Article In Brief

With the right training, advanced practice providers (APPs) can obtain the knowledge needed to be effective team members in inpatient or outpatient neurology. APPs and neurologists discuss the opportunities for greater training and collaboration.

When they start their first job in neurology, advanced practice providers (APP) may not know how to perform the detailed examination needed to localize the neurological lesion and make a diagnosis. The nuances of headache, spine disorders, multiple sclerosis, and other common neurological conditions may be unfamiliar to them, let alone the treatment options and how to create a specific neurology treatment plan.

Their graduate education trains them well to be generalists in medicine, several physician assistants (PAs) and nurse practitioners (NPs) told Neurology Today in interviews, but that does not necessarily include a focus on neurology.

With the right training, however, they can obtain the knowledge needed to be effective team members in the settinginpatient or outpatient, general neurology or subspecialtyin which they are working, said Robert D. Brown, Jr., MD, MPH, FAAN, chair of the Division of Stroke and Cerebrovascular Disease and professor of neurology at Mayo Clinic College of Medicine.

APP staff members are integral to the care of neurology patients, and that is increasingly the case at small and large neurology practices, he said.

But the right training is key. An AAN survey of APPs practicing in neurology completed in 2018 found that, during their formal APP schooling, 87 percent attended neurology lectures but only 30 percent had a neurology course and just 25 percent had a clinical rotation in neurology.

It's apparent that on-the-job training is essential, Dr. Brown said.

That is the basic approach used for most advanced APPsnurse practitioners and PAsworking in neurology. But every APP's training needs are different, said Jessica Erfan, MPAS, PA-C, APP manager at Ascension Seton. Their graduate education prepares them to be generalists, so their neurology-specific training is limited to what they learned in their previous work experiences.

I think some neurologists have trouble understanding the different backgrounds and that every advanced practice nurse is not the same, every PA is not [the] same, said Erfan, a PA at Seton Brain & Spine Institute in Austin, TX. That can make it difficult when a neurologist wants to hire an APP. They have to factor in the training time [in neurology] to make APPs successful so that ultimately they can become [productive] members of the practice.

That is why training in neurology is a critical need. This past October, the AAN stepped in to help address that need by sponsoring the Academy's first APP conferencea one-day education event that preceded the AAN Fall Conference in October. Approximately 175 PAs, NPs, and clinical nurse specialists attended the conferencefar surpassing the goal of 100 APPs, said Calli Cook, DNP, APRN, FNP-C, chair of the Academy's Consortium of Neurology APPs. Because of the participants' enthusiasm, a multi-day standalone conference for APPs will take place in 2020.

Most attendees at the initial event had been practicing in neurology for three years or less.

APPs who are practicing in neurology are really hungry for information and education, said Bryan Walker, PA-C, associate director for the APP residency program in neurology at Duke University School of Medicine. These are folks who are now coming into the specialty or have been in practice for just a little while they are figuring out what they know and what they need to know.

APPs make up the fastest-growing membership category for the AAN, said Cook, a NP at Emory Brain Health and co-director of the October pre-conference. As of last month, the consortium included more than 1,400 members, up from about 350 when Cook joined just four years ago.

That growth reflects the increasing role that APPs are playing in the delivery of neurological care in both private and academic practices. By working together to deliver team-based care, APPs and neurologists can shorten the waits for patients seeking appointments and make sure all patients get the high-quality care they need, she said.

I see a lot of my physician colleagues really embracing this concept, valuing the APP's role and understanding the positive effect it has on their practice and on their patient population, she said.

When fully trained, APPs and neurologists often work in teams, although there is no standard model for team-based care, Cook said. In some practices, the neurologist sees a patient in the first few visits to establish the diagnosis and create the treatment plan; the APP provides follow-up care, adjusting the treatment plan as needed; the patient is scheduled with the neurologist perhaps once a year or at another routine interval.

Another approach is for the APP to evaluate a patient on their first visit and order the appropriate tests needed for diagnosis. Armed with that information, the neurologist sees the patient on a second visit to establish the diagnosis and treatment plan. In another model, patients are scheduled so that both the neurologist and APP, operating in tag-team fashion, will see each patient during each visit, sharing responsibilities so that high-quality care is delivered in an efficient fashion.

All of these models can be successfulit depends on what works best for the culture that these two people are going to be practicing in together, Cook said.

But attracting APPs to neurology, equipping them with the clinical knowledge they need to succeed and retaining them in the specialty can be a challenge.

AAN President James C. Stevens, MD, FAAN, said neurology education to support APP careers is an essential component to overcoming that challenge.

The need is there, and I think it's our responsibility as an organization to meet these education needs and to show examples of how this team concept of neurologist and APP working together can be done in a successful manner, Dr. Stevens said.

The importance of APPs became clear to AAN leaders when its Workforce Task Force Report, published in 2013, revealed that demand for neurologic services exceeded the supply of neurologists and projected that the shortfall will increase substantially by 2025, Dr. Stevens said.

With too few neurology residency slots available to meet demand, the focus turned to another way to increase patients' access to care.

Many neurologists, who for decades have been utilizing advanced practice providers to help shorten waiting lists, found that it was very successful in doing so and could be done with excellent patient satisfaction concerning their care, Dr. Stevens said.

He was one of them. Since the 1990s, NPs and PAs have worked in his practice, learning their neurologic clinical skills by shadowing him for at least six months before seeing patients on their own.

On-the-job training is common for APPs working in neurology because graduate education programs for NPs and PAs typically provide little or no education specific to the specialty, said Walker, a PA at Duke Neurology.

PA programs are standardized because there is a single accrediting body nationally, he said. During the first year, students take didactic courses which will include, at most, four weeks of neurology content. During the second year, students do clinical rotations and while a neurology rotation may be an option, it is not required. NP programs vary in content because there are multiple accrediting bodies, he said. In general, neurology content is not included in the required curriculum.

In PA programs, neurology education is minimal; in NP programs, it's variable from none to minimal, he said. So we find that folks coming out of either PA school or NP school really have to rely on on-the-job training.

While that worked well for Walker and many APPs, that training model has its limits. For one thing, the variability of on-the-job training may worry inexperienced APPs, who know that neurology is a particularly complex field.

It's challenging, Erfan said. There are a lot of things you have to put together compared to other specialties.

And, unlike physicians, who are tied to the specialty in which they completed a residency, APPs are trained as generalists and can easily move to a different field if they are unsatisfied with their on-the-job training or other aspects of the work, she said.

The AAN wants to address that stickiness issue by increasing the likelihood that APPs working in neurology are pleased with their choice of specialty, Dr. Stevens said.

Many of our members have observed over the years that APPs have a tendency to rotate out of neurology and go to some other specialty or back to primary care, he said. We really want to create a home for them where they can get their academic needs met and be successful in a rewarding career.

Joel C. Morgenlander, MD, FAAN, chief of general and community neurology at Duke University School of Medicine, became interested in creating a formal one-year training program after seeing his fellow neurologists and APPs get frustrated with each other because of unrealistic expectations about what the APPs should be able to do.

An in-depth training program, he believed, would help APPs have greater job satisfactionand longer tenuresbecause they would be able to think like a neurologist.

The hope was that they would feel more comfortable and be a bigger part of the team, working on many aspects of what we do, including patient care, education and research, Dr. Morgenlander said. And that would give our faculty better job satisfaction because they would have valuable partners in practice that they can share patients with as a team.

That has proven to be the case, he said. Now in its fifth year, Duke's Neurology APP Residency program has trained two to three APPs in each class. The program works because our neurology faculty has bought into the concept and is a critical part of the APP resident education, he said.

The APP residents receive a salary but do not bill for any patients.

We see them and treat them as true residents because I felt that to do anything less was doing them a disservice, he said. To keep them in the learner mindset was really important to me.

The residents, who take an online neuroscience course before they join the program, do clinical rotations through the neurology subspecialties and attend the same lectures that neurology residents do. Because their training overlaps, APP and physician residents form relationships that make it easy for them to work together after their training programs end.

This, to me has been a great plus because these are the kind of teams that we need in the future to be successful, Dr. Morgenlander said.

Several APP residents have taken positions in Duke Neurology subspecialty clinics after completing the program. The Duke residency is one of only a handful of APP neurology post-graduate training programs in the country, each of which varies in content and training approach. Dr. Morgenlander is working to encourage other neurology departments at other academic medical centers to establish APP residencies of their own.

The Medical College of South Carolina (MUSC) takes a different approach in its one-year fellowship program for neurology APPs. That program, now in its second year, trains APPs to do outpatient general neurology, said Kimberly Robeson, MD, the program's faculty director.

The program was started to address two challenges: the difficulty of recruiting enough general neurologists to MUSC and the difficulty of onboarding APPs with no experience in neurology.

We don't necessarily have people who have the time to train them, she said.

Dr. Robeson, who also serves as associate program director for MUSC's neurology residency program, said the APP curriculum includes hands-on training and didactic learning. The APP fellows see new patients in mentored clinicsthe APP examines the patient alone, then with the attendingand sees follow-up patients on their own. They shadow APPs working in subspecialty clinics, attend lectures with neurology residents, and have two half-days a week dedicated for studying. Each APP in the first class received AAN membership as part of the fellowship, providing access to online education materials offered by the Academy.

The APP trainees in the MUSC program bill for patient visits, so the program pays for itself, she said.

Meanwhile, the AAN intends to provide increased short-term opportunities for APPs, starting with next year's conference. The standalone conference will be relevant for all APPs, whether they are new as a neurology APP or have been in practice for many years, Dr. Brown said.

Presentations will include neurology fundamentals, including localizing the lesion, anatomical and clinical correlations, and the basics of the neurologic history and exam. Attendees will learn also diagnostic fundamentals, including the appropriate use of neuroimaging studies, EMG, EEG, and other exams, as well as how to read test results and key findings that might be detected.

Excerpt from:
For APPs, Now There Are More Training Opportunities in... : Neurology Today - LWW Journals