Practical Radiation Oncology (2012) 2, e31–e37
www.practicalradonc.org
Original Report
Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center Marc Moote MS, PA-C a,⁎, Richard Wetherhold BSE b,† , Karin Olson PhD, PA-C c , Rachel Froelich BSE b , Nadia Vedhapudi b , Kathy Lash BS, RT (R)(T)c , Sheri Moore MSIE d , James A. Hayman MD, MBA c a
Office of Clinical Affairs, University of Michigan Health System, Ann Arbor, Michigan Industrial & Operations Engineering Program, University of Michigan, Ann Arbor, Michigan c Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan d Program and Operations Analysis, University of Michigan Health System, Ann Arbor, Michigan b
Received 29 February 2012; revised 19 March 2012; accepted 23 March 2012
Abstract Purpose: To assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization. Methods and Materials: A workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow. Results: Nearly half (46%) of physician extender time was spent performing indirect patient care. Physician extenders performed most (84.3%) of the first encounters for follow-up appointments; however, these patients were seen independently by physician assistants (PAs) and nurse practitioners (NPs) only 51% of the time. Physician extenders perceived their utilization within the department would be improved with well-defined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%). Conclusions: This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization. © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Supplementary material for this article (http://dx.doi.org/j.prro.2012.03.009) can be found at www.practicalradonc.org. Sources of support: This study was funded by the University of Michigan. Conflicts of interest: None. ⁎ Corresponding author. University of Michigan Hospitals and Health Centers, Office of Clinical Affairs, C201 Med Inn Building/0825, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0825. E-mail address: [email protected] (M. Moote). † Co-first author. 1879-8500/$ – see front matter © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.prro.2012.03.009
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Introduction
Practical Radiation Oncology: October-December 2012
were divided among 3 workload task categories: direct patient care, indirect patient care, and miscellaneous. Direct patient care consisted of touch-time tasks spent directly with patients. These tasks included the following: consult appointments in the department; consult appointments in a multidisciplinary clinic (outside of radiation oncology); follow-up appointments; and on-treatment visits. Indirect patient care consisted of patient non-touch time tasks required for patient care such as dictation (performing and editing), ordering and interpreting laboratory and radiographic studies, clinic preparation, discussing patient care with physicians, and patient phone calls. The miscellaneous category was designated for other tasks not directly related to patient care such as checking schedules, both clinical and nonclinical emailing, and personal breaks.
Demand for oncology services will increase dramatically over the next decade, driven by the aging population, increasing cancer rates, increased cancer survivorship, and the diversification of the US population.1,2 Similarly, the demand for radiation therapy will increase 22% by 2020, a growth in demand increasing 10 times faster than the supply of radiation oncologists.2 If indications for radiation therapy expand, demand could increase by more than 30%, further straining the supply of radiation oncologists. Physician extenders (physician assistants [PAs] and nurse practitioners [NPs]) have been identified as one solution to meet projected health care provider shortages.3-6 Over two-thirds of oncologists have previously reported that employing PAs and NPs benefits their practice by increasing efficiency, improving overall patient care, increasing physician satisfaction, increasing physician time for more complex cases, and increasing physician time for clinical research.7 At present it is estimated that only 2.4% of PAs and 1% of NPs currently practice within oncology.7 According to recent estimates, the percentage of PAs practicing in radiation oncology is even smaller (0.3%).8 There are no data on how many NPs work in radiation oncology.9 Understanding that most specialties face similar provider shortages, competition for PAs and NPs will likely intensify, underscoring the importance of optimizing utilization of this limited supply of providers. The purpose of this study was to assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization. This study could serve as a model for future studies in other practices and specialties.
The patient flow analysis data were collected February 14, 2011 through March 11, 2011. Follow-up appointment patients received a form (Appendix B, Fig e2; available online only at www.practicalradonc.org) on a clipboard with an electronic clock upon appointment check-in. Initial start times were prerecorded by the clerks. Patients then filled in the type of medical staff participating in their care throughout the duration of the appointment along with associated start and end times. If necessary, the clerks recorded the final appointment end time at check-out. Data from fully or partially completed forms were used to calculate median wait times between each medical staff encounter and median process times for each medical staff encounter as well as to create a value stream map of the movement of patients through the department.
Methods and materials
Formal interviews
In February and March 2011, a workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow.
Formal interviews were conducted individually by undergraduate engineering students over 3 weeks (February 22, 2011 through March 18, 2011), with the physicians, a chief resident, and the physician extenders. Two standardized interview scripts were used; 1 for physicians and 1 for the physician extenders, and included both quantitative ranking questions and qualitative open-ended questions.
Physician extender workload analysis The workload analysis occurred February 14, 2011 through February 18, 2011 and March 7, 2011 through March 11, 2011. Task allocation data among physician extenders were collected utilizing the Physician Extender Workload Analysis form (Appendix A, Fig e1; available online only at www.practicalradonc.org). The physician extenders wore beepers set to randomly alarm approximately 4 times per hour, prompting them to record the primary task they were performing by placing a tally mark in the appropriate box on the collection form. The tasks
Patient flow analysis for follow-up appointments
Results Physician extender workload analysis At the time of data collection, 5 physician extenders were employed; 4 PAs and 1 NP. One PA was a new graduate hired the same month data collection began, and was therefore excluded from data analysis. This resulted in
Practical Radiation Oncology: October-December 2012
PA and NP utilization in radiation oncology
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extender time. The tasks receiving highest utilization were follow-up appointment-physical exam and history (16%), dictation (general) (10%), and clinic prep (9%). Taken together, follow-up appointment-physical exam and history and follow-up appointment-medical decision making accounted for 24% of the total workday, and dictation (general plus editing) accounted for 18% of the total workday. New patient consult visits accounted for 3.3% of time (range, 0.0%-6.1%).
Patient flow analysis for follow-up appointments
Figure 1 Overall percentages and minutes/8.5 hour workday for workload task categories. Misc., miscellaneous.
data on 4 physician extenders: 3 PAs and 1 NP. Mean experience practicing in Radiation Oncology was 4.75 years (range, 4-7 years). Figure 1 illustrates physician extender time allocation. Nearly half (46%) of physician extender time was spent performing indirect patient care. Figure 2 provides the top 10 tasks performed throughout the workday. Collectively, these top 10 tasks comprised 72% of total physician
A total of 259 patients were seen in follow-up appointments. A total of 131 (50.6%) patient-completed forms were appropriate for analysis; 79 fully completed (60.3%) and 52 partially completed (39.7%). Figures 3A and 3B depict patient flow through the radiation oncology department during follow-up appointments. After their vitals were taken, patients had 1, 2, or 3 medical encounters, consisting of various combinations of attending physicians, residents, physician extenders, nurses, and medical assistants. More medical staff encounters resulted in longer appointment durations (Table 1). In most cases, as the encounter number increased the duration of each subsequent encounter decreased. The first medical encounter was performed by the physician extender 84.3% of the time; 49% of
Figure 2 Top 10 overall physician extender tasks by percentages of workday, with estimated minutes/workday. Appt., appointment; Misc., miscellaneous.
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Practical Radiation Oncology: October-December 2012
Figure 3 Patient flow through the radiation oncology department during follow-up appointments. (A) First half of value stream map of patient flow process. (B) Second half of value stream map of patient flow process. W/T, wait time; P/T, process time; μ, mean; σ, standard deviation; X, median; min, minimum; max, maximum; N, sample size; MA, medical assistant; MD, physician; RN, nurse; MA, medical assistant; PA/NP, physician assistant/nurse practitioner (physician extender); R, resident.
Practical Radiation Oncology: October-December 2012 Table 1 Wait times, process times, and total time associated with the number of medical encounters Time
1 Encounter 2 Encounters 3 Encounters
Median wait 18 time (min) Median process 19 time/direct patient care (min) Median total 37 time (min)
25
27
25
29
50
56
these patients stayed for a second encounter with an attending physician.
Formal interviews Nine of 10 physicians, 1 of the chief residents, and all 5 physician extenders were interviewed. Physician extenders and physicians agreed that physician extenders were utilized primarily for follow-up appointments. Other duties reported by physician extenders included new patient consults, treatment planning, ordering and evaluating laboratory and radiographic tests, patient phone calls, ontreatment visits, paperwork such as disability forms and prior authorizations, scheduling, dictations, and prescription writing. Physician extenders perceived their utilization within the department would be improved with welldefined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). In addition, the physician extenders stated that they would like to spend more time in clinical research (40%) and correspondingly less time on disability and prior authorization paperwork (80%) and on dictation (40%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%).
Discussion It is clear from this study that radiation oncology physician extenders in our center are currently being utilized primarily for follow-up appointments. Presumably, this allows physicians more time to see new patients thereby allowing for faster initiation of treatment and to complete more complex clinical tasks such as new patient evaluations and simulation and treatment planning. In theory, this should also result in increased revenue. A study comparing a common indicator for productivity (such as work relative value units) between a team using
PA and NP utilization in radiation oncology
e35
physician extenders in radiation oncology with a control group using only physicians could confirm this hypothesis. Similarly, the use of physician extenders also allows physicians more time for academic pursuits such as research and education. The results of our current study validate the need for clearer expectations regarding the roles and training of physician extenders in the department. In addition to increasing utilization, designing PA and NP roles that include new patient consultations, treatment planning, simulation, and research within radiation oncology will be important for provider satisfaction and retention. We recommend that radiation oncology practices develop clear physician extender expectations, role descriptions, competencies, and a training plan prior to integrating physician extenders into a practice. Physician expectations related to proper utilization and delegation of physician extenders should also be standardized within practices that choose to employ PAs and NPs. Within our radiation oncology department, both physicians and physician extenders agreed that the utilization of the physician extenders across physicians was not standardized. Four of the 5 physician extenders felt that their utilization would improve with more clearly defined job descriptions and expectations, something that was never delineated prior to the initial integration of PAs and NPs into the department. Both physicians and physician extenders agreed that PA and NP utilization would improve with increased training. Employing an educational model that promotes growth through lectures, seminars, hands-on training, mentoring, and graded clinical responsibilities over time has been shown to foster physician extender development and improve retention.10 Similarly, both physicians and physician extenders felt utilization could improve with expanded clinical roles such as greater extender involvement in treatment planning and new patient consultations, duties not uncommon in other radiation oncology practices. In 1997, a nationwide survey revealed that PAs and NPs were most likely to perform tasks traditionally performed by physicians.11 PAs were more likely than NPs to obtain patient histories for consultations; 90% vs 57%, respectively. Similarly, PAs were more likely than NPs to perform physical examination for consultation patients, on treatment patients, and follow-up patients (80% vs 42%, 80% vs 74%, and 70% vs 57%, respectively). Other common responsibilities reported by PAs and NPs in this study included ordering laboratory studies and radiology studies, prescribing medications, educating patients, and participating in quality improvement initiatives. While 0 respondents reported that they performed simulation independently, approximately 25% had at least some simulation duties. Similarly, in a 2005 survey of radiation oncology NPs, duties reported included symptom management outside of weekly treatment visits (100%), conducting weekly treatment visits (93%), seeing patients
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in follow-up (90%), performing histories and physicals (78%), participating in hospital admissions (48%), inpatient care (44%), research (28%), management (32%), and performing simulation (26%).9 While involvement in new patient consultations and treatment planning in our study was less common, some extenders in our study were more involved in new patient consultations and treatment planning than others, primarily due to physician preference. This therefore can easily be modified by addressing physician behavior. Time spent in direct patient care accounted for only 32% of physician extender time, representing an opportunity for role enhancement in our academic system. Increasing time spent in direct patient care by PAs and NPs would yield higher billable revenue and return on investment.12 Additionally, while the physician extenders performed most (84.3%) of the first encounters for followup appointments, these patients were seen independently by PAs and NPs only 51% of the time. Additional encounters led to increased patient wait time and decreased patient throughput. Efforts within academic radiation oncology practices should focus on decreasing average appointment length, which should have a positive effect on both patient satisfaction and overall volume. This may be accomplished, in part, by increasing the volume of independent patient visits provided by physician extenders. Alternatively, if a shared service model is employed, academic practices should ensure that overall combined PA/NP plus physician revenue is net positive, with the total collections more than compensating for the costs plus overhead associated with the team. Future studies could include billable productivity measures such as gross charges or work relative value units, inclusive of physician productivity to ensure that use of physician extenders actually extends physician practice by increasing overall volume and revenue. Other benefits of employing PAs and NPs, such as increased time for research and other academic pursuits, will be more difficult to quantify, particularly financially. Nearly half of physician extender time in our study was spent on indirect care activities, including evaluating laboratory and radiographic test results, communicating with patients, discussing patient care and test results with attending or referring physicians, dictating and editing, preparing for upcoming clinics, triaging patient phone calls, and scheduling. Dictation and editing dictations accounted for 18% of total work time within this study. PAs and NPs see the majority of patients in the department, either independently or in conjunction with a physician, and they dictate 100% of the encounters in which they participate. They also dictate notes from phone triage encounters as well as test results. At least 80% of physician extenders in our study stated that they spend too much time on paperwork and tasks such as scheduling, prior authorizations, and calling in prescriptions that could be performed by lower cost personnel. Academic medical
Practical Radiation Oncology: October-December 2012
centers seeking to increase PA and NP productivity and improve utilization within radiation oncology should reduce PA and NP time spent in indirect patient care and other duties, particularly indirect care tasks that can be performed by other staff members such as nurses, medical assistants, and clerks. Care should be taken to ensure that PA and NP assigned roles, tasks, and functions represent services that would otherwise require a physician. Physician extenders in our study spent only one-third of their work time in direct patient care, and only onehalf of the patient visits were performed independently. This may be the result of physician preference and delegating style. It has previously been reported that physicians have inherent biases about the abilities of nonphysician clinicians to perform functions usually performed by residents in an academic medical center, potentially resulting in underutilization within academic settings.13 Equally likely is that the educational mission of an academic practice, in contrast to a community practice, may result in different roles for physician extenders. There are duties and responsibilities which physician extenders are qualified to perform but may be tasks that physicians in training need to perform in order to properly learn, and depending on the total volume of such tasks may result in fewer opportunities for physician extenders to perform those activities. In our physician interviews, 4 of 9 physicians interviewed (44.4%) stated that PAs and NPs are often not utilized for certain tasks specifically because of the need to allow residents to perform tasks as a part of their education. Ultimately, the goal of a practice employing PAs and NPs should be to optimize their utilization through judicious delegation of physician equivalent work. Subspecialty fields such as radiation oncology also need to commit to education and training in order to maximize their efficacy and contribution to the practice. The primary limitation of this study is the small sample size and the uncertainty as to how representative the sample is of the population as a whole. In addition, this was a single center study within an academic medical center environment. It is possible that assigned duties and utilization patterns within our study population differ from those in nonacademic settings. The limited period of data collection may not be reflective of the entire year. As such, these data may not be reflective of the full scope of physician extender duties and functions. As an example, new patient consults and treatment planning, commonly performed by some physician extenders in our center, was not reflected in our data due to fluctuations in the schedules that occurred during the 2 weeks of data collection. Also, the work delegated to the physician extenders in the department is physician driven. Consequently, physician attitudes greatly impact delegated roles, level of functioning, amount of training, and ultimately the return on investment from PAs and NPs. Despite these limitations, this study provides important information on
Practical Radiation Oncology: October-December 2012
physician extender utilization in an academic radiation oncology practice.
Conclusions This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization.
Acknowledgments The authors wish to thank Theodore S. Lawrence, MD, PhD, Isadore Lampe Professor of Radiation Oncology, and Chair of the Department of Radiation Oncology, University of Michigan Health System for critical review of this manuscript.
References 1. Erikson C, Salsberg E, Forte G, Bruinooge S, Goldstein M. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Practice. 2007; 3:79-86. 2. Smith BD, Haffty BG, Wilson LD, Smith GL, Patel AN, Bucholz TA. The future of radiation oncology in the United States from 2010 to 2020: will supply keep pace with demand? J Clin Oncol. 2010;28: 5160-5165.
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3. Singer AD, Swenson D, Wilcox G, et al. Confronting the Hospitalist Workforce Shortage. Available at: http://www.phoenixgroupwhitepaper. com/docs/confronting_hospitalist_workforce_shortage.PDF. Updated February, 2008. Accessed September 4, 2010. 4. Hooker RS. Physician assistants and nurse practitioners: the United States experience. Med J Aust. 2006;185:4-7. 5. Gordon CR, Axelrad A, Alexander JB, Dellinger RP, Ross SE. Care of critically ill surgical patients using the 80-Hour Accreditation Council of Graduate Medical Education Work-Week Guidelines: a survey of current strategies. Am Surg. 2006;72:497-499. 6. Iglehart IK. Revisiting duty-hour limits – IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359: 2633-2635. 7. Association of American Medical Colleges. Forecasting the supply of and demand for oncologists: a report to the American Society of Clinical Oncology (ASCO) from the AAMC Center for Workforce Studies. Available at: http://www.asco.org/ASCO/Downloads/ Cancer%20Research/Oncology%20Workforce%20Report% 20FINAL.pdf. Accessed August 2, 2011. 8. American Academy of Physician Assistants. 2009 National Physician Assistant Census Report. Available at: http://www.aapa. org/images/stories/Data_2009/National_Final_with_Graphics.pdf. Accessed May 5, 2011. 9. Carper E, Haas M. Advanced practice nursing in radiation oncology. Semin Oncol Nurs. 2006;22:203-211. 10. Russel JC, Kaplowe J, Heinrich J. One hospital's successful 20-year experience with physician assistants in graduate medical education. Acad Med. 1999;74:641-645. 11. Kelvin JF, Moore-Higgs GJ. Description of the role of nonphysician practitioners in radiation oncology. Int J Radiat Oncol Biol Phys. 1999;45:163-169. 12. Moote M, Nelson R, Veltkamp R, Campbell D. Productivity assessment of physician assistants (PAs) and nurse practitioners (NPs) in oncology within an academic medical center. [e-pub ahead of print March 13, 2012]. J Oncol Pract. doi:10.1200/JOP.2011. 000395. Accessed March 22, 2012. 13. Abrass CK, Ballweg R, Gilshannon M, Coombs JB. A process for reducing workload and enhancing residents' education at an academic medical center. Acad Med. 2001;76:798-805.
www.practicalradonc.org
Original Report
Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center Marc Moote MS, PA-C a,⁎, Richard Wetherhold BSE b,† , Karin Olson PhD, PA-C c , Rachel Froelich BSE b , Nadia Vedhapudi b , Kathy Lash BS, RT (R)(T)c , Sheri Moore MSIE d , James A. Hayman MD, MBA c a
Office of Clinical Affairs, University of Michigan Health System, Ann Arbor, Michigan Industrial & Operations Engineering Program, University of Michigan, Ann Arbor, Michigan c Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan d Program and Operations Analysis, University of Michigan Health System, Ann Arbor, Michigan b
Received 29 February 2012; revised 19 March 2012; accepted 23 March 2012
Abstract Purpose: To assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization. Methods and Materials: A workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow. Results: Nearly half (46%) of physician extender time was spent performing indirect patient care. Physician extenders performed most (84.3%) of the first encounters for follow-up appointments; however, these patients were seen independently by physician assistants (PAs) and nurse practitioners (NPs) only 51% of the time. Physician extenders perceived their utilization within the department would be improved with well-defined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%). Conclusions: This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization. © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Supplementary material for this article (http://dx.doi.org/j.prro.2012.03.009) can be found at www.practicalradonc.org. Sources of support: This study was funded by the University of Michigan. Conflicts of interest: None. ⁎ Corresponding author. University of Michigan Hospitals and Health Centers, Office of Clinical Affairs, C201 Med Inn Building/0825, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0825. E-mail address: [email protected] (M. Moote). † Co-first author. 1879-8500/$ – see front matter © 2012 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.prro.2012.03.009
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Introduction
Practical Radiation Oncology: October-December 2012
were divided among 3 workload task categories: direct patient care, indirect patient care, and miscellaneous. Direct patient care consisted of touch-time tasks spent directly with patients. These tasks included the following: consult appointments in the department; consult appointments in a multidisciplinary clinic (outside of radiation oncology); follow-up appointments; and on-treatment visits. Indirect patient care consisted of patient non-touch time tasks required for patient care such as dictation (performing and editing), ordering and interpreting laboratory and radiographic studies, clinic preparation, discussing patient care with physicians, and patient phone calls. The miscellaneous category was designated for other tasks not directly related to patient care such as checking schedules, both clinical and nonclinical emailing, and personal breaks.
Demand for oncology services will increase dramatically over the next decade, driven by the aging population, increasing cancer rates, increased cancer survivorship, and the diversification of the US population.1,2 Similarly, the demand for radiation therapy will increase 22% by 2020, a growth in demand increasing 10 times faster than the supply of radiation oncologists.2 If indications for radiation therapy expand, demand could increase by more than 30%, further straining the supply of radiation oncologists. Physician extenders (physician assistants [PAs] and nurse practitioners [NPs]) have been identified as one solution to meet projected health care provider shortages.3-6 Over two-thirds of oncologists have previously reported that employing PAs and NPs benefits their practice by increasing efficiency, improving overall patient care, increasing physician satisfaction, increasing physician time for more complex cases, and increasing physician time for clinical research.7 At present it is estimated that only 2.4% of PAs and 1% of NPs currently practice within oncology.7 According to recent estimates, the percentage of PAs practicing in radiation oncology is even smaller (0.3%).8 There are no data on how many NPs work in radiation oncology.9 Understanding that most specialties face similar provider shortages, competition for PAs and NPs will likely intensify, underscoring the importance of optimizing utilization of this limited supply of providers. The purpose of this study was to assess the utilization of physician extenders working in radiation oncology in an academic medical center and to identify opportunities to improve their utilization. This study could serve as a model for future studies in other practices and specialties.
The patient flow analysis data were collected February 14, 2011 through March 11, 2011. Follow-up appointment patients received a form (Appendix B, Fig e2; available online only at www.practicalradonc.org) on a clipboard with an electronic clock upon appointment check-in. Initial start times were prerecorded by the clerks. Patients then filled in the type of medical staff participating in their care throughout the duration of the appointment along with associated start and end times. If necessary, the clerks recorded the final appointment end time at check-out. Data from fully or partially completed forms were used to calculate median wait times between each medical staff encounter and median process times for each medical staff encounter as well as to create a value stream map of the movement of patients through the department.
Methods and materials
Formal interviews
In February and March 2011, a workload analysis and patient flow analysis were conducted on physician extenders employed by the University of Michigan Health System Radiation Oncology Department in order to better understand their utilization and impact on patient flow.
Formal interviews were conducted individually by undergraduate engineering students over 3 weeks (February 22, 2011 through March 18, 2011), with the physicians, a chief resident, and the physician extenders. Two standardized interview scripts were used; 1 for physicians and 1 for the physician extenders, and included both quantitative ranking questions and qualitative open-ended questions.
Physician extender workload analysis The workload analysis occurred February 14, 2011 through February 18, 2011 and March 7, 2011 through March 11, 2011. Task allocation data among physician extenders were collected utilizing the Physician Extender Workload Analysis form (Appendix A, Fig e1; available online only at www.practicalradonc.org). The physician extenders wore beepers set to randomly alarm approximately 4 times per hour, prompting them to record the primary task they were performing by placing a tally mark in the appropriate box on the collection form. The tasks
Patient flow analysis for follow-up appointments
Results Physician extender workload analysis At the time of data collection, 5 physician extenders were employed; 4 PAs and 1 NP. One PA was a new graduate hired the same month data collection began, and was therefore excluded from data analysis. This resulted in
Practical Radiation Oncology: October-December 2012
PA and NP utilization in radiation oncology
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extender time. The tasks receiving highest utilization were follow-up appointment-physical exam and history (16%), dictation (general) (10%), and clinic prep (9%). Taken together, follow-up appointment-physical exam and history and follow-up appointment-medical decision making accounted for 24% of the total workday, and dictation (general plus editing) accounted for 18% of the total workday. New patient consult visits accounted for 3.3% of time (range, 0.0%-6.1%).
Patient flow analysis for follow-up appointments
Figure 1 Overall percentages and minutes/8.5 hour workday for workload task categories. Misc., miscellaneous.
data on 4 physician extenders: 3 PAs and 1 NP. Mean experience practicing in Radiation Oncology was 4.75 years (range, 4-7 years). Figure 1 illustrates physician extender time allocation. Nearly half (46%) of physician extender time was spent performing indirect patient care. Figure 2 provides the top 10 tasks performed throughout the workday. Collectively, these top 10 tasks comprised 72% of total physician
A total of 259 patients were seen in follow-up appointments. A total of 131 (50.6%) patient-completed forms were appropriate for analysis; 79 fully completed (60.3%) and 52 partially completed (39.7%). Figures 3A and 3B depict patient flow through the radiation oncology department during follow-up appointments. After their vitals were taken, patients had 1, 2, or 3 medical encounters, consisting of various combinations of attending physicians, residents, physician extenders, nurses, and medical assistants. More medical staff encounters resulted in longer appointment durations (Table 1). In most cases, as the encounter number increased the duration of each subsequent encounter decreased. The first medical encounter was performed by the physician extender 84.3% of the time; 49% of
Figure 2 Top 10 overall physician extender tasks by percentages of workday, with estimated minutes/workday. Appt., appointment; Misc., miscellaneous.
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Practical Radiation Oncology: October-December 2012
Figure 3 Patient flow through the radiation oncology department during follow-up appointments. (A) First half of value stream map of patient flow process. (B) Second half of value stream map of patient flow process. W/T, wait time; P/T, process time; μ, mean; σ, standard deviation; X, median; min, minimum; max, maximum; N, sample size; MA, medical assistant; MD, physician; RN, nurse; MA, medical assistant; PA/NP, physician assistant/nurse practitioner (physician extender); R, resident.
Practical Radiation Oncology: October-December 2012 Table 1 Wait times, process times, and total time associated with the number of medical encounters Time
1 Encounter 2 Encounters 3 Encounters
Median wait 18 time (min) Median process 19 time/direct patient care (min) Median total 37 time (min)
25
27
25
29
50
56
these patients stayed for a second encounter with an attending physician.
Formal interviews Nine of 10 physicians, 1 of the chief residents, and all 5 physician extenders were interviewed. Physician extenders and physicians agreed that physician extenders were utilized primarily for follow-up appointments. Other duties reported by physician extenders included new patient consults, treatment planning, ordering and evaluating laboratory and radiographic tests, patient phone calls, ontreatment visits, paperwork such as disability forms and prior authorizations, scheduling, dictations, and prescription writing. Physician extenders perceived their utilization within the department would be improved with welldefined position goals (80%), less clerical work (40%), more involvement in treatment planning (40%), more training (40%), and more involvement with new patient consults (20%). In addition, the physician extenders stated that they would like to spend more time in clinical research (40%) and correspondingly less time on disability and prior authorization paperwork (80%) and on dictation (40%). Physicians felt the utilization of physician extenders could be improved by providing more training (33%), increased physician extender involvement in treatment planning (22%), increased physician extender involvement in new patient consults (11%), and increased autonomy (11%).
Discussion It is clear from this study that radiation oncology physician extenders in our center are currently being utilized primarily for follow-up appointments. Presumably, this allows physicians more time to see new patients thereby allowing for faster initiation of treatment and to complete more complex clinical tasks such as new patient evaluations and simulation and treatment planning. In theory, this should also result in increased revenue. A study comparing a common indicator for productivity (such as work relative value units) between a team using
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physician extenders in radiation oncology with a control group using only physicians could confirm this hypothesis. Similarly, the use of physician extenders also allows physicians more time for academic pursuits such as research and education. The results of our current study validate the need for clearer expectations regarding the roles and training of physician extenders in the department. In addition to increasing utilization, designing PA and NP roles that include new patient consultations, treatment planning, simulation, and research within radiation oncology will be important for provider satisfaction and retention. We recommend that radiation oncology practices develop clear physician extender expectations, role descriptions, competencies, and a training plan prior to integrating physician extenders into a practice. Physician expectations related to proper utilization and delegation of physician extenders should also be standardized within practices that choose to employ PAs and NPs. Within our radiation oncology department, both physicians and physician extenders agreed that the utilization of the physician extenders across physicians was not standardized. Four of the 5 physician extenders felt that their utilization would improve with more clearly defined job descriptions and expectations, something that was never delineated prior to the initial integration of PAs and NPs into the department. Both physicians and physician extenders agreed that PA and NP utilization would improve with increased training. Employing an educational model that promotes growth through lectures, seminars, hands-on training, mentoring, and graded clinical responsibilities over time has been shown to foster physician extender development and improve retention.10 Similarly, both physicians and physician extenders felt utilization could improve with expanded clinical roles such as greater extender involvement in treatment planning and new patient consultations, duties not uncommon in other radiation oncology practices. In 1997, a nationwide survey revealed that PAs and NPs were most likely to perform tasks traditionally performed by physicians.11 PAs were more likely than NPs to obtain patient histories for consultations; 90% vs 57%, respectively. Similarly, PAs were more likely than NPs to perform physical examination for consultation patients, on treatment patients, and follow-up patients (80% vs 42%, 80% vs 74%, and 70% vs 57%, respectively). Other common responsibilities reported by PAs and NPs in this study included ordering laboratory studies and radiology studies, prescribing medications, educating patients, and participating in quality improvement initiatives. While 0 respondents reported that they performed simulation independently, approximately 25% had at least some simulation duties. Similarly, in a 2005 survey of radiation oncology NPs, duties reported included symptom management outside of weekly treatment visits (100%), conducting weekly treatment visits (93%), seeing patients
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in follow-up (90%), performing histories and physicals (78%), participating in hospital admissions (48%), inpatient care (44%), research (28%), management (32%), and performing simulation (26%).9 While involvement in new patient consultations and treatment planning in our study was less common, some extenders in our study were more involved in new patient consultations and treatment planning than others, primarily due to physician preference. This therefore can easily be modified by addressing physician behavior. Time spent in direct patient care accounted for only 32% of physician extender time, representing an opportunity for role enhancement in our academic system. Increasing time spent in direct patient care by PAs and NPs would yield higher billable revenue and return on investment.12 Additionally, while the physician extenders performed most (84.3%) of the first encounters for followup appointments, these patients were seen independently by PAs and NPs only 51% of the time. Additional encounters led to increased patient wait time and decreased patient throughput. Efforts within academic radiation oncology practices should focus on decreasing average appointment length, which should have a positive effect on both patient satisfaction and overall volume. This may be accomplished, in part, by increasing the volume of independent patient visits provided by physician extenders. Alternatively, if a shared service model is employed, academic practices should ensure that overall combined PA/NP plus physician revenue is net positive, with the total collections more than compensating for the costs plus overhead associated with the team. Future studies could include billable productivity measures such as gross charges or work relative value units, inclusive of physician productivity to ensure that use of physician extenders actually extends physician practice by increasing overall volume and revenue. Other benefits of employing PAs and NPs, such as increased time for research and other academic pursuits, will be more difficult to quantify, particularly financially. Nearly half of physician extender time in our study was spent on indirect care activities, including evaluating laboratory and radiographic test results, communicating with patients, discussing patient care and test results with attending or referring physicians, dictating and editing, preparing for upcoming clinics, triaging patient phone calls, and scheduling. Dictation and editing dictations accounted for 18% of total work time within this study. PAs and NPs see the majority of patients in the department, either independently or in conjunction with a physician, and they dictate 100% of the encounters in which they participate. They also dictate notes from phone triage encounters as well as test results. At least 80% of physician extenders in our study stated that they spend too much time on paperwork and tasks such as scheduling, prior authorizations, and calling in prescriptions that could be performed by lower cost personnel. Academic medical
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centers seeking to increase PA and NP productivity and improve utilization within radiation oncology should reduce PA and NP time spent in indirect patient care and other duties, particularly indirect care tasks that can be performed by other staff members such as nurses, medical assistants, and clerks. Care should be taken to ensure that PA and NP assigned roles, tasks, and functions represent services that would otherwise require a physician. Physician extenders in our study spent only one-third of their work time in direct patient care, and only onehalf of the patient visits were performed independently. This may be the result of physician preference and delegating style. It has previously been reported that physicians have inherent biases about the abilities of nonphysician clinicians to perform functions usually performed by residents in an academic medical center, potentially resulting in underutilization within academic settings.13 Equally likely is that the educational mission of an academic practice, in contrast to a community practice, may result in different roles for physician extenders. There are duties and responsibilities which physician extenders are qualified to perform but may be tasks that physicians in training need to perform in order to properly learn, and depending on the total volume of such tasks may result in fewer opportunities for physician extenders to perform those activities. In our physician interviews, 4 of 9 physicians interviewed (44.4%) stated that PAs and NPs are often not utilized for certain tasks specifically because of the need to allow residents to perform tasks as a part of their education. Ultimately, the goal of a practice employing PAs and NPs should be to optimize their utilization through judicious delegation of physician equivalent work. Subspecialty fields such as radiation oncology also need to commit to education and training in order to maximize their efficacy and contribution to the practice. The primary limitation of this study is the small sample size and the uncertainty as to how representative the sample is of the population as a whole. In addition, this was a single center study within an academic medical center environment. It is possible that assigned duties and utilization patterns within our study population differ from those in nonacademic settings. The limited period of data collection may not be reflective of the entire year. As such, these data may not be reflective of the full scope of physician extender duties and functions. As an example, new patient consults and treatment planning, commonly performed by some physician extenders in our center, was not reflected in our data due to fluctuations in the schedules that occurred during the 2 weeks of data collection. Also, the work delegated to the physician extenders in the department is physician driven. Consequently, physician attitudes greatly impact delegated roles, level of functioning, amount of training, and ultimately the return on investment from PAs and NPs. Despite these limitations, this study provides important information on
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physician extender utilization in an academic radiation oncology practice.
Conclusions This study highlights the importance of collecting data to allow for evaluation of PA and NP performance and utilization. We have highlighted a unique methodology for analyzing physician extender duties and workflow that could be employed by other organizations and medical practices, regardless of specialty, to examine PA and NP deployment and to identify opportunities to optimize their utilization.
Acknowledgments The authors wish to thank Theodore S. Lawrence, MD, PhD, Isadore Lampe Professor of Radiation Oncology, and Chair of the Department of Radiation Oncology, University of Michigan Health System for critical review of this manuscript.
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