Onboarding and Working with APPs

Advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs), play an essential role in delivering timely, high-quality otolaryngology care. Yet the onboarding process for APPs and the scope of their responsibilities can look very different across subspecialties and between academic and private practice settings.

“APPs are an essential part of providing high-quality care and meeting growing demands for outpatient and inpatient timely care,” said Ron B. Mitchell, MD, professor of otolaryngology and pediatrics and chief of pediatric otolaryngology in the department of otolaryngology–head and neck surgery at UT Southwestern Medical Center in Dallas. Dr. Mitchell, who has been working with APPs since 2000, added that “we currently have more APPs than physicians.”

“APPs independently see new and follow-up patients in clinic, including multidisciplinary clinics, and manage inpatient consultations. They perform procedures in clinic and in the inpatient setting. They take day and night calls for urgent/emergency cases,” Dr. Mitchell said. APPs “promote efficiency and patient access, they participate and lead policies, and are leaders in writing and improving educational material for patients.”

Cecelia E. Schmalbach, MD, MSc, David Myers MD professor and chair in the department of otolaryngology– head and neck surgery and director of the Temple Head and Neck Institute at Lewis Katz School of Medicine at Temple University, and chief of the head and neck division at Fox Chase Cancer Center, both in Philadelphia, has worked with PAs and NPs throughout her entire otolaryngology career. The impactful partnership “helps to ensure timely and quality care,” she said. “It has been an incredibly rewarding working relationship that allows me to do more for my patients and their families.”

“In my current cancer practice, our APPs participate in patient care in both the outpatient and inpatient settings. In the outpatient setting, they assist attending physicians during clinic sessions by seeing patients. In addition, they hold their own independent clinics, which include a ‘survivorship clinic’ when patients are more than five years out from cancer care, wound checks, and add-ons. On the inpatient side, they participate in daily multidisciplinary rounds to assist with timely discharge. This inpatient rounding provides a great opportunity for the APP and patient/ family to get to know one another; in doing so, there is meaningful continuity of care, which facilitates seamless transition in the outpatient setting,” Dr. Schmalbach said. “The APPs assist in returning patient phone calls (managing the electronic health record patient portal), sharing non-urgent test results, and following up on orders/ recommendations from our weekly tumor board.”

C. Gaelyn Garrett, MD, MMHC, Guy M. Maness chair and professor of laryngology and voice in the department of otolaryngology–head and neck surgery at Vanderbilt University Medical Center in Nashville, explained that her department first hired an APP—Ken Watford, MSN, DNP—in 2000 to focus on the medical management of balance disorders presenting to the ENT practice. Dr. Watford “also saw some general presenting symptoms, as our MD faculty was much smaller than it is now and we had a need for a generalist practice,” Dr. Garrett said.

“Since then, APPs have been an integral part of our practice, with involvement primarily in the pediatric otolaryngology area, but also with a specific focus in head and neck, rhinology, general otolaryngology, facial plastics, and sleep,” Dr. Garrett said. “We now have a total of 18 APPs in our department, including on both the pediatric and adult sides. They also enhance our regional presence with satellite offices, providing more local care to surrounding communities and counties with otherwise less access to specialty care.”

Onboarding Process

“Prior to 2023, new APPs would rotate within our various divisions to gain experience. Each APP has an MD overseeing their clinical decision making early on, and the APPs are encouraged to reach out when appropriate for questions, etc.,” Dr. Garrett said.

“In 2023, our department developed an APP training program specific to otolaryngology–head and neck surgery, with the initial fellow starting in January 2024,” Dr. Garrett said. The General Otolaryngology–Head and Neck Surgery (O-HNS) Advanced Practice Provider Fellowship Program of Vanderbilt University Medical Center is run by Filipina Cevallos Schnabel, MD, MPH, DNP, FNP-BC, APRN, who is the lead director of the program, and Dr. Watford, co-director of the program. Dr. Garrett explained that Dr. Schnabel and Dr. Watford “have created a curriculum incorporating knowledge and practical learning in all areas of otolaryngology clinical practice.”

Dr. Schnabel believes the fellowship program was the first to accept both PAs and NPs. “This is a one-year program wherein the fellow spends 75% of their time in clinical settings with general O-HNS and its subspecialties, and 25% on didactics, research, and professional development,” Dr. Schnabel said. “The goal of the program is not only to improve the APP’s skill set in O-HNS, but that also leads to safety, increased provider/patient satisfaction, increased APP retention, and decreased costs.”

Currently, the program is planning for its Advanced Practice Provider Fellowship Accreditation (AAPFA) credential through the American Nurses Credentialing Center (AACN). This accreditation recognizes transition-to-practice programs for both PAs and NPs, Dr. Schnabel said.

Adam Zanation, MD, MBA, an otolaryngologist and head–neck surgeon, partner of Carolina Ear Nose and Throat–Sinus and Allergy Center, and shareholder and board co-chair of Viewmont Surgery Center, both in Hickory, N.C., previously worked with APPs in academia for over five years and has been working with APPs now in private practice for approximately five years.

“Our APPs rotate with each physician, shoulder to shoulder, learning their practice as well as in clinic procedures for a total of approximately three months. After this, they do run independent, clinical practices. However, they have access to physician mentorship and input at all times,” Dr. Zanation said, adding that this onboarding process is important because the learning curve for laryngology-specific diseases and procedures is very steep and often not taught in schools related to APPs.

According to Dr. Schmalbach, “One should anticipate that onboarding will take approximately six months.” During this period, the APP is not seeing patients independently but “shadowing each attending with whomthey will work to learn the different practice patterns. Participating in our laryngologist’s clinic is immensely helpful, as those clinic sessions are a great opportunity to gain hands-on experience with scoping. Similarly, the APP shadows our residents on morning rounds to gain insight into the surgeries and associated post-operative care of our patients. Lastly, we have the other APPs and residents reach out to onboarding APPs when they are doing drain pulls and tracheostomy tube changes in order to gain hands-on experience,” Dr. Schmalbach said. “This onboarding process is imperative in order to give APPs the needed skill set to allow them, as well as the patients/ families, to feel comfortable with the care rendered.”

Dr. Mitchell explained that UT Southwestern Medical Center takes care of the paperwork required for onboarding APPs. “Within the department, we have a detailed process for clinically onboarding APPs that is focused on the experience and background of the individual. We allow three to six months for onboarding new APPs.”

Challenges and Best Practices

“The main challenge is to hire the correct people who work effectively with the current APPs and interact effectively with residents, fellows, and faculty. We want APPs who are well-trained and plan to work with us for many years. Turnover of APPs is wasteful and should be avoided,” Dr. Mitchell said, adding that “we have an excellent track record.”

Onboarding success is constantly monitored, ensuring that clinical competence is present and grows over time. Productivity and patient satisfaction metrics are available monthly, Dr. Mitchell said, adding that it generally takes two years for an APP to be fully trained.

According to Dr. Schmalbach, “One of the greatest challenges is allowing patients and their families to feel comfortable being seen and treated by APPs. This challenge can be overcome by having APPs participate on the inpatient floors during rounds so that they are a familiar face and very knowledgeable of the patient’s diagnosis, care, challenges, and needs, and having APPs spend some clinic sessions working side by side with the attending physician. During this time, the patient/family can meet the APP and establish a rapport. I have found it very helpful to have the attending physician then introduce the idea that the follow-up is with the APP.”

Success is measured through formal performance reviews that include competency measures, patient satisfaction scores, and informal feedback. “The ultimate measure of onboarding success is the APP gaining independence to conduct clinic. Equally important is both the patient’s satisfaction with the care as well as the APP’s satisfaction with growth and career development. A great deal of time is required for the physician to onboard an APP, so retention becomes imperative,” Dr. Schmalbach said. “It is important for the APP to feel a part of the team and to be allowed to function at the highest level of their license— they are more than glorified scribes. It is helpful to have career development opportunities for APPs and a leadership trajectory for their field.”

The best practices for onboarding AAPs, according to Dr. Zanation, include “a longitudinal mentorship experience that focuses both on learning anatomy and disease processes as well as the technical expertise in performing procedures. Additionally, having direct access to a laryngologist as long-term mentors or to ask questions about specific patients at all times is important—never leaving your APPs solely on an island.”

Private Versus Academic Settings

The APP’s role in private practice is inherently different from most of the academic practice environments Dr. Zanation has worked in. He explained that in academic settings, “APPs are often partially supported by health system resources and have a significant component of their work related to inpatient care. Additionally, APPs would often see clinic patients with the doctor in the doctor’s clinic, not working with their own independent schedule, which results in independent revenue.”

“In private practice, the traditional model for APPs is to run independent clinical practices in the outpatient setting, usually as part of new and returning patient overflow care,” Dr. Zanation said. He explained that his clinic is moving away from this model. “Our practice is moving to more disease-specific APP clinic processes. These include a head and neck cancer survivorship clinic and a vestibular disorders clinic. Additionally, there are plans for endocrine as well as sleep disease follow-up as additional disease-specific APP clinics. These types of clinics allow us to have templated patient workup as well as integration with our physician clinics.”

According to Dr. Zanation, this type of APP strategy has four major benefits. First, “the expectation for the provider and the patient is well delineated by the standardized workflows within thatspecific subject area. For example, in the survivorship clinic, each patient knows they will have alternating visits with the physician and the APP. They also understand they’re likely to be scoped as well as have speech and swallow evaluations, as well as yearly TSH [thyroid-stimulating hormone test] and health labs.”

“Second, these clinics free up patient access on the physician’s schedule for urgent disease-specific problems. Third, each one of these clinics aligns very well with our ancillary care services, which also drives additional utilization and revenue. In the vestibular disorders clinic, we have a complete setup for vestibular testing, including rotary chair testing as well as CNS [central nervous system] and vertebrobasilar testing. By increasing needed patient access, we can drive appropriate utilization of our ancillary investments,” Dr. Zanation said. “Fourth and finally, there is an educational and expertise component to seeing the same types of patients over and over again. For APPs, this drives confidence in clinic procedures as well as understanding of complex diagnostic testing and clinical needs.”

Expanding Demand

Dr. Schmalbach explained that there are many different models for APPs. “The otolaryngologist and department/practice should aim to identify the greatest need and manner in which an APP can best augment patient care.”

As more and more is being asked of physicians, the role of otolaryngology– head and neck surgery APPs will increase, Dr. Schmalbach said. “A well-trained APP allows better communication with patients, timely discharge/decrease in length of stay, and increased access to patient care. APPs will also be invaluable in rural regions and other areas where there is limited patient access to otolaryngology physicians.”

Looking ahead, Dr. Zanation expects APPs will significantly impact disease-specific intake and long-term follow-up for ENT patients. “Disease-specific pathway strategies will be important for both maintaining appropriate access for patients as well as physicians’ schedules,” he said.

Healthcare access, especially in rural settings, continues to deteriorate as the breadth of ENT practice continues to expand. Many academic centers in North Carolina will not “see balance patients, and there are fewer endocrinology and sleep/neurology practices in North Carolina than ever before. So, we have a huge patient need in these areas that has developed faster than we are creating otolaryngologists,” Dr. Zanation said. APP-based specialty clinics enable a much faster start-up at a lower cost to provide care. These clinics also create synergy with medical and surgical practices and enhance the utilization of ancillary departments. Dr. Zanation said, “It’s a win for the patients, a win for the referring practices, and a win for us as owners and operators of private practice businesses.”

Over the next few years, Dr. Mitchell expects the number of APPs will grow. APPs “will have more national leadership roles and will be recognized as the essential part of the healthcare system that they clearly are,” he said. “Most new patients/families who see APPs are extremely satisfied. APPs consistently get higher patient satisfaction scores than physicians. This speaks for itself.”

Katie Robinson is a freelance medical writer based in New York.