their learning. PAs themselves often recognized their learning needs based on perceived gaps in competencies noted with patient encounters. Though many PAs reported having an orientation period, most PAs said that this orientation was not well adapted to their unique learning needs. A variety of methods were used during workplace learning, with those related to real patient problems deemed most helpful by PAs. Although PAs reported that their learning was assessed, review of patient outcome data was uncommon. CONCLUSIONS: Consistent with principles of adult learning theory, these findings suggest that PAs find active forms of learning most valuable. Employers and supervising physicians should consider these findings and the available literature on adult learning in developing an environment that is supportive of continuing professional development.

Understanding the role of physician assistants in oncology.

PURPOSE: To understand the deployment of physician assistants (PAs) in oncology. A recent analysis of the oncology workforce in the United States commissioned by ASCO predicted a significant shortage of providers by 2020. METHODS: A descriptive study was undertaken using a Web-based questionnaire survey. Invited participants, including all PAs listed in the national PA database (n = 855) and all PAs at The University of Texas M. D. Anderson Cancer Center (Houston, TX; n = 159), were mailed letters directing them to the Web-based survey. RESULTS: The study produced a 30% response rate. A total of 186 PAs worked in medical oncology (the population of interest). Of the respondents, 80% were women, mean age was 36 years, average time employed as a PA was 9.5 years (6.5 years in oncology), 55% had obtained a master's degree, four had completed a postgraduate oncology program, 91% reported that direct mentorship by a supervising physician was very important in obtaining oncology-based knowledge, and 61% reported that becoming fully competent in the practice of oncology required 1 to 2 years. The majority of PAs (78.5%) worked 33 to 50 hours per week, and 56% of those reported working 41 to 50 hours per week. Three fourths (77%) wrote chemotherapy orders, most requiring physician co-signature, and 69% prescribed schedule III to V controlled substances. Additional data were gathered regarding clinical duties, research, and teaching. CONCLUSION: Oncology PAs are used in multiple medical settings, and many assume high-level responsibilities. Future research addressing function and factors that limit use of PAs may allow for improved organizational efficiency and enhancement in the delivery of health care.