APPs Changing the Landscape of Otolaryngology

Integrating physician assistants and nurse practitioners in practices.


(From left to right) Richard W. Waguespack, MD, Pratyusha Yalamanchi, MD, MBA, Michael J. Brenner, MD, and Hardy Shah
(From left to right) Richard W. Waguespack, MD, Pratyusha Yalamanchi, MD, MBA, Michael J. Brenner, MD, and Hardy Shah

In the face of an aging population, there is expected to be a shortage of otolaryngologists by 2025, especially noted in rural markets. By contrast, the advanced practice provider (APP) workforce has grown nearly 35% over the past five years in the form of physician assistants and nurse practitioners.

Speakers on Tuesday’s panel, “Advanced Practice Providers in Otolaryngology: Addressing the Patient Access Gap,” explored how using APPs is changing the practice environment and provided practical tips for onboarding and training those individuals.

Hardy Shah, executive chief administrative officer at the David Geffen School of Medicine at UCLA, said it is essential for otolaryngologists to clearly define their needs when integrating an APP into their practices. Determine if the APP will treat inpatient or outpatient, new versus established patients, will they perform procedures or assist in the operating room, he said.

Richard W. Waguespack, MD, AAO-HNS/F Past President, agreed. “You need to look very closely at the individual and their abilities, nearly as much as you would for bringing in an otolaryngologist. What are they bringing? What is their role? What is their level of experience?

“If they have no real experience in otolaryngology, what is the expected investment on your part to get them up to speed? If they have been in otolaryngology, does their skillset fit with your practice? Hopefully, you won’t have to break bad habits to make them right for you,” he said.

Pratyusha Yalamanchi, MD, MBA, University of Michigan, looked back on her experience with good APPs in an inpatient setting and explored what they may be seeking in their practice environment. 

“Are they looking to be part of a team to manage an inpatient service, or are they looking primarily to be in an outpatient setting? And what degree of autonomy are they looking for?” she said. “It is important to look at your own patient panel to understand where the needs are—postoperative, patient satisfaction, access? Is your APP interested in getting incorporated into a team-based model, or are they primarily looking to be autonomous provider who will work with you in a parallel setting?”

When onboarding, Mr. Shah encouraged otolaryngologists to define a training schedule and identify who will provide mentorship. In doing so, they should monitor schedules to ensure that the patient mix is aligned with expectations, make adjustments as necessary, and provide frequent feedback, adhering to a Plan, Do, Check, Act (PDCA) protocol.

“You really need to think in advance of a training schedule and what that looks like because you will be bringing on a full-time person who is not going to be able to see patients independently on day one,” said Dr. Waguespack. “Even if they were independent prior to coming to your practice, it will take time for them to understand what your needs are and get up to speed.”

Mr. Shah recommended having a schedule for the APP to follow to ensure you are checking off competencies and the individual is ready to do more than collect history.

“If you plan ahead, you can reduce the amount of dissatisfaction or frustration that may follow if you just go in and expect somebody to come in on day one and be productive,” said Mr. Shah.

He cautioned individuals in an academic setting or in an office model where productivity is a driving force to be sure that training the new APP is calculated into contracts.

Dr. Waguespack recalled his 33 years in private practice and could not recall any of his peers using an APP. “However, that all changed in 2013, with physician assistants and nurse practitioners.”

He said the changing landscape goes beyond an access issue. “It translates into better care for our patients. This team-based approach is driving the growth of otolaryngology.”

As the clinician on the panel, Michael J. Brenner, MD, associate professor, Department of Otolaryngology-Head and Neck Surgery at the University of Michigan, said his patients get aggravated when he is running behind, citing the increased presence of APPs as increasing access and yielding results. “They are definitely part of the solution.”