Show notes
"There are different types of advanced practice providers that you may meet in an oncology practice - PAs, APRNs, NPs, but what's the difference between them? In the second episode of ASCO Education's podcast series on Advanced Practice Providers (APPs), co-hosts Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guest speakers, Leslie Hinds (Centura Health), Martin Clarke (Arizona Oncology), and Kathleen Sacharian (Main Line Health), break down the differences and similarities between physician assistants and advanced practice registered nurses, share what their days might entail in each of these roles in an oncology practice, as well as address some common misconceptions surrounding these types of APPs. Duration 35:52. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org." TRANSCRIPT Dr. Stephanie Williams: Hello and welcome to ASCO Education's Podcast Series Advanced Practice Providers, APP 101: Physician Assistants and Advanced Practice Registered Nurses in Oncology. I am your co-host, Dr. Stephanie Williams, with physician assistant, Todd Pickard. Today, we are joined by Leslie Hinds and Kathleen Sacharian, both of whom are nurse practitioners, along with physician assistant, Marty Clarke. All three of today's guests are a part of the APP Task Force. Thank you all for being on our panel today. Leslie, Kathleen, and Marty, could you please tell our audience a little bit about yourselves, starting with you, Leslie? Leslie Hinds: Good morning! I am a nurse practitioner in the Denver, Colorado area and I am in community practice. Kathleen Sacharian: Good morning, everybody! I'm Kathleen Sacharian, and I'm an oncology nurse practitioner. I've had over 20 years of experience in both academics setting and community practices in the Philadelphia area. Marty Clarke: Hello, everyone! I'm Marty Clarke. I'm in Tucson, Arizona. I've got closer to 30 years of practice in general medical oncology, as well as a fairly lengthy stint in cancer psychiatry. I'm also a clinical psychologist. Dr. Stephanie Williams: Thank you all. Today's episode will be a deeper dive into the specifics of what physician assistants and advanced practice registered nurses or nurse practitioners do on a day-to-day basis in an oncology practice, as well as addressing some common misconceptions of what PAs, APRNs, NPs do in practice. So, jumping right in, I'd like to ask you all to shed some light on the general differences between a physician assistant and an advanced practice registered nurse or nurse practitioner. Who would like to start? Todd Pickard: I'll get the ball rolling. This is Todd. This is a great question. It's one that people ask a lot, you know, what is the difference? And honestly, in the clinical setting, there really is no difference. When you see an advanced practice provider, whether they be an APRN or a PA, you're going to get the same kind of team-based care with quality and safety and that really focuses on the totality of the patient. PAs and NPs arrive to their clinical work from different educational perspectives. But the work we do really is the same high-quality level of care. I'll defer to my colleagues to add some to that conversation. Leslie Hinds: Yeah, I would agree with you, Todd, that in practice, NPs and PAs provide the same quality of care and the same type of care but our education and background is oftentimes different from a nursing role versus a medical role. Kathleen Sacharian: I'll add that, you know, I think when we think about some of the main differences, really focusing, as Leslie said, like how are we prepared? How are we trained? A nurse practitioner is typically a registered nurse with a bachelor's degree and then goes back for a graduate degree in either a Master of Science in Nursing or a Doctorate in Nursing Practice. And typically, some of the main educational differences in a nurse practitioner role are that their focus in education is population-based, meaning it's based on a specific patient population or health condition. So, you might have an adult gerontology nurse practitioner or a pediatric nurse practitioner. Marty Clarke: Kathleen, I have a daughter that happens to be a GYN oncology nurse practitioner. And so, her focus is a little different than mine but it's always fun when she reminds me how much smarter she is in certain areas. Dr. Stephanie Williams: Just from my standpoint as a poor old physician here, are there differences from state to state between what you guys can do? That's one question. Two, your histories are so different in terms of how you came to become PAs, how the field of PAs and how the field of nurse practitioners developed, which is, in my opinion, very fascinating. So, I wonder if there are any comments on any of those issues? Todd Pickard: Yes, Stephanie. That's a great question. I was just thinking about how really, when people see differences between APRNs and PAs, it's generally because of state law or an institutional policy. And that's what's very unique about advanced practice providers is that their practice can vary wildly from state to state, unlike physicians, who basically have one standard national type of practice. An APP in Texas looks very different than an APP in New York or Alaska or Hawaii or Mississippi. And so, you do have to be very cognizant of the fact that it is important to be aware of what each state says or what even individual institutions say. Leslie Hinds: At my institution, physician assistants are not allowed to supervise infusion, which is a big part of medical oncology. So, unfortunately, in my practice, we have nurse practitioners only and have been unable to hire PAs because of that limitation. Dr. Stephanie Williams: So, these institutional guidelines, are they based on state regulations or just based on current practices at those institutions? Kathleen Sacharian: Well, I think it's really dependent on the institutional experience, you know, there might be a large academic center that has a very well-developed advanced practice provider program compared to maybe a smaller community practice that has one nurse practitioner or PA. So, I think the experience with the individual institution or clinic, but overall, that really is dictated by the state licensure and regulations. So, that is the first thing that needs to be looked at when considering these roles and responsibilities of advanced practice providers. Todd Pickard: Stephanie, you bring up a very good point, which is whenever an institution or an individual practice takes a position, it's always good to explore the 'why'. Is this customary? Is it a habit we've been in? Or is it based simply on a misunderstanding or even a preference? Many times, when you go to explore these things, you'll find that it's either a misunderstanding or a preference. It's not because something is required that way. At my institution, for the longest time, we only hired nurse practitioners on the inpatient side, because somebody thought that PAs didn't learn how to take care of patients in the hospital. And we had to have a conversation. I said, "No, actually, when I was in PA school, I actually had to sleep in the hospital, and for 6 weeks on my inpatient medicine rotation, so that I could give care 24 hours a day." So, no, we are trained there. So, it was completely a misunderstanding. And so, I think that's why it's very important that you have advanced practice providers who are part of your leadership in your governance, so they can help you craft good practices, good policies, top of license practice so that you really maximize all the team members. Marty Clarke: All these points are really poignant. The example of PAs not being able to oversee infusions, that probably stems out of an assumption that PAs, unlike oncology nurses that then become NPs, are more qualified somehow for infusion. And it goes back, I think, to what we talked a little bit about the training, where PAs are trained in the medical model. There are assumptions that are made around that that sometimes are not correct, just as the nurses are trained under nursing theory. And there are assumptions that are made around that. In my practice, there's a belief that the nurses can't function in the hospital, which is, you know, kind of ironic to me. And I think it's an assumption based on their training and an incorrect assumption. So, again, Todd, you're right. You need leadership and an open mind to this and also, you've got to pay close attention to what the individual, you know, state laws are, but they're more similar than they are different, I would say. Dr. Stephanie Williams: Just as a for instance, guys, I practiced for several years in the state of Michigan, the law has changed now, thankfully, but I had a combination of nurse practitioners and physician assistants, and my nurse practitioner, by law, could not order a consult for physical therapy, only my physician assistants can. So, I think it gets frustrating for physicians, because then how do I know what a PA can do and what an NP can do if, you know, I go to Illinois now and I practice under a different set of state laws. When I started in my career over 30 years ago, PAs were quote, "surgical", they held retractors, they stitched people up, they did our urology consults for instance and put Foleys in. And nurse practitioners were more bedside, taking care of patients. I think some of that has changed. But I don't know if you guys have any comments, how does a physician who's in practice in the rural community, and a more cosmopolitan community and academia, how do these things differ in your daily day-to-day routines? Todd Pickard: This is a great transition, you know, Stephanie, that's a very salient point, is really to take a little bit of a deeper dive into thinking about how PAs and APRNs are trained. So, Marty, we'll get you to say a little more about PAs, and then Kathleen and Leslie a little bit more about the APRNs. But generally speaking, PAs attend schools which are generally housed in medical schools. And so, we share the same faculty, we rotate with the medical students, sometimes we take the same courses as the medical students, and we're really trained in that medical model, which is basically a little bit of everything, the same thing as medical students. And one thing that we have included in our training, which is different than nurse practitioners and APRNs, generally speaking, is we have surgical training, not to say that APRNs cannot be in the OR, they do some extra training as an RN first assist certification for that type of role. But for PAs, that's just simply built into our training. And the reason that PAs are trained in this way is, you know, because we have our background in the military. In the military, we were part of the medical units. We were field medics. And then, after folks started coming back from their military service, they realized there really wasn't any civilian role for those highly trained folks. So, some physicians at Duke University created the PA profession. And of course, they built it to work alongside physicians. So, they taught them the only way that they know how, which is the medical model, which is how they were trained, and it's interesting that PAs and nurse practitioners were born in the same year, 1965, but just in two different parts of the country. So, Leslie, Kathleen, tell us a little bit more about the training that you receive, and why does the population model matter? Kathleen Sacharian: So, I'd say when you think about the nurse practitioner, you know, typically, and not always, but a lot of times, they'll have some registered nursing experience. And then, they decide to go back for an Advanced Practice degree. They choose a specialty based on interests, so that might be Adult-Gerontology or a Pediatric focus. So, we're really focused and trained clinicals, you know, all of that training is really built around that population focus. So, once you graduate, national certification, and licensure is then required. It really then takes on what happens next of roles and responsibilities, I think really goes into the training, the onboarding, and training of the provider, is a lot of times, you know, built into that on-the-job training. There might be fellowships that the nurse practitioner is a part of. For example, there's a lot of new oncology fellowships that are coming out for advanced practice providers, which really gives them a good additional focused training to be able to be ready to provide that advanced practice care for oncology patients. Leslie, I don't know if you have anything to add to that. Leslie Hinds: Yeah, I agree with the background and the education. you know, there are a lot of different specialties that you can graduate with an Advanced Practice Nursing degree, and I completely agree that most of the education for practice is learned after graduation. And then, you learn the specialty that you're interested in, or family practice, whatever you choose to do, but the education that you receive after graduation is mainly affecting your practice. Marty Clarke: Leslie, I really agree with what you were saying about, regardless of your training model, what really happens in my experience working with PAs and NPs is that you develop a way of practicing that is consistent and congruent with how the team that you're on practices, whether it's just you and a physician, that's a team, and you develop a pattern of practice that is complementary. And I think that both PAs and NPs, at least in my experience, are able to make those adjustments on the fly, really. Having said that, there are times that I'll have questions about a patient I'm seeing. And in my practice, I can go to a PA or to an NP, and there are times that I'll go to one of the NPs because they have a just a little different flavor, a little different take on something that I think might help me sort things out a little better. Other times, I'll choose to go to a PA because I know that their training is going to lend itself to kind of my way of thinking. The medical model piece is to me an advantage and a disadvantage, and here's how I mean that. One of the things I tell the oncologists I work with, when they're looking for us to see a certain number of patients in a certain period of time, they're operating out of their experience. And because of their training, they can see to the bottom of the bucket faster than I can, and faster than any of my peers can be it PAs or NPs. So, I'm constantly reminding the oncologist one of the things that we all bring to the table as APPs is a little more time with the patient. But the medical model sort of is focused on the biological, the pathological aspects of what's going on with the patient. The personhood often becomes after that. And that's sometimes why I'll go to an NP because a lot of times that personhood is closer to the surface with them. So, my personal experience with the medical model, when I applied to get into the clinical psychology program, I was told, "We can't let you in this program because you've been taught in a medical model, you think in a medical model, and you'll never unlearn that enough to be a good psychologist." And I had to beg and plead with them for an opportunity to prove them wrong. And fortunately, I guess I said something that allowed me to do that, but they were right, it w…
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