Background: From 2016 to 2018, advanced practice provider (APP) utilization in academic hospital medicine groups (HMGs) has increased by 23.6%, with 75.7% of academic HMGs now employing APPs. Due to a lack of standardization around APP utilization, and the frequent use of shared billing models, determination of return on investment for APPs is challenging and must consider both productivity and value-based metrics. In addition, physician burnout continues to be a substantial issue in hospital medicine. Informal studies have suggested APPs can help mitigate burnout for physicians in addition to bringing efficiency and high quality of care. We aimed to better understand physician perspectives on physician only services compared to physician-APP services.

Methods: Data was collected through a mixed methodology survey with open and closed-ended questions. Surveys examined physician reports of burnout symptoms, comparing physician only services with a 12-patient cap, to physician-APP services with a 16-patient cap. Physicians were asked open-ended questions around individual service line preference and perceived differences in physician only services versus physician-APP services.

Results: Surveys were sent to a total of 50 physicians, 36 responses were collected (response rate of 72%). Sixty-seven percent of physicians reported they would rather work on physician-APP services, with 13.9% reporting they would rather work on a physician only service and 19.4% reporting no preference between the two services. Fifty-three percent of physicians felt they provided the highest quality of care on physician-APP services, while 38.9% reported ability to provide the same quality of care on both services. Only 8.3% of physicians reported feeling they provided the highest quality of care on physician only services. Fifty-six percent of physicians reported feeling more emotionally exhausted working on physician only services, while 8.3% reported feeling more emotionally exhausted on physician-APP services. Regarding efficiency, 41.7% of respondents felt that they were more efficient on physician only services compared to 44.4% who felt that they could be more efficient on physician-APP services. A majority of physicians felt they could more reasonably handle admissions, discharges, and changes in patient acuity on physician-APP services (91.7%, 80.6%, 83.3% respectively) compared to physician only services. Free text responses obtained in the survey demonstrated that in general, physicians valued the experience of teamwork and camaraderie on physician-APP teams, felt that a second provider improved clinical decision making, and appreciated that APPs had significant knowledge of the system, which improved efficiency. Perceived negatives of working on physician-APP teams included sentiments that lower volume services were easier to manage, attesting APP notes was as time consuming as writing a full note, difficulty managing learners on high-volume services, and variability in roles carried out by APPs.

Conclusions: Overall, a majority of physicians reported more positive experiences and a preference for physician-APP services and felt they were able to provide higher quality of care than physician only services, in spite of higher patient volumes. Further research is needed to better identify and implement best practices for utilization of APPs in team-based physician-APP models.