Andrew Seidman, MD, focuses on his view of the increasing role of nurse practitioners in the outpatient setting and hospitalists in the inpatient setting.
Andrew Seidman, MD
I offer a prespective from the field— the musings of a medical oncologist who has spent a quarter of a century in an academic clinical practice and has witnessed a major evolution, not only in cancer treatment, but also in the models by which we deliver cancer care. Here, I will focus on my view of the increasing role of nurse practitioners (NPs) in the outpatient setting and hospitalists in the inpatient setting. Physician assistants (PAs) also have been integrated into many areas of oncology care, where they make important contributions. I hope that what follows might resonate with you or suggest previously unconsidered opportunities.The American Society of Clinical Oncology projects a shortage of medical oncologists over the next 5 to 10 years, and the demand for visits is expected to increase far above capacity by 2020— to 300% of the available appointment slots.1 Nonphysician practitioners (NPPs) or advanced practice providers (APPs) have increasingly been integrated into clinical care, requiring a thoughtful reassessment of team-based approaches toward optimizing resource utilization and improving the quality of care. Five years ago, the American Academy of Physician Assistants reported that there were approximately 2140 clinically practicing PAs in adult medical, surgical, and radiation oncology subspecialties.2 Similarly, the American Association of Nurse Practitioners reported that of the more than 205,000 licensed NPs in 2013, approximately 2050 worked in oncology.3 These were a median of 48 years of age and had been in practice for an average of 7.7 years.
Medical oncologists face increasing demands in the outpatient clinic that often involve time not spent with the patient. These tasks include composing electronic notes (cutting, pasting, and editing), electronic order entry, electronic billing, maintaining patient medication logs, completing forms for clinical trials (eg, toxicity grading), coordinating multidisciplinary care, communicating with consultants, and “examination tableside” teaching (of medical students, residents, and fellows). In my own journey, I was able to pull all of this off, comfortably (albeit energetically) seeing 4 outpatients per hour at 15 minutes each, completing all necessary orders and documentation in real time, and getting home for dinner.
Indeed, a recent survey of medical oncologist members of my institution’s Solid Tumor Service showed that per patient time has more than doubled compared with 2 decades ago. Each encounter involves preclinic, in-clinic, and postclinic time that adds up to about 40 minutes. The use of APPs has the potential to solve this problem. It has been suggested that “you can get physicians and nurses to work together on the front lines; [but] at the association level, there is a lot of guild protection.”4 Greater leadership among physicians and nurses who are prepared to challenge the “guilds” will likely become central to addressing the complex issues facing the integration of NPPs/ APPs into oncology care.5,6
The integration of an NP into my own practice has been very positive, but it has required me to stretch myself to break with old habits, labor to understand my NP’s capabilities and knowledge base, and—yes—stop being such a control freak. This adjustment is only several months old. I have spoken with many of my oncologist colleagues about their own experiences. As we strive to deliver both high-quality and high-quantity care to outpatients with cancer, it behooves us to critically examine the unmet need, as well as how this transition to APPs has already made a positive impact on the care of patients with breast cancer, both in communitybased and academic medical centers.
I have found that a successful introduction of the NP to an existing or new patient requires a careful, considered approach. It is best couched in the language of teamwork and partnership and should leave the patient with a sense that the engagement is a care enhancement rather than a form of abandonment. Instill confidence. I often expect my NP to return after the encounter, telling me that the patient still wishes to ask me a few questions, but this happens less when a thoughtful transition strategy is employed. We work at the same time, in the same physical location, and share a clinical practice nurse. An early explanation—eg, “You may see Dr Seidman on cycles 1, 3, 5, and 7 of your planned chemotherapy regimen and the nurse practitioner on cycles 2, 4, 6, and 8. We are both here for you always”—can go a long way.Approximately 4.7 million cancer-related hospitalizations and 1.2 million hospital discharges with cancer as the principal diagnosis occurred in the United States in 2009.7 For patients with advanced cancer, the average duration of survival after an unplanned hospitalization is 3 to 5 months.8 As medical oncologists face growing demands in the outpatient setting, there has been an increased focus on using hospitalists in caring for inpatients with cancer.9,10 These experts in hospital-based care processes can provide efficient, organized care by coordinating oncologists, consultants, nursing staff, social work, and case management, offering a unique opportunity for critical analysis of health and care goals for patients with advanced cancer. Hospitalists can diagnose and treat acute illness while putting it into the context of the underlying cancer. They can identify decision makers, clarify health literacy, manage expectations, and provide anticipatory guidance (Table).
An observational retrospective cohort study led to the finding that, compared with medical oncologist—led care, a hospitalist-led inpatient service in an academic hospital had no significant differences in average length of stay, new do-not-resuscitate orders, nosocomial pneumonia, urinary tract infection rates, number of radiographic studies and laboratory tests, or disposition on discharge.10 The study examined 829 patient discharges from August 2012 to January 2013 in the gastrointestinal oncology inpatient teaching service at Memorial Sloan Kettering Cancer Center in New York, New York.
Historically, as a medical oncologist in an academic medical center, I have shared inpatient attending physician care responsibility with other team members, in rotation, spending no more than 4 weeks per year on this activity. Indeed, in recent years, with expansion of faculty, this has become 2 to 3 weeks per year. Just how good can anyone be at something they do for 2 weeks per year? (Witness my skiing ability, for example.) Is inpatient care something you never forget—like riding a bike? Not in my experience. While hospitalists take an increasing role in inpatient care, it is important that the medical oncologist not vanish. Close communication—whether in person, by telephone, or via email—between the hospitalist and primary medical oncologist is imperative to ensure optimal and appropriate care. Critical decisions on cancer management can happen only through continued engagement and may be warranted in the context of critical disease scenarios, infections, thromboses, pain crises, and other reasons for an inpatient stay.
It is high time to examine how collaborative hospitalist-based but medical oncologist—engaged inpatient practice plans may improve patient care and allow medical oncologists to reallocate necessary time toward the growing demand for outpatient services. As the population ages, so will the cancer burden. Given the projections for increased ratios of patients to physicians, NPPs/APPs and hospitalists will undoubtedly play an increasing role in cancer care. This is a trend to embrace—indeed, it takes a village to provide the best cancer care.