Advanced Healthcare Practitioners in Hematology

HELEN: Helen Osborne: Welcome to Talking About Blood. I’m Helen Osborne, host of this podcast series and a member of the advisory board for The Blood Project. I also produce and host my own podcast series that’s about health communication, and it’s called Health Literacy Out Loud. Today, I’m talking with two guests. Kendra Church is a physician assistant at Dana-Farber Cancer Institute, Brigham and Women’s Hospital in Boston, Massachusetts. She is also an associate deputy editor for DynaMed, an evidence-based point-of-care database. Samantha, or as she prefers, Sam, Neeson, is a nurse practitioner in the division of hematology and hematological malignancies at Beth Israel Deaconess Medical Center, also in Boston. Welcome to you both to Talking About Blood.

KENDRA: Thank you, Helen.

SAM: Thank you for having us.

HELEN: Now, in my experience as a patient, and I’m hearing about this from all my friends and colleagues who are patients too, more and more it seems to be that when we’re having a medical appointment, we might be seeing a physician assistant or a physician associate, or we’re going to see a nurse practitioner. We’re not always going to see, you know, a physician, as we used to. One of you is a nurse practitioner, one’s a physician associate. What’s happening these days that this whole practice pattern seems to be changing? And I’m also going to ask you both, because we’re three women, three women’s voices, that at least at the beginning you say who you are, whether you’re Sam or Kendra, so we know who is who and keep orienting us a little bit from the beginning till we all get used to each other’s voices. So thank you. So what’s happening in health care these days when we go see a provider?

SAM: This is Sam. I’m a nurse practitioner, and, you know, my sense of things is that there is an increase in patient volume, generally speaking. People are living longer. They’re developing more medical problems over their lifespan, and unfortunately there’s just not enough doctors out there. You know, it’s a really difficult field to get into. It’s incredibly challenging to get, you know, admitted to programs for medical school, and also just the allure of the job has changed. You know, it used to be that you would go through this training and have, you know, excellent job security, financial security.

HELEN: As a physician or?

SAM: As a physician. Yeah, and as, you know, time has gone on, the job has become, you know, less, I think, financially supportive. Like, you know, people are making less money as physicians as opposed to other jobs, and it also requires several, several years of, you know, dedicated training where you’re not actually, you know, making a lot of money. And so I think that there’s definitely a, it’s a harder job for people to be interested in, just given the degree of commitment that there is, you know, again, you’re talking 10 years of training before you can even start as a practicing physician, as an attending physician. And so we still need to meet the needs of the growing patient population, you know, as I said before. So nurse practitioners, physicians assistants, physicians associates, all together, we are considered advanced practice providers or APPs. And that training is, although intense and, you know, requires a lot of dedication, a lot of time, you know, a degree of intellect and understanding of, you know, medical problems, it’s only, you know, two or three years as opposed to you’re talking 10 years. And so with the way the laws are, we’re able to see patients independently, do assessments, diagnostics, interpret labs, and implement plans of treatment, including, you know, medications, referrals, et cetera, with or without supervision of a physician. So it’s really, we’re getting more to the forefront of medicine based on needs.

HELEN: Thank you. I’m hearing about the needs of the patients, of the physicians, of the whole practice world, and the needs of care. Kendra, you are a, is it the term a physician’s associate or a physician’s assistant? You’re one of those. Tell us more.

KENDRA: So, yes, I’m both. The physician assistant is the original term that was used back in the seventies when this, this role was created. However, there has been in recent times, a move to physician associate because the definition of a PA, we don’t assist the physician so much. We are an associate practitioner for the physician. So I think there is a little bit of a misnomer and over the years, we’ve tried to change that title, but I will respond to either.

HELEN: Okay.

KENDRA: And I can agree with what Sam said, the, the need for APPs and this growing need from the patient perspective, and also from an organizational perspective, the cost structure of physicians can be balanced with the APPs from an organizational standpoint as well. And I think that that is an appeal.

HELEN: Okay. So it sounds as though this body of advanced practice professionals or providers is meeting the needs of the, the organization. Is it meeting the needs of the patient and then is it meeting the needs of the physician too? Is this just like, Oh, this is the missing piece of the jigsaw puzzle, or are there some kind of hard places to fit in, in there?

KENDRA: So this is Kendra. I think that from a patient perspective, I think it largely has shifted for the better. As, as, as we practice for more years and become more comfortable with seeing somebody that’s not a physician. However, that is, I think a constant challenge in such that we will get questions like, why aren’t I seeing the physician? Or can I see the doctor instead of you, or I don’t understand what your role is. And so there is a lot of education around what this role is and what we can do and how we can help. I have had feedback and I know Sam has as well, where we sometimes are allowed more time. This is more in the outpatient setting for, for appointments. Sometimes we’re allotted more time spent with a patient. And that is important. A lot of patient education, a lot of behind the scenes that the patient really values, not saying the physician can’t do that, but again, it’s an extension of the services of a physician. And once you have that team, that true team mentality, the patients have responded quite well, but there is certainly a level of educating about the roles of an advanced practice provider that come into play.

HELEN: Thank you. I have a whole list of questions as you were talking about this. What’s the difference in… I come in as a patient…. I could see either you, Sam, or I could see Kendra. Are you going to be equivalent in how you would be treating me as a patient or are there differences between a physician associate and a nurse practitioner?

SAM: This is Sam. So I’m a nurse practitioner. Theoretically, no, I mean, our training is very comparable. The main difference is that I was trained as a registered nurse before I became a nurse practitioner. So, which there are different ways to go to the nurse practitioner track, but generally speaking, you advance as a registered nurse and then go on to continuing education to become a nurse practitioner. However, you know, the training of a nurse practitioner and a physician’s assistant requires clinical rotations, you know, similar kind of classroom studies in pharmacology and pathology and different patient population spectrums. So women’s health, children, adult medicine, again, kind of depending on your, on your track, but overall our education is very similar. And then once we get into the field itself, our relationships and collaborations with physicians are very similar. So no matter whether you’re seeing a physician assistant, a nurse practitioner, we are all under the umbrella of the same kind of training. So if you’re seeing a physician assistant, a nurse practitioner, we are all under the umbrella of an advanced practice provider and are able to do the same kinds of things and take care of patients appropriately with our individual trainings.

HELEN: You talked about that team mentality. You both talked about that. I mean, we’re kind of all in it together. What does a doctor do anymore as part of a team?

KENDRA: This is Kendra. They do, they do everything as well. In my current practice, I work in a, in a hospital based setting. So my day to day looks like a team of physician assistants that in the morning, we each have an assigned number of hospital patients and the attending physician and the team round on each patient. So the physician is there. We’re making a care plan together. We’re executing that care plan. Mostly the PAs on the team are the ones that are the responding clinicians. So get the page first and are diagnosing and first at bedside, so to speak, but the physician is involved in the plan of care and questions and sees the patient with us in the morning. And then we are there for the full length of the day to be the first call and manage the patient. The physician role at that point, they obviously are extraordinarily busy, have clinics, have research, and they are not physically necessarily in the hospital with us for the rest of the shift, but are reachable. So we are managing the patients in the, in the inpatient side ourselves. There’s a lot of autonomy, but I do think the crux of all of this is that team mentality is that the trust and the training between the physicians and the APP. And as you gain experience as an APP, that trust with the physician can really be an incredibly strong team model. And the respect that goes there, it kind of just remains the full spectrum of great quality patient care. But the trust and respect between the roles is crucial.

SAM: Yeah. And I’ll, I’ll comment as an outpatient provider. Again, this is Sam. So I, I actually work in a hospital-based outpatient clinic. So rather than seeing patients in the hospital, like what Kendra does, I see patients outside of the hospital that come to clinic to see me and see the physician that I work with. And the way that we typically work is that I’ll see patients on my own. He’ll see patients on his own. We’re both in clinic at the same time. So we can bounce ideas off of each other. If I see somebody and I’m like, Hey, you know what? This person’s really sick. I’m very concerned. I can always get him and we can kind of take tag team together. And then usually it’ll be an alternating. So I’ll see a patient for a visit. They come back in three months, they see the attending. And that way you, the way my attending always describes me as he introduces me to patients as his partner, that talking to me is like talking to him. And that he often refers to me when we’re talking as his second brain meeting that, you know, if I see a patient, I may see or catch something that he didn’t catch or vice versa. And so by having that team mentality that Kendra, you know, was commenting on is that you’re actually getting better care because you’re having different people with different skill sets, looking at a patient from a different perspective. And I think that that really puts in a lot of ability to catch things that may otherwise fall through the cracks. So I really love the model that, that I personally have taking care of patients. And I think patients really appreciate it once they understand what the dynamic is.

HELEN: Thank you both. Now I’m hearing all the good news. Is there any pushback either from perhaps patients? You say that they want to know what you’re doing and maybe I really need to see the doctor. That’s a little inkling of perhaps some pushback or questioning and any pushback from physicians. It sounds like you’re in wonderful situations and I would be happy seeing any of you, but tell us the other side of this.

KENDRA: Kendra here, as we mentioned before, comes back to teaching and sharing and educating what the role can be. When I started at Dana-Farber on the inpatient hospital, there were no inpatient physician assistant led teams. So there was pushback. It came in the flavor of actually a lot of the nursing staff and hospital staff that weren’t aware of what a PA or an NP could do. And so we, you know, we write orders and write medication orders, and there was some hesitation. Well, you’re not the attending physician, so we’re not going to take that order off. And things like that were happening. So it was a lot of education. That was really when it was important for the attending physician to show up and say, no, this is an extension of the team. This is like having me, you know, this role is now a part of our team. And so there was a lot of teaching and a lot of people who were uncomfortable with that process at first, but now that we’re 20 years in, they love having us and now there’s that comfort and trust and respect. But yes, inpatients, I’ve definitely had experiences where we had to, they didn’t, they want a physician. End of story. Doesn’t matter what you say or what you explain. They just would prefer the physician. And it’s just a matter of explaining what our roles are. And again, it’s where the full team, I think to support each other and having a physician that has that experience that can say, no, this is, this is my second brain.

HELEN: OK

KENDRA: Which would be helpful, but it, but it isn’t always like that.

HELEN: Thanks. I’m also thinking both of you are based in Boston. I’m based in the Boston area too. We have a wealth of wonderful providers and brilliance, and we’re really very much known as a healthcare hub here. And we’re extremely fortunate in that.  Listeners to this podcast might be in other situations and they might be in rural situations or another part of the world where healthcare is done a little bit differently. Is this happening everywhere? This team approach, or is this unique to Boston or the US?

SAM: This is Sam. So I think that the team approach is probably more often seen in like urban areas especially, you know, Kendra and I are both working at major medical centers, academic centers where this is kind of more of the standard model is it’s a lot of the APP is do a collaborative approach with a physician. However, those physicians are also very much engaged in academia doing research and whatnot. So the doctors are definitely more available. You have more resources, you have referral services, you have specialists that you can send patients to and bounce ideas off of. There are tumor boards and, you know, just kind of endless resources for us, whereas in rural areas, that’s not always the case. And it’s also very hard to, again, kind of recruit physicians to these areas. And so I think we’ll actually see as time goes on that advanced practice providers will be the primary providers in rural areas where you may have a practice that only has one physician, but has five or six APPs that are essentially giving all of the care to the patients under the umbrella of one physician attending. And so I, you know, my hope is is that as this becomes more of the forefront that people become more comfortable with it and recognize that we are here to meet the needs of, of our fellow man. And, you know, I, so I can only really comment on like domestic, like US, I don’t know what, what goes on abroad, but I would think it would be similar.

HELEN: So what I’m hearing from you is it’s really opening up the capacity for treatment and care in ways that it may not have been. I’m curious for both of you, you’re very much focused on areas of hematology. At what point do you pick your specialty area and is that common or could you practice anywhere and you just today happened to be in hematology?

KENDRA: I’ll go first, Kendra here. When you obtain your degree for physician assistant studies, most of them are master’s degree programs and you, it is a master of physician assistant studies. So the idea is you can go into multiple areas. And a lot of the training is when you have your first role, you really can dig into specific training. For example, my first job was in outpatient neurology and I did that for a few years and I had always wanted oncology, but there were, there weren’t roles available. And then I was able to make that transition to Dana Farber and got the training specific for oncology and hematology in that, in that space, which is amazing. The idea is we, from a PA perspective, we have to recertify. It was every seven years, now 10 in every field. So surgery, pediatrics, emergency medicine, you kind of have to take.

HELEN: You have to recertify in all those 10 fields?

KENDRA: Yep. Medicine in general, every, every 10 years. So it’s a really fun study cram for a long time to get those. But the idea is that we can transition to different areas should we want/need to. Okay. It allows for that and it also allows for a lot of stressful studying when you’re in the same field for 20 plus years and have to take a pediatrics exam, but that’s, you know, it’s good for me. Okay. Challenge.

HELEN: So, so Kendra, you have to recertify in all the fields. Sam, are you more specialized in your area of practice now?

SAM: Yeah. So as a nurse practitioner, there’s a couple of different tracks that you can pursue. For example, I am a family nurse practitioner, so I have certification in kind of the breadth of patient populations. So I have the ability based on my master’s degree to work in pediatrics, women’s health, geriatric medicine, adult medicine. The only thing that is separate from that is psychiatry, which you have to have a separate degree in, in order to, to work in that field. But there are other tracks, including, you can do acute care medicine, which is primarily adult to geriatric. You can do women’s health where you would be working more in kind of OB GYN. You can also do breast clinic care, breast oncology, ovarian oncology, et cetera, or pediatrics. You can do as, as a separate, but for me, I wanted to do a family because it, I went into my master’s program kind of in my mid-twenties. And I was like, I don’t know what I’m going to want to do 10 years from now, 20 years from now. So I wanted to give myself the flexibility and the opportunity to, you know, change fields if I so chose. That being said, I’ve been in hematology and heme malignancy for 10 years now, and I have no interest in doing anything else, but I do have the opportunity should someday I wake up and decide to go to sleep medicine or something like that. But there is the difference. So I, I applaud you Kendra because I actually don’t have to do any recertification. So I take, I take one test and then as long as I renew my certification, there are certain trainings that you have to take in order to maintain your, your certification, but there’s, there’s not a licensing like tests that you have to take, which the physicians have to do too. So I don’t know how we escaped that, but hopefully nobody, nobody in the NP like higher ups are listening to this. They’re like, Oh,

KENDRA: Listeners beware.

SAM: Yeah.

HELEN: Okay. So we have the inside track. So talking about listeners, the listeners to this podcast can be seasoned physicians well along in their career, accomplished hematologists. They might be much earlier in their career, whether they’re in a health science program, perhaps as an undergrad deciding what profession to go into or in the early stages of either medical school or being a resident or a trainee. So those are two big groups of our listeners. And then the other big group, and I feel I represent them are people who are just curious, curious about all aspects about medicine and science and hematology. I’m looking for a little advice or recommendation for each of those audiences. So start wherever you want. What do you want to share about the advanced practice professionals with seasoned professionals and physicians, those in the early stages of their career and the general public who will all be patients at some time or another.

SAM: So to the kind of physician population, you know, definitely the more seasoned physicians, I think maybe this may be ignorant of me to say, but I think have perhaps less experience with APPs working more independently. And so kind of recognizing that, you know, we are not assistants to the physician, we are actually able to practice independently and really can be an asset to your clinical care, whether that be inpatient or outpatient. We’re able to see patients diagnosed, do an assessment, you know, prescribe medications, implement plans. And so, you know, a lot of us, and I mean, I speak for myself is that I got into this field because there was the appeal of having that autonomy and the challenge and both, you know, intellectually, emotionally, mentally, it’s a tough job, but the people who do it, do it because we want to work hard. And so just making sure that you utilize us to our fullest potential and, and also educate us, you know, take the time, sit down with us and recognizing that, yes, we, we kind of had this more broad education. And so when we are in specialties, you know, sit down with us and say, Hey, like, what do you know about this? And I may say, I’ve never heard of that before. And they’re like, okay, let’s sit down. Let’s talk about the pathology. What do we do? And then you’re, you’re now building me to be a big, even bigger asset to your practice and, and whatnot. To kind of patients, you know, I’ll say that again, the other part of getting into this job is wanting to take care of people and, you know, be a part of being in oncology, or you’re involved in some really, really challenging times for patients and family members. And, you know, just recognizing that even though I’m, I’m not a doctor, I, I have a lot of knowledge, a lot of experience and although you may not come off the bat, trusting me, I, I hope that, you know, patients are willing to give APPs like myself, like Kendra, the opportunity to show you that, you know, we, we really work hard to take good care of our patients. We’re thoughtful from not just a scientific and intellectual perspective, but again, we are also spending most time with our patients, as opposed to the physicians, not to any dig to doctors. They just have other responsibilities, whereas we are strictly clinical. And so our job is to be there for patients. So if you’re calling in with questions, you’re writing in messages, it’s really Kendra and I on, on that side of things, being at the front lines of triaging. So, you know, even if we’re not the doctor, we’re going to get to know you well, and, you know, we’re going to be able to answer your questions, address your concerns and recognize when we can’t, you know, I always tell all of my patients in the beginning of their visit, especially if they’ve never met me before that, you know, I’m, I’m an APP, I’m going to be doing your visit today. If there are questions or issues that I can’t address, I will escalate to the physician. So just to kind of lay that out there. And I think that that does help build some trust.

HELEN: I’m hearing that trust and that confidence coming through. Kendra, anything you want to add for those three audiences there?

KENDRA: I mean, I couldn’t have said it better myself, Sam. That’s fantastic. I think on the other side being for the younger physicians that come in, it’s really the same message, but also a real opportunity for joint learning. And those of us that have maybe been practicing for 10, 20 years, although we’re not physicians, we do have some pearls. We do have some, some tricks up our sleeve and, and we are wanting to learn what they know as well, being fresh in training. And so using each other and really understanding how well we can work together, I think would, is a, is something I would like to highlight for a resident or somebody of our fellow coming out. We can learn a lot from each other and strengthen that team. But I couldn’t really add much to what Sam said about the older physicians, not older, more seasoned physicians.

HELEN: What I’m also hearing from both of you is perhaps it’s not overtly said, but let me identify this for those who are considering what health professions to go into. They know they want to be in one of the fields. They might want to consider learning more about the track to either be a physician associate or a nurse practitioner, that there are other ways to get into clinical care. So you’re both an inspiration. You’re giving me a lot of confidence and I am getting increasingly familiar when I go see a provider, getting much more comfortable. Whoever is answering my questions, if they’re knowledgeable about the answer or if not, they’ll go find the answer. And indeed the team approach, it really seems as though this is a new model, a new model for someone who’s been doing this a long time, but this is today’s model of treatment and care. Thank you. Thank you for making it so much clearer to me and to all the listeners of Talking About Blood. Thank you so much.

KENDRA: Thank you, Helen, for allowing us to spotlight this really great career. We’re lucky. I’m lucky. I feel very lucky to be in it, but thank you for allowing us to discuss it here.

SAM: Yeah, I’ll echo the same. Thank you, Helen, for having us on. And thank you for introducing me to Kendra too. It’s nice to meet someone in the field who’s also just kind of right across the street.

KENDRA: I was going to say, we’ll probably see each other across the street.

SAM: I know.

HELEN: And both of you are, Bill Ayer knows both of you and he’s the one who’s the brains behind and the impetus behind the whole blood project and Talking About Blood, he makes sure that that happens. So moving forward, I’m very enthusiastic about this model of care. Thank you so much.

SAM: You’re welcome. Thanks again.

HELEN: As we just heard from Kendra Church and Sam Neeson, it’s important to think about the entire team approach to care. And that includes the advanced practice professionals, including nurse practitioners and physician associates. To learn more about the blood project and explore its many resources for professionals and trainees and patients, go to thebloodproject.com. I invite you to also listen to my other podcast series. It’s about health communication and that’s at healthliteracyoutloud.com. Please help spread the word about Talking About Blood and the Blood Project. Thank you for listening. Until next time, I’m Helen Osborne.