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SCCM Pod-509: APP Fellowship Series: Insights Beyond the Classroom

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As advanced practice provider (APP) postgraduate programs expand, what can we learn from the graduates themselves? Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is joined by Dalton Gifford, PA-C, and Benjamin Lassow, PA-C, to discuss their experiences as recent graduates of APP fellowships in critical care, focusing on the benefits and barriers of APP fellowship programs and the learners' experience.

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Dr. McLaughlin: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Diane McLaughlin. Today I am joined by Benjamin Lassow and Dalton Gifford to discuss pearls and pitfalls of APP ICU fellowships from the learner perspective. As advanced practice provider postgraduate training programs expand, what can we learn from the graduates themselves? Benjamin Lassow is a physician assistant at St. Francis Hospital and Medical Center cardiac medicine intensive care unit in Hartford, Connecticut, and Dalton Gifford is a physician assistant at the University of Kentucky Healthcare in the medical ICU in Lexington, Kentucky. Welcome. Before we start, do either of you have any disclosures to report?

Dr. Lassow: No disclosures for me.

Dr. Gifford: No disclosures for me either.

Dr. McLaughlin: All right. So, jumping in, the first point of discussion is going to be, what made both of you decide to pursue postgraduate training programs? We’ll start with Dalton.

Dr. Gifford: Coming out of PA school, obviously you’re trained as a generalist, so you get a good broad experience in a lot of different fields, but critical care specifically is something we don’t get a lot of training in, so just wanting to get a little more further education in the field and a higher level of education in terms of that. I knew I wanted to go into critical care out of school, but it’s kind of a hard field to crack into as a new grad PA and has a very steep learning curve, which I think would be very difficult without some further education and training.

Dr. McLaughlin: Ben, what made you choose to go through a postgraduate training program?

Dr. Lassow: Yeah, very well said, Dal, and that sort of echoed what he said in that we’re trained as generalists, typically outpatient providers, right out of PA school. Just to give an example, PA school will teach you how to interpret an ABG, but they may not teach you how to make a ventilator change, so that was kind of an example, and lots more examples that I can think about about things that I learned in PA school that I wouldn’t necessarily be able to apply and sort of excel in the ICU right away. So formal postgraduate training was very interesting to me and something I wanted to pursue.

Dr. McLaughlin: Now, was your program general critical care or was it a specialty unit? I see you work in a cardiac ICU.

Dr. Lassow: Yeah, mine was a general critical care fellowship. We did MICU, SICU, trauma ICU, cardiac, cardiac surgery ICU, a few different nuances to specific medical ICUs like oncology ICU and things of that nature. I picked to generalize in cardiac critical care after, given the fact that I had a couple rotations in cardiac medicine ICU in my fellowship that I really enjoyed.

Dr. McLaughlin: Dalton, did you go through a general or specialty training program?

Dr. Gifford: Yeah, similar to Ben, I did a general critical care residency program. We did six months of medicine ICU and then six months of surgical ICU with, again, various surgical rotations such as surgical ICU, neurology, neurosurgical ICU, cardiovascular ICU, and a few others as well.

Dr. McLaughlin: What were some of the more challenging aspects of your postgraduate training?

Dr. Lassow: Probably the most challenging aspect for me was just jumping into critical care right away. I think the fellowship aspect sort of buffered that, in that my role was to be an autonomous provider but also with the understanding that I’d have a lot of support and care from physicians and other APPs, and in a center like Emory where there’s a lot of teaching and whatnot, there was a lot of support from that perspective. The schedule was difficult as well. We typically worked our resident schedule on mostly six days a week, which was difficult but definitely worth it in the long run.

Dr. Gifford: I think that was very well said on Benjamin’s part. I’d totally agree. I think all of his points are very well taken. Intensity for me was probably the big thing, going from doing rotations in PA school where maybe a four- to six-week duration, you just kind of follow your preceptor schedule, to going to a resident schedule where you’re working five-, six-plus days a week. Sometimes you can have stretches even longer, hours are long and critical care is not an easy field by any stretch. So getting up to that learning curve and trying to focus on getting a better understanding of topics while trying to keep in mind your work-life balance and everything was pretty challenging.

Dr. McLaughlin: What was your ICU exposure prior to undergoing your fellowship?

Dr. Lassow: I was particularly lucky enough to score a couple of different ICU rotations as a PA student. I did a cardiac surgery rotation where I spent a couple weeks on a CVICU, and then I did a MICU rotation and got to spend a lot of time there. But from what I know, I was pretty lucky in that I got to spend a lot of time. I know some of my colleagues in PA school weren’t so lucky to spend as much time in their respective settings that they wanted to.

Dr. Gifford: I had a couple mentors who worked in critical care, so they were able to let me shadow a little bit, and I was able to get a little bit of experience that way. But unfortunately, I finished PA school in the midst of COVID. I saved up my electives for the end but unfortunately I lost all of them due to COVID.

Dr. McLaughlin: For you, do you feel like going for the fellowship was particularly useful because you didn’t have those experiences?

Dr. Gifford: Absolutely. It’s hard enough to really get the exposure you need during the four- to six-week rotation, whatever the program gives you, but particularly in the case of having virtually zero experience, it was essential for me.

Dr. McLaughlin: In what ways do you feel like you’re more prepared for your role now after completing this additional training?

Dr. Lassow: I certainly feel as though I don’t really look at myself as an experienced, tenured provider, but I definitely have the skills enough to get through the day and take really good care of patients with the help of my attending. I think that’s attributed to the variety of rotations that I was offered in fellowship, from NICU to neuro-ICU to surgery in different cardiac settings. Definitely the variety is a big part and also the procedures are a big part. We had a certain number of procedures we’d have to do throughout the year and, going into my second year as a PA with the comfort of doing procedures alone at that time was, I think, a really big bonus for me.

Dr. Gifford: I agree with Ben. I think having the experience in a diverse set of ICUs, seeing how things are done differently in other places and being able to take bits and pieces of that to your own practice, as well as just having the procedural experience and the vast knowledge. Again, I agree, it’s not like you’re a tenured provider, that you’ve been doing this for many, many years, but I think it’s certainly a jumpstart compared to new APPs in this kind of role.

Dr. McLaughlin: Dalton, you work at University of Kentucky now. Did you do your fellowship training there as well?

Dr. Gifford: I did. I did the fellowship here. I was one of the first residents in our program.

Dr. McLaughlin: Ben, it sounds like you went through Emory’s program and now you’ve moved to another institution. Have you found a lot of similarities or more differences between how the two programs practice?

Dr. Lassow: As far as the fellowship at Emory, definitely a much bigger teaching facility. The hospital I’m at now has a few residency programs that bring residents through, but my particular ICU doesn’t have residents. There’s a lot less teaching that goes on in the unit that I’m in now. I certainly miss that about Emory, but I’m really enjoying it.

Dr. McLaughlin: I know that you alluded earlier to work-life balance. How did you manage work-life balance, particularly with the added demands of postgraduate training?

Dr. Gifford: I think for me, honestly, work-life balance is so difficult to achieve in that year just because it’s so fast paced. With ICU rotations in particular, medical residents sometimes will do medical ICU or surgical ICU, whatever their ICU rotation is, for a month and then they may switch to outpatient or something with a little more lenient schedule, but for us it’s just nonstop, ICU rotation after ICU rotation. So the balance is pretty tough, but you just got to tell yourself, hey, it’s one year, I signed up for this. I’m going to be grateful for it at the end of that year. In the beginning, particularly, it takes a lot of work up front to try to get yourself up to par, so to speak, trying to get where you can be a more functional provider. As you get further along into that, when you have your days off, you can spend more time with family, friends, and doing things that are meaningful to you.

Dr. Lassow: Yeah, I think beautifully said there, Dal. Like I said, overall, it’s a really difficult schedule, and I think the time that you do have off, you have to really learn how to disconnect in the day or so per week to try to get your mind off of it. But other than that, you’ve got to commit yourself to the year and grind it out.

Dr. McLaughlin: There’s a stress level that comes with being a novice that people don’t really talk about. One of the stories that I have is actually not my own. It’s coming into the unit as an experienced APP and getting signup from a novice NP who tells a story about how she wanted to start IV fluids on a neuro patient and wrestled with the decision for quite a long period of time about, oh, do I do LR or can I do saline? I know I don’t want anything with dextrose, but is this isotonic or hypertonic?

Then eventually she texts the attending and says, I want to start normal saline at 50, and she gets back the typical answer, okay. When I think about that moment, it just tells me that stress level that’s existent. What’s some advice that you would give to new PAs or new NPs about balancing professional development and personal life and how do you manage that stress level?

Dr. Lassow: I think the first thing you have to do in the moment as far as the stress level goes is just involve the care of your patients with other experienced clinicians around you. I think working in an ICU is obviously a team sport. I think there are settings where you’re sort of the loner, but I think most ICUs you typically have a few different providers on. I think generally there’s an understanding among APPs that newer APPs particularly are going to need help and support. So I think the first thing you do is reach out to your colleagues and involve them in the care. You’re not asking them to do work for you, you’re just asking for their opinion and sort of asking them to help you out with certain clinical decisions like that, that may be easier or may not be.

Dr. Gifford: I think Ben perfectly crafted that response. I think, and that’s one of the benefits of residency initially too is, people understand and accept that you are a learner, you’re in a learning role. I think there is a component to residency that’s special about that. But that being said, I also think it kind of helps you develop a level of resilience and things as well, because as you go through and have those situations, you become more resilient and eventually you learn what is okay and what is not okay in terms of basic things like that. I think, as time progresses, you have less and less of those questions and things kind of improve for you, so to speak.

Dr. McLaughlin: That’s actually one of the things that I really like about these programs, and when I’m telling students about them, is that it is like a supervised immersion. As opposed to general onboarding that they might say, okay, you get this many weeks or this, then it’s as you go along in the program, you’re getting more autonomy once you earn it. And it’s not a set, at the end of this, you have to do this. It’s, you’re gradually joining practice until you get to that level of autonomy. One of the things that I’ve heard from people who are not proponents of these programs is why would you go through this year when you should be prepared to enter practice now? What advice do you give to people who are naysayers of the programs as people who have gone through the program?

Dr. Lassow: I would just say, I’m certainly not in the business of talking anybody out of it, but I would say you have a unique opportunity to be sort of a paid learner in that you’re going to be slowly emerged into a setting that’s very difficult for new grad APPs. I think, from my perspective, I don’t particularly know how safe I would feel going into an ICU right away with the experience that I had prior to going to PA school and in the education that I got in PA school. I think the residency or fellowship offers you that unique opportunity to develop those skills and still have a learner and support system around you with the understanding that you still are a learner and you’re sort of like, that’s your role for the year.

Dr. Gifford: Yeah, I agree with Ben. I think I wouldn’t necessarily talk anyone out of it. I mean, it’s not for everyone, but I do think there is tremendous value to it, especially depending on what your experience in school was. My thing is, you don’t know what you don’t know, especially coming out of school or out of your initial training. My opinion is it’s very hard to learn the skills and knowledge you really need to have in a four- to six-week rotation, or even if you had a couple of rotations, it’s still very different. You’re not the one who’s signing in to the patients and writing the notes and putting in the orders and doing things. I think that certainly brings it to another level. I find they have great value and I definitely do not regret my decision.

Dr. McLaughlin: Ben, anything to add to that?

Dr. Lassow: Yeah, I think just the other aspect of it is, in my experience, most critical care fellowships have a variety of different rotations. I would say that that unique opportunity provides you the chance to take care of all different types of patients, right? If you work in a cardiac medicine ICU, like me, you’re not going to necessarily admit stroke patients or trauma patients or general surgery patients who need ICU level of care. But there are always instances that the cardiac medicine patient that you’re taking care of develops a need for a neurosurgeon or a general surgeon or issues like they develop cholecystitis or they develop a hemorrhagic stroke that you’d be familiar taking care of given the fact that you did a fellowship and you had that unique opportunity to work in a unit where that was their sort of niche, if you know what I mean.

Dr. McLaughlin: I’m going to go out on a limb here a little bit. I actually think that everybody would benefit from some type of postgraduate training. What are some common misconceptions that you’ve heard about these programs that either of you would like to address?

Dr. Gifford: I think some misconceptions about the field is that you’re kind of stuck in the same specialty or field for the rest of your life, but I find that’s largely not true. A lot of the skills you learn are largely transferable. I had several of my colleagues who went to different positions, whether it be interventional radiology or other things, and they already have a lot of the skillset that they’ll need for that field. The medical knowledge and surgical knowledge that they have from their training is highly useful in other fields. I also think that, from the PA perspective, sometimes you can get some pushback if the program’s not accredited, but the whole accreditation process is another topic within itself.

Dr. Lassow: I couldn’t agree more there with Dal, and I think the big thing that I hear about is you only have a specific set of skills that are not really transferable, and I’d say that couldn’t be further from the truth. You get procedural skills, you learn general medicine very well, and you learn how to think and act in situations that are stressful, and I think that’s probably one of the biggest learning experiences that I could get from fellowship is that it forces you to be in uncomfortable situations. Whether you work in the ICU, the emergency department, you work in surgery, you’re going to develop those situations where there is high level of stress, and I think one of the best parts about the fellowship is you’re sort of pushed into those situations, and you learn how to act.

Dr. McLaughlin: One of the other areas that you don’t get a lot of training in your educational program, be it nurse practitioner or PA programs, is what we say are the soft sciences, ethical dilemmas that might come up. Do you feel like both of your postgraduate training programs gave you some background into how to solve ethical dilemmas?

Dr. Gifford: Yeah, I absolutely think so. Getting to see and be a part of those conversations was particularly useful, I think, in my residency program. I was able to kind of initially watch more experienced providers have these conversations and, again, watching a variety of different providers have these conversations, NP, PA, MD, DO, whoever it may be, and take bits and pieces from their talks and conversations with family and mold it into my own thing when I’m having these conversations. As you get more independence and autonomy over time, you can approach this with a new level of confidence and understanding and maybe even a different viewpoint now that you have all these different rotations and all these different specialties, and I think that’s extremely useful.

Dr. Lassow: Yeah, I couldn’t agree more. I think my fellowship offered a lot of unique training in family meetings and difficult conversations. We had didactics and mock training simulations that displayed family meetings and difficult conversations, difficult patients, difficult team members, that you sort of practice and conduct with feedback at the end, and I think there’s just something to be said for the volume of patient care that you’re involved in, given the fact that your schedule is so hectic with, like Dalton said, five, six days a week. You’re just involved in so many different patient care scenarios, and you get to see so many different providers conduct family meetings in different ways. I look at those situations, I sort of pick out things that I think would be good for my approach and things that I don’t think would be good for my approach. I think just the general volume of ethical dilemmas and family meetings and difficult conversations is probably one of the things that was the most important for me.

Dr. McLaughlin: You both talk about how your training included interprofessional training and collaboration. Can you share an experience where this interprofessional collaboration significantly impacted patient outcomes?

Dr. Lassow: Yeah, that’s a great question. I can’t think of an exact instance, but I can share something unique to my fellowship. We got to spend a lot of days with different subspecialties, different people of the care team. We got to spend time with nursing, respiratory, nutrition, other physicians inside the ICU care team, and I think my understanding of what their role is and what their job is gives me a unique opportunity to utilize myself and them within the critical care team to better take care of patients.

Dr. Gifford: I couldn’t agree more. Again, I can’t think of a specific example off the top of my head. Just because we work with everyone daily, I think that’s one of the advantages of residency as well, you’re working with physicians, residents, fellows, PT/OT, respiratory, nursing, PA, nurse practitioner, all these different roles. I think you can learn and see a lot of different things that each of these specialties and roles do that you didn’t necessarily think of, and I think bringing it all together in a multidisciplinary approach is really unique and a good experience for learners.

Dr. McLaughlin: Putting all of this together, do you feel like you’re at a different skill level right now because you went through a postgraduate training program?

Dr. Lassow: Yeah, I certainly do. I think that my practice is fairly advanced, given the fact that I’m a second-year PA, given the fact that I graduated this past year. Like I said, I think I’ve had great exposure to lots of different types of critical care. I have the procedural exposure, the multidisciplinary exposure. I think those skills are only really achieved in an intensive postgraduate training program.

Dr. Gifford: I couldn’t agree more. I think, like we said earlier, it kind of gives you a jumpstart on everything and kind of accelerates your learning and your procedural skills.

Dr. McLaughlin: Would you say the same thing about your career trajectory as a result? Because it seems like people who go through these programs are more on a career path than just working a job.

Dr. Lassow: I would definitely agree there. I think my career trajectory is pointed in definitely the right direction, given the fact that, I think part of it too is just people who generally do these types of training programs have significant interest in critical care. That sort of drives them in that direction. Then, having the experience and the knowledge that the fellowship offers allows you to be set up for success as far as your career rather than just working in your single job.

Dr. Gifford: I couldn’t agree more. I think it’s certainly positively impacted my career trajectory. I think it helps you develop skills outside of patient care as well. I think you learn some leadership attributes and different things that you can carry with you moving forward as well.

Dr. McLaughlin: I don’t think anybody would be surprised by how I anticipate you answering this, but if you had somebody who was a PA student right now asking, should I consider going through a postgraduate training program, what would your response be?

Dr. Lassow: I think I could speak for Dalton and myself that we would definitely push that person in the direction of postgraduate training. I think it offers unique opportunities and, like I said, it’s just the best thing for your career moving forward as a brand-new PA.

Dr. Gifford: I couldn’t agree more. I think the pros certainly outweigh the cons. I would absolutely recommend it.

Dr. McLaughlin: I don’t think anybody will be surprised by that, so let’s put a little twist on it then. If you had the opportunity to say anything that you probably haven’t had the chance to yet, to people in your program who helped train you, what would you say to them? Think about your mentors or the people who really helped you get through the program and put something special into your training.

Dr. Gifford: I would say a resounding thank you. I know it’s a lot to take on, a learner. There’s a lot involved trying to make sure that you allow them enough autonomy to grow but also be mindful enough of what they’re doing. That way you don’t compromise patient care. So I think that would be the biggest thing is just thank you. It’s a lot to ask and the lessons and knowledge and things you’ll carry with you for the rest of your career. So I think it’s super important.

Dr. Lassow: Yeah, certainly couldn’t have been said better. I think it could be exhausting taking a learner with you, specifically someone who’s interested with lots of questions. I’m sure I was like that, and I’m sure that can be exhausting for that person. I guess what I would say and wish that they could see is the tools that I have that they afforded me that I use in my day-to-day practice, whether I’m doing lines or conducting field meetings or rounding with attendings. I think there’s a lot of things that I do that I sort of stole from those mentors and keep in my tool bag and use every day. I think that’s probably the biggest compliment to them and just an overall big thank you to all of them.

Dr. McLaughlin: I bet these mentors would be very proud to see where you both are now. If there’s anything that either of you want to add now, otherwise, I think we’ll wrap it up.

Dr. Lassow: Gotcha. I’m all set. Thank you so much for having me.

Dr. Gifford: I agree. Thank you very much. It’s been a pleasure.

Dr. McLaughlin: All right. Thank you so much for being here. With that, this will conclude another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I’m Diane McLaughlin. Thank you.

Announcer: Diane C. McLaughlin, DNP, AGA, CNP, BC, CCRN, FCCM, is a neurocritical care nurse practitioner at University of Florida Health Jacksonville. She is active within SCCM, serving on both the APP Resource and Ultrasound Committees and is a social media ambassador for SCCM.

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Knowledge Area: Professional Development and Education