What Roles Can NPs and PAs Play in a Practice? Part 2

When a nurse practitioner or physician assistant is hired, initially they receive some type of orientation and training. The nurse practitioner at the Center for Endocrine Health at Hunterdon Medical Center in Clinton, New Jersey, shadowed the endocrinologists for a month so that she could gain a sense of how they interacted with patients and understand how the endocrinologists evaluated patients, says Felice Caldarella, MD, an endocrinologist at the center. This would ultimately enable a more seamless transition from the endocrinologist to the nurse practitioner. The endocrinologists also provided her with literature to review, which contained the American Association of Clinical Endocrinologists’ most recent algorithms on diabetes management and weight loss.

Similarly, Marilyn Tan, MD, clinical assistant professor of medicine (endocrinology) at Stanford University School of Medicine, and chief of the Endocrine Clinic at Stanford Healthcare in Stanford, California, reports that the nurse practitioner initially saw patients with the clinic’s physicians to become familiar with how they specifically provide endocrine-related care before she saw them independently.

At the Mayo Clinic in Rochester, Minnesota, the nurse practitioner dedicated to the thyroid practice observed patients with a thyroidologist for the first 6 months at that practice, says Marius Stan, MD, associate professor of medicine.

Richard Levy, MD, an endocrinology consultant affiliated with multiple hospitals in the Chicago, Illinois, area, says nurse practitioners review cases and are taught patient management by example and by reviewing the literature.

At North Raleigh Endocrinology & Diabetes Center in Raleigh, North Carolina, Amit A. Patel, MD, an endocrinologist, has new physician assistants shadow him seeing patients during the morning of their first day on the job. Then, they transcribe for him the remainder of the day. “This helps them to understand the flow of our charting and electronic medical record system,” he says. The next day, they see patients on their own and Dr. Patel reviews each case prior to signing off on it.

Giving Oversight

On a daily basis, Dr. Caldarella says endocrinologists touch base with the nurse practitioner and ask if any patients have concerns or issues. “We have an open dialogue,” he says. “We have informal discussions on a weekly basis to see if there’s anything she wants to discuss with us. But in between, she may also send us a quick question or note through the electronic health record system.”

Endocrinologists seek feedback from patients regarding their interaction with the nurse practitioner and also obtain feedback through chart notes reviews. In addition, they keep metrics on the endocrinologists and nurse practitioner through the electronic health record system.

Dr. Tan says nurse practitioners receive feedback from all staff, including medical assistants, registered nurses, and physicians, as well as patients. The clinic manager evaluates them and provides feedback, and their charts and documentation are periodically audited. When the nurse practitioner sees patients independently, physicians are always available to give advice about more challenging cases.

As requested by the nurse practitioner, the thyroidologist will discuss individual cases, discuss the nurse practitioner’s role in the practice at thyroid core group meetings, have the nurse practitioner involved in case conferences, and support the nurse practitioner in academic projects.

Dr. Levy reviews the physician assistant’s and the nurse practitioner’s notes, and they agree on an assessment and plan.

Dr. Patel reviews new physician assistants’ notes and makes recommendations accordingly. By having an endocrinologist and a physician assistant alternate seeing patients, he can better track the physician assistant’s performance.

Overcoming Challenges

For Dr. Caldarella, the biggest challenge resulting from having a nurse practitioner on staff is that patients are unclear about her role. To overcome this issue, the practice created a handout that tells patients who she is and how she fits into their diabetes management plan. The brochure is given to patients when they schedule their first appointment with the nurse practitioner.

At times, Dr. Stan says the nurse practitioner has had challenging cases that did not fit neatly into a clear algorithm. The solution was to have a thyroidologist available at all times and to have periodic discussions as a group to decide whether the nurse practitioner’s spectrum of practice is appropriate.