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SCCM Pod-510: APP Fellowship Series: The Director's Viewpoint

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As advanced practice provider (APP) postgraduate programs expand, what lessons have we learned as program directors? In this second episode of the APP Fellowship series, Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, is joined by Melissa Ricker, DMSc, PA-C, and Sarah Peacock, DNP, APRN, ACNP-BC, to discuss their experiences as program directors of APP fellowships in critical care, focusing on the benefits and barriers of APP fellowship programs and program directors' experiences.

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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’m joined by Sarah Peacock and Melissa Ricker to discuss pearls and pitfalls of APP ICU fellowships: the director’s experience. As APP postgraduate programs expand, what can we learn from the program directors themselves?

Melissa Ricker is the PA fellowship director for the Atrium Health Center for Advanced Practice in Charlotte, North Carolina, overseeing both medical and surgical critical tracks in Charlotte, North Carolina, and medical critical care in Macon, Georgia. She serves as the immediate past and incoming president of the Association of Postgraduate PA Programs. Sarah Peacock is the lead acute care nurse practitioner in the Department of Critical Care Medicine and the program director of the Nurse Practitioner PA Critical Care Fellowship Program at Mayo Clinic Hospital in Jacksonville, Florida. Before we start, do either of you have any disclosures to report?

Melissa Ricker: I do not.

Dr. McLaughlin: Okay. Full disclosure from me is I actually know these two women really, really well, and I think it’s going to be a great conversation about APP postgraduate training programs. I think, to get started, since I know them well, but you guys might not, if you guys don’t mind telling us a little bit about your journey from postgraduate to becoming the director of these big fellowship programs. Melissa, do you want to start?

Melissa Ricker: Yes, I’d love to. Following graduation from East Carolina’s PA program, I actually did a critical care fellowship myself. It wasn’t until I looked back in the rearview mirror after this program completion, recognizing how much I really enjoyed teaching, precepting, and really motivating a really vulnerable population. I’d worked in critical care at the institution for which I trained for about two-and-a-half years, and then my next job, I really wanted to get involved with fellowship education. So I specifically sought out on this interview journey at these institutions, asking for a portion of my FTE or leadership title that would afford me the opportunity to get involved.

My first job was a coordinator, specifically at the specialty level. I was in that role for just a mere 18 months before a directorship at the same institution became available. At the time, I wasn’t even 30 years old, and I felt very unprepared compared to the people I knew I was interviewing against. But I think it was ultimately the passion for which I approached that interview with wanting to get involved in postgraduate education and the fact that I was a graduate myself, I sort of knew what it took to complete programs like such and ultimately got the job. And I’ve been a program director for five years.

Dr. McLaughlin: And definitely one of the most well-educated on APP fellowships of people that I’ve met. Then Sarah, we’re not Pirates like Melissa there. We’re both Gators, and there weren’t fellowship programs when we graduated in our areas. Can you talk a little bit about how you went from postgraduate Gator to leader of acute care APPs at Mayo?

Sarah Peacock: Sure. Thank you. As Diane said, I’m a graduate of the University of Florida. I spent my nursing background working as a critical care cardiac ICU nurse and then was a new graduate and found myself working for a private practice. Starting with that private practice, they had a small group of NPs and PAs and really no formal training program.

NPs and PAs at that time were a little bit newer to critical care, so there wasn’t an option for fellowship programs, nor had I heard of one. I spent a year in private practice before transitioning to Mayo Clinic, where I was hired as a nurse practitioner in the Department of Critical Care. Looking at some of the nursing training programs, they had very well-oiled programs for our critical care registered nurses and thought we could do something more formal for our new graduate nurse practitioners and PAs.

There were several other programs within Mayo Clinic, both at our Rochester and Arizona campuses, but we didn’t have any fellowship programs in Florida. So we, myself and two other colleagues from critical care, got together with our Mayo Clinic School of Health Sciences and asked, could we start a fellowship program, which would be the first on the Florida campus. We started that program back in 2017, and I’ve been the program director since we started it.

It’s been a journey. We have been fortunate to have colleagues in both Rochester and Arizona Mayo Clinic sites that have been able to support us but really started the program from scratch and thought about, what do our new graduate nurse practitioners and PAs need to be successful in the Department of Critical Care. Here we are six years later, and we’ve graduated seven fellows from our program and feel like we’ve been able to really provide a good training program, a year of foundation, and structured independence to make them successful in critical care.

Dr. McLaughlin: It’s not easy being a program director for these types of programs. Did you receive special training or was it learning on the go?

Melissa Ricker: I’ll start, Diane. I didn’t have any formal academic or administrative training. After about three-and-a-half years in this role, recognizing publications and really academically demonstrating financial return on investment to some of the leaders that I worked with, both within my institution and outside, I knew I had to seek some additional training to really speak this narrative eloquently and pull the data that I needed to to demonstrate the value. So I did seek a doctorate of medical science degree to enhance that education, really give me a platform to do so.

Dr. McLaughlin: That’s awesome. I don’t believe that there are many PAs who have doctorates, so that’s pretty cool.

Melissa Ricker: Yes, there were very few in my cohort. I believe only about seven PAs at the time. And after two, two-and-a-half years of that education that I did above and beyond my clinical work, I did above and beyond my administrative work, I graduated and received their clinical excellence in research award, which was fantastic. Most of that work was demonstrating value with fellowship programs.

Dr. McLaughlin: Awesome. I mean, we’ll get into that because I think that’s another area that people are interested in, but I want to know, Sarah, have you received any additional training with how to lead a program such as yours?

Sarah Peacock: I haven’t received any formal training, but a lot of the support I’ve received is just through the resources we have at Mayo Clinic with having a residency program for physicians and several other programs through our School of Health Sciences with pharmacy residencies. I was able to rely on a lot of those leaders and their program to provide me with mentorship with starting a program. In addition, the programs that were already in place in both Rochester and Arizona, those program directors were a great support and are great mentors to me still with our program.

In terms of formal coursework, I had a similar path to Melissa and went back and got my doctorate about four years ago now, in the midst of being a program director. That doctorate I do feel really helped think about the educational structure of a program. So that did give me a little bit more formalized training but not specifically in education.

Dr. McLaughlin: Well, it sounds like both of your advanced degrees have helped prepare you to follow some of the important metrics from starting an APP postgraduate training program. I think one of the big areas of interest in regard to that is talking about money. There are two perspectives and maybe we can touch on both. One is from the institutional standpoint, are these programs profitable in some way or at least don’t cost money? Then also, from the view of your potential applicants, are they missing out on money by going through an additional training program? Maybe we can start with talking about, how do we show that these are actually valuable in whichever way to the institution?

Melissa Ricker: Absolutely. As healthcare has become more of a business, despite many of our passions to do just really good work as clinicians, I think it’s really important to understand the metrics for which your program was used as a springboard. For example, was it designed to improve retention? Was it designed to improve provider efficiency, systems-based practice, engagement?

Whatever those metrics were, really being sure that those are quantified prior to program initiation, or if you’re taking over a program like myself, it’s finding the people and the stakeholders who had access to that historical data. Then it’s ensuring that your program’s sufficiently built around those quantifiable metrics and how are you going to capture both current and future data to show the value?

For example, if you had a retention rate or some efficiency metrics with their unique patient scene, RVU, net or gross collections or charges, looking at your fellows at periodic points during their training and then periodic points after their training, and either comparing them to the pre-fellowship data or comparing them to even non-fellowship hires to demonstrate likely greater efficiency, longer retention, etc.

I think what can be a little bit more difficult, still within the realm of financial ROI, is how, through quantitative surveys like patient or provider satisfaction, maybe it’s hiring leader surveys, or maybe it’s through things like citizenship demonstration, that your fellows are more engaged and are viewed and rated higher than, again, pre-fellowship initiation or even some other non-fellowship hires. Through this, we definitely have to publish this data and I think it’s important to make sure that you collaborate with some of the system leaders to make sure that you’re either approved and/or that you’re disseminating this information to a larger body so that we can all benefit from each other.

Dr. McLaughlin: I think, with some of the work that the three of us are doing together, we know there’s definitely a lack of dissemination of what’s been successful and not successful. Melissa, if you were to pull your most striking, like wow, metric from your experience at Atrium that might make administrators stop and say, oh, we should consider doing this, what would it be?

Melissa Ricker: Great. We do post-fellowship completion surveys of both our hiring leaders and our graduates. To date, we’ve graduated over 370 fellows, and 99% of them would either recommend it to someone else or acknowledge that this training was pivotal in the trajectory of their career. Additionally, 100% of our hiring leaders indicate that they would hire a fellow over a new graduate, with 20% of them acknowledging, I’ll even hire someone who didn’t train in critical care because I know they’re a different type of professional than someone who didn’t do a fellowship.

With respect to quantifiable RVU and productivity metrics, we’ve definitely seen more efficient, longer-tenured, and greater satisfied patients from our providers who have been trained through our fellowship versus those who haven’t.

Dr. McLaughlin: Wow, I think that would give pause to both administrators and potential applicants, actually.

Melissa Ricker: That’s exactly right.

Dr. McLaughlin: Sarah, you started from scratch here. How were you able to get Mayo on board to start something that wasn’t in the region at all?

Sarah Peacock: I think our department at Mayo Clinic in Florida is unique. We cover multiple different subspecialties in the ICU. We have a large NP/PA team and we have them cover different areas and provide cross-coverage, which is a unique model in critical care where they may work one day as a neuro-ICU APP, the next day in a CVICU.

Naturally, hiring and training to find NPs and PAs to cover multiple different ICU specialties is challenging. We would hire a new graduate or we would hire an experienced provider and still have to provide them with anywhere from three to six months of onboarding. So a lot of our sell to our department to start our program was, we can start a fellowship program, train these NPs and PAs over a year.

As Melissa said, it really is a special breed of someone who wants to dedicate the time to do a year-long fellowship with the goal of decreasing that onboarding time of three to six months where we have had several fellows complete the fellowship. They start on our schedule and are billing productive providers day one of employment rather than waiting that three to six months. As Melissa said, I think it is thinking about what the value of your program is and what kind of value are you looking to provide? Is it increased retention? Is it reducing onboarding time? Is it RVUs and billing? Every program is different and thinking about what is your goal for your program when you’re starting it.

Dr. McLaughlin: Let’s flip from the other perspective then, that of the applicant, because one of maybe sales points to administration is the decreased onboarding time but also at a lower cost because most postgraduate training programs do not pay their fellows at the same rate as the regular staff. How do you, when you’re interviewing people, talk about the decreased salary that first year, whatever the length of your program is?

Melissa Ricker: I think this is a very important question, to be very transparent with future applicants. I’ll first start by saying that this concept of reducing the salary of a trainee is not unique to postgraduate education for PAs and NPs. We see this with our medical residents as well. With that, I think there’s this innate understanding that to be really invested in as a professional and to endure such a unique training experience, that does come with a bit of a cost, a cost to the institution, but also a cost to the applicant. Is it a little bit of money that I’m willing to give up acutely to more long-term benefit both my patients and myself?

I think for those who accept a little bit of that pay reduction upfront, it’s how can I leverage this really neat training, both subacutely and long-term to really not only reap the gains that I potentially lost but to really even further invest and even make more out of my career? I think the people who really embrace that mentality are the best fits for programs but also the ones who we see do the best in programs.

We actually have a PA who’s a certified financial planner meet with our fellows in the first few weeks of fellowship because we understand it is a big financial commitment. We don’t want to minimize that. But we also want to ease some anxiety that it’s just a small pay cut in the grand scheme of things and that they’re not alone, they’re not the only professionals experiencing this, but to kind of shift their focus into getting as much out of this one-year program as possible.

Dr. McLaughlin: That’s a really unique feature that you offer to people who are going through your program. I’ve never heard of anybody else doing that. I think that’s really cool. Sarah, I remember you were negotiating pretty hard on behalf of the applicants to have a little bit of a bump to that initial salary so that at least it was higher than what the average nurse was making. How did those conversations go?

Sarah Peacock: I’ve been fortunate that we’ve done several market analyses in the six years I’ve been a program director, and we have substantially increased our fellowship from our starting rate to what it is now. We’ve gone up $13,000 a year. We have really been able to look at the market and look at the comparable other NP and PA fellowship programs and ensure that our fellowship is on par. It is a very common question. I will say it comes up with a lot of applicants. Why should I take a pay cut? It really boils down to wanting to invest in your education.

As Melissa said, a small pay cut now and investing in your future, we find that those applicants who decide to do a fellowship are very successful because they are committed to take that small pay cut in the beginning to really invest in their education, make them a really, really excellent critical care provider who is very well trained. But it is being transparent. I talk to just about every applicant. It always comes up. Why should I do this? Why should I take a pay cut? Or tell me the reason. So it is being open to talk about it with your applicants, being open to talk about it in the interview process and really trying to make the applicants understand the value of the program.

Melissa Ricker: And one thing that we also educate our fellows on at the time of graduation is if we do not have a retention mandate with our employee agreement, they can choose to leave to go to another institution, albeit we very strongly encourage. With having a fellowship, it gives them some leverage to negotiate, often a sign-on bonus, and a higher salary. At Atrium Health, we do afford a $20,000 sign-on bonus if they stay for two years after training, and we accelerate their pay to someone who has two full years of experience versus what they otherwise would qualify for, which is one year of employment.

Dr. McLaughlin: So the more features to have somebody stay on is another way that you kind of get those losses, if you look at it like that, back. You guys know I’m a huge proponent of postgraduate training. To me, I can’t believe somebody is paying you to learn. As somebody who has accrued quite a bit of student loan debt, that seems pretty cool that we even have the option to do this, which is kind of a segue into something we’ve alluded to. Who tends to be successful in these programs? What type of applicants are you looking for? Who do you find really excels?

Melissa Ricker: Absolutely. It’s really important, I think, as a program director, to minimize any bias and really go into these interviews with an open mind. I think we’ve seen a trend across the board, institutions utilizing the holistic interview process, where you really look at someone’s narratives and letters of recommendation to say, what has this person endured professionally, personally, and how have they been able to navigate those wins, losses, hardships to be the professional they are? I think this really comes out secondarily in the interview. Tell me about a time that you’ve really struggled or a time that you’ve excelled despite hardship.

Dr. McLaughlin: Oh, those questions are the hardest, Melissa.

Melissa Ricker: I know, I know. But it really gets to quantifying using past experiences, how and why this person might be the best fit for your program. I think then, tertiarily, looking at life experience to say, has this person traveled? Has this person taken an initiative to participate in the road less traveled or to do something unique? I think those people who take calculated risks, who are deeply people people, who have demonstrated resilience, are standout candidates.

Dr. McLaughlin: Then do you feel, this is kind of a hot topic question, do you feel that there’s any bias toward PAs or NPs or does it depend on the program or really you’re looking at the person and not the degree?

Melissa Ricker: That’s a great question. We hear the same with male, female. The importance I think is, are you hiring the right person for the position? Whether they come from a different background or they’re coming from a different state, how is your program set up so that your institution and your fellows mutually benefit from this relationship? Part of that is cultural fit. Part of that is desire to learn and academic curiosity.

Our program personally has seen a much higher PA application rate. I think that is because the narrative between the postgraduate education programs and the program directors of the master’s PA schools has improved. Because the PA profession has founded itself on flexibility, that PAs can work in any specialty of medicine or surgery, initially, the program directors were a little apprehensive about endorsing PA fellowships, indicating, well, maybe my training wasn’t good enough to prepare this person for professional practice.

Where our opinion is, no, your training was good enough. But unfortunately, just due to the two-year duration of training, there wasn’t enough time for them to spend in critical care for them to truly become a competent provider and, because of that, it’s become a little bit more competitive for the nurse practitioners. Maybe I’ll pass it over to Sarah to see what her opinion has been.

Sarah Peacock: That’s a great question. I do get a lot of questions from some of the bedside nurses in the ICU who are going back to school to become a nurse practitioner on, do I need a fellowship? It’s kind of a hot question. Well, who needs a fellowship and who wants a fellowship? I do get that question a little bit more from nurses as they feel like they have good clinical experience in their role as a bedside nurse. I tell all of my nurse practitioners and PA applicants the same thing. It boils down to, do you want to invest in your education? Do you want to do a fellowship?

There are a lot of benefits of a fellowship. Both a registered nurse who has bedside nursing experience and a brand-new graduate PA would both benefit. We’ve had both go through our program and their paths are a little bit different just because our nurse who’s gone through―we’ve had one―had that bedside nursing experience. Some things that came more natural to her were a little bit slower for a brand-new graduate PA. So it really boils down to thinking about who wants to do it. I think lots of different types of applicants could benefit, but it just depends on that particular person and what they’re looking for with their career path.

Dr. McLaughlin: We’ve talked about what the benefit of these programs are to the institution. We’ve talked about who the potential applicants are and the benefit to them. Where are these programs going in the future? What is the future of APP postgraduate training?

Melissa Ricker: That’s a great question. I think, if we look in the rearview mirror to say, how far has postgraduate education come in the past decade or more, we’ve seen more programs come on the map. We’ve seen more interest in both PAs and NPs over time. But where we really see, I think, the administrator’s opinion changing is, as program financial ROI is demonstrated, I think these programs will become more centralized to enterprises.

For example, the Atrium Health fellowship is currently run out of the Center for Advanced Practice, serving fellowships in three different cities and two different states. Having this operational and administrative hub ensures that there’s this quality control, that there’s this operational efficiency with respect to program operations. And yet the local specialty directors at the boots-on-the-ground level are really able to continue to do what they love to do, which is train clinically.

As more programs shift from this siloed approach to more enterprise-level shared operational services, I think there’s going to be this huge need for training in that area to show other system leaders how to make that transition because it’s going to be a huge one. Then lastly, I really hope that this training continues to be optional. I love the fact that after NP and PA graduation, these professionals can transition into practice. But by having this competitive advantage of completing a program, getting really invested in academically, didactically, they’re better. Our patients are better. They’re better for completion of this program.

Dr. McLaughlin: What do you think, Sarah?

Sarah Peacock: I love that. Atrium, with starting a fellowship program, looking at a big institution like that that has a very well-oiled, very large fellowship program is different if you were at a smaller institution. While Mayo itself isn’t small, being the single program with one fellow at my institution was a little bit of a challenge. But I do think, through the years, as Melissa said, institutions will understand the value. One thing that we did in the past year was we had a lot of fellowship programs and we didn’t have a big centralized way to organize them. They were all kind of siloed.

We were all working on our own, and then we came together across the enterprise, our three sites, and developed nurse practitioner, physician assistant program standards. And that was really the first time that we were able to generate ideas and standards, from who should be a preceptor to what type of onboarding and orientation, curriculum, didactics, to give people who wanted to start a fellowship program some sort of guide so you weren’t starting from scratch.

I think, as fellowship programs continue to grow and become more popular, more institutions will be on board with starting them. And having all of these standards, both institutionally and nationally, there’s a lot of information out there to help people start programs and be successful. I agree, I would love to see them stay optional. I think it is nice to be able to transition into practice if that’s what you need at that time. But it is nice to have an option for those who want to do a year of intense training to be a critical care provider and really get that specialized training from procedures to managing complex patients that you’re not going to be able to get in a two-year nurse practitioner or physician assistant program.

Dr. McLaughlin: It’s interesting that you both talk about centralizing these programs a little bit. To be honest, I haven’t really thought about that. But I could see it really benefiting small programs to have somebody else to look to to help get them started. It’s also interesting that you both want to keep them optional. I guess I kind of thought that postgraduate training was going to go more the way that pharmacy went, which does offer still an option for you to directly enter practice.

But if you want to work in a specialty unit, you do need that specialty training via a postgraduate training-type program. So it’s interesting to me. It’ll be cool to see what actually happens in the future. With that, we’re kind of winding down to the last minute or two. Is there anything that either of you haven’t had a chance to say to either convince people that this is what they need to do or say maybe it’s not for certain applicants?

Melissa Ricker: That’s a great question. I think one thing I didn’t quite have a grasp on as I entered into my program director role was the network across the country. The Society of Critical Care Medicine has been a phenomenal resource. Just from a networking perspective, hearing how other programs do things, what challenges have they come across or what solutions have they been able to put in place to mitigate some of those challenges. Making an effort to go to Congress, making an effort to be involved with either the PA or NP or education sections.

I think for most of us who are in the program director role, we experience training a very transient and young population, even though some of us still identify as young, even though we’re aging. But they grow so much in this year and it can be a little bit emotionally exhausting, physically exhausting, spiritually exhausting, training during that year. But I think helping them and maintaining this focus on developing their resiliency and really setting the stage and setting the best expectation and best example you can for them and what the real world is like and how this year is really, really preparing you for the next few years of your career.

After you see them graduate and transition into their full-time jobs, I look up to so many of them who have continued on this journey, whether it be in academics or leadership, and they come back years later and are just so thankful for that opportunity. Then they’re investing in the next generation of APP fellows. So the circle definitely comes full circle most times, but if you find yourself alone on an island, recognize you’re not and reach out to SCCM for connections in the program director world.

Dr. McLaughlin: I love the plug. That’s actually how we all know each other is working on a project about APP postgraduate training for the Society of Critical Care Medicine. Something to watch for in the next year. Sarah, what about you? Any final comments?

Sarah Peacock: I think, for just those interested in programs, is to apply and to be open-minded and think that there is, you don’t have to go right into practice. When we interview for our program, there’s a large amount of applicants from diverse backgrounds and just being open to the idea of a fellowship program and thinking about the benefits it can have for you and just taking that next step. If you’re unsure, reach out, there are a lot of resources. There are a lot of people who are program directors and a lot of now APPs who have gone through fellowship programs.

I think being open-minded if you’re considering it and then using the great network that SCCM and just nurse practitioners and physician assistants across the country, it’s a great network. There’s a lot of mentorship, a lot of resources available and making sure you take advantage of all those things that are out there.

Dr. McLaughlin: Great. I think that’s a nice way to close. This concludes 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. Thank you guys for being here. For the Society of Critical Care Medicine Podcast, I’m Diane McLaughlin.

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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