The Emergence of Post- Graduate Training Programs for APPs

This month CHEST launched a new quarterly column called “APP Intersection.” Spearheaded by Corinne Young, this column will highlight content for APPs and other members of the chest medicine healthcare team. 

We are so excited to share the first article from the February 2024 CHEST Physician Newspaper co-authored by 2 of our members, Vincent DeRienzo, PA-C and Sarah Tomashefski, MSN, AGNP-C.

Title: “The Emergence of Post- Graduate Training Programs for Advanced Practice Providers in Pulmonary & Critical Care”

Post-graduate training opportunities for Advanced Practice Providers (APPs) have existed in one form or another since the genesis of the allied professions and are referred to as residencies, fellowships, post-graduate programs, and transition-to-practice. The desire and necessity for these programs has increased in the past decade with workforce changes; namely the increasing number of NPs graduating with fewer years of experience at the bedside when compared to previous eras, a similar decrease in patient contact hours for graduating PAs, the transition of our physician colleagues from employers to employees and the subsequent change in priorities in training new graduate APPs, and resident work hour restrictions necessitating more APPs to staff inpatient units and work in various specialties.  

The goal of these programs is to provide post-graduate training to Physician Assistants/Associates (PAs) and Nurse Practitioners (NPs) across myriad medical specialties, and is geared toward both newly graduated APPs and those looking to transition specialties. Current programs exist in family medicine, emergency medicine, urgent care, critical care medicine, pulmonary medicine, oncology, surgery, and various surgical subspecialties, to name a few. Program length is highly variable, though most programs advertise as lasting around twelve months and have varying ratios of clinical and didactic education. Post-graduate APP programs largely advertise as salaried, benefitted positions, though usually at a rate below that of a so-called “direct-hire” due to the protected learning time associated with the post-graduate training year.  Accreditation for these programs is still disjointed, though unifying efforts have been made as of late. Accreditation is currently available through the Advanced Practice Provider Fellowship Accreditation, Association of Postgraduate Physician Assistant Programs, ARC-PA, the Accreditation Commission for Education in Nursing, and the Consortium for Advanced Practice Providers. Other organizations, such as the Association of Post Graduate APRN Programs, host regular conferences to discuss the formulation of post-graduate APP education curricula and program development.  While accreditation offers guidance for fledgling programs, many utilize the standards published by the American College of Graduate Medical Education to ensure appropriate clinical milestones are being met, and for a common language amongst APPs and physicians that are involved in the evaluation of the post-graduate APP trainees.  Programs also seek to utilize other well-established curricula and certification programs published by various national and international organizations. Contrasting physician post-graduate training, there is currently no fiscal or legislative support for post-graduate APP programs; issues that have been cited as reasons for the limited scope and number of programs.    

When starting APP Fellowship programs, it is important to consider why this would be beneficial to a specific division and to a healthcare organization. Usually fellowship programs develop out of a need to train and retain APP’s. It is no secret that turnover and retention of skilled APP’s is a nationwide problem associated with significant costs to organizations. The ability to retain fellowship trained APP’s will result in cost savings due to the reduction in onboarding time and orientation costs, as these APP fellows finish their programs ready to be fully productive team members. Additional considerations for the development of an APP fellowship include improving access to care and increasing the quality of the care provided. Fellowship programs encourage a smoother transition to practice by offering more support through education, closer evaluation, and frequent feedback which improves competence and confidence of these providers. A supported APP is more likely to practice to the fullest extent of their license and have improved personal and professional satisfaction, leading to employee retention and improved patient care.

When developing a budget for these types of programs it is important to include the FTE for the fellow, benefits, onboarding/licensure, simulations, and fellowship faculty costs.  Faculty compensation varies by institution, but can include salary support, FTE reduction, and non-clinical appointments. Tracking metrics such as fellow billing, length of stay, and access to care during the fellowship year is helpful to highlight the benefits of these programs to the organization.

Initiating a program like those described above may seem a Herculean feat, though motivated individuals have been able to accomplish similar goals in both well and poorly resourced areas. For those aspiring to start a postgraduate APP program at their instruction, these authors suggest the following approach. First, identify your institution’s need for such a program. Next, define your curriculum, evaluation process, and expectations. Then, create buy-in from stakeholders including administrative and clinical personnel. Finally, focus on recruitment. Seeking accreditation may be challenging for new programs, but identifying the accreditation standard you plan to pursue early will pay dividends when the time comes for the program to apply. Those starting down this path should realistically expect an eighteen to twenty-four month period between their first efforts and the start of the first class.

You can find the full February issue HERE, and read this article on page 13. Be sure to register for our June Conference to hear Vinny present on the ‘Lifespan of COPD Patient: Management; Exacerbation; End-of-Life.’ 

This post was published by The APAPP staff on behalf of the author(s) – listed above.