An Advanced Practice Provider Clinical Fellowship as a Pipeline to Staffing a Hospitalist Program
BACKGROUND: Approximately 83% of hospitalist groups around the country utilize advanced practice providers; however, the demand for hospitalists continues to exceed the supply, and this has led to increased utilization of advanced practice providers in hospital medicine. Advanced practice providers receive very limited inpatient training, and there is wide variation in their clinical abilities after graduation.
OBJECTIVE: To determine if an advanced practice provider fellowship is a cost-effective pipeline for filling vacancies within a hospitalist program.
METHODS: In 2014, a one-year advanced practice providers clinical fellowship in hospital medicine was established. Working one-on-one with an experienced hospitalist faculty member, the fellows evaluate and manage patients. The program consists of 80% clinical experience, in the inpatient setting, and 20% didactic instruction. Up to four fellows are accepted each year and are eligible for hire, after training, if there are vacancies.
RESULTS: The duration of onboarding and cost to the division were significantly reduced after implementation of the program (25.4 vs 11.0 weeks, P = .017 and $361,714 vs $66,000, P = .004).
CONCLUSION: The advanced practice provider fellowship has proven beneficial for the hospitalist division by (1) reducing costs associated with having unfilled vacancies, (2) improving capacity on the hospitalist service, and (3) providing a pipeline for filling nurse practitioners (NP) and physician assistant (PA) vacancies on the hospitalist service.
© 2019 Society of Hospital Medicine
As we have developed and grown this program, the one great challenge has been what to do with graduating fellows when we cannot hire them. Fortunately, the market for highly qualified, well trained APPs is strong, and every one of the fellows that we could not hire within our group has been able to find a position either within our facility or outside our institution. To facilitate this process, program directors and recruiters are invited to meet with the fellows toward the end of their fellowship to share employment opportunities with them.
Our study has limitations. First, had the $276,000 from the attrition of two physicians been used to hire nonfellow APPs under the old model, then the costs of the two models would have been similar, but this was simply not possible because the positions could not be filled. Second, this is a single-site experience, and our findings may not be generalizable, particularly those pertaining to remuneration. Third, our study was underpowered to detect small but important differences in characteristics of APPs, especially time from graduation to hire, before and after the implementation of our fellowship. Further research comparing various programs both in structure and outcomes—such as fellows’ readiness for practice, costs, duration of vacancies, and provider satisfaction—are an important next step.
We have developed a pool of applicants within our division to fill vacancies left by turnover from senior NPs and PAs. This program has reduced costs and improved the joy of practice for both doctors and APPs. As the need for highly qualified NPs and PAs in hospital medicine continues to grow, we may see more APP fellowships in hospital medicine in the United States.
Acknowledgments
The authors thank the advanced practice providers who have helped us grow and refine our fellowship.
Disclosures
The authors have nothing to disclose
