Todd Pickard, MMSc, PA-C
Director of the Physician Assistant Administrative Programs at the University of Texas MD Anderson Cancer Center in Houston, Texas

More than ever, hematology and oncology practices are relying on advanced practice providers (APPs; nurse practitioners [NPs] and physician assistants [PAs]) to fill the unmet needs created by a growing patient base and a looming physician shortage. Of course, staffing your clinic with APPs doesn’t automatically improve patient care and productivity. We need to be integrated effectively into practice and allowed to operate to the full extent of our skills.

Both NPs and PAs are trained to provide a wide spectrum of medical service to our patients; bringing an APP into practice allows physicians to increase access to care and the volume of services they provide. So, please, help us help you.

What Can an APP Do for Your Practice?

When I talk with physician groups – and even to physicians within my own institution – I encounter several misconceptions about the role of the NP and PA in clinical operations.

The first misconception is that patients will always want to see a physician for the service they are receiving, and, when they learn that they are being seen by someone who is not a physician, they will be confused. Patients, it turns out, are not that unsophisticated. A survey of oncology practices (including those that collaborate with non-physician practitioners) and their patients showed that patients not only can tell who they are being seen by, but were perfectly happy with it: Patients expressed high satisfaction when they were treated by non-physician practitioners.1

Second, people believe there is a magic number for the appropriate ratio of APPs to physicians, and APPs to patients. I cringe when people ask me for the “best” number of NPs and PAs to have in their practice because, honestly, there is no standard answer to that question. That “magic number” is something each practice will have to figure out for itself. Many practice-level decisions need to be made based on the patient population being served, the acuity of care, the type of diseases being treated, and what local recourses are available.

Third, physicians may think that they are liable for anything and everything that an NP or PA does – putting their own licenses in jeopardy and making them very fearful about working with an NP and PA. However, that’s not the case: NPs and PAs are licensed providers who are primarily accountable for what they do when they practice.

Physician liability becomes an issue when physicians recognize inappropriate or dangerous practices occurring and allow them to happen without correcting them. One example would be if state practice laws dictate that an NP cannot prescribe opioids, but the physician is aware and allows the nurse practitioner to do so without correcting the practice.

I encourage physicians to appropriately structure their practices to make every member accountable under state law. When APPs are working in an appropriately structured environment with collaboration agreements, there is very little risk to the physician.

A Little Knowledge Goes a Long Way

What you are able to accomplish at your practice depends on your location and the regulations outlining NPs’ and PAs’ scope of practice. There are many practice differences among states, but usually not huge differences. The variations are fairly nuanced and usually very easy to understand; depending on the state, a chemotherapy order may only be filed by a physician, but even one state over, that type of rule may not exist. Some states require that physicians review charts completed by the APP, or that the APP may not have the authority to prescribe scheduled medications; others may not have those rules.

In every state, though, PAs and NPs have standard responsibilities, including evaluating and screening patients, performing a history and physical exam, managing symptoms, and educating patients. They can also supervise other professionals when services are being rendered.
Both the American Association of Nurse Practitioners and the American Academy of Physician Assistants have state practice summaries outlining the specific practicing abilities of the NP and PA.2,3 I encourage physicians and practice administrators to view these summaries to understand the state-to-state differences.

The Possibilities are Endless

The only limitation to how physicians can work with APPs to improve their practices, from both a quality standpoint and a productivity standpoint, is their imagination. Adding NPs and PAs to your practice adds an extra layer of service and fulfills your patients’ needs – without detracting from the physicians’ time.

For instance, when thinking about ways to better serve patients, ask these questions: “Do we need to open another clinic day to see more patients and start them on treatments? Do we need to offer new patient services, such as a coordinator who helps patients navigate the health-care system to avoid missed appointments and delays in care, particularly when that care is delivered in a multidisciplinary practice setting?”

In our urology practice, APPs run a prostate screening program: Patients come in for PSA checks and prostate exams, and, when indicated, the APPs perform a transrectal ultrasound. The APPs even perform all of the prostate biopsies.

APPs can also take on the leadership in creating community screening and surveillance clinics, as well as “fast-track” programs for patients who may not need to see a physician for their regular clinical checkup. Patients’ blood counts are checked, prescriptions are written, and any toxicities or symptoms are managed within that fast-track program.

The infusion clinic is another place to embed a PA or an NP: If a patient has an allergic reaction, needs premedication before receiving infusional therapies, or has symptoms that need to be managed during infusion, the PA or NP can manage those cases. Running symptom management clinics for patients experiencing nausea or pain, as well, falls within an APPs’ scope of practice. The physicians, then, can focus their attention on creating treatment plans for new patients.

Barriers to Success

To be successful in these endeavors, all parties involved must be open to change. In my experiences, there are three common barriers to success.

First, physicians may not fully comprehend the APP scope of practice – an obstacle easily overcome with a little bit of homework into each state’s practice environments.

The next barrier is a lack of commitment to team-based practice. If you are a lone wolf, working with a PA or NP is not going to be a rewarding experience for you. When physicians work as a team with APPs, they must have confidence that they are interacting with professionals who have complementary skills. Everybody must be committed to delivering the best-possible patient care, including shared performance goals and mutual accountability to each other and the patients. This requires excellent communication and ongoing mentorship and support. This goes both ways – between the physician and APP and between the APP and physician.

Concerns about productivity are the third barrier to success that I witness among physicians who are wary of integrating APPs more thoroughly into practice or handing off responsibilities. Again, with a bit of education and a shift in perspective, it is a barrier that can be quickly overcome. Many physicians may view the NP or PA as a competitor instead of a team member – particularly in a system where providers are being measured as individuals. For example, if you are in a practice with 10 physicians, and every physician is being seen as an individual, the physician is predisposed to view an NP or a PA as a competitor taking away from the physician’s patient encounters, relative value units, and case volumes.

What I prescribe is a change in perspective. Instead of viewing it as an individual-based practice, think of it as a team-based practice. Look at your metrics of productivity and value from a team standpoint. Take this example: Before working with a PA, an individual physician may see 30 new patients per month and produce 3,000 RVUs. With a PA joining their “team,” together they may see 48 new patients per month, bumping the RVUs up to 4,500 per month.

Rather than replacing or undermining what the physician is doing, APPs can enhance productivity. We are equally invested in patients’ success.

The Ideal Physician–APP Dynamic

The ideal relationship is a team-based model, where the APP and the physician have shared goals, mutual accountability, team-based productivity metrics, and are committed to working as a team with mentorship; support; and open, ongoing communication.

Yes, there are patients who require the physician’s expert knowledge and care, but there are also patients who can be seen and cared for by the APP; and then there is a whole group of patients who can benefit from shared care from both the physician and the APP. With a collegial physician–APP relationship, everybody – including the patients – wins.


  1. Towle EL, Barr TR, Hanley A, et al. Results of the ASCO Study of Collaborative Practice Arrangements. J Oncol Pract. 2011;7:278-82.
  2. American Association of Nurse Practitioners. “State Practice Environment.” Accessed June 18, 2015, from
  3. American Academy of Physician Assistants. “State Practice Profiles.” Accessed June 18, 2015, from