An Advanced Practice Provider Clinical Fellowship as a Pipeline to Staffing a Hospitalist Program

There is an increasing utilization of advanced practice providers (APPs) in the delivery of healthcare in the United States.^1,2 As of 2016, there were 157, 025 nurse practitioners (NPs) and 102,084 physician assistants (PAs) with a projected growth rate of 6.8% and 4.3%, respectively, which exceeds the physician growth rate of 1.1%.² This increased growth rate has been attributed to the expectation that APPs can enhance the quality of physician care, relieve physician shortages, and reduce service costs, as APPs are less expensive to hire than physicians.^3,4 Hospital medicine is the fastest growing medical field in the United States, and approximately 83% of hospitalist groups around the country utilize APPs; however, the demand for hospitalists continues to exceed the supply, and this has led to increased utilization of APPs in hospital medicine.^5-10

APPs receive very limited inpatient training and there is wide variation in their clinical abilities after graduation.¹¹ This is an issue that has become exacerbated in recent years by a change in the training process for PAs. Before 2005, PA programs were typically two to three years long and required the same prerequisite courses as medical schools.¹¹ PA students completed more than 2,000 hours of clinical rotations and then had to pass the Physician Assistant National Certifying Exam before they could practice.¹² Traditionally, PA programs typically attracted students with prior healthcare experience.¹¹ In 2005, PA programs began transitioning from bachelor’s degrees to requiring a master’s level degree for completion of the programs. This has shifted the demographics of the students matriculating to younger students with little-to-no prior healthcare experience; moreover, these fresh graduates lack exposure to hospital medicine.¹¹

NPs usually gain clinical experience working as registered nurses (RNs) for two or more years prior to entry into the NP program. NP programs for baccalaureate-prepared RNs vary in length from two to three years.² There is an acute care focus for NPs in training; however, there is no standardized training or licensure to ensure that hospital medicine competencies are met.^13-15 Some studies have shown that a lack of structured support has been found to affect NP role transition negatively during the first year of practice,¹⁶ and graduating NPs have indicated that they needed more out of their clinical education in terms of content, clinical experience, and competency testing.¹⁷

Hiring new APP graduates as hospitalists requires a longer and more rigorous onboarding process. On‐the‐job training in hospital medicine for new APP graduates can take as long as six to 12 months in order for them to acquire the basic skill set necessary to adequately manage hospitalized patients.¹⁵ This extended onboarding is costly because the APPs are receiving a full hospitalist salary, yet they are not functioning at full capacity. Ideally, there should be an intermediary training step between graduation and employment as hospitalist APPs. Studies have shown that APPs are interested in formal postgraduate hospital medicine training, even if it means having a lower stipend during the first year after graduating from their NP or PA program.^9,15,18

The growing need for hospitalists, driven by residency work-hour reform, increased age and complexity of patients, and the need to improve the quality of inpatient care while simultaneously reducing waste, has contributed to the increasing utilization of and need for highly qualified APPs in hospital medicine.^11,19,20 We established a fellowship to train APPs. The goal of this study was to determine if an APP fellowship is a cost-effective pipeline for filling vacancies within a hospitalist program.