Leveraging the full potential of APPs: Mark Edney, MD, on tips for successful collaboration

In this interview, Mark T. Edney, MD, shares advice on how to successfully integrate advanced practice providers (APPs) into urologic practice, which was discussed at the 2024 Stronger United conference in Phoenix, Arizona. Edney is a urologist with Chesapeake Urology in Salisbury, Maryland.

Mark T. Edney, MD

You took part in a session at the Stronger United conference titled “APP Optimization”. Could you share the key takeaways from that discussion?

We've gone a long way towards optimizing the integration of APPs into urology practice, and I wanted to communicate that to the rest of our group. There is a tremendous amount of clinical work that the APPs can do in urology with appropriate training and appropriate oversight. With that, they can have tremendous job satisfaction, feel like they're members of a urologic team, and help handle the volume that's coming at us. At the end of the day, one of the issues, from a national policy standpoint, that has floated to the top is work force shortages. It used to be administrative burden, and it still is—there’s a lot of administrative burden the practice urology—but there just aren't enough of us to deliver the care that needs to be delivered to the numbers of people that are presenting to us for care.

[As a solution to that,] we can talk about GME and expanding training slots, and those are absolutely all necessary items. But when you talk about expanding GME slots and residency slots, even if you do that tomorrow, you are 6 to 8 years away from realizing that extra urology work force. In the meantime, we have to figure out how to take care of the patients that are presenting to us in the highest quality way, and part of that equation has to be the integration of advanced practice providers into your practice.

There's a tremendous amount they can do with high quality and with very high job satisfaction for them; it just has to be done the right way. That was my main thrust at the meeting, and also that you can integrate them in a way where they're extremely productive. When we look at United Urology Group, which has more than 120 APPs, we have the top 3 performing APPs across the platform with respect to RVUs and collections. That didn't happen by accident. It's how we approach their utilization and how we integrate them into the team.

How do you define the roles of APPs in your urology practice? How do they complement the work of urologists?

It starts with how we approach the APP role in our practice. We consider them trained medical professionals who are key elements of our team. You've got to start with that mindset. Early on in United Urology Group's evolution, Dr. Geoffrey Sklar, the CMO and I actually did a series of town hall meetings with urologists across the platform to try to get a sense of the attitudes toward integrating APPs with the team. The attitudes were all over the place. There are some who were like us: fully on board and integrating them actively. There are others who were a bit more resistant. There's some who haven't integrated them at all, and there are some who [have an] arm's length approach to APP participation on the team.

That's something that we need to address and continue to speak with our colleagues about. That's primarily why I gave that presentation at the meeting, to let them know what's possible. It involves changing some attitudes on the part of some doctors who feel like, "I'm the trained professional. I'm the MD or DO. I'm the only one who can make clinical decisions for my patients." It's just frankly not true. I understand that's an old holdover sentiment, and it comes from a place of, "We do all of this clinical training. We have all of these clinical hours. We are the only ones who can make decisions for our patients." The truth is that's not the case.

Everybody needs to be practicing at the top of their license and their credentials. For physicians, absolutely, there's a lot of complex decision making in urology that can only be done by doctors. No doubt about it. There's also a whole lot of stuff that goes on in the clinic that's what I call algorithmic, meaning a patient comes in with X complaint, and these are the options and the things that need to happen. There's not a whole lot of critical decision making with respect to that. For example, someone comes in with painless gross hematuria. The workup for that is a CT urogram and a cystoscopy. It always is. There's not a lot of nuance to that decision making. There are other examples in urology of those sorts of things.

A properly trained and supported APP can see those patients, make those clinical decisions, and set those folks up. I don't need to be spending my time seeing a new patient for gross hematuria. I can see the complex cancer patients who may have much more nuanced decision making that requires my level of training. I should be devoting my time to doing that and leaving the basic hematuria workups and the basic kidney stone workups to the APPs. Absolutely, the APP needs some training and some experience to get used to these algorithms. Once they do, they can make the same decisions that we make. They do require our ongoing oversight, and we need to remember that we need to continue to provide oversight, but they're perfectly capable of making all these decisions.

Once you can start offloading a lot of this basic clinical decision making to the APPs, it frees you up to act at the top of your license and start making the complex decisions that only you can make. That's how you handle the increased volumes that are moving through our offices.

How do you help to foster a collaborative environment between urologists and APPs?

It starts by treating them as true colleagues. They're not less than. At that roundtable that Dr. Sklar and I did, I heard from a lot of colleagues in the platform that some have an attitude of, "Well, they're just APPs. They can only do so much." It's a 'less than' attitude. You have to get rid of that. They're trained medical professionals. Yes, they're trained at a much lower level than we are, but they're trained and they have capabilities.

You have to switch your thinking to: How do I harness those capabilities? How do I increase their training in urology? How do I provide the proper oversight so they can start doing a lot of things that I don't need to be doing? It frees up time to do the things [for which you’re] trained and needed, given the volume. So, number one is treat them like trained, professional colleagues. That's how we treat our APPs. They're not less than. They're not the folks handling the stuff that I don't care about. They're colleagues.

One of our APPs runs the Advanced Prostate Cancer Clinic. It's been a tremendous boon to his practice [and] his job satisfaction, because he's been able to wrap his mind around a clinical area. He knows the literature better than almost anyone in our practice, because it's a defined amount of literature with respect to staggering these drugs for advanced prostate cancer. He's the local expert in it. There are times where I will go to him, and say, "Hey, would you start this drug or that drug?" And he'll say, "I'd go with this for these reasons," and he'll give the reasons. They can develop that level of expertise in a particular niche in our practice. You have to support them in doing that. That's the culture in our practice. No one's better than anybody else. We all have a certain level of training. We have licenses, and we all ought to be working at the top of those.

The other thing is you have to be open, as an attending in your practice, to any question, anytime, from the APPs. There's never a bad question, and there's never a bad time. [I tell them,] “If you're seeing a patient and you don't know what to do, come talk to me. I don't care if I'm busy.” Sometimes I am busy and sometimes I'm the middle of something. Take 2 seconds [and say,], "What's your question? Let me help you." Everybody's harried, everybody's got too many patients on their schedule, and everybody's in a rush. It's hard, because sometimes you've got many things going on. The last thing you want to do is take 2 minutes to field a question from an APP, but you have to do it. You have to find that inner strength and peace to say, "This is critical. This is how our practice runs. I don't have time right now, but I'm going to make 2 minutes for you. What's your question? How can I help you?" As long as APPs are properly supported, they will take off and they will change your practice. That's the culture in our practice, and I hear it back from them that they really appreciate that we are also available and willing to help at any time.

The more you do that, the more they get comfortable making those decisions on their own. It's all about clinical experience. We get so much in training, but practicing good urology is really about your experience and your time. You get better as you gain clinical experience. We as urologists sometimes make a decision that we wish had gone a different way because you had an outcome you didn't like. You learn from that. Same thing with them. They have a question, you answer it, and then the next time that question presents, [they’ll say], "I remember that conversation I had. I think I'm going to go this way instead." That's how they evolve. You have to help them evolve. If they feel an integrated part of the team, it takes off. They have tremendous job satisfaction when they feel like they actually have a place on the team.

Are there any challenges that you've encountered with the integration of APPs into your practice?

Nothing's perfect. There's always challenges. As great a concept as it is to integrate APPs to help with the workload in your practice, there are challenges in certain areas. One of them being patient resistance. There are certainly those patients who say, "I only want to see the doctor. I don't want to see an extender." They're actually pretty rare. I would say that's probably 5% to 10%, tops. The vast majority of people don't mind seeing the APPs; they're just happy to have a clinic spot. With the waiting lists and everything else going on, they'll see anybody. They've got a problem, and they want it addressed. I'd say that's the majority opinion, but you do run into people who are like, "I don't want to see the APP, I want to see the doctor." You can mitigate that by really talking up your APPs.

With respect to Joy and his advanced prostate cancer clinic, when I make a diagnosis of advanced prostate cancer, I will say, "When you come back, you're going to see Joy, who's one of our nurse practitioners. He is our local expert in prostate cancer. He's tremendously well-read. He knows the literature. He's a great guy to work with, and he's going to excellent care of you." If you spend a couple minutes to talk them up to the patient and say, "Listen, this is an expert in our practice in this area," they're fine with it. It just takes a little bit of effort. With a couple words of encouragement to the patient, they're fine with it. That's how you mitigate the patient pushback.

The other challenge, I would say is oversight. It's so important, particularly with new APPs in your practice. You have to read every note and you have to go over every clinical decision. As they gain more experience, you can take your foot off the pedal a little bit. Once you get confidence that they're making the decisions you would make, you can let them go a little bit, but initially it's a lot.

Things do occasionally fall through the cracks. Understanding they have much less training than we do, and starting off, much less clinical experience, they are sometimes ordering diagnostic tests that we would not order, and sometimes they're booking folks for minor surgical procedures, for example, a cystoscopy or prostate biopsy. If a doctor didn't happen to go over that note at the time, and sometimes that happens, you may find somebody scheduled for a procedure that you wouldn't necessarily have scheduled. That happens, and that comes with the territory. You try to minimize that by keeping as close an eye as you can. But when that happens, I always circle back to the APP. [I’ll say,] "Hey, so and so ended up on my schedule for cystoscopy today. I wouldn't necessarily have scheduled that for these reasons, because, you might have tried this or that first or may have seen them back and checked something else." Once you have that conversation once, they've learned that lesson. They're not going to schedule those people for you anymore, but it requires that feedback.

There may be circumstances where that happens to certain urologists and they get frustrated, and they move on with their day. They don't give the feedback to the APP. You have to give them feedback. Sometimes you feel like you don't have time, or it's uncomfortable, but it doesn't matter. Give them the feedback. If you want to successfully integrate APPs and have them become the workhorses in your office that they are in my office, you got to take the time, even when you don't have time to say, "Listen, you scheduled this patient for whatever. It's not a punitive thing. I want to give you professional feedback. I wouldn't have scheduled a patient for this. It happens. Fine, we did it. Here's what I would have done [for] next time." They won't make the same mistake. They're smart people, and they're professional clinicians. They will learn their lesson, but you have to help them along. You have to take the time even when you think you don't have time to do it.

How do you see the role of APPs evolving in urology over the next 5 to 10 years?

They're going to be an increasingly important part of the team, largely because of the supply/demand mismatch that we've talked about. There are far more people presenting to us for care than we have people able to provide it. The APPs are going to be a critical part of trying to solve that puzzle.

There are APPs across the country now in urology who are starting to do cystoscopy, for example, for stent removals, cystoscopy, to help place difficult Foley catheters. There are APPs doing vasectomies and doing prostate biopsies. We have traditionally thought of that as the purview of the doctor in urology. Depending on where you are, you may have enough doctors to handle the procedural load, and that's fine. Your APPs can help you in the office, doing the things you don't need to be doing in the office. That's where you need to focus them.

But I imagine there are also areas—and I think we're going to see this evolve—where the doctors can't keep up with the procedural load. My local procedures, meaning the non-anesthesia procedures—cystoscopies, vasectomies, prostate biopsies—I am booking out 3 to 4 months right now. That's only going to get worse. So, you can envision a time where we're actually utilizing more APPs to help with some of the basic procedures that they can learn to do and do well.

Probably not things like diagnostic cystoscopy—looking at a bladder and determining is that a spot of concern or not—that's probably going to be the purview of the urologist for a long time, just because of our training and our lengthy clinical experience. But there are procedural things where you're going in for a specific task—pulling a stent, placing a catheter—where an APP can learn that, and they can do that proficiently. I think we're going to see APPs moving more slowly into minor procedures and [having] increased utilization on the office side.

Is there anything else you wanted to add?

One of my favorite leadership books, and I mentioned this during the during the talk, [is a book by] Daniel Pink called Drive. This is probably now 15 years old, but the principles remain. He was the first one to put together the notion of what creates job satisfaction. If you go back to the 60s and 70s, people thought it was money; if you pay people more, they'd be happier on the job. It's actually not the case. What creates job satisfaction are 3 principles: mastery, autonomy, and a sense of purpose.

Mastery. Give them the ability to become good at something on their own. Again, the example in our group is Joy doing his advanced prostate cancer clinic. He's become the local master of advanced prostate cancer, and that creates tremendous job satisfaction. He loves being the go-to guy when we have questions. "Hey, Joy, this drug vs that drug? What would you suggest?" "Well, I would suggest this drug, because this study said this, and this is the literature." He can do that, and that mastery is really good for him.

Autonomy. We have to be available for them [and] we have to train them up, but you also need to let them go. Let them practice urology without hovering and being a smothering oversight. You need to provide appropriate oversight. Talk to me when you need to talk to me. If I see something that I need to reach out to you about, I'm going to do it. But let them practice urology. That sense of autonomy—like I have my own practice, I can make my own decisions—is really critical.

The final point that Pink makes in that book is a sense of purpose. [This is] the sense that my job actually has a critical role in the organization I'm working in, and I can see where my role relates to the whole. They need to not feel like they're an island out there on their own, without any kind of connection to the mothership. We are all on this team together. Your role is critical, and this is how what you do makes it easier for me to do what I do. This is how this all comes together to provide community urology care.

Those 3 elements combined absolutely elevate job satisfaction and make them happy. It makes them stick around. Once you train up an APP and you get them some experience, you don't want to go somewhere else, because they can. They can easily. You want them to feel like they've got a place here that they value. They value being part of your team. They've been allowed to develop a certain amount of autonomy and mastery of the subject, and they feel well supported. They feel like a colleague with the doctors. They don't feel like an employee. If you do those things, you're going to be extremely successful at integrating APPs.