Advanced practice providers (APPs) have become an integral part of interventional radiology service. We are heavily involved in all phases of the patient-care value chain—consultation, education, triage, procedural, advocacy, multidisciplinary team collaboration and many others. However, there is no standardized process for training procedural or clinical APPs, and each practice utilizes APPs differently.
The goal of this panel discussion is to contrast and compare clinical and procedural APP practice in IR from both the APP and physician perspectives. This insight may be useful for any colleagues looking to change or expand their careers as well as any physicians and practice administrators interested in utilizing APPs more.
Panel participants
- Muneeb Ahmed, MD, FSIR: Beth Israel Deaconess Medical Center
- Michael J. Miller, Jr., MD, FSIR: Atrium Health and Wake Forest Baptist
- Andrew Bojanowski, PA: Mecklenburg Radiology Associates
- Julie Fung, PA-C: Mount Sinai Medical Center
Tell us about the APP model at your practice. How are they trained? When are they considered independent?
Muneeb Ahmed, MD, FSIR
Muneeb Ahmed, MD, FSIR: In our practice, we have a large group of APPs across the hospital who perform clinical evaluation and management (E&M) and provide periprocedural care for our clinical IR service. They support all procedural radiology, even if the actual procedure is performed by a diagnostic abdominal or MSK radiologist.
We use an apprenticeship model of onboarding, with the new APP working with or shadowing an experienced APP over several months. We aim to train our APPs so they are comfortable covering different procedural areas across the institution. Based on feedback from the supervising APPs, APPs-in-training are transitioned to independence when they have completed this onboarding.
Our APP group also performs minor procedures. All APPs undergo annual reviews and evaluation as part of institutional credentialing requirements. When able, we supplement APP education with a formal lecture series conducted by our IR attendings, which covers different IR procedures and the clinical management of IR patients. Finally, we have built a supportive physician/APP culture in which attending physicians are always immediately available to answer questions or provide additional clinical support to the APP team.
Michael J. Miller, Jr., MD, FSIR
Michael J. Miller, Jr., MD, FSIR: We onboard our APPs using a combination of clinical and procedural guidance approaches. This is a 3-month process. We teach new hires the procedures using a one-on-one process of sequential steps toward operator independence. We take small wins early and skill build for all procedures. This involves both APP and IR faculty engagement. For less structured interventions, such as tube exchanges and catheter manipulations, we have a stepwise approach from direct supervision to early escalation to build confidence in the operator. We use materials developed by the division and APPs to orient the new hire about the clinical practice of IR and management of the consult service. They start supporting our Board APP and then work progressively with direct supervision to independent running of the board.
Andrew Bojanovski, PA: We tailor the new IR APP training process to the individuals’ specific preexisting clinical and procedural skills. Although this will cause some degree of variability in the training process, we still have a general structure.
Andrew Bojanowski, PA
The new APP starts with 2-week rotations within a specific modality, such as fluoroscopy, ultrasound and CT. During these times, they are expected to learn about the procedures and departments and begin to do the procedures themselves. The new APP will be paired with a senior APP who will begin involving the new APP within certain portions of the procedure. Gradually, the new APP will begin performing procedures proctored, but without assistance from the senior APP.
We define success by APPs obtaining a certain number of proctored, but independently performed procedures. We require that a certain number of these cases be completed with physician supervision and some to be completed with APP supervision. The new APP will be cycled through all the departments until they have enough proctored cases to be credentialed for the procedure.
For a newly graduated APP, this process takes approximately one year. As new procedures, like intrathecal chemotherapy injections, are added to our procedural responsibilities, this proctoring process repeats for senior PAs.
Julie Fung, PA-C
Julie Fung, PA: When I was first hired, there was no structured clinical IR training for APPs. However, I realized the importance of working alongside my attendings, asking questions and reviewing scans. That was how I initially learned and received hands-on experience and an understanding of IR. The combination of my previous experiences and newly learned skills elevated me to an integral part of our IR team. This provided me with growing autonomy to review consults prior to procedures as well as post-procedure concerns.
What are the patient-related benefits of utilizing APPs, and how do they contribute to improving patient satisfaction?
MA: There are several patient-centered benefits from implementing a robust clinical APP practice in our IR division. As the consistent face of IR in periprocedural care, our regular patients get to know our APPs and appreciate the continuity of care. Our APPs also get to know the specific nuances of some patients and can ensure that their individual needs are met. Many of our APPs now have years of experience in IR and can clearly explain why a procedure is being performed and what patients can expect when receiving care. This ability to communicate effectively inspires confidence in our patients and offers them reassurance and comfort during difficult times. Our APPs have also built strong cross-disciplinary relationships with other services and are very helpful in arranging for necessary care with other teams—which also improves the patient experience.
MM: Our APPs run the venous access service line, which has been a big win for the division and the health system. They have optimized patient evaluation, procedure performance and follow-up. This has created increased effectiveness and efficiency for the division and multiple service lines that rely on venous access for care such as our cancer center. APPs also manage our daily low-acuity interventions so faculty are freed up for more complex cases. They have taken the charge for optimizing patient evaluations and plans, which allow providers to optimally perform within their scope.
JF: Having an APP as a physician extender improves patient satisfaction by having immediate access to questions or concerns prior to and after the procedure rather than waiting for the physicians to return a call. In addition, an APP allows workflow improvement to the axillary staff. They can assist with any clinical/scheduling/follow-up issues that arise during a workday to allow efficient teamwork. My role is ensuring that IR plans and recommendations are implemented in a timely manner—by providing detailed plans, patients can be involved and part of the decision and care process, which I believe increases patient compliance as well. I can collaborate with referring providers to resolve issues quickly. This increases trust and rapport for more collaborative patient care in the future.
The attrition rates for NPs and PAs are increasing. How does the model implemented in your practice encourage or increase APP retention?
MA: I believe that the strongest way to preserve our team is to foster a culture where every individual is valued and treated with respect, and teams can work closely together in a non-hierarchical manner. IR is also in an exciting phase of growth, with new procedures being introduced regularly—physicians and APPs both want to be part of that. Creating an environment where everyone is excited to learn also provides a lot of professional satisfaction. Flexible work schedules are also important, and this has been shown to reduce burnout and attrition across multiple types of providers. Ultimately, workplace happiness and satisfaction (and therefore retention) are most often about people liking the team that they work with, feeling appreciated and seeing the value in the work performed. Much of that comes from creating a great workplace culture for all parts of the IR team (APPs, technologists, nurses, front- and back-office staff and physicians).
MM: The first step is to deliver on the 4-10 model of their work week. Second is to understand their work output and align with health system policy for hiring. Currently, our APPs perform at the 75th percentile and we are hiring an additional APP to bring them to market expectation of the 60th percentile.
We are currently working to gather better data with regards to E&M efforts so that we can capture their professional effort, thus allowing us to better understand their effort and capture professional revenue. This in turn will allow us to expand our APP complement and look at other practice expansion or optimization opportunities.
AB: I think that new APPs recognize the amount of time and resources that both parties (the new APP and the trainer) put in to train them and honor this with their loyalty and time. As the training progresses, the new APP becomes increasingly involved in planning their training, which provides greater confidence that they were trained well and can perform image-guided interventions. This confidence fuels job satisfaction and fulfillment.
Additionally, we are quite candid with our newly hired providers about the training process and expectations; we are honest that the training period is difficult and has a steep learning curve. This helps stymie any thoughts of inadequacy or lack of contribution, which tend to discourage providers and provide fodder for dissatisfaction.
JF: My IR practice encourages autonomy for the APPs. Given the culture and nature of our transplant academic center, independence in this IR practice would not be possible unless the APP truly mirrors the attendings in both procedures and clinical hours. I remain at my current practice because of the autonomy, but also because the attendings are readily available for support when I need. This is the key to my retention. The autonomy I’ve gained promotes job satisfaction and my fulfillment in the job. However, autonomy comes with stress; stress for productivity, responsiveness and ability to complete the day's work. The ability to recognize staff's mental wellness and nurture healthy growth are other keys to retention.
In what way does your model drive revenue growth?
MA: There are several direct and indirect ways that a strong APP service can drive revenue growth in IR. Much of the clinical E&M work done by APPs, especially new IR consults and clinical follow-up, can be billed for the IR service. With APPs performing clinical E&M services, this can free up IR physicians to perform procedures—which indirectly helps grow revenue and practice volume.
MM: We are going to make sure all professional efforts of APPs are captured and correctly billed to reflect their work. We are using IR APP experience and collaboration to seek opportunities to expand APP impact across the radiology department. This will be in two potential roles: a procedural role which will allow APPs to free up DRs for interpretation time, and a clinical role which will focus on patient optimization for any procedural service within the department.
AB: The use of APPs will improve access to IR services and allow physicians to focus on more high-complexity and high-reimbursement cases. Also, I think that a slow and intentional training structure helps improve patient outcomes, which will hopefully give insurance providers the information they need to increase reimbursements to our specialty.
JF: During COVID, our practice utilized APPs to perform tele-visits for minimally complicated cases, and we have continued that post-COVID. In addition, our APPs can accommodate urgent requests and consult or triage patients with any issues or concerns. As a result, the practice can accommodate more patients without sacrificing patient experience.
