APPs play multifaceted role as urology team members

When properly trained and working as part of the clinical team, physician assistants and nurse practitioners can take on a wide range of responsibilities, according to Jim Kovarik, PA-C. In this interview, Kovarik discusses the role of advanced-practice providers in a urology practice, how they are trained, and what procedures they can and should perform.

Kovarik is a urology-trained physician assistant at the University of Kansas Hospital, Kansas City. He is the current president of the Urological Association of Physician Assistants (UAPA) and a member of the AUA Advanced Practice Providers Education Committee.

Kovarik was interviewed by J. Brantley Thrasher, MD, professor of urology at the University of Kansas Medical Center, Kansas City.

There are manpower issues in urology, and we have a huge aging population. We have a lot of patients to see and not enough urologists to see them. With our current throughput, that’s not going to change; I think residency programs are set. This leads to the question, how should advanced-practice providers (APPs) be used in urology practice?

APPs can really be utilized almost anywhere in a urology practice. They can be utilized in clinic to help see more patients, whether they’re routine follow-up patients, post-op and pre-op patients, or new patients. They can assist in the OR as first assists, including robotic cases with appropriate training. They can help out with hospital rounds, hospital consults, and even ER consults. APPs assist with evening or weekend call to take some of the pressure off physicians or to spread the workload among providers in the practice.

In your practice, what is your role within the department of urology? How do you fit into the workflow?

In general, APPs need to be allowed to work at the top of their licensure, competency, and level of experience. In my current role, I act as an adjunct to the faculty. I work in their clinics part of the time. The other 50% of the time, I have my own clinical practice and see my own template of patients, thus helping improve the efficiency of the practice to make sure patients are getting seen in a timely manner.

You received specialty-specific training in urology and, in fact, you have procedures under your belt. Do you think doing procedures within a scope of practice is important for the use of an APP?

Absolutely, it is within the scope of practice for APPs to perform urologic procedures such as complex catheter placements with or without cystoscope assistance. Given the appropriate training and experience, APPs can perform cystoscopic stent removal and even diagnostic cystoscopies. Some APPs perform transrectal ultrasound and prostate biopsies, urodynamic studies, penile injection, testosterone pellet implants, and shock wave lithotripsies.

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If the APPs have been appropriately trained, they can take on some of those procedures and improve patient satisfaction by improving patient access and decreasing wait times.

Next:"One of the most important aspects of being an APP in a urology-specific practice is to work as a team"You’re very good about making sure that you’re under supervision, for example, by taking pictures at the time of cystoscopy. Do you consider it important to work side by side with your attending and your supervisor?

Absolutely. One of the most important aspects of being an APP in a urology-specific practice is to work as a team. I think it is appropriate and essential to make sure you are communicating well with your supervising/collaborating physician or colleague physicians. Communication includes taking relevant cystoscopic pictures so if something is questionable, you can not only document it for the medical record, but also take it back to your supervising physician to ask his or her opinion, if necessary.

Some hospitals or practices do APP training in their clinics, so it’s on-the-job training as it were. There are also courses available. What do you think is the optimal training-within a practice so that you can fit it to the needs of the practice, or is it something that should be done on a national level?

This is a controversial issue in the urology world right now. Currently, most urology APPs receive on-the-job urology-specific training and procedure training. There are a few urology PA and APP postgraduate training programs. Regarding performing cystoscopy, the Society of Urologic Nurses and Associates (SUNA) and Urological Association of Physician Assistants (UAPA) provide cystoscopy workshops and hands-on opportunities to expose APPs to cystoscopic procedure possibilities.

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I know the AUA is evalauting how to appropriately provide cystoscopy and procedure education and possibly training to make sure those people who go through a course are truly qualified to do what they need to do. Ultimately, I do not believe that a single course will allow an APP to immediately perform completely unsupervised cystoscopies or prostate biopsies.

But just like with residency training, the more procedures someone performs, the more proficient and knowledgeable he or she becomes at performing the procedure. They must also know what is expected and know their own limitations-that’s where having the supervising physician’s support and knowledge is critically important.

What resources do you think are needed for an APP to be successful in practice?

I would answer the same way if you were hiring a new physician to the practice. It sounds simple, but they essentially need all the same tools and resources, including some form of administrative assistant or someone to help with scheduling and a nurse or medical assistant for rooming patients and doing ancillary tasks in clinic. They need an appropriate number of clinic rooms to see patients, depending on how many patients they are expected to see in the course of a day.

They possibly need some administration time to get through the paperwork that goes along with a clinical practice. They need some place to work-at minimum, a desk, a computer, and phone. Again, it sounds simple but others have told me that’s not always a given. I would argue they also need a CME budget to attend courses from the AUA, UAPA, and SUNA to gain specialty-specific urology education and training.

What specific training courses are offered right now that you would recommend?

There are great resources out there. The AUA Urology Core Curriculum and AUA University APP Education curriculum are fantastic resources. Both are available online. The AUA annual meetings have an APP track with numerous options for APPs to attend, including instructional courses throughout the meeting and the current two-day course, Urologic Care for the Advanced Practice Provider.

Next: "APPs are best integrated in a team-based approach"How do you see APPs being best utilized in a urology practice?

APPs are best integrated in a team-based approach. I do not believe urology APPs should be independent providers, although we should be working autonomously. We want to improve patient access to care, improve patient satisfaction, which is certainly being monitored closely nowadays, and ultimately improve the efficiency of the practice.

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You can think of it as allowing the physician to be at two places at once. When an APP has worked with a supervising/collaborating physician or physicians long enough, the APP knows how they think and how they want their patients managed. Therefore, using that background and the APP’s clinical judgment and expertise, he or she can continue that quality of care in the same manner as the physician.

What do you consider inappropriate uses of an APP? What do you see as a waste of time, energy, training, or beyond scope of practice?

APPs should practice at the top of their license. They should be treated as providers and be given that expectation. They should not be used as scribes. They should see patients on their own, whether that’s triaging the patient for the supervising physician or seeing patients autonomously in their own clinic.

Do you have any other take-homes for the readership regarding APPs and what procedures they might perform to best utilize their specialty-specific expertise?

I think it’s helpful to find out what the APP is passionate about and what he or she is good at doing. Some people are passionate about men’s health or women’s urologic health, while some are more comfortable dealing with oncology issues, erectile dysfunction, pelvic pain, or stone medical management. Some APPs prefer to be in the operating room and may be best utilized as first assists. Some APPs are interested in research. Some are interested in managing inpatients and hospital consults. Some APPs want to take call. All of those are certainly available options.

As far as procedures go, APPs may perform a multitude of procedures, including but not limited to complicated catheter placements, performing and interpreting urodynamic studies, transrectal ultrasonography, and prostate biopsies. MRI fusion-guided biopsies are certainly reasonable, as are cystoscopies for stent removals or diagnostic cystoscopies-with the appropriate training and initial supervision-and minor office procedures such as penile injections and testosterone pellet implants. Performing these types of procedures expands the services of the practice and allows physicians to see more complex patients who are better suited for their training and expertise.