Harold (Rick) Pillsbury, MD, President-Elect of the Triological Society, has been predicting for 10 years that there would be a need to hire people to help extend otolaryngology practices—in other words, physician assistants (PAs) and nurse practitioners (NPs). “I was right. That makes me the soothsayer here,” he joked.
But needing to extend the provision of care, he will tell you, is no joking matter. Physicians have become increasingly busy and the ability to simultaneously provide quality care, expand one’s patient base, and draw in sufficient revenue is a problem that faces most otolaryngologists. There are definite benefits to adding PAs and NPs to the practice, however, and there are key issues that otolaryngologists should be aware of when hiring them.
Benefits, Risks, and Requirements
Quality was a word Dr. Pillsbury mentioned often when he discussed the benefits of working with PAs and NPs: the quality of time the doctor spends with patients?those who have serious problems and those whose problems are not as intense. If you have “somebody with enough expertise to handle the basic issues that come in and can help you sort those things out and see more patients, you have better quality in every visit,” he said.
The inherent risks or pitfalls of providing patient care with the help of NPs or PAs pertain to how well these individuals can perform assessments, said Dr. Pillsbury, who is the Thomas J. Dark Distinguished Professor of Otolaryngology–Head and Neck Surgery at the University of North Carolina at Chapel Hill Medical Center. PAs, in particular, may view patient problems from a global perspective as opposed to one specifically honed in otolaryngology practice. “They may be less impressed with some of the symptoms they see than perhaps they ought to be.”
For example, he said, the patient who presents as a little bit dizzy might have an acoustic tumor, an impending stroke, or a number of other diagnoses not exclusively and clearly based on the symptom complex. Other examples are a patient with unilateral tinnitus who might have an acoustic tumor; a patient with a plugged-up nose on one side who might have a cancer; or a child who has had a runny nose on one side for six months who might have an ENT foreign body. Training an ancillary provider to recognize those possibilities “isn’t done overnight,” he said.
Most PAs and NPs are educated with the context of family practice as their primary background. Dr. Pillsbury speculated that if you begin with someone who has a basic level of motivation and talent, training would take six months to a year for them to become facile with the required clinical needs for otolaryngology.
The salient issue for a PA or NP entering an otolaryngology practice, then, is to acquire “a sense of the complexity of the problems so that you know when to appropriately do extra testing.” Because audiograms, CT scans, and ENGs, for example, are expensive, providers must be astute historians, said Dr. Pillsbury, and capable of performing an excellent physical exam so that they will know when to appropriately order ancillary tests.
Physician Assistants
The American Academy of Physician Assistants (AAPP) estimates that there are currently about 575 PAs practicing in otolaryngology. Physician assistants graduate from a competency-based medical program that is accredited by organizations including the American Medical Association and the Academy of Physician Assistants; are certified with the National Commission on Certification of Physician Assistants, and are licensed providers (see sidebars). But “one PA will not necessarily fit in the same slot covered by another PA,” said Mel D. Brown, MPAS, PA-C, SA, of the Otolaryngology, Head and Neck Surgery Division at University of New Mexico Health Sciences Center in Albuquerque, N.M. “Individuals have different levels of expertise and we do fit into a certain niche.”
Mr. Brown earned a master’s degree in otolaryngology at the University of Nebraska and then did a postgraduate fellowship through the US Air Force, from which he retired in 2003. He believes his postgraduate training in education makes him more marketable in otolaryngology. He is also exceedingly knowledgeable about what it takes to succeed as a PA in this specialty: he was at one time the surgeon general’s consultant for otolaryngology PAs and addressed the surgeon general, other physicians, and various CEOs of the Air Force hospitals on the topic of using and training PAs as providers in otolaryngology.
Based on the many questions prospective employers have asked him over the years, Mr. Brown has two key pieces of advice: First, PAs do provide the standard of care; second, they are very cost-effective. “Our salaries are not what a physician’s salary is,” he said, but he emphasized that you get what you pay for. “If you want someone right out of school who has little experience and training, of course you can pay them less; but with more experience, we also do quite a few more procedures, manage more complex patients, and generate more surgeries and revenue for the practice as well—all while giving peace of mind for the physicians, that their patients are well cared for.” The lines of communication between a PA and physician must be open. “I have colleagues who are not doing the same thing I am; some are doing more, some are doing less, and that’s the way it is with any profession—you progress according to your own speed and motivation.”
Mr. Brown, who moved often with the Air Force, and therefore has worked with almost 100 otolaryngologists, also recommended that physicians be especially careful to elicit the appropriate and pertinent information when interviewing prospective PA candidates. What are the criteria for which hiring otolaryngologists should be on the lookout? “They need to look for somebody who knows their limits and somebody they can trust.” Trust between a physician and PA means they are able to care for each patient mutually or alone, augmenting each other’s strengths. “It’s not a competition,” he said. “You need a mutual agreement to take care of these patients as effectively and efficiently as you possibly can.” He also thought the physician and PA should have a good match of personalities. In other words, “if you want a very aggressive practice, both PA and physicians have to want that. If you want a more laid-back practice, those personalities have to match.” Sharing a commitment to the organization’s mission is also important.
Marie Gilbert, PA-C, former president of the Society of Physician Assistants in Otolaryngology and Head & Neck Surgery (SPAO–HNS), who practices with otolaryngologists Joseph White, MD, and Christopher Knox, MD, in Dover, N.H., has worked as a PA in otolaryngology for 27 years and helps otolaryngologists find PAs for their practices. She also teaches a course at AAO–HNS annual meetings on the scope of practice and utilization of PAs. She would advise otolaryngologists who are hiring PAs to be exact about what they are looking for in a PA. Of the PAs she has known in otolaryngology practice, “the only time they left is when the practice did not know what to do with the PA, or didn’t have set ideas about what the PA would be allowed or asked to do.”
What would make a PA want to stay in the specialty? “ENT is such a broad specialty that you really don’t get bored with it,” said Ms. Gilbert. “[One might] think that it’s one small area of the body, that there can’t be all that much to know about it; but that couldn’t be farther from the truth. Most people I know who got into otolaryngology enjoy the specialty, enjoy the range of patients we see, and [get to see a wide variety] of illnesses, so most PAs who get into ENT, stay.”
From a legal standpoint, the physician who serves as supervisor of PAs (or other health providers) is also responsible for their practices, even though PAs often have their own malpractice policies. “Some practices don’t pay for an individual policy and only have the PA or nurse practitioner added to the group policy,” said Ms. Gilbert. In terms of reimbursement, PAs are credentialed providers with Medicare and Medicaid and are reimbursed at 85% of the supervising physician’s contracted charges. Details will depend on the state and insurance regulations.
The AAPA has some helpful forms at their Web site (see Resources) including a pre-employment checklist and a sample contract outline. Individual state regulations are also available to download at the site. Mr. Brown, who is the president-elect of SPAO–HNS and who has been a member of its board of directors since 1993, frequently answers questions about PAs for inquiring physicians and others who are available to answer questions are accessible through the organization’s Web site. The site also has a link for physicians who want to post job opportunities. SPAO–HNS also annually conducts scope-of-practice and salary/benefit surveys of their members and will share this information with otolaryngologists and office managers.
Nurse Practitioners
Judith Lynch, MS, APRN, FAANP, advises physicians who are interested in working with nurse practitioners that they recognize NPs as professionals working under their nursing licenses who can be used as colleagues in ENT practice settings.
Ms. Lynch, who is employed by ENT Associates in Waterbury, Conn., is an expert on the subject. She taught nurse practitioners at the School of Nursing at Yale and is still on their clinical faculty. “There aren’t many of us working in otolaryngology,” she said. Indeed not. The Society of Otorhinolaryngology Head–Neck Nurses (SOHN) reported that in 1996 there were 34 NPs practicing in this specialty; 10 years later that number had increased to 134.
To her, the benefits of an otolaryngology practice working with NPs overwhelmingly override any drawbacks. Because most otolaryngology practices are comprised of surgeons, with a rare allergist on staff, “there is no one usually available in the office to provide a medical, as opposed to a surgical, approach to care,” she said. Ms. Lynch, who works with three otolaryngologists who have active surgical practices, specializes primarily in vertigo, ear disorders including tinnitus, allergy management, and chronic sinus disease. She has her own panel of patients whom she refers as necessary to the physicians, and they also refer patients to her.
“Having a nurse practitioner in an ENT setting is of great benefit to the patients,” said Ms. Lynch, “because nurses view the patient differently than physicians do. Not that one is better than the other, but they are different [and complementary]. I look at the patient in the context of their lifestyle, how the problem is going to impact their life, their work, their environment.”The difference in education between an otolaryngologist and an NP can be a boon to holistic care. “I tend to take a multisystem approach because my training is so different from the training that my surgical colleagues undergo,” she said.
As with PAs, nurse practitioners are educated against a backdrop of family practice or internal medicine. Although there is no formal educational program to certify otolaryngology nurse practitioners, they can become certified in otolaryngology and head-neck nursing once they meet certain criteria.
Ms. Lynch would advise prospective physician employers to educate themselves on NPs’ advanced practice and clinical training. “Physicians often think that nurse practitioners are meant to come in and do basic office procedures such as histories and blood pressures and they don’t recognize it as its own specialty. I’m here to bring my own brand of expertise.” She has been employed in two ENT practices and they have both allowed her the independence to work at a collegial and optimal level. She hesitates to recommend any specialty as an initial clinical setting for beginning practitioners. “The more conventional style of nurse practitioner work is far better because you learn basic assessment skills and build confidence in yourself,” she said.
Linda Miller Calandra, MSN, RN, CRNP, CORLN, past president of both SOHN and the Society for Ear, Nose and Throat Advances in Children (SENTAC), is one of 16 nurse practitioners working with 10 physicians in a practice associated with Children’s Hospital of Philadelphia. In her practice, nurse practitioners assess and evaluate patients before the physician sees the patient, reviews the plan of care, and makes the disposition. NPs also do presurgical evaluations and workups so that the families do not have to return to the hospital before the day of surgery for an anesthesia evaluation. Outside of a surgical practice, however, she said, “globally nurse practitioners can address issues that patients have, such as the need for education, setting up home care, and identifying issues that could be problems postsurgically. This can save physicians a lot of time and frees the physicians to do what they were trained to do.”
What is the general difference between what PAs and NPs can do in a practice? “I think in practice, there’s very little difference,” said Ms. Calandra. “In theory, the difference is that we’re trained in the nursing model, with more of a holistic approach, and PAs are trained in the medical model. For instance, I’ll go in [to an exam room] and look at a child for breathing problems and a PA will go in and specifically look at big tonsils.” But Ms. Gilbert disagreed. “No [PA working] in ENT would just look at tonsils and not consider the whole patient,” she said, and thought this might be an often-held misconception NPs have about PAs.
Dr. Pillsbury’s assessment is somewhat different. “Nurse practitioners have support of the patient as part of their primary modus,” he said. “They’re there because they were taught in nursing school to be patient advocates. They’re very good at interacting with the patients in a positive way—making them feel comfortable, getting little bits out of the history that someone else might skip— and a PA is, in generally, more focused on doing things.” He added that in his own practice and experience, patient satisfaction with NPs is “almost always high, and it can be more mixed with PAs.” What this points out is that the hiring physicians must be clear about what he or she is seeking for their practice and whether the role of PA or NP will best meet their needs.
“Because most of the bigger practices have nurse practitioners,” said Ms. Calandra, “the newer fellows, at least in pediatric otolaryngology, have been exposed to NPs and know how they work.” But the physicians who will have the toughest time working comfortably with NPs are those who feel compelled to control all aspects of the practice, she said. The physician who will best collaborate with an NP is the one who can delegate responsibilities. To feel most comfortable with an NP’s specific training and experience, Ms. Calandra said, ENT physicians should look for a candidate’s certification in otolaryngology; that is, CORLN. She is the current president of the National Certifying Board of Otorhinolaryngology and Head-Neck Nurses (NCBOHN).
Legal authority for nurse practitioners’ scope of practice varies by state. Prescriptive authority also varies from state to state; although NPs can prescribe in all states, some may have conditions for prescribing controlled substances. Individual state regulations are accessible from risk management departments and from the SOHN Web site (see Resources).
Ms. Calandra regularly lectures to ENT physicians on what to look for in an NP. At a recent national meeting of SENTAC, she participated on a panel of registered and advanced practice nurses. “The physicians were asking questions such as, ‘Will it cost me money to hire a nurse practitioner or does it save money?’ One of the physicians in the group said his practice had done cost analyses and found that after three months, the [value of the] nurse practitioner exceeds her cost.”
What Can a PA Do?
The tasks that physician assistants perform depend on their practice setting, education, experience, and state laws and regulations, but in general, PAs:
- Perform physical examinations
- Elicit medical histories
- Diagnose and treat illnesses and injuries
- Order and interpret laboratory and radiographic studies
- Educate and counsel patients
- Perform minor surgical procedures
- First-assist in surgery
- Assist with call
- Render emergency care
- Facilitate patient referral to the appropriate physician or agency
- Conduct research and drug studies
- Prescribe medication (in most states)
Source: The Society of Physician Assistants in Otorhinolaryngology–Head—Neck Surgery: www.entpa.org/FAQ.html
The Survey Says’
The Society of Physician Assistants in Otorhinolaryngology/Head—Neck Surgery surveyed their membership in 2003 about the specifics of their productivity. The following represents the proportion of PAs who perform these tasks in their ENT practices.
- 93% Removal of ear foreign bodies
- 89% Nasal cautery (32% electrical, 86% chemical)
- 89% Fiberoptic laryngoscopy
- 89% Removal of nasal foreign body
- 86% Packs / splints removal
- 82% Mastoid cavity cleansing
- 82% Pre / post-op H&P
- 75% Rigid nasal endoscopy
- 75% Post-op FESS cleansing
- 68% Anterior nasal packs
- 64% Epley’s or Semont’s maneuver
- 64% Excision/biopsy skin lesion
- 64% Tracheostomy tube change
- 61% I&D of peritonsillar abscess
- 57% Oral biopsy
- 50% Fine needle aspiration
- 50% Hospital consults
- 43% Removal of tubes
- 32% I&D of helical hematoma
- 29% Posterior nasal packs
- 25% Submandibular sialolithotomy
- 25% Stroboscopy
- 21% Myringotomy and tube insertion
- 21% Allergy testing
- 21% Turbinate steroid injection
- 18% Tympanostomy
- 14% Closed reduction nasal fracture
- 14% Transnasal esophagoscopy
- 11% Nasal polypectomy
- 11% Frenulotomy
- 7% Audiometry
- 7% TM patch
- 7% Antral or Proetz irrigation
- 4% Middle ear gentamicin infusion
- 4% Hearing aids
- 4% Placement of sialogram tubing
- 4% Esophageal dilation
- 4% pH probe testing
Source: Adapted from www.entpa.org /scope_of_practice.html
Resources
- Society of Physician Assistants in Otorhinolaryngology–Head & Neck Surgery (SPAO–HNS) www.entpa.org
- American Academy of Physician Assistants (AAPA) www.aapa.org
- Society of Otorhinolaryngology Head-Neck Nurses (SOHN) www.sohnnurse.com
- American Academy of Nurse Practitioners (AANP) www.aanp.org
©2007 The Triological Society