How to Develop APP Skills

Schematic of 4 steps

Brief description Here

1. Specify Expectations of the Role

2. Identify Key EPAs for the APP

3. Draft Idealized Ramp-Up Schedule

4. Ensure Foundational Knowledge

Specify Expectations of the Role

In order to understand how to best develop needed skills of APPs, you must have thorough understanding of where you are going. Undoubtedly, there are near countless topics that a new APP in any field could learn and numerous clinical problems they could encounter. For a provider who might be new to even some of these tasks/expectations/types of role, this can be overwhelming. To help your department and your new APP optimize learning and prioritize which topics to learn first and which clinical skills to focus on early, it is essential that the expectations of the APP’s role are clearly established. This means more than simply specifying how many hours an inpatient shift may be or how many patients an APP will be expected to cover. Your APP will benefit from knowing what types of patients they will see, the foundational knowledge they will require to evaluate and manage them, their own role vs the role of others on the multidisciplinary care team, and their responsibilities throughout the continuum of care.

• If Consulting Service

• If admitting Service

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Brainstorming Guide

• Will PA see new patient consultations

• Will visit be shared, independent? If mixed

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• Will PA be doing Procedures?

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Where will APP be Practicing?

Inpatient

Outpatient

Procedural Area

Virtual

• Will APP be working virtually?

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Identify Key Entrustable Professional Activities (EPAs) for the APP

You have already defined the role that your new APP will be expected to fufill in your department. To help inform the APP’s clinical ramp-up for both the department and the APP in training, it can be very useful to define a small set of “entrustable professional activities” (EPAs) that are necessary to meet the expectations of the role. Not every department will choose this method to define goals and assess APPs’ progress, but there are distinct advantages outlined in the sections below.

What is an EPA?

An EPA is a “unit of practice” that succinctly describes a key task required for a trainee’s work. An EPA must be observable and measurable, and should focus on essential work in a specific environment. Each EPA is made up of the needed knowledge, skills, and attitudes needed to complete that task. An EPA therefore cannot simply be a learning objective. But, an EPA can range from a very narrow task (e.g., “Place an arterial line”) to a broad clinical task (e.g. “admit a patient with new shortness of breath”, “manage a post-operative care clinic”).  

EPAs are assessed on a scale of increasing “entrustability” to complete the task. When worded to explicitly specify how much independence an APP may be entrusted with for the task at hand, EPAs can be especially useful for guiding an APPs transition to practice:  

• 1 = no permission to act  

• 2 = permission to act with direct, pro-active supervision present in room 

• 3 – permission to act with indirect supervision, not present but quickly available if needed 

• 4 = Permission to act under distant supervision not directly available (“unsupervised”) 

• 5 = Permission to provide supervision to junior trainees 

 

Desired supervision can be specified with even greater granularity (see linked example, Chen et al):

Creating EPAs

An EPA should be given a clear title and further summarized in 20-50 words that provides both the PA and those involved in their training an overview of its content and scope. Since EPAs measure a real unit of clinical practice, it is helpful to keep in mind the phrase - “you are now entrusted with XXX”  when defining/formulating an EPA. It will avoid creating EPAs that are instead a general learning objective or skill.  

For example, “you are now entrusted with evaluating a patient with altered mental status” is more appropriate than “you are now entrusted with listing the differential diagnosis for altered mental status” 

 

Multiple underlying competencies will be required for the APP to achieve entrustment of a well-designed EPA.

For example, the EPA “Conducts a routine post-operative visit” would require specific medical knowledge (e.g. what are common and uncommon complications after this type of surgery), proficiency at examination (e.g. inspection of the surgical wound), communication skills (e.g. proper documentation in the medical record, conferring with the attending surgeon), and systems-based practice (e.g. engaging appropriate consulting team when needed, collaborating with additional disciplines).

 

Explicitly listing the knowledge, skills, and attitudes required for the EPA is recommended (Kwan – Five step approach).  

The selection of tasks delegated to the PA is inherently specialty specific, but may even vary with the specific demands of the individual hired. It is not necessary nor practical to create an exhaustive list of EPAs covering all tasks an APP will eventually perform. A catalog of five to 15 EPAs is typically advised, depending on how granular the units of practice will be and how comprehensive you desire the list to be (Mulder – workplace curriculum). EPAs often implicitly include smaller EPAs within them, which can allow for a shorter list.

For example, the EPA “Providing care for patients with urinary retention” may conceivably include the implicit EPAs of “Inserting an indwelling urinary catheter” and “Interpreting the results of urodynamic testing.”

Keep in mind that EPAs are only useful if they are assessed! Keeping your catalog as short and simple as feasible while remaining representative of the breadth of the job is wise. 

• More Info about EPAs

• What are EPAS - Journals/Resources

Defining EPAs explicitly identifies the most representative and critical tasks that must be mastered for the APP in training. Therefore, ensuring APP has appropriate understanding of expectations for role, knowledge, and training; creating shared responsibility for training between supervisor and trainee. Additionally, defining them helps outline foundational knowledge needed for role, and therefore needed to be covered during training. Given this, EPAs help establish a “road-map” for training, which allows progress to be tracked by supervisors and developing APP - informing their self-study and empowering development of graded automomy

 

Utility of EPAs 

The EPA catalog you develop will help to outline what knowledge and skills an APP will need, and therefore can help you structure both your clinical ramp-up (see next section) and your curriculum for the APP (link). It is most useful to design a “schedule” of EPAs throughout the APP’s training period, specifying when targeted levels of entrustability are expected for each EPA.  

 

Based on the number of APPs and frequency of new hires, the formality of the EPA creation process will understandably vary widely between departments. A supervising MD in an independent clinic may only have the bandwidth to informally outline 3-5 key units of practice. A larger department may want to more formally develop a set of “core” EPAs for their group.

Why EPAs?

Elements of "fully described” EPA

This example highlights the advantages of using EPAs and creating a schedule around them

• APP in training knows exactly what to focus on when

• Didactic curriculum for APP in training can be tailored to this schedule

• Catalog of EPAs allows for easy tracking of progress (0-2 years and beyond)

• Examples of fully formed EPAs

• Resources on more formal process:

Neurology example of EPA

Develop Clinical Ramp Up

Unless they have prior experience in your field, your newly hired APP will likely not be able to perform all the desired expectations of their role on day one or even by end of “orientation”. However, an APP should ideally start contributing meaningfully to clinical service as soon as it is safe and feasible. Therefore, successful transition to practice therefore requires an appropriate “ramp-up” plan, with the APP gaining increasing responsibility and progressive independence/autonomy as they develop the appropriate knowledge and skills to allow it.  

Traditionally, the “orientation period” of an APP has lasted for three months at BWH. But an APP will not necessarily be fully functioning in the desired role within that timeframe. Therefore, it is important to think about what parts of the role can be accomplished within that time frame and what parts will need continued work after that time frame. Think about the expectations you just defined for the APP. The time required for an APP to be fully autonomous in the desired role will depend on their foundational knowledge/prior experience and the expectations of their role. You can anticipate longer time frame if they are required to see new patients, have mostly independent visits, and/or have an expansive number of diagnoses they may encounter). In contrast, you can anticipate a shorter time frame if they will be conducting largely shared visits for a small number of patient types. 

 

In the sections that follow, we will help you design an optimal ramp-up schedule, guided by trackable, observable metrics. Using this structure, we aim to help you identify “intermediate wins.” Even if the APP is not yet fully autonomous in their desired role, they should be able to perform some key tasks independently well before the end of their formal training.

<<For example, by month two after hire, the APP may not yet be ready to admit patients on their own, but they could reasonably be expected to serve as responding clinician for a handful of patients. An outpatient APP may not be conducting new patients visits without supervision, but they could do a straightforward procedure clinic on their own. >> can have this as a part of section that can “expand”

A major advantage of designing a “schedule” of EPAs is the ability to use the schedule to facilitate such a ramp-up in complexity. The areas of focus are explicitly clear, as are the expectations of when additional patient groups should be taken on. Educational activities can be scheduled alongside the area of clinical focus, further accelerating the APP’s growth. Patient logs can serve as a complimentary or alternative method for facilitating this ramp-up. 

 

 

 

Draft a Ramp-Up Schedule

It is not realistic to expect that a new-hire APP will be able to perform all aspects of their eventual role on day one. A gradual ramp-up of both patient volume and care complexity will be required to avoid overwhelming the APP and ensure high quality care is delivered. A well-executed ramp-up will also ensure speedy progress is made and minimize the financial burden on the department.  

 

On average, PAs report that it takes 6-8 months to feel comfortable in their new role, but they area often expected to be autonomous before this time frame. This was highlighted in a survey of program administrators at community health centers, where new APPs were expected to see a full clinical schedule between 20 and 40 weeks after starting on average (Morgan P – Emerging Practices). It is therefore key to structure early clinical responsibilities and early educational experiences to match the types of patient encounters, medical complaints, and clinical skills that will be most common and most essential for their desired role. Think carefully about some “early wins” for both the APP and the department.  

• What patient encounters are the highest priority where the APP can start to make an impact, based on departmental needs?

  • For example, might having the APP see 1-2 sessions of independent follow-ups for a specific low-complexity diagnosis allow attendings to see additional new patients and improve patient access? 

• What types of clinical activities might be financially productive for the department but also feasible for the APP to master early on in training?

  • For example, a PA in a headache clinic might be able to quickly administer botox independently 1-2 days per week. 

 

Clinical volume ramp-up 

Specify how and when the APP will be expected to gradually shift from purely observing to eventually fulfilling their desired role. In addition to specifying how patient volume will increase over time, also consider how dedicated supervision will taper over time. The pace of ramp-up will be guided by the baseline skills and experience of the new APP, the learning curve, the complexity of patients encountered, and the breadth of medical problems the APP would be expected to handle.

 

 Example:

• Inpatient Service

• Outpatient Service

• Procedural Service or Consulting Service****

Dos and Donts - Consider making this section drop down and adding more??

Shadowing

Shadowing is generally not encouraged, except very early in the training process. (Anglin – Strategies for Onboarding). Shadowing does not encourage graded independence and does not offer the APP to practice the skills and apply the knowledge necessary for their eventual success. Shadowing also offers no financial productivity for the department, making the burden of the training period greater.  Early on, “reverse shadowing” may be a preferred method, whereby the preceptor observes the APP in training conducting the visit themselves. Later in training, shared precepted visits can become the norm.  

 

Supporting activities 

The APP’s training period offers a unique opportunity for observation opportunities outside of the APP’s specific responsibilities. Consider having the APP join other services that are frequently utilized by your patients. For example, a neurology APP training for practice in the ALS clinic may benefit from short experiences working with physical therapy, speech therapy, palliative care, the EMG lab, and pulmonology. While the APP’s administrative burden is low, have them use administrative days to observe in these areas.