For rheumatology practices, one solution to the shortage of physicians in this specialty in the United States is to add nonphysician providers such as nurse practitioners (NPs) and physician assistants (PAs) to the care team. Many practices now successfully employ such a model, which was suggested by the 2005-2006 American College of Rheumatology (ACR) workforce study and is supported by available research.1
A 2015 study by physicians at Brigham and Women’s Hospital and the Yale School of Medicine compared outcomes of 301 patients with rheumatoid arthritis (RA) who were seen in 3 rheumatologist-only practices vs 4 practices that include NPs or PAs.2 Their findings revealed lower disease activity during a 2-year period in patients seen in practices with NPs or PAs vs those seen in rheumatologist-only practices.
In a 2014 study, the same group conducted a nationwide survey of rheumatology NPs and PAs and reported the following observations3:
- Of 174 respondents, 53% had formal training in rheumatology
- Nearly two-thirds had their own panel of patients
- The top 3 practice responsibilities reported by respondents were patient education (99%), adjusting medication doses (98%), and conducting physical examinations (97%)
- More than 90% reported feeling very or somewhat comfortable diagnosing RA, and a similar number of respondents indicated that they prescribed disease-modifying antirheumatic drugs
- Three-quarters of respondents reported that they used disease activity measures for RA, and 56% said their practices used treat-to-target strategies.
These findings suggest NPs and PAs “may help to reduce shortages in the rheumatology workforce and conform with recommendations to employ [treat-to-target] strategies in RA treatment,” according to the authors. Additional studies further support the treatment competency of nonphysician rheumatology clinicians.4,5
To gain perspective from clinicians who currently practice in an integrated setting, Rheumatology Advisor interviewed Charles M. King II, MD, a rheumatologist based in Tupelo, Mississippi, and Brandon Young, DNP, one of the NPs who works in his practice. They described the topic in detail in an article published in the Journal of Clinical Rheumatology in 2015.6
Rheumatology Advisor: What prompted your practice to adopt the use of a nonphysician provider?
Dr King: In 2008, my practice stopped seeing new patients due to my established patient load. Access to timely rheumatologic care for patients in North Mississippi was compromised due to the difficulty in recruiting a rheumatologist and the distances that patients had to travel to receive care. In 2009, the decision was made to recruit an NP. I hired my first NP in 2010 to facilitate the evaluation of new patients and to aid in the care of established patients, and I added a second NP in 2014.
Rheumatology Advisor: What was the transition like, and what did training include?
Dr King: Training of the NP included 3 portions: side-by-side training and mentorship with the physician, lectures, and independent study. During the first 3 months, the NP shadowed me and learned how to obtain a pertinent medical history, perform an accurate joint examination, and interpret laboratory results and radiographs. The NP also became proficient in the use of the electronic health record.
The observation period gave me the opportunity to introduce the NP to the patients, with the goal of obtaining their buy-in. I also gave lunch lectures about rheumatic disease at least 3 times weekly, and the NP studied articles suggested by me and read books, including Rheumatology Secrets by Sterling West. Later, the NP completed the ACR’s Advanced Rheumatology Course to further improve her knowledge.
Rheumatology Advisor: How did patients respond to the change?
Mr Young: Many established patients initially voiced concerns over seeing a nurse practitioner rather than the physician and worried that the physician would no longer be a part of their care.
Dr King: Patients who were established in my practice for more than 10 years had a difficult time with the transition to comanagement of their diseases with an NP. New patients who saw the NP as part of their first visit accepted comanagement more quickly than established patients did.
Rheumatology Advisor: When is it more appropriate for nonphysician providers to see patients instead of the rheumatologist and vice versa?
Mr Young: Uncomplicated new patient appointments [for] osteoarthritis, gout, [or] osteoporosis and established stable patients are appropriate for [care by nonphysician providers]. Complicated new patients and established patients should be seen by the rheumatologist. It is our belief that the rheumatologist should be involved in the patient’s care and should see the patients at least once or twice yearly. We try to ensure that a patient does not see an NP more than twice without seeing the rheumatologist. There are actually some patients who prefer seeing the NP.
Rheumatology Advisor: What are the benefits of using nonphysician providers, and are there any potential downsides?
Dr King: My practice stopped seeing new patients in 2008 entirely. With the addition of the NP in 2009, our practice facilitated 192 new patient appointments. By 2013, we saw more than 550 new patients. After adding a second NP in 2014, our practice facilitated more than 1000 new patient appointments. Currently, the wait time to see a rheumatologist or rheumatology NP is less than 4 weeks, and urgent patients are seen on the day requested if the need exists.
The potential downside is that the integration is a long process with no shortcuts. Proper training takes time and money, and there is no guarantee that the NP or PA will stay in the practice.
Rheumatology Advisor: What types of potential issues need to be considered and addressed for practices considering adding nonphysician care providers?
Dr King: Buy-in from patients can be difficult when adding a nonphysician provider, particularly in long-established practices. Setting both patient and provider expectations up front is paramount. Also, it is important to never place an NP in a position to fail. It is never appropriate to ask an NP to see “problem” patients just because the rheumatologist doesn’t feel like it, or to ask them to see a difficult case above their skill set.
Mr Young: Constant instruction and supervision in a nonthreatening environment are key. The integration of an NP or PA is a lengthy process, and the study of rheumatology is a lifelong commitment. Once the provider is integrated, the teaching and learning process should continue. Occasional reimbursement issues have also surfaced since some insurers will not cover an NP or PA.
Summary and Clinical Applicability
Rheumatology practices are increasingly integrating NPs and PAs into their care teams. Provider reports and peer-reviewed research support the efficacy of this approach, which is encouraged by the ACR.
- Deal CL, Hooker R, Harrington T, et al. The United States rheumatology workforce: supply and demand, 2005-2025. Arthritis Rheum. 2007;56(3):722-729. doi: 10.1002/art.22437
- Solomon DH, Fraenkel L, Lu B, et al. Comparison of care provided in practices with nurse practitioners and physician assistants versus subspecialist physicians only: a cohort study of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2015;67:1664-1670. doi: 10.1002/acr.22643
- Solomon DH, Bitton A, Fraenkel L, Brown E, Tsao P, Katz JN. Roles of nurse practitioners and physician assistants in rheumatology practices in the US. Arthritis Care Res (Hoboken). 2014;66:1108-1113. doi: 10.1002/acr.22255
- Vinall-Collier K, Madill A, Firth J. A multi-centre study of interactional style in nurse specialist- and physician-led rheumatology clinics in the UK. Int J Nurs Stud. 2016;59:41-50. doi: 10.1016/j.ijnurstu.2016.02.009
- Broderick JE, Keefe FJ, Bruckenthal P, et al. Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial. Pain. 2014;155:1743-1754. doi: 10.1016/j.pain.2014.05.024
- King C, Young B, Hinton A. Clinical practice extenders in rheumatology. J Clin Rheumatol. 2015;21:131-132. doi: 10.1097/RHU.0000000000000234