Background: Per the 2014 State of Hospital Medicine Survey, 94% of adult hospital medicine groups (HMGs) reported financial shortfalls, with a mean of $169,886 in financial support per full time equivalent physician. In addition, many groups face recruitment challenges which lead to workforce shortage and physician burnout. To offset these problems, some groups employ increasing numbers of physician assistants (PAs) and nurse practitioners (NPs). Mechanisms to ensure successful recruitment and retention and to standardize efficiency and proficiency of newly hired PAs/NPs are integral to successful implementation of such a model.
Purpose: Our private HMG based in Maryland operates successfully with substantially less hospital financial support than the national mean by using a team-based approach which robustly incorporates adept and productive hospitalist PAs/NPs into the practice. We strove to design a succinct and effective training program tailored for PAs and NPs with little experience in the practice of inpatient internal medicine. Our goal was to ensure successful integration of these clinicians into our clinical model after six months of standardized training.
Description: We implemented a six month hospital medicine internship program combining didactics delivered by a physician experienced in medical education and clinical hospital medicine with bedside training by physicians and experienced PAs/NPs. Our lecture curriculum was modified from SHM’s Core Competencies in Hospital Medicine, with emphasis on clinical conditions. Trainees were protected from clinical duties for a total of 80 hours of didactic learning over the training period. Initial training and teaching on site occurred via an apprenticeship model pairing a trainee with an experienced supervisor, with graduated increases in workload and expectations over the training period. Trainees were largely comprised of newly graduated PAs and NPs or those experienced in areas other than inpatient internal medicine. Trainee performance was assessed via performance on standardized metrics of productivity and compliance with Physician Quality Reporting System (PQRS) mandates, self-evaluation, supervisor evaluation, and case-based hospital medicine written examinations. Between 6/2012 and 12/2014, 23 interns at 7 hospitals completed the program. Over the course of the six month training period, productivity measured as relative value units more than doubled and PQRS compliance increased by 11.7%. Written examination scores increased by 23.6%, and interns’ scores at the end of the training period matched those of experienced PAs/NPs in the practice. The initial written examination score strongly predicted likelihood of successful completion of the program. Of the 23 graduates, 21 remain employed with the company by the end of the 30 month study period.
Conclusions: Our private practice HMG successfully implemented a standardized training program to rapidly bolster inexperienced PAs/NPs in areas of hospital medicine knowledge, efficiency, and readiness for collaborative autonomous practice alongside our hospitalist physicians. The program is vital to our continued success and growth in the Mid-Atlantic region by using an expansive PA and NP integration model to improve our HMG’s financial viability with less dependence on hospital financial support. This program could be replicated at relatively low cost in other HMGs interested in increasing or improving PA and NP participation in clinical practice.