Bailey Mars, NP | Saint Luke's Health System
What Exactly is an Advanced Practice Provider (APP)?
The Advanced Practice Provider (APP) spectrum encompasses NPs (Nurse Practitioners), and PA’s (Physician Assistants). The APP term is used to encompass these mid-level healthcare providers, and the term is relatively new to the field. But patients may ask, what exactly is a Nurse Practitioner or a Physician Assistant, and why am I seeing them and not a doctor? Is it OK that I’m not seeing a doctor, and are they qualified to treat me? We know that seeing a healthcare professional in general can be very anxiety-provoking to a lot of people, and adding an unknown provider to that scenario can result in further anxiety, so let’s dig into what an APP, or Advanced Practice Provider is, what they do, how they are qualified, why you may be scheduled to see one, and lastly, why I decided being an NP was the best path for my career.
Both PAs and NPs are being increasingly recognized as an integral component of our healthcare system in the United States. As noted by the American Association of Nurse Practitioners (AANP), “As clinicians that blend clinical expertise in diagnosing and treating health conditions with an added emphasis on disease prevention and health management, NPs bring a comprehensive perspective and personal touch to health care.”¹ All NPs are well educated and must complete either a master’s or doctoral degree in order to practice. This degree requires education consisting of both didactic and clinical competencies. Some NPs may go even further by taking national board testing for certification with either the American Nurses Credentialing Center (ANCC) or the AANP. NPs are held to the same standards as physicians regarding periodic peer review and clinical outcome evaluations, and must adhere to a code for ethical practices.
As noted by the AANP¹ , in addition to their function as healthcare providers, NPs also play a vital roles in mentoring and education, as well as research and administration. Professional standards are maintained, and the role of the NP is also advanced through participation in professional organizations and health policy initiatives.¹ By providing high-quality and patient-centered care and counseling, NPs can also help to reduce the patient burden on primary care physicians and lower health care costs by decreasing ER visits, shortening hospital stays, and decreasing medication costs.¹ As such, NPs fulfill an important adjunctive role in the current healthcare continuum. Healthcare is continually changing and advancing to address the needs of patients. By integrating NPs into this algorithm, patients can be seen in a timely manner, by a well-trained, qualified, and competent provider.
Some Personal Perspective
One of the most frequent questions I am asked is: “Why didn’t you become a doctor?” The short answer to that question that I always reply with is: “I don’t/didn’t want to be a doctor.” There is a profound difference in medicine theory taught in medical school and nursing theory taught in nursing and NP school. Medicine theory focuses on the treatment of a disease. Doctors see an illness, figure out the pathogen and/or underlying condition, and decide on what drug to best treat it with. Nursing theory, on the other hand, involves treating the patient who has the disease. Nurses are trained in holistic care, which involves looking at the whole person in order to determine the best treatment plan. This can mean factoring in social determinates, personal preferences, financial resources, family situations, etc. Nurses and NPs look to make sure that whatever medical intervention required is going to be feasible and sustainable over the long term. Therefore, a collaborative team that integrates both doctors and NPs helps patients get the best of both worlds.
A deep appreciation of nursing theory is why I decided to pursue my advanced degree in the field, and become an NP. I love being a nurse. It is the most rewarding thing (besides being a mother) that I have done in my life. I also knew as a bedside nurse that I wanted to do more, participate more, and help to make decisions. So instead of changing direction and applying to medical school, I stuck with my core values and nursing background to follow my dreams by becoming an NP.
As an NP, I use my nursing and holistic care background not only to care for patients, but to help make medical decisions based on the totality of the person being treated. The physician/NP collaboration provides an optimal balance in both medical decision-making expertise, in addition to a careful consideration of all aspects of the patient’s and life and clinical care plan. As an NP, I love being able to interact and connect with my patients to build rapport, while also helping them to make clinical decisions and improve their treatment plans, and/or manage side effects and symptoms of their treatment.
There are various reasons why you might be scheduled to see an NP, ranging from staff shortages causing patients to be moved to another provider’s schedule, availability, and/or the complexity of your diagnosis. Staffing shortages, for example, are one of the biggest hurdles facing healthcare today. Patients still need to be seen, and if there are fewer doctors available to see them, this inevitably creates longer wait times, reduces patient satisfaction, and increases provider burnout. Fortunately, this is an area where nurse practitioners can help!
Take my role, I work in oncology, where patients are sometimes seen between 2 and 3 times per week, and those visits can last anywhere between 20 and 30 minutes. If you imagine a doctor, who must see 17-20 of these patients a day, with new patients coming every day, you can begin to appreciate the role of the NP. As part of a truly collaborative treatment team, the NP can see patients for follow-up visits and continue the plan of care that the doctor has set into motion. This frees up the doctor who can now see new patients as well as those needing to be seen more often, so they can get the care they need. Another important aspect to appreciate is that the doctors are always available if needed. If something more acute and/or challenging arises that requires a doctor’s attention, the patient will then be transferred to the doctor’s care and seen by them. Because the doctors and NPs can work so closely together, the patient’s care remains seamless.
Role of the NP in Oncology Adverse Event Management
Another area within oncology where nurse practitioners play a vital role is in adverse event management. Oncology treatment is evolving constantly, with new medications coming on to the market all the time, and many promising clinical trials underway. As will all medications, these treatments come with both known and unknown potential side effects. When patients are receiving chemotherapy and experience an unexpected or particularly severe reaction, nurse practitioners are trained to respond. They are educated on the management of various drug-related adverse events, and these skills can aid in keeping the rest of the providers on time with their clinic schedule. Imagine going to see your doctor, who also has several patients receiving some sort of oncologic treatment that day. They may not be scheduled to see the doctor as they are simply there to receive their treatment. The doctor has a normal, albeit packed, schedule, but now, one of their patients has an adverse event that needs attending to. While infusion nurses are also highly trained in these scenarios, without clinical orders, they are unable to administer medications or even transport the patient to the emergency department if needed. Now imagine not one, but two or three of these patients who have had a reaction - and the doctor you are scheduled to see is now pulled in several directions to help with acute incident management. Again, in come the trained nurse practitioners. The NP can give orders and help to manage and resolve the reaction, or in the worst case, advise that the patient be seen in the emergency department for a higher level of care. The doctor is then updated on the incident and can take that into account when planning future treatment. As such, this helps to keep the clinic flowing smoothly, and you still get to see your doctor on time.
Role of the NP in Oncology Palliative Care
In addition to adverse event management, NPs play a large role in palliative care and hospice care within the oncology setting. Palliative care and hospice are often used interchangeably, but this can be especially misleading. Whereas many know hospice care deals with end of life, palliative care on the other hand, is much broader, and ideally starts at the diagnosis of a chronic or terminal illness, such as cancer. Palliative care is an approach to an illness that encompasses the entire person. The goal of palliative care is to “palliate”, comfort, and relieve symptoms. The health system where I currently work has actually moved towards calling this team the “supportive medicine” team, because that is what palliation is. It is providing comfort, support, and relieving symptoms for a chronic or terminal illness, with the goal of continuing treatment. Palliative care and early integration of this team is vital to improving patient outcomes and overall treatment experiences. When patients are in control of their pain or nausea, or whatever side effect is plaguing them, they ultimately feel better and do better. This can also extend to mental health issues such as anxiety and depression, which tend to occur situationally in patients when they receive a life-altering diagnosis. I believe NPs are vital in the role of palliative care as they are trained in holistic care of the patient, which is what palliative care focuses on. NPs in this role are able to focus on the little pieces of the big picture in order to make sure treatment is beneficial. If treatment is given for a cancer, but comes with uncontrolled pain and nausea, there is no quality of life and one can question the point of treatment in the first place. Palliative medicine helps to make quality of life the forefront of treatment, as opposed to just quantity of life. I am very passionate about palliative care and work to integrate this from day one in order to provide my patients with the best treatment experience possible and ensure that their quality of life is one that is acceptable to them. Treatment, after all, is meant to give you more life, but if you cannot live that life in a way that is acceptable to you, then treatment is more of a poison than a cure.
In so many aspects, APPs are a valuable and essential part of modern healthcare. From primary care, to specialties, the education and training of APPs prepares them for a variety of settings and clinical scenarios. Next time you get the chance or are scheduled to see one, I hope you will think about your NP or PA as another member of the healthcare team adding to your care and who may indeed have a different view and a beneficial approach to the care you receive. It could make a world of difference.
¹ What’s a Nurse Practitioner (NP)? Available at: https://www.aanp.org/about/all-about-nps/whats-a-nurse-practitioner Accessed January 13, 2023.