MCW Otolaryngology and Communication Sciences Headlights Winter 2023 - Role of the Advanced Practice Provider in an Academic Setting

First conceived in the 1960s to aid in a primary care shortage, Physician Assistants (PAs) and Nurse Practitioners (NPs), or Advanced Practice Providers (APPs), currently represent a growing aspect of most every specialty of medicine and surgery. The Department of Otolaryngology & Communication Sciences is proud of and grateful for their APPs as they play a critical role in team-based care.

Two of the department’s APPs have reflected on their careers: Laurie Newton and Helen Kim:

Reflection by Laurie Newton, APNP

When asked to write a self-reflection on the role of advanced practice providers (APPs) in academic medicine, I enthusiastically agreed. Spending my entire career at Children’s Wisconsin and Medical College of Wisconsin (MCW), academic medicine is all that I have known, and I cannot imagine practicing anywhere else. I am proud of the work that APPs have done within the walls of MCW and beyond, and hope that this reflection gives a glimpse into the role of the APP in otolaryngology and opportunities to engage APPs in academic medicine beyond their daily clinical workload.

As mentioned above, I have spent my entire career at MCW and have been practicing within pediatric otolaryngology for the past 15 years. As with most novice APPs, the first few years of my career were spent becoming comfortable with providing clinical care for pediatric ENT patients. It is well documented in the literature that transition to practice for APPs, specifically nurse practitioners (NPs) who move from the expert registered nurse role, into the novice provider role, often struggle with elevated levels of stress, knowledge deficits, and quite honestly just feel overwhelmed. Thus, the first year or so of practice really needs to focus on becoming proficient in the knowledge and skills necessary to provide quality patient care. Specifically in pediatric ENT, APPs tend to move along a progression of knowledge and responsibilities in our on-the-job training, focusing on more straightforward patients, such as postoperative ear tube patients, and then progressing to more complicated patients, such as new surgical consults.
The beauty of our academic medicine team is that we truly provide team-based care where APPs always have a resource and often work side by side with our surgeons, allowing real-time discussion to take place on patients, which was so important for me both early on in my career and now seeing higher acuity patients.

Utilization of APPs in our division has changed over time and has contributed to the growth of APPs employed through Children’s Specialty Group (CSG) and MCW, as you can see in Figure 1. In pediatric ENT we have grown from a division of four nurse practitioners all working in an outpatient role 15 years ago, to now a group of 9 APPs- now including one physician assistant- with two of those serving our inpatient service line. The growth of our APP group is due in part to our expanding role, both clinically and academically. For example, APPs primarily worked in “tandem” clinics alongside the physicians in clinic in the past; due to patient care needs and the push for APPs to practice to full scope, we now work in both independent and tandem clinics, see new surgical consults, and work as a consultative service on the inpatient team. This model seems to work well to allow for independent clinical practice, but also allow the APP to see more complicated surgical patients in collaboration with our surgeons, allowing for continual learning and promoting job satisfaction for APPs. As we have expanded to “Care Closer to Home” clinic sites, the volume of patients seen continues to support the need for APPs to support ENT practice, and likely these numbers will continue to grow even more over the coming years. Academically, there has been a push and support within our division for APPs to become involved with hospital committees, professional organizations, and other regional/national health care organizations. Many of our APPs participate in hospital committees, such as the Professional Development Committee and APP Virtual Conference planning committee, and there is support from division leadership to participate in this work. All our APPs are active members of the Society for Otolaryngology-Head and Neck Nurses, which has allowed for networking opportunities with APPs around the country, as well as the opportunity to share our expertise at national meetings.

While patient care is still the primary reason that I became an APP and what gives me the most joy in the workplace, I decided to go back to pursue my Doctorate of Nursing Practice (DNP), as I knew I was interested in the areas of education, quality improvement, and leadership. Moreover, I knew long term I would not want to be 100% clinical. I completed my DNP with a scholarly project that focused on health literacy, looking specifically at the use of “teach back” with tonsillectomy patients. This was my first larger-scale quality improvement project and sparked my love for quality improvement and evidence-based practice projects. Since that time, I have been involved in several other quality improvement projects, including leveraging the electronic medical record to message families in lieu of postoperative phone calls following tonsillectomy and our “fast track” ear tube program, which has helped to decrease the time for ENT consult and surgery for patients with difficult to treat recurrent otitis media. The latter project started as a small-scale pilot and has now expanded to all referring providers into our system and continues to receive high satisfaction scores from families and referring providers alike. I was fortunate to receive mentorship for another project as a part of MCW’s Scholars in Quality Improvement and Patient Safety (SQIPS) program, which has the end goal of completion of a quality improvement project. This was a cooperative project involving APPs from ENT and oncology, pediatric audiology, pharmacy, and oncologists that worked to improve ototoxicity monitoring protocol adherence in pediatric oncology patients. Lastly, I received grant funding for two other projects: use of telehealth in pediatric otolaryngology and primary care, and identification of the professionalism needs of novice APPs. Work on these projects has allowed me the opportunity to present at peer-reviewed conferences, as well as publish several articles on our project outcomes.

The role of APPs in education at MCW has also changed over the years. I have frequently been a preceptor for nurse practitioner students, as I love the opportunity to help educate our future work force and give back to the profession. However, a few years ago MCW started a pilot program looking for APPs to help mentor first year medical students as they transitioned into the clinical setting. I was fortunate to be selected as an APP mentor for these medical students and have been working with medical students annually the last 5 years. This has been a wonderful experience for myself, but I also think it has been a nice opportunity for medical students to become familiar with the APP role and how they will interact with APPs as a part of the interdisciplinary team upon completion of their medical degree. Lastly, I have recently taken on an additional role as an assistant director for our APP fellowship program at CSG; I have really enjoyed this innovative teaching role and look forward to seeing continued growth and improvement in this program essential for successful transition to practice for novice APPs.

In closing, I feel so fortunate to be a part of the MCW team, where I feel not only valued as a medical provider who can provide high quality patient care, but also for the value I can bring to the table in evidence-based practice, quality improvement, and education. I am appreciative of a leadership team that values the role of the APP in all these aspects as well, contributing to my overall job satisfaction and clinician well-being. Of course, I genuinely believe you are only as good as those surrounding you; so very thankful for the wonderful team of APPs and physician colleagues that I am fortunate to work with every day. I look forward to continuing a lengthy career within academic medicine and the Medical College of Wisconsin.

Reflection by Helen Kim, APNP

It’s amazing to reflect on the evolution of my 30 year career which began as a fresh out-of-school medical – surgical nurse in the suburbs of Chicago. I was fortunate enough to work at Loyola University Medical Center’s Otolaryngology Department as their clinical research nurse and otology/skull base surgery clinical nurse. The academic setting set the stage for my cravings for knowledge, teamwork, and advancement.  After completing a graduate nurse practitioner program and after two days of marathon interviews with over a dozen members of the Department of Otolaryngology & Communication Sciences, I was offered a position and I moved across the border into Wisconsin.

When I first started at MCW in 2004, the ENT nurse practitioner model was a combination of nursing and advance practice. Responsibilities included working alongside providers in the clinic taking histories, performing limited exams, assisting with procedures, providing patient education, and reviewing consents.  Outside of patient clinic visits, we managed all triage calls, completion of forms, prescriptions, refills, orders and results, and prior authorizations.  Some APPs had the  opportunity to see patients independently in a regular scheduled block of time, and some APPs only saw patients as needed if time and experience allowed. However, this model of practice was inconsistent and did not fully utilize our potential as advanced practice providers. 

In 2008 Mark Vukovich, APNP and I were the only nurse practitioners still standing on the adult side of ENT. Our new leadership team acknowledged it was time to utilize our training and experience to bring more revenue when providers and resources were strained. During those earlier years when we worked side by side with our collaborative physicians in clinic, we gained valuable training and experience that prepared us for independence similar to a residency program. After the first heart-poundingly scary and exciting year of full time clinical practice on our own, our adult MCW ENT APP program began to grow to the success it is today.

Though there may be differences in how our adult and pediatric APPs practice, we share a common theme. Each of us brings our own unique expertise to the team whether we have a nursing background, business, or research experience.  In the adult practice, we currently have four well established APPs, one currently onboarding and one on the way. Our Children’s practice has grown to nine APPs.

Practicing in an academic otolaryngology setting offers a world of possibilities for the APP, department, institution, and community at large. The breadth of services APPs offer enhances patients’ access to care, appropriate referrals, and immediate intervention for acute and serious ENT patient problems. We also see many general ENT patients and post-op visits. We may be the initial provider a patient sees and we offer coordination of care.  We also perform a variety of outpatient clinic procedures based on our core or commonly performed procedures or subspecialty such as cerumen removals, mastoid debridement, rigid and flexible nasal endoscopies, trach tube changes, I&Ds, biopsies, etc.  Our triage nurses seek us for help before directly contacting the surgeons, and they often refer patients to us when physicians are not available.  We often times screen patients then refer to the subspecialist in an expedited fashion.  APPs are a professional asset across every area including patient access and satisfaction, performance excellence, provider coverage, safety, and income revenue.

Practicing as an APP in an academic center also offers benefits of both general and subspecialty practice. I enjoy the variety between them as do my colleagues. Our team of APPS often es clinical cases and offer each other support and help if there is an area we are not as experienced in.  Because of the academic learning environment we practice in, we are always challenged to learn and keep up with new treatment options and practice guidelines. It also stimulates my desire to engage in training, leadership, professional speaking, community involvement and volunteerism. It is an advantage for us to have the vast resources at our disposal and peer relationships to fuel that desire.

As a veteran member of the Society of Otorhinolaryngology Head and Neck Nursing,  I am witnessing the exciting growth of APPs in otolaryngology. Networking with others from across the country has  proven one thing, we love what we do and give 110% to our professional calling as advance practice providers. The trust and respect that builds between our peers and collaborating physicians is something that only happens with time. I believe I speak for each and every one of us APPs in the department,  that without the key APP and MD mentors, leadership and training to nurture and challenge us,  our APP program would not be the success it is today.

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