The greatest barrier to competency & confidence is complexity: the variation of presentations & physical findings of the same disorder, the ambiguity of lab studies & the complexity of treatment selection.
When our practice experienced a rapid growth period in 2016–17, a spike in APC turnover led us to recognize that our newer physicians were not getting the mentoring they needed in the process of APC development. One measure we took was to explore the aggregate knowledge available from our APCs about how an APC achieves competency in rheumatology and what sustains them.
Our quasi-scientific administrative study was fraught with the obvious bias of recruiting participants within one company, as well as the participants knowing the interviewer and knowing the interviewer was an owner with implicit power over their employment. Nonetheless, our sample has some relevance because all of the participants had a uniform employment structure with similar operational structures—in teams consisting of a rheumatologist, one or more APCs and an administrative medical assistant responsible for a common panel of patients.
A semi-structured interview was completed by 12 volunteer participants—seven NPs and five PAs, just under half our APC population. All the participants were women with a mean age of 48 years and a mean experience in rheumatology of seven years. Participants were recruited through direct internal messaging and verbal consent. Narratives were obtained during December 2017 and March 2018. Open-ended questions were posed by a single interviewer regarding major barriers to competency, what best helped surmount those barriers, the single best and worst things about practicing rheumatology, the profile that may predict the success of an APC in rheumatology and the profile of the ideal attending rheumatologist.
APCs who had participated directly in the training of newer APCs, an advantage of our lengthy utilization pattern, were asked about what expedites a trainee’s reaching competency and self-confidence in rheumatology. Last, participants were asked what lecture format works best to enable clinical proficiency and what else rheumatologists should know about achieving success with APCs.
Responses were manually recorded and subsequently coded for similar content, then quantified in a fashion similar to directed qualitative content data analysis.
The results pointed to a number of key themes. The greatest barrier to competency and confidence is complexity: the variation of presentations and physical findings of the same disorder, the ambiguity of lab studies and the complexity of treatment selection. Overcoming the barriers required continuous feedback from the physician and other team APCs on these elements, as well as reading and physician lectures.
APCs see this complexity as the worst thing about rheumatology, but at the same time, the best thing, in that it leads to constant variety in the day’s work, the stimulation of solving clinical puzzles and seeing the results of therapy in a complex disease, as opposed to the narrowness of challenges in other disciplines.
The profile of the successful APC is the person who is attracted to that complexity and thrives in long-term relationships with patients.
The ideal attending is an inexhaustible fountain of teaching and reinforcement on the fly, someone who identifies holes in knowledge and kindly fills them in, and who leads a team with singularity of purpose for the panel.
APCs expect to play a role in the full spectrum of rheumatic diseases and their management—working at the top of their licenses.
Those APCs who have trained others in rheumatology reinforce the benefit of early, intense exposure to physical findings and their variations and alert other teams to call in the trainee when less common findings present.
Experienced APCs appreciate the high science of lectures in immunopathology and treatment target molecules, but the ideal lecture is completed in 45 minutes, including questions and answers, and delivers content that directly boosts their ability to function in the clinic.
APCs aspire to be treated as valued clinicians and to have that value conveyed by their attending to patients, primary and other referring physicians, and to outside consultants.
With all these features in place, flexibility in employment related to work-life balance is the secret sauce of sustainability.