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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
The primary role of NPs and PAs within hospitals is to assist the hospitalist and other attending physicians in the management of hospitalized
patients. During the first few years of employment, recent graduates
traditionally work under the close direct supervision of a physician.
Attending physicians should be readily available to answer questions and
provide backup. The attending physicians should also be actively involved
in the initial care, management and treatment decisions and plans for discharge of the patient, particularly early in hospitalization and while the
patients are unstable. However, as the NPPs gain more clinical experience
and acumen, they typically become more independent and autonomous.
NPPs may work independently and manage hospitalized patients on
their own, with appropriate consultations with physicians about complex
cases. Alternatively, NPPs may work closely with the physician and be
primarily responsible for specific tasks assigned to them (e.g. follow-up
of test results, consulting specialists, implementing discharge planning).
NPPs are also often utilized to help provide 24-hour coverage to the
critical needs of hospitalized patients, particularly when fewer or no
physicians are available in-house.
Autonomy and Scope of Practice
NPs are registered nurses with an advanced master’s degree and clinical
training to provide preventive and acute care in the hospital. NPs perform
services as authorized by a state’s nurse practice act which varies from
state-to-state, with some states having independent practice for NPs (not
requiring any physician involvement), and some requiring a collaborative
practice agreement with a physician.
NPs Responsibilities Include15:
• Taking health histories and performing complete physical examinations
• Diagnosing and treating common acute and chronic diseases
• Interpreting laboratory results and diagnostic tests
• Prescribing medications
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A. Briones
• Rendering patient education
• Preventive counseling on medical care and health maintenance
• Referring patients to subspecialty care when indicated.
Similarly, PAs have advanced education and clinical training and experience to diagnose and treat acute and chronic illnesses. They always work
as members of a physician-directed team. Their scope of practice is determined by four parameters: education and experience; state law; facility
policy; and the supervising physician’s delegating decisions.
16
PAs roles
are varied and depend on the institution’s needs.
General Types of NPPs Models of Care
17
NPPs in Academic Centers
The NPPs work in teams, with ratios varying from 2–3 NPPs to 1 physician. This practice model is similar to resident/attending model where an
NPPs act as the primary provider, working very autonomously and independently in medical decision making. Besides admitting and following
up on patients, writing notes and placing orders, interpreting lab tests, and
communicating with other providers, consultants and families, they also
perform simple bedside procedures such as thoracentesis, paracentesis
and arterial blood gas, etc. The NPPs communicate frequently with the
physician who is available constantly for consultation, whenever necessary. The NPPs may also be integrated in a team with house staff residents/physicians and performs the duties of an intern. Encounters are
usually billed as shared visits.
NPPs in Small Community Hospital
The NPPs collaborate with the physician, and patient encounters are jointly
done. The NPPs responsibilities depend on NPPs comfort and experience.
The billing is done by the physicians under their provider numbers for 100%
reimbursement. The average number of patient visits or census is low (less
than 10 per day). NPPs are less autonomous in medical decision making.
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Non-Physician Practitioners in the Hospital Setting
NPPs in Private Physician Hospitalist Service
NPPs are usually employed by the hospital and are supervised by the
“Hospitalist group,” but they provide care for patients admitted to the
“Private Attending Service.” The private physicians are mainly responsible for their patients and NPPs services are strategically used by them
when they are in their private offices during the day. The NPPs role is collaborative. Billing is done by the private physicians.
Potential Pitfalls of Collaboration
The most common barriers and impediments to a successful NPPs or
PAs–Physician collaboration in clinical practice are:
18
• Physician’s lack of knowledge of NPs/PAs role and scope of practice
• Poor Physician attitudes towards NPs/PAs
• Poor communication and lack of respect
• Patient and family reluctance of NPs/PAs care
Continuing physician education and awareness through special sessions in
scientific meetings, in hospital board meetings, and potentially requiring
this for state board licensure or Hospital Medicine board certification are
some means of overcoming these barriers. Moreover, resident house staff
physicians are more exposed and educated early during residency training
regarding the roles of NPs and PAs in patient care. To improve patient and
family acceptance of NPPs, physicians can help by educating them on the
NPPs role, responsibilities and scope of practice.
Reimbursement and Billing
As recognition of their autonomy, NPs and PAs services are reimbursed
by Medicare in three ways:
1) NPPs may bill directly for their services under the physician fee
schedule and their employers receive a percentage (typically 85%) of
the fee schedule payment.
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A. Briones
2) NPPs services may be billed incident to physician services, in which
case the physicians bill for the services at 100 percent of the fee
schedule payment, even though NPP provided the services.
NPPs services may be included in the payment bundle for services provided in hospitals or skilled nursing facilities.
19
References
1. Benesch K, Morris D , Hyman D. (2010) Non-Physician Practitioners:
A bridge to the future of healthcare. Health Lawyers Weekly. March
19, 2010 Vol. VIII Issue 11.
2. Mundinger MO, Kane RL, Lenz ER, et al. (2000) Primary outcomes in
patients treated by nurse practitioners or physicians. JAMA 283: 59–68.
3. Horrocks S, Anderson E, Salisbury C. (2002) Systematic review of
whether nurse practitioners working in primary care can provide care
equivalent to doctors. BMJ 324: 819–823.
4. Wilson IB, Landon BE, Hirschhorn LR, et al. (2005) Quality of HIV
care provided by nurse practitioner, physician assistants and physicians.
Ann Intern Med 143: 729–736.
5. Roy CL, Liang CL, Lund M, et al. (2008) Implementation of a physician assistant/hospitalist service in an academic medical center:
Impact on efficiency and patient outcomes. J Hosp Med 3: 361–368.
6. Budzi D, Lurie S, Singh K, Hooker R. (2010) Veterans’ Perceptions
of Care by Nurse Practitioners, Physician Assistants, and Physicians:
A Comparison From Satisfaction Surveys. J Am Acad Nurse Pract
22: 170–176.
7. Centers for Medicare and Medicaid Services, Office of the Actuary,
National Health Statistics Group, National Health Care Expenditures
Data, January 2010. Retrieved March 2010 at http://www.cms.gov/
nationalhealthexpenddata/01_overview.asp?
8. 2010 SHM/MGMA salary compensation survey for adult hospitalist
medicine (data based 2009). Retrieved March 2011 at http://
thehappyhospitalist.blogspot.com/2010/09/hospitalist-salarycompensation-survey.html
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Non-Physician Practitioners in the Hospital Setting
9. Best Jobs in America-CNNmoney.com survey 2009. Retrieved March
2011 at http://money.cnn.com/magazines/moneymag/bestjobs/2009/
snapshots/2.html
10. American Academy of Nurse Practitioners (2010). Documentation of
quality nurse practitioner care. Retrieved March 2011 at www.anp.org.
11. Roblin OW, Howard DH, Becker ER, et al. (2004) Use of midlevel
practitioners to achieve labor cost savings in the primary care practice
of an MCO. Health Services Research 39: 607–626.
12. Chenoweth D, Martin N, Pankowski J, et al. (2008) Nurse
Practitioner Services: Three-Year Impact on Health Care Costs.
Journal of Occupational & Environmental Medicine 50: 1293–1298.
13. Cowan M, Shapiro M, Hays R, et al. (2006) The Effect of a
Multidisciplinary Hospitalist/Physician and Advanced Practice Nurse
Collaboration on Hospital Costs. Journal of Nursing Administration
36: 79–85.
14. Baer ED. (1999) Philosophical and historical bases of advanced practice
nursing roles. In: Mezey MD, McGivern DO, eds. Nurses, nurse practitioners: Evolution to advanced practice. 3rd ed. New York: Springer.
15. NP scope of Practice: American College of Nurse Practitioners.
Retrieved March 2011 at http://www.acnpweb.org/i4a/pages/index.
cfm?pageid=3465
16. PA Scope of Practice. American academy of Physician assistants.
Retrieved March 2011 at http://www.aapa.org/advocacy-and-practiceresources/state-government-and-licensing/scope-of-practice.
17. NPP-Society of Hospital Medicine Practice Models. Retrieved June
23, 2011 at http://www.hospitalmedicine.org/AM/Template.cfm?
Section=Non_Physician_Providers&Template=/CM/HTMLDisplay.
cfm&ContentID=25093
18. Clarin OA. (2007) Strategies to Overcome Barriers to Effective Nurse
Practitioner and Physician Collaboration. Journal for Nurse
Practitioners 3: 538–548.
19. Medicare payments to Nurse practitioners and Physician assistants.
(2002) Retrieved March 2011 at http://www.medpac.gov/documents/
jun02_NonPhysPay.pdf
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Hospitalist as Educator
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Teaching Tips and Pearls
Lisa Coplit*
Key Pearls
• Keep teaching relevant for learners and tap into their motivations.
• Teach often in small doses: Two minutes on the go, using the patient
as the context, can be more useful than an hour in the classroom.
• When teaching different levels of learners at the same time, try a variety of techniques to make sure everyone is engaged.
• Utilize the five Microskills of Clinical Teaching to ensure an effective
teaching encounter when time is limited: Get a Commitment, Probe
for Supporting Evidence, Teach General Rules, Reinforce What Was
Right, Correct Mistakes.
• When giving feedback, remind your learner that your intention is to
help them succeed; keep your observations specific, and help create a
plan for improvement.
Our role as teachers is a privilege and brings some of the greatest per-
sonal rewards to the practice of medicine, yet it can be easy to neglect on
a busy inpatient service. This chapter is meant to serve as a primer on clinical teaching, provide straightforward recommendations to enhance effectiveness as a teacher, provide references for more in depth study of
teaching, and help make teaching an integral part of daily life in the
hospital for busy hospitalists.
161
16
Chapter
*Quinnipiac University School of Medicine, Hamden, CT, USA.
There are two overarching concepts that can help teaching to be more
efficient, deliberate, and effective (see Table 1). One simple key to teaching in any setting, and the backbone of adult learning theory, is to keep
your teaching relevant for your learners.
1,2
Relevance can mean different
things, such as needing information to take care of a patient, academic
interest in the topic, and learning for the boards. Hospitalists are surrounded by what is most relevant — acutely ill patients with a variety of
diseases; immediately necessary treatments; complex social issues that
need your intervention in a matter of days; ethical dilemmas, medical systems issues and errors; etc. Osler knew this without the benefit of studying learning theory: “In what may be called the natural method of
teaching, the student begins with the patient, continues with the patient,
and ends his studies with the patient, using books and lectures as tools, as
means to an end.
3
” However, teachers may be tempted to go to their
comfort zone and teach what they know, rather than what the learner
needs to know. This approach robs teachers of time because they may be
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L. Coplit
Table 1. General Principles to Maximize Efficiency
Principle Actions
Make your teaching relevant 1. Diagnose your learner before you teach
2. “Target then Teach”
3. Choose topics that are relevant to the learner’s
experience, interests, and knowledge gaps
4. Use cases and problems that help solve
real clinical problems
5. Have learners identify their own learning
needs (self-directed learning)
Use small “Teachable Moments” 1. Discuss 1–2 key teaching points just before,
frequently during, or after seeing a patient
2. Model (demonstrate and explain) an exam
technique in a patient with clinical findings
3. Use the Microskills of Clinical Teaching —
see below
4. Give learners opportunities for skill practice
in your presence and provide feedback
5. Ask learners to reflect on their own practice
teaching what learners feel is already obvious to them, or teaching so far
above the learners’ level that they cannot connect to the content.
To ensure that the time you spend teaching is efficient and relevant, take
the time to find out what your learner wants and needs to learn. Irby and
Wilkerson call this timesaving rule “Target then teach”
4
where the teacher
uses questions and observations to direct his or her teaching. Begin by asking
questions to help you determine what your learners already know: “Why do
you think he has pneumonia?” “Have you ever seen the effects of hyperkalemia on an ECG?” “What is the most appropriate next test?” Next,
conduct a 2-minute observation of your learner interacting with the patient.
Inform the patient and the learner that you are briefly observing for teaching
purposes and debrief afterwards. Lastly, direct your teaching based upon
what you have learned. This intuitive 3-step process will help you “diagnose” your learner’s needs, and give you the information you need to choose
among the countless possible topics that arise each day with each learner.
Second, consider that good teaching can happen in small doses. The
belief that teaching requires an hour in the classroom or at the bedside
during a formal teaching session can inhibit us from grasping the teach-
able moments. Most clinicians remember being on-call as a medical student, busily moving through the hallways on the way to the emergency
room to see a new patient with their resident, and reviewing the differential diagnosis of chest pain or the meaning of pre-test probability in a
patient who may have had a pulmonary embolism. For many students and
residents, these exciting but brief teaching moments are the most memorable and effective because they have immediate relevance to their
patients and the learning is based on their direct experience.
5,6
Two minutes on the go may be more meaningful than an hour in the classroom
because contextual learning deepens learning experiences.
7
The clinical teacher’s role is critical because experiential learning
depends heavily on the facilitation of learning by the teacher and not simply
the exposure to patients.
4,6–8
As an example, after evaluating a patient whose
labs just returned and reveal evidence of a microangiopathic hemolytic anemia and thrombocytopenia, the teacher may ask the team, “Let’s review the
five criteria for TTP and decide whether she meets the criteria.”
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Teaching Tips and Pearls