The role and training of the critical care APP

This is neither a review of evidence, nor a tutorial of medicine, but merely a discussion. What follows is nothing but opinions.

What is the role for advanced practice providers (APPs) in the modern American ICU?

(By this, I mean the general group consisting of physician assistants [PAs] and nurse practitioners [NPs]. Although many departments tend to predominantly hire either NPs or PAs out of habit, there is little to no functional difference between them in this role, and anybody who says differently is selling something.)

This story didn’t begin yesterday. It has been unfolding for decades, and involves issues like the trend toward critical care as a boarded specialty (instead of merely a function of generalists, such as internists), leading to a relative shortage of trained intensivists compared to the number of ICU beds; the work-hour limitations imposed upon house staff by the ACGME in 2003; and the resulting need for trained providers to fill the gap in coverage.

In the scheme of history, however, I am just a baby provider myself, and someone older and wiser could spin a better tale. Let’s focus instead on where we are today.

What can they do?

APPs are a flexible tool. Their role in the ICU will usually fall into one of several categories:

  1. Sole staffing. In non-teaching units without resident coverage, APPs (with intensivist supervision) can be the primary providers. In their absence, the attending intensivist would need to perform all aspects of patient care on their own; with the APP team, work can be divided in whatever manner is most appropriate, both laterally (splitting the workload) and hierarchically (APP managing care with supervision/consultation from the intensivist). A well-trained APP can manage a unit fairly autonomously.
  2. Staff extension. In busy teaching units that use residents, the ratio of patient load to available resident hours may be too heavy to allow for adequate care. (Residents are a finite resource and so are their work hours.) APPs can be added to the team to bridge this gap.
  3. Education, cohesion, and continuity. Academic units are usually run by house staff that rotate every several weeks. Depending on their seniority and the strength of their critical care training, this can mean an almost continuously-renewed stream of novice providers with little understanding of critical care in general or unit culture in particular. Attendings may only be available for rounding and for earth-shattering crises. In such an environment, a team of trained APPs interlaced through the unit can offer guidance to the residents, help teach and supervise procedures, assist with emergencies, and ensure that local policies and good practice are being consistently applied (versus medicine in the style of monkeys hammering typewriters).

Implementation and training

Although there can be numerous challenges to implementing and maintaining a critical care APP program, most of them involve training.

APPs don’t come stamped with a fellowship certifying their basic competence in critical care medicine. Fresh out of school, they are usually trained in a generalist model, often one emphasizing primary care in the outpatient setting. Even for those with a stronger background in acute care, a new graduate will inevitably need a substantial amount of postgraduate experience before they can safely and competently manage critically ill patients. This is not always easy to acquire.

Formal post-graduate residency/fellowship programs for APPs do exist (call them what you will, as terminology is non-standard). I did one. The benefit of this is a formal teaching environment designed to guarantee competency in key areas. It will usually involve a number of activities that are not possible outside of a teaching program, such as rotations through different specialty settings and protected didactic time—things you can’t get after an infinite number of years “on the job.” The downside: few of these programs exist, and since they are not required by most employers, many APPs don’t see the point of dedicating time after school to work long hours for little pay.

The alternative is on-the-job training. In centers with well-developed on-ramp programs, this may take the form of a miniature residency, with classes, off-service rotations, and competency-based completion requirements. In simpler settings, it will merely involve new hires spending a certain number of shifts working alongside an experienced APP while they learn the ropes. Since this training period can only last so long, however, it’s important that the learning doesn’t end there; once “released,” the novice APP will still need to be able to make decisions in a supervised, assisted setting, similar to a resident.

This highlights an important dilemma. A critical care APP, even one that is “trained,” is a heterogeneous creature. His or her understanding of critical care medicine, competency with procedures, and familiarity with the spectrum of disease may all vary widely according to training and experience—and any point along this spectrum may be acceptable and appropriate in the right context. One ICU may use its APPs in a very limited way—exclusively to place lines, for instance—and in that case, adequate training would only require competence within that small domain. On the other end of the spectrum, an APP’s role may be to admit patients, diagnose acute illness, direct treatment, write notes, run codes and rapid responses, manage beds, and supervise all aspects of the unit (in consort with an attending physician to assist and advise). Competence for that role would require a much greater degree of training.

Along with the unit’s needs is the APP’s own desires, including the type and scope of medicine they wish to practice, which may lie anywhere along that spectrum.

A happy unit is one where the needs of the role, the desires of the APP, and the training of the APP all coincide. There are two functional models for how this can work: either you hire untrained APPs and train them to the level needed for their role, or you hire trained APPs (and need merely to show them where the restrooms are).

On the other hand, two non-functional models are also possible:

  1. Hiring untrained people—then not training them. This is not an option. Many centers, particularly non-academic community hospitals, lack the necessary patient volume or simply the correct environment for training. (For instance, rounding may not be performed in a didactic manner, and decisions may either be made by the attending or by the APP, but not by the APP with attending supervision and commentary.) This is an ICU that can employ APPs but not train them, one that may work perfectly well if it hires staff who cut their teeth elsewhere, but could not possibly grow their own. Unfortunately, these centers may try to save money by hiring new providers anyway. The result is usually that these poor APPs, overstressed and unfairly misused, are able to fumble through learning the raw basics of the job—the skills required from day to day to make the wheels turn—but then “top out” and never learn more. The unit doesn’t function particularly well, because they are only capable of contributing the bare minimum; and the provider is unhappy, because they are not growing and have no prospect of doing so.
  2. Hiring trained people—then not using them. The reverse pitfall is hiring skilled, trained APPs accustomed to a broad scope and a high degree of autonomy, then placing them in an environment where their role is very limited. This is equally troublesome, because while working below your level of training is not as dangerous as being asked to work above it, it is boring, unsatisfying, and a little offensive. If your vision of the APP in your unit is to act as a scribe and secretary, then it behooves you to hire an APP who is looking for that job.

The upshot

The APP is a utility player in the modern ICU, and can be applied in a number of ways according to each unit’s needs. However, while this is true for APPs as a group, they are not coming to work with you “as a group”; you will hire specific human beings, and since their specific skills and goals vary so widely, it’s important to find the right fit.

Hire people who want to do the work you need to be done, and who either have the training you need, or want the training you’ll provide. With this, harmony can be achieved. When one of these pillars is missing, darkness and discontent unfold.

Do you have your own opinions and experiences with APPs in the ICU? Share them in the comments!