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Introduction

The role of advanced practice providers (APPs) is quickly evolving nationwide, particularly in primary care. Whether they are known by an umbrella term such as APP or licensed independent provider (LIP), or by their specific qualification such as nurse practitioner (NP) or physician assistant (PA), these team members are filling an increasing need in both inpatient and outpatient settings. You will find a wide spectrum of how practices with APPs structure their workflow, and what your role as the physician will be.

Know Your Nomenclature

Nurse practitioners (NPs) are graduates of a master’s (2–3 years) or doctoral program of nursing, usually after having practiced as a nurse or bedside clinician with a Bachelor of Science in Nursing (BSN) beforehand [1]. NPs specialize early in their training for a specific patient population, and you may encounter pediatric NPs that are acute care (PNP-AC), primary care (PNP-PC), family (FNP), or neonatal (NNP). More than 75% of practicing NPs work in primary care [1].

Physician assistants (PAs) are graduates of a master’s program (2–3 years) and may have a previous background in medical care but are not required to. According to the American Academy of Physician Assistants (AAPA), their educational model is based on medical school curricula [2]. PAs receive more broad medical training and may complete the clinical components in a specific area of focus or can wait to specialize until after their PA certification.

Both certifications require didactic and clinical experiences and to practice, both NPs and PAs pass a certification exam. The description of their difference in training is sometimes described as a patient population-based vs. medical model, respectively [3]. Their scopes of practice are often very similar and can be practice- and state-specified.

Understand Your Team Dynamic

There is a common theme among these sections about your first job, which is to get to know your environment. Each practice will have differences in the way they structure responsibilities and autonomy not just for APPs but for all the components of the care team. In some hospital units, a respiratory therapist may make changes to respiratory support or perform arterial puncture; in others, they may intubate. In some offices, the nurse may triage patient calls and make recommendations on at-home management; in others, an APP may take calls and send in prescriptions when needed.

As of 2019, 22 states allow NPs “full autonomy” in the realm of primary care [4]. As of 2018, 47 states require PAs to practice with physician supervision, and the scope of the PA’s practice is determined by their practice site [5]. Your institution may have requirements separate from the state, and the preexisting culture within your practice may also influence the physician-APP relationship.

When entertaining job offers, it is important to know if there will be APPs on your team, and how you will work with them—especially if APPs cover a significant portion of the practice’s patient load. In most cases, even if an APP is seeing patients independently, a physician needs to be on record as the supervising provider. Clarifying whether this will be the case for you, and how involved your role will be with them, is helpful to delineate so that you can assure the right fit before accepting.

Variations in practice structure involving APPs and physicians are extremely wide. In some clinics, APPs may see patients with a single “[physician] director” listed as their general supervisory resource, but said director has no actual involvement with individual patients. Even within the same institution, there may be neonatal ICU APPs that round with physicians but document and bill themselves with said physician listed as a “team member,” and there may be subspecialty APPs who document but require a physician attestation to their notes and are not allowed to independently bill. APPs may require supervision for certain procedures but not others, or they may have variable levels of independent practice depending on their experience.

Understand as best as possible what the practical, legal, and cultural expectations are for those relationships at your potential job. The physician leadership may be best to ask about these nuances and appreciate that there can be a lot of political (and personal) history behind your practice’s dynamics.

Early in your arrival at your new job make a point to ask about further specifics regarding the roles each provider fills in your practice. Consider asking for time specifically with the APPs to better understand their perspective and responsibilities. Similarly, ask questions about the roles the other new team members—such as social workers, therapists, dieticians, and pharmacists—play to better understand your resources and team structure.