Postgraduate training/Residency Question

Browndog · Jun 13, 2010

Short answer.....for all practical purposes, no. There are a couple of NP residencies out there for primary care, but they are few and far between. Now, that said, most PAs do not complete a residency either.

My unsolicited opinion is that we (NPs) should have a residency component. Much has been said here and elsewhere about the inconsistency of NP education. Frankly, it is a hard truth. I am 100% for the inclusion of a residency element to the NP educational path.

Sorry, I know this ruffles some feathers.

t2krookie · Jun 13, 2010

i was wondering if there are such programs (residencies) for nps once they are finishing with their respective programs?
i know that they have such residencies for pas, residencies such as in ( emergency medicine, critical care, surgery, etc..) they are usually 1-2 years long.
if an np can do the same thing a pa can, does this mean that pa residency programs are also for nps? are their such programs?
eddie

they are few and far between but growing. i myself am very much in favor of such a trend, but md/ods get practically all the gme money so not much left for nurses. \

www.npresidency.com

http://www.mayo.edu/mshs/np-npr-rch.html

are two found with a quick trip to google. more exist. most are part of internal hospital education expansion projects. if the funding like gme were expanded to include nursing, there obviously would be more of them. right now that is not the case.

core0 · Jun 13, 2010

they are few and far between but growing. i myself am very much in favor of such a trend, but md/ods get practically all the gme money so not much left for nurses. \
www.npresidency.com
http://www.mayo.edu/mshs/np-npr-rch.html
are two found with a quick trip to google. more exist. most are part of internal hospital education expansion projects. if the funding like gme were expanded to include nursing, there obviously would be more of them. right now that is not the case.

your second link is incorrect:

to participate in mayo school of health sciences' nurse practitioner clinical residency, you must be a practicing nurse at mayo clinic and enrolled in a master's-level program at one of the following affiliated academic institutions:

this is simply a page for how to do clinical sites at mayo if you are affiliated with one of the np programs linked below. that being said the two other post grad programs that i know of are at mayo scottsdale:

nurse practitioner career overview (two different programs)

and st lukes:

trauma and critical care fellowship (physician assistants and nurse practitioners) - st. luke's hospital & health network

there is no real need to have gme funded post grad programs. post grad programs are completely able to stand on their own in terms of financial support. remember since the students have a license the program is completely free to bill for them (a major difference from physician residencies). as someone that is involved in starting a post grad program the major distractor here will come from the school of nursing.

david carpenter, pa-c

t2krookie · Jun 13, 2010

There is no real need to have GME funded post grad programs. Post grad programs are completely able to stand on their own in terms of financial support. Remember since the students have a license the program is completely free to bill for them (a major difference from physician residencies). As someone that is involved in starting a post grad program the major distractor here will come from the school of nursing.
David Carpenter, PA-C

I value your insight sir as I pay attention to your many posts. In this instance though we must agree to disagree. Private initiatives have had 40 years + to make paid residency options a reality. (Having a family and obligations make this a necessity) This has not come to pass. I think only a comprehensive federal or perhaps State level funded initiative can get this ball rolling. Private initiatives are extreemly limited on a national level at this time, and obviously are not up to the task of serving all NPs who need or desire them.

core0 · Jun 13, 2010

I value your insight sir as I pay attention to your many posts. In this instance though we must agree to disagree. Private initiatives have had 40 years + to make paid residency options a reality. (Having a family and obligations make this a necessity) This has not come to pass. I think only a comprehensive federal or perhaps State level funded initiative can get this ball rolling. Private initiatives are extreemly limited on a national level at this time, and obviously are not up to the task of serving all NPs who need or desire them.

The trade off that physician residency programs make for themselves is that they get administrative money and salary support for residents. In turn they cannot charge for the work the resident does. For critical access hospitals (the Parklands, Gradys, DG's and Cook Counties) this is probably the difference between staying open and not. For many university hospitals its a break even. For hospitals with better payor mixes they actually lose money vs hiring more physicians or NPPs. The other flip side of this is that these residencies have become mandatory.

Right now post grad programs are voluntary in the PA world. They exist for those who want extra experience in a particular specialty. They also exist so that a particular institution can jump start the orientation process. The payoff is hard to quantify. The studies are mixed on whether there is benefit for a post grad program.

The amount of of post grad PA programs have grown about 4-5 per year for the last five years. There is no reason that the NP world could not use this same mechanism. For the NP profession to do the same thing they would need to do a number of things that are unlikely to happen including developing accreditation standards and a coherent policy. Realistically given the state of Medicare funding and overall healthcare funding its unlikely there is any money for post grad programs.

David Carpenter, PA-C

AbeFrohman, BSN, RN · Jun 15, 2010

Hey now, David! I told ya about that St. Luke program on SDN. Credit where it's due

and you are spot on about GME money.

core0 · Jun 15, 2010

Hey now, David! I told ya about that St. Luke program on SDN. Credit where it's due
and you are spot on about GME money.

While I would love to give you credit, I've been talking with their APD for the better part of a year about their program structure. We are fairly far along in starting a post grad program on a (hopefully) larger scale.

For most large institutions the economics absolutely make sense. You only need 2-3 hours of critical care billing to be able to pay of the student. You need to have a large, robust ICU system and a reasonable administration. On the developmental side the internal politics are the biggest problem.

David Carpenter, PA-C

AbeFrohman, BSN, RN · Jun 16, 2010

Ah, didn't realize that of course. Just noticed you didn't mention in that other thread.

Advanced Practice Columnist / Guide · Jun 16, 2010

David,

You mentioned how the results are mixed as far as pay-off for NPP residencies to the institutions sponsoring them. I can see how such residencies can be beneficial in being able to maintain a pool of prospective NPP's who can eventually be hired as regular employees once they finished the residency. These residency grads can certainly perform at a higher skill level than the ones who just graduated from their respective programs at least in a specialty setting like mine. But I'm wondering how financially rewarding such program could be to the institution given that funding will have to come from revenue in insurance reimbursements as you implied. An additional 1 or 2 NPP residents per year who will bill for their services is definitely adding to the existing number of NPP's in the institution and there will be no guarantee that RVU's will increase given the fluctuations in patient census (which existed even before the economy took a turn for the worse) and the fact the staff NPP's will have to somehow provide some sort of oversight to the residents (at least in the first 6 months maybe).

I have been practicing in Michigan in the last 5 years and although I do not live there anymore, I know of one residency program for PA's in Cardiothoracic Surgery at a major teaching medical center there (over 500 beds) and the catch was the PA residents are given a "stipend" much lower than what the market commands for a new grad, non-specialty PA. I can see how this can work financially for the hospital as the NPP's wll be divided into staff NPP's and resident NPP's and this is going to be the staffing mix for the department for years to come as long as there's a resideny program. However, this particular program wasn't very popular as far as the PA's I spoke to. One, because the "pay" was low and PA's can usually find employment in other fields and make PA-level income right out of school. Two, there is no guarantee of employment after finishing the residency. Three, there is an oversupply of Cardiothoracic Surgeons and most institutions in the area who don't have a fellowship program in this field have 2 attending surgeons perform the operations, one surgeon being the assistant.

At any rate, the issue of a CT Surgery residency came up in the institution I used to work for right before I left because suddenly, there was an exodus of very highly skilled NPP's (both PA's and NP's) who worked in Cardiothoracic Surgery (some both intraop and periop management). The institution was considering starting their own PA-exclusive residency in Cardiothoracic Surgery but it just didn't materialize for many reasons (maybe one being the political incorrectness of having a stricty PA residency in an institution with a strong NP representation?). I think, however, that if the hospital thought such program was financially viable, the department would would have gone ahead regardless of all the political hoops they needed to jump through.

core0 · Jun 17, 2010

David,
You mentioned how the results are mixed as far as pay-off for NPP residencies to the institutions sponsoring them. I can see how such residencies can be beneficial in being able to maintain a pool of prospective NPP's who can eventually be hired as regular employees once they finished the residency. These residency grads can certainly perform at a higher skill level than the ones who just graduated from their respective programs at least in a specialty setting like mine. But I'm wondering how financially rewarding such program could be to the institution given that funding will have to come from revenue in insurance reimbursements as you implied. An additional 1 or 2 NPP residents per year who will bill for their services is definitely adding to the existing number of NPP's in the institution and there will be no guarantee that RVU's will increase given the fluctuations in patient census (which existed even before the economy took a turn for the worse) and the fact the staff NPP's will have to somehow provide some sort of oversight to the residents (at least in the first 6 months maybe).

When I spoke of the results being mixed as far as payoff I was referring to the students. There are 5-6 small studies out there. 1/2 find a financial benefit for students and 1/2 don't. Ie. the salaries in one case were higher for post grad students than the population at large. In the other cases there was no statistical salary differrence between post grad students and the population. In reality its probably more complex than it appears. For example graduating from a CVS post grad program may allow a student to get a job in CVS (which has an overall higher salary compared to the general new grad population) vs not being able to get a CVS job.

From an institutional standpoint there are a couple of areas that it benefits them. They get low priced labor which allows them to make a small profit off of the work. They also pay less for "orientation" in that the student is ready to work immediately after the program if they are hired. The overall benefit financially is not huge, but more importantly there is less dead time.

I have been practicing in Michigan in the last 5 years and although I do not live there anymore, I know of one residency program for PA's in Cardiothoracic Surgery at a major teaching medical center there (over 500 beds) and the catch was the PA residents are given a "stipend" much lower than what the market commands for a new grad, non-specialty PA. I can see how this can work financially for the hospital as the NPP's wll be divided into staff NPP's and resident NPP's and this is going to be the staffing mix for the department for years to come as long as there's a resideny program. However, this particular program wasn't very popular as far as the PA's I spoke to. One, because the "pay" was low and PA's can usually find employment in other fields and make PA-level income right out of school. Two, there is no guarantee of employment after finishing the residency. Three, there is an oversupply of Cardiothoracic Surgeons and most institutions in the area who don't have a fellowship program in this field have 2 attending surgeons perform the operations, one surgeon being the assistant.

CT surgery is one of the bigger areas of post grad programs for PAs. The reasons are fairly broad but it boils down to a need to have a high level of skill at certain procedures (endoscopic vein harvesting). I agree that there is no guarantee in a particular institution but if you look at the jobs pointed out on the CVPA website there are plenty of jobs for new grads. So if the student is willing to move its pretty easy to find a job. When I was in Denver for example there were very few CV PAs for the reasons you mention. Here in Atlanta there are lots of CV PA jobs. Its very location dependent.

The issue with pay is a reasonable one. There has to be a pay off. For example we are discussing putting post grad hires at year two or three on our salary step scale which is a pretty substantial salary improvement. In return they get a shot (not a guarantee) at the job and pay during first year similar to a residents. There are generally sufficient students out there for all the PA post grad programs.

As far as resident NPPs its essentially extra work force. We plan on treating like orientation. Right now the NPP works with another NPP and takes part of their patient load. The "supervising" NPP codes the time as no charge time in our billing program to document time. You have to be prepared for them not to be there. In our case we have very rare slow days, but in the unit I work in there is rarely an empty bed.

At any rate, the issue of a CT Surgery residency came up in the institution I used to work for right before I left because suddenly, there was an exodus of very highly skilled NPP's (both PA's and NP's) who worked in Cardiothoracic Surgery (some both intraop and periop management). The institution was considering starting their own PA-exclusive residency in Cardiothoracic Surgery but it just didn't materialize for many reasons (maybe one being the political incorrectness of having a stricty PA residency in an institution with a strong NP representation?). I think, however, that if the hospital thought such program was financially viable, the department would would have gone ahead regardless of all the political hoops they needed to jump through.

Starting a PA post grad program for most academic medical centers is easy. There are plenty of models out there and the model fits easily into the residency model that academic centers use. In short there are a lot of resources out there. Making combined models is much more difficult. My experience is that involving nursing academia provides magnitudes of additional difficulties. Nursing educators are not in tune with the post grad education model in my experience. The other issue with your problem above is you need NPP champions among your physicians and a core of experienced NPPs to instruct neither of which probably existed.

What our hospital is looking at is the need to staff more than 150 ICU beds across 2 (maybe 3) hospitals. This is common problem faced in many ICUs. In academic centers in particular the resident work hours and RRC requirements are restricting manpower and hours. Also patient safety is becoming a bigger issue so that leaving an R1 in charge of the ICU is no longer considered safe. So like many ICUs we are working toward 24/7 coverage. There are two problems here. We have a liberal orientation policy. Experienced NPPs get at least 3 months orientation. New grads and those without ICU experience get six or more months. They get full salary during this time at dramatically lower productivity. The second problem is getting night time coverage. Older experienced NPPs are less likely to want to do night coverage. The group that is generally willing to do nights are the younger newer NPPs who want extra money and have less social commitments. These are also the people that you don't want alone at night in an ICU. In theory a post grad programs solves both of these problems. New grads can get lots of orientation at a reduced cost (salary). Also it provides an entry into the system. The expectation is that new grads will take night positions and then move into daytime positions in a few years. Some will like it and stay providing sufficient night coverage. This is a model that nursing uses on the floors and ICUs (where good or bad is a matter of opinion).

Given the interest at the AAPA conference I would say that critical care is the next hot area. I would not be surprised to see another 10 post grad programs in the next few years. Whether there are any mixed programs is going to depend on local politics.

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Jun 20, 2010

What our hospital is looking at is the need to staff more than 150 ICU beds across 2 (maybe 3) hospitals. This is common problem faced in many ICUs. In academic centers in particular the resident work hours and RRC requirements are restricting manpower and hours. Also patient safety is becoming a bigger issue so that leaving an R1 in charge of the ICU is no longer considered safe. So like many ICUs we are working toward 24/7 coverage. There are two problems here. We have a liberal orientation policy. Experienced NPPs get at least 3 months orientation. New grads and those without ICU experience get six or more months. They get full salary during this time at dramatically lower productivity. The second problem is getting night time coverage. Older experienced NPPs are less likely to want to do night coverage. The group that is generally willing to do nights are the younger newer NPPs who want extra money and have less social commitments. These are also the people that you don't want alone at night in an ICU. In theory a post grad programs solves both of these problems. New grads can get lots of orientation at a reduced cost (salary). Also it provides an entry into the system. The expectation is that new grads will take night positions and then move into daytime positions in a few years. Some will like it and stay providing sufficient night coverage. This is a model that nursing uses on the floors and ICUs (where good or bad is a matter of opinion).
Given the interest at the AAPA conference I would say that critical care is the next hot area. I would not be surprised to see another 10 post grad programs in the next few years. Whether there are any mixed programs is going to depend on local politics.
David Carpenter, PA-C

ICU is definitely going to be a boom for NPP's if it hasn't already. We had the same issues in Michigan trying to keep the unit staffed for 24/7 coverage. We have little interest from experienced NPP's due to the rotating schedule but were faced with a huge pool of applicants from new grads. The work is very heavy and demanding in terms of skill and knowledge level. I know that they were still trying to hire NPP's there to meet the staffing requirements of the unit though this might have changed due to the economy.

Where I am now is very different, however. We have a fully staffed team of NP's who cover 4 adult ICU's in a university hospital setting and this, despite having to work weekends, holidays, and a rotating schedule. Without having to name the institution, there is an awesome ACNP program affiliated with the hospital though less than half of the NP's graduated and has previous experience from well known centers in other parts of the country.