NPPs: Exploring their contribution and impact on resident education

As an intern, I have seen the wide-ranging effects of nonphysician providers (NPPs) firsthand. NPPs have afforded me many advantages this year, including decreased administrative workload and increased exposure to the operating room (OR). I have turned to them for everything from clinical questions to supervision and assistance for minor procedures. As my intern year draws to a close, I am deeply appreciative of the guidance and support they have provided. However, I also have witnessed significant downsides to their presence in residency training. If we do not carefully define our role as residents, we risk becoming the accessory “parallel players” in patient care.

NPPs have been in practice for more than two decades, with their workforce increasing significantly following the introduction of the 80-hour workweek in 2003. They filled a critical void at a time when the culture of residency was undergoing necessary changes. Their scope of practice varies widely from simple documentation and discharge needs to assisting in the OR.¹ Case studies of early implementation touted NPPs as promising partners. Residents reported decreased workload and increased OR time. Improved continuity of care also has been noted.¹ Residents can rotate through services over the course of several months and for that reason may be less familiar with the complexities of patients requiring multiple hospitalizations in their perioperative course. However, conflicts also arose. NPPs and residents disagree on the hierarchy of responsibility, with 90.5 percent of residents (n = 66) ranking NPPs at an intern level or below and 67.8 percent of NPPs (n = 28), stating their position in the chain of command to be at the senior/chief resident or attending level.¹ Confusion about the division of responsibilities and problems in communication between junior residents and NPPs also became evident.²

With the proliferation of NPPs on almost every clinical service, varied effects on the education of surgical residents—effects that are sometimes less than positive—are becoming clear. A recent survey of 279 faculty academic surgeons from across the country reveals the high educational cost of reduced resident workload.³ Faculty respondents to the survey cite concerns about resident experience with preoperative and postoperative care, with 50 percent agreeing that NPP coverage reduces resident exposure to valuable educational opportunities. In the old model, all nursing concerns were funneled through one person, and the team plans were enacted through one person. Although this system creates a high workload for that individual, it ensured that steps didn’t get overlooked or missed because of miscommunication. With the diffusion of responsibility and without established lines of communication, it can be difficult to keep up with nursing concerns that went to the NPPs first or updates from various consultant teams.

I cannot help but worry that I am not sufficiently learning and preparing for eventual independent management of patients. Each small decision that I am denied the opportunity to make is a lost opportunity to refine my clinical judgment. For the same reason that we log operative cases, numbers matter. Seeing patient number 100 with tachycardia and hypotension in the immediate postoperative period is different than seeing number 50. Each of those small clinical decisions—determining whether I should bolus for low urine output, place a Foley after multiple failed void attempts, or drop a nasogastric tube in a patient with a largely distended abdomen—allows me to develop astute clinical decision-making skills. If I cannot systematically evaluate the “small” problems of surgical perioperative care, how can I develop confidence and competence to make the larger decisions surrounding the trajectory of surgical patient care?

The faculty survey also noted disruptions in team dynamics that sideline the residents.3 Rather than relying on and teaching the residents their patient care preferences, senior attendings turn to NPPs to get the job done. In fact, 77 percent of academic faculty report rounding without residents, which effectively releases residents from direct patient care responsibilities. As residents who rotate on and off services, it is difficult to compete with the expertise of NPPs who never leave the service. That level of familiarity cannot be overcome in a four-to-eight-week rotation, especially when residents have minimal opportunities to take care of the patients on the floor because day-to-day responsibilities are delegated to the NPPs.

Resident surveys regarding their experiences with NPPs have generated mixed responses. Surveys ranging from single institution to nationally administered have demonstrated that residents report a lighter workload and less operative interruptions with NPPs on service.⁴ Most studies report that residents view NPPs as a benefit, and residents will even advocate in some instances for adding NPPs.⁵ However, do residents really understand what is best for their education? When the resident responses are compared with the responses from the attending survey, a chasm in opinion emerges, with residents reporting that NPPs have little impact on their education and the faculty describing significant gaps.

The truth is likely somewhere in the middle, but perceived improvements in the educational value of a service by residents do not necessarily equate to true improvements in resident education. We know there are problems with our current educational structure, with the widespread concern that graduating residents may lack the confidence to enter independent practice,⁶ necessitating the creation of fellowships such as the American College of Surgeons Mastery in General Surgery program.

Furthermore, the effect of this systematic shift in floor responsibility may extend to the OR. It has been reported that intraoperative autonomy decisions are framed by perceptions of resident capacity in managing patients on the floor.⁷ If residents are no longer accountable for the care of the patients on the floor and cannot demonstrate clinical judgment in that venue, what does that portend for autonomy acquisition in our operative experience?

Ultimately, further investigation is warranted to determine if the detriments to resident education can be overcome. Setting clear expectations about the responsibilities of the team members, collaborating regarding patient decisions, and using group texting are all ways in which I have seen functional teams provide excellent patient care in spite of these challenges this year.

We, as trainees, risk being the casualties of this new system. The looming danger of becoming bystanders in patient care is real if we are unable to effectively define our own roles within the team. We can also take responsibility for identifying ways to make the relationship between residents and NPPs constructive for both patient care and education. Clear delineation of team members’ roles, direct collaboration on patient care decision, and improved communication can benefit our patients and our learning opportunities.

I became a surgeon not only to perform operations that can save and improve patients’ lives, but also for the responsibility and ownership that comes with being trusted to operate on another human being. With this privilege comes great responsibility, but I refuse to relinquish this characteristic that defines my practice and inspiration in medicine. The care of my future patients depends on it.

References

1. Buch KE, Genovese MY, Conigliaro JL, et al. Non-physician practitioners’ overall enhancement to a surgical resident’s experience. J Surg Educ. 2008;65(1):50-53.
2. Resnick AS, Todd BA, Mullen JL, Morris JB. How do surgical resident and non-physician practitioners play together in the sandbox? Curr Surg. 2006;63(2):155-164.
3. Coverdill JE, Shelton JS, Alseidi A, et al. The promise and problems of non-physician practitioners on general surgery education: Results of a multi-center, mixed-methods study of faculty. Am J Surg. 2018;215(2):222-226.
4. Kang R, Columbo JA, Kunkel ST, et al. Residents’ impressions of the impact of advanced practice providers on surgical training. J Am Coll Surg. 2017;226(6):1036-1043.
5. Caniano DA, Hamstra SJ. Program strengths and opportunities for improvement identified by residents during ACGME site visits in 5 surgical specialties. J Grad Med Educ. 2016:8(2):208-213.
6. Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and the Young Fellows Association. J Am Coll Surg. 2014;218(5):1063-1072.
7. Chen X, Sullivan AM, Alseidi A, Kwakye G, Smink DS. Assessing residents’ readiness for OR autonomy: A qualitative descriptive study of expert surgical teachers’ best practice. J Surg Educ. 2017;74(6):e15-e21.