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.
Integrating an NP Into a Medical Oncology Practice
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.