The Role of Advanced Practice Providers (APPs)

Welcome to Cancer Shop Talk, Behind the Diagnosis. I am your host, Dr. Christopher Vaughn, Physician and Owner of Hematology Oncology Associates of Fredericksburg in Virginia. We are redefining the conversation about cancer through the lens of an independent Oncology practice. Thank you for joining us.

Vaughn: Welcome back, listening audience. I am so thankful today to be with our excellent advance practice providers. And I thought today we’d discuss their roles in the medical practice that we have here at HOAF. I am going to have them introduce themselves.

Danielle: I’m Danielle. I’m a Nurse Practitioner here at HOAF and I’ve been here for nine years.

Candice: I’m Candice. I’m also a Nurse Practitioner and I’ve been here just over three years in my current role and I also was here about one year as a Nurse.

Liz: My name is Liz. I’m one of the Physician Assistants here and I’ve worked here for about four years.

Linda: And I’m Linda, and I have been working here as a Nurse Practitioner for about five years.

Vaughn: So, I will start with Danielle since she has the most experience with us, but I would like to – I think one of the confusing things patients have is to understand what an advanced practice provider means. Do you mind maybe helping us out and just help the patients. Sometimes they get confused with that term cause it is a fairly new term.

Danielle: Sure. It is fairly new and especially in Oncology. I think we’re using more and more advanced practice providers in Oncology. So, our roles are very similar. We’re masters prepared health providers. Nurses – nurse practitioners have a background in nursing first and then go to a graduate program either as a masters or a doctorate and become a nurse practitioner. And Liz, I’ll let you speak about physicians assistants cause that’s – you’re more knowledgeable about that role obviously.

But we work closely with doctors and other providers to provide patient care at an advanced level, so we can do diagnosis, we can do symptom management, we can order procedures, we can review scans. We can pretty much do a lot of the same things that a physician can do, but our role is such to provide support to the physician, if you will, and make sure that the patient has continuity of care. I think that’s pretty much it.

Liz: Okay, yeah, okay, so a physician assistant is similar to a nurse practitioner in that it’s also a master’s degree program. Typically, you’ll have your four-year undergraduate program in some type of health science, biology, even pre-med, and then go on to a master’s degree program where you’ll learn more about the physician assistant aspect and then also do your clinical rotations that are similar to a residency that a physician would have. So, we have oftentimes less I would say medical background going in. Some PA’s are nurses. Typically, nurses become a nurse practitioner but sometimes EMTs, other time corpsmen that have been in the military may go on to be a physician assistant or people like myself who just know they want to go into medicine from an early age and kind of jump right in.

Vaughn: I think one of – and I’m trying to think when we did this but 2011, I think, Danielle, you mentioned joining us. I was the fourth physician brought on, but we really didn’t have any advanced practice provider.

Danielle:  No, you guys didn’t know what to do with us when I started. You didn’t know what to do with me.

Vaughn:  No, no, thank God we finally – maybe, you know, six months ago we figured it out, but I think one of the things that I mean that really helped us manage complex patients was to have the help of an APP, and it has been just a tremendous change in comfort level for the physician to know that our patients are being seen, being diagnosed, being treated, staying on schedule. It’s really helped improve drastically I think the quality of care we can provide here at HOAF.

I know I just want to kind of go around the room just to kind of personalize it. I mean we went through at our last podcast with some of the physicians, we got into Oncology, but it is a specific field that has its own traits and characteristics, and so I’m just a little curious why the four of you got into it. Maybe if we could go around the room and see.

Danielle:  I actually – I went into nursing late. I actually graduated from Nursing School in 2000. I had a career prior to that as a hotel manager. My first degree was in French Literature with a minor in Portuguese so, but I decided later in life to go into nursing and my first rotation was in Oncology, fell in love with it. I ended up doing Oncology Nursing at the bedside and then ended up in Trauma ICU and went back to Oncology as an Advanced Practice Provider.

And really sort of fell into this role as an accident because my father was a patient here. He was a patient of Dr. Maurer’s and when I started, he was being treated for Stage 4 Lung Cancer, and I was kind of hesitant to start, but it was a great decision, and I’ve been here since. And unfortunately, Dad’s gone, but, you know, I look at him every day and say I’m still here.

Candice:  I really had never considered Oncology. Really all of my nursing experience was in Cardiac and Intensive Care and I actually had a girlfriend that worked here as a nurse and she just called me up one day and said do you want to come over here and work? I said well, I have a day off every week, so sure. And I kind of came over and started out as an infusion nurse just one day a week, and you know, with my other job and kind of just fell in love with the patients that we take care of and just the whole culture here with just something I had never seen before.

In a hospital setting as nurse you’re very used to doctors sort of talking down to you and not really having a lot of interaction that’s positive, and here it was like very different. It was like kind of a family and the physicians were approachable and they like truly cared about their patients, and then the patients are just a whole other realm of things that you just don’t expect, you know, you’re used to dealing with patients that are very difficult and, you know, very demanding, and the patients here are just like grateful and, you know, thankful for everything that you do for them, and most of the time super compliant which is nice, you know, they just want to get better so they’ll do whatever, you know, you ask them to do.

When I graduated with my Nurse Practitioner, I got a call from Danielle just out of the blue and said like when are you looking for a job? And I said I just graduated. So now. And I came back over, and it was just kind of a natural sort of way that that happened.

Liz:   When I was in school, I actually thought I wanted to go into women’s health or Pediatrics. And then I did my clinical rotations and I pretty much loved everything, so it kind of opened the door where I was like well, I could picture myself pretty much anywhere other than surgery. So, when I was applying for a job there was an in-patient in a hospital Oncology position that was open in Pittsburgh, which is where I was living at the time.

I went in and interviewed, and I fell in love with the team there and then when I met the patients and just, you know, what they’re going through and like what Candice said, they’re so grateful for everything you do for them, you know. Sometimes you’re the best part of their day and oftentimes they’re the best part of our day. And then when I decided to move back closer to home cause this is home for me, I just walked in at HOAF and asked them to hire me.

And it’s been a really nice transition going from on-patient which is a lot of symptom management and, you know, critical care, to being more in an out-patient setting where there’s a lot of survivorship and you just become so close to the patients. They become like a family to you. You see them month after month or week after week, and then, you know, when they’re done with chemotherapy or treatment and they come back and see you and it’s just like, you know, being with family again, so it’s great.

Linda:  And I – the nurse, knew I wanted to be a nurse since I was small. Most of my career, 20 some years, was in Critical Care before I went back to school, got my graduate degree, and I knew that I – the thing that I had enjoyed most as a Critical Care Nurse actually was working with family members and patients and kind of getting to know them, and so I was looking for something where I could use a lot of those skills, and I tried a couple of different specialties and then I got a call from Danielle and came in and interviewed here and was initially, you know, pretty apprehensive about jumping into Oncology because it’s a very different knowledge base, but I also loved the culture here that really truly is very patient centered.

And cancer patients are just wonderful, like you said, they kind of become almost like family and you’re, you know, it sounds, I don’t know, kind of maybe over the top when you talk about how inspirational they are, but truly they are as you watch people facing a really, really huge challenge, life threatening, in their life, and the way they and their families pull together to confront that challenge, it’s very rewarding to be able to work with.

Vaughn:  Well, yeah, a couple key items there, for one I think culture, and that’s I think what sort of separates us. We talked about it last time. I think our sort of patient centered culture, how everything sort of revolves around the patient either being, you know, from the front desk to the infusion nurse to the physicians, advanced practitioner providers, medical assistants and keeping that goal and that patient-centered attitude is just critical, and I think it separates us from a lot of other practices.

And I think trying – what we’ve tried to do is maintain a sort of community feel, you know, still even as we grow. But I was wondering just as you guys were going around the table, and I think to myself, you guys are kind of like the glue of each kind of team in a sense that I think we have moved into a sort of kind of team models, but you know, I think nurses come to you, you know, for questions, doctors come to you for questions. You’re kind of like the champion for patients to keep them motivated. I mean how do you guys balance sort of this – I think your roles are so dynamic, you know, what you guys do, you know.

Of course, you’ve got to listen to myself of Dr. Maurer kind of hounding, you know, let’s do this, that and then you have nurses coming to you with questions that they don’t want to bother us, you’ve got to deal with, you know, in the middle of your day. I think you guys, what’s great is you kind of see some of the patients on schedule, motivate them, I mean it’s kind of vast what you do, you know.

Danielle: It’s very vast, it’s very vast. I’m so glad you said all this. I think all of us would say that, you know, between the phone calls, you know, answering triage questions, between patients that walk in and want to be seen or devastated family members that need more time than usual and, you know, the patients. There’s just so much, I mean it really is, but I think it’s all rewarding in its own little sector, don’t you think?

Linda: Yeah, I think whenever, it’s never boring. The fact that there is all of that keeps it a very stimulating, wonderful place where you can grow. I think all of us feel like we learn something literally every day, and really, you never feel like you just came in and had a boring day where you just went from room to room, you know. It’s never like that.

Danielle: No, no.

Danielle: And I think one of the things that I think that we have as advanced practice providers have also – I think the reason we all talk about our patients and we love them so much, and I always say it’s like a cancer patient’s almost like an onion, you know, when they get diagnosed like they’ve got the grief and the anger and all of that stuff. And I think we get to see that, and we sort of hopefully educate our nurses and they feel the same way. You peel back the layers of onions, you know, as patients are being treated or go through their, you know, disease whether it’s, you know, palliative or whether it’s curative, you get to know the real person. You get to know the real person inside. And I think that’s what’s so amazing with our job, don’t you think, because you really do establish relationships and they’re just phenomenal.

Vaughn: Yeah, it truly is. I mean I get a little jealous cause Liz finds out certain histories that I don’t – they don’t tell me at the first visit cause sometimes, you know, as they meet me, of course, it’s more centered around the, you know, the disease, you know, prognosis, treatments and sort of a medical question. But I do love to kind of get to know them and the family, but sometimes it’s maybe Liz follows up with them or they, you know, I guess their shields are down, unguarded, they open up a little more and share all these tidbits that I never – I feel like gosh, I didn’t know that, you know. So, it is – I think you guys do get to really – we really do get to know our patients well and it’s rewarding, especially you guys cause you see them a lot, you know.

Danielle:  I think it’s key, and I think the fact that we really do allow our practitioners to spend a good 30 minutes with a cancer patient is important too because, you know, our insurance company now mandates, you know, that people get seen 15 minutes, but we as a practice have made a decision that our cancer patients would be seen in 30 minutes as it’s by our advanced practice providers, and I think that gives them the time to really talk about how they’re feeling and for us to really see how they’re doing, you know, instead of rushing them through, and so I think that’s really important, and it gives them time to tell us more.

Liz:  Yeah, and to learn who they are as a person outside of their cancer diagnosis and why they’re doing this, why they’re choosing to go through treatment or why they need that third week off to see their grandson graduate college or whatever it may be, and you know, you learn who the person is, not just the patient, so that’s important.

Vaughn: I think the team aspect has been something that HOAF has done really, and we’re still doing, really well. We’re still evolving that, but I think, you know, having one physician with, you know, one advanced practice provider has been a really good model because you do really get a chance to develop those relationships and it allows us the time to say okay, this person is going to need a little more sort of hand holding and TLC and you can have more frequent visits with them and, you know, the APP can see them, you know, maybe two times as opposed to what they would see someone else that’s just kind of going through things easily like maybe once, you know.

So, that’s really helped, I think, and then you get like a really good sort of working relationship with the physician and you kind of almost become just like an extension. You know, you like learn what their practice is and how they would do something, and so you sort of develop your practice based on like their practice model, and all of our physicians are like vastly different. So, it is sort of challenging to try to take on, you know, all of them, but if you’re working really closer with one it works pretty well, I think.

Candice:  And the fact that we have nurses on that team too is great because probably of all of us I think the bedside nurses are the ones that get to know the patients the most. And when we meet together and have weekly team meetings, we find out things that, you know, we didn’t know that are going on, symptoms they are having, challenges they are having in their lives, that kind of thing. I know that helps us guide their care.

Danielle: One thing we’ve done really well too, especially with the team models and with the addition of Advanced Practice Providers for each team is being able to keep these patients out of the hospital because these guys are so sick and, you know, the worst place for them is really the hospital. You don’t want them in the Emergency Room if they don’t need to be. You know, when you get to the Emergency Room as a cancer patient if they’re having dehydration secondary to nausea and they know if the ER doc says oh, my God, they’re a cancer patient, they’re admitted.

And sometimes they don’t need to be admitted. Sometimes they need some IV fluids, sometimes they need some antibiotics, they might need some electrolyte repletion, different medications prescribed, and I think we see that and we’re able to keep them in the office and offer those services here, so we do our IV antibiotics and hydrations in the office instead of sending them to the hospital where they’re going to be admitted for days and to be, you know, exposed to new germs. So, I think we’ve done that really well, and I think that’s an important part of our role.

Vaughn: As we move – so we moved this team model about maybe two years ago, 18 months ago?

Speaker:  Yeah.

Speaker:  Uh-huh.

Vaughn: So, that is a physician, an APP, two infusion nurses and medical assistants for that team to kind of call it a pod. Liz unfortunately has to work with me all the time, so she’s on the team, but so I think it has really improved and I’m glad you brought that up, Danielle, cause I think that the team model has really improved. I think the continuity of care, you’re really able – it’s much easier when you’re kind of seeing the same patient every week to know even a subtle change, If you’re familiar with the patient you can catch it early, and I think that’s one of the key moves we did was really to maintain, as mentioned, symptom management and also we just don’t want our patients to get to the hospital.

I think things, you know, they get off schedule and it just can kind of create a lot of issues when that happens, you know, being in the hospital, infections, and you want to kind of keep them out of the Emergency Room the best we can, so I think we try. We meet once a week and we go through kind of our patient list, you know, certain, you know, CAT scans or PET scans that are due, if we have scheduling conflicts, we review as a team the – now we’re moving in this era of molecular testing so they go through all these molecular tests that are so – that are due or hopefully coming up for treatment decisions. So, I think the team model which we kind of adapted 18 years – 18 months ago, not years has – I mean I think it’s really provided a really strong movement in sort of our quality that we provide.

Speaker: I agree.

Vaughn: Well, Danielle, I just wanted to ask a question to you because this came up. Yesterday I was seeing a new patient and I kind of went through the protocol of their treatments and how they were going to be seeing me but also alternate with visits with Liz who is the APP on my team, and I could see there was a little bit of hesitation on the patient’s part, a little nervous maybe that I wasn’t seeing them every time. I tried to offer reassurance that we talk all the time about events even if I’m not the one seeing the patient that day and I just wanted to hear from your perspective, you know, how you handle that. I’m sure it comes up. And just how you offer reassurance to the patient.

Danielle:  Sure, actually it comes up quite often because patients come in there and they’re scared. They have cancer and they want to make sure that their medical oncologist is really on top of what’s happening, so you know, while they may trust us as Advanced Practice Providers, they really want to make sure their oncologist knows what’s happening. So, typically when patients bring that up, I reassure them that we are always in contact with you guys, that we use email, we use telephone, we use team meetings, we actually even use text if we need to get an immediate answer.

We always put everything in our note and that you guys read our notes so that the physicians are well aware in present time of what’s happening with that patient and there’s no lag in letting you guys know what’s going on with them. I think that’s really important. And you know, and basically we also try to explain to them that we are an extension of you guys so that really, you know, if there is something very complicated most of the times we have spoken to you already about what is to be expected during that visit, and then we always go back if we have additional questions or anything like that.

Vaughn: Well thank you for addressing that question.

Danielle:  Oh sure.

Speaker: I think our sort of I guess our network of advanced practice providers is very unique also because total now we have two PAs or physician assistants, and we have five or six nurse practitioners total. We all really work well together, so that’s kind of – the other nice thing, you know, when physicians are pulled in a million directions, they’re in the hospital, they’re, you know, we cover three different hospitals so they’re rounding and they’re at our Stafford Office, and you know, so any given day or week at a time, you know, the physician may not be in the office at all.

Speaker: Right.

Speaker: And so even if you have a question about that physician, you know, sometimes I can go to Liz, you know. In my role, I see just sort of any patient that comes in, but I can go to Liz and say hey, can you come and look at this with me because I don’t know this patient and can you like we can kind of figure it out together like if it’s an acute change in the patient or if this is sort their normal baseline.

Vaughn: One other thing – well I think it’s really exciting and I think one of the special qualities of our practice, and I think it’s been since the beginning even when I came in is we allow sort of the people inside to kind of grow the practice and develop certain strategies to continue to provide excellent, you know, patient care. So, one of the things I want to get your guys’ input on this because patients always come up to me and ask about I got this class to go to, this education class, but one thing I think we started which has helped especially with patients cause when you start, when I came on board over 10 years ago, we would kind of design the treatment plan and the patient would start and come in with a lot of anxiety not really knowing.

As best we could in that hour, hour and a half, we would go through everything, but you know, I think patients are like as you’re going through everything about 30 percent is retained, but we sort of developed this kind of chemotherapy education sort of session which you guys have really kind of championed and pioneered on a separate day before they start to kind of answer all their questions, anxieties. I don’t know how that – that’s been going on about four or five years, and that was kind of recommended from you guys.

Speaker:  Yeah, I think so. So, when I first started here the nurses were basically doing chair side – when the patient was starting Cycle 1, day one, they would go through it with them as they’re being infused, and the anxiety level is so high at that point, you know, so then the nurses started doing the teaching or, you know, the education with the patients a couple days before and really we didn’t really have any nurse practitioner or PA involvement at all at that point, and then we decided it was probably better to really get to know the patient that’s on your team and develop that patient education session, if you will, put the patient at ease, get to know their advance practice provider.

They just spend a good 45 minutes with them, they go through the symptoms, they go through the treatment schedules, you know, at that point we can address anything that comes up so that might be, you know, whether it’s emotional or whether it’s physical before they start treatment. A lot of times we end up going through scans, believe it or not, like that might happen between [inaudible 22:07] saw you.

Speaker:  Even things that they’ve thought of from the time they meet with the doctor and get the diagnoses to then they come in to hear about the chemotherapy, typically there’s a list of questions that comes along with it because like Dr. Vaughn said, you know, 30 percent of what he said maybe was retained, and then they come in with all these questions that may or may not have already been addressed, but it’s scary in what they’re going through and so we’ll go through all that in addition to the chemotherapy expected side effects, symptom management, the schedule, all those things, and they get everything in writing, which I think is helpful too because even in our appointment I’m sure they don’t remember everything we say.

Speaker:          It’s too much information.

Speaker:          Overwhelming.

Speaker:   Yeah, and then we try to take them next door and we give them a tour of the infusion center which is actually really beautiful. It’s definitely not clinical, and of course, they get to meet their nurses, you know, at the same time too. It’s been a great improvement, and I think it’s improved the patient experience, still continuing to tweak it a little bit better so it gets even better, but great improvement.

Vaughn:  Yeah, I think it is very comforting to the patient to kind of see the team, who they’re going to be with before they start. And I mean I’ve had great feedback, you know, it lessens the anxiety the first day I’m sure.

Speaker:  So, in addition to the chemotherapy education that we do, we also use a lot of new oral oncolytics or oral chemotherapies. So, we do a lot of education on that. What’s really neat is we have an oncology nurse navigator, if you will, who is in charge of just making sure that patients can get their oral chemotherapy medications and they work really closely with us via the Advanced Practice Providers in making sure that they communicate with us whether the patient is having issues, that they’re taking their drugs on time, if they were able to get their refill or if they’re even having financial difficulty getting it so we can work with the team to come up with other options or try to help them get their treatment.

Vaughn: From you guys standpoint, what are some other roles, or some other sort of developments you guys have been taking on at HOAF cause I am so proud of you guys and what you guys have done but talk a little about that because that’s been such an exciting thing going on.

Speaker:  Yeah, and I think that’s been one of the really nice things about working here is having an interest – I knew I had an interest in palliative care which is symptom management and just also looking at how the cancer is affecting the individual, their family, how they’re coping, what they’re understanding is of the illness and how – what challenges they see ahead, that kind of thing. And I had an interest in the that from the time I came to the practice and the physicians were nice enough to support me where I got a post master’s certificate in palliative care and then certification in that.

So, now I do have a clinic that meets on Tuesday mornings and Thursday afternoons and I see patients individually. Those are a little longer appointments, usually about 45 minutes, and a lot of times it’s a lot of just talking about what do they understand about their illness just cause, you know, I think you’re overwhelmed when you get a diagnosis with cancer and even though you maybe met with your oncologist and you’ve had your education session, you sometimes still aren’t really clear and you kind of get on a conveyor belt almost of, you know, am I ready for my next treatment and you may not understand the whole plan.

So, I’ve been able to have some conferences where families have come in to help them talk with one another, sometimes just couples to talk with each other, and then we did start a support group which has continued to grow. That meets on the third Tuesday in the afternoon here in our office and usually have lunch with that, and we’ve had some different presentations and that’s been more and more well attended. I think we had 20 people this last Tuesday.

Speaker:  I’m going to toot Linda’s horn, okay, because the last group we had did not fit in our conference room anymore. So, I think we talked about moving to our activity room downstairs. But Linda got our therapy in here and I think that was a huge success, and it looks like we might be able to do that more than –

Speaker:  She’s willing to do it monthly.

Speaker: That’s great.

Speaker: Another thing Linda has done, actually done a little bit of a support group for the staff too.

Speaker: She’s orchestrated some of that where yeah, the nurses and providers can come and sort of just share their feelings because, I mean obviously this is a little bit different sort of profession and it can be like taxing on your emotions and your, you know, sometimes even caregivers need that sort of relief, and that’s been kind of I think helpful too.

Speaker: Therapeutic. Yeah.

Speaker:  And I think too, especially for – I think for all of us, but especially our nursing staff, they are very supportive of one another. They get together a lot outside, so they do a lot of their own kind of informal, you know, debriefing so to speak, you know.

Vaughn: That’s wonderful. No, I think it’s wonderful to take care of our own cause our employees do a lot for our patients and it can be overbearing at times, so it’s nice to have an outlet like that.

Speaker: Uh-huh.

Vaughn:  But I’m so excited. I think that the art therapy right here, that’s wonderful. We’re trying to move in to, you know, other ways to improve the kind of quality of care, that emotional and psychologic outlet for patients is excellent.

Speaker: So excited.

Vaughn: Yeah, that’s great. And I know, Candace, we can talk with Candace here a little bit about what she’s done the past year plus, maybe. Has it been a year now, the Surveillance Clinic, which is so exciting?

Candice: I don’t know exactly when it opened but it’s still – it’s everchanging, but, you know, what types of patients we’re seeing and what’s coming through the door, but it’s I think something that sort of sets us apart from any other practice that I’m aware of, you know, that we have this ability to just see patients like urgently, acutely, whoever needs to be seen, because one thing I try to remind myself of often is that, you know, whatever that patient is going through at that moment, it may be just the very worst thing for them.

So, to have someone available that, you know, when these patients call the nurses and they have what feels like to them just the worst possible thing going on, that the nurses can reassure them and say okay, why don’t you come in and talk to one of our providers and have them just, you know, look you over and see what we can do to help you. And I think that’s a lot of my role. Another part of it is, you know, we make patients, predispose them, I guess to lots of side effects and lots of, you know, potential really I guess challenging things with the chemo and with the treatments that we give so, you know, if a patient is acutely ill or if they’re having a fever, you know, we don’t want them to end up in the Emergency Room.

So, we would bring them in through the Surveillance Clinic. We can do, you know, labs on site, we can do antibiotics on site, we can do blood cultures and urine cultures and sort of all of these things that they would do, you know, in an Emergency Room other than imaging, and we can hopefully, you know, keep them out of the hospital and treat them here. You know, we have patients that come in and have, you know, fever on a Tuesday and I’ll bring them back and see them every single day until Friday, and that buys us time.

If things aren’t getting better by Friday then we can sort of look at even just direct admitting them to the hospital where they don’t have to go through the Emergency Room and be exposed to whatever is there and wait in the lobby and we can maybe just get them a room in the hospital because we’ve been, you know, managing this and we sort of already know what the issue is. So, I think that’s been the one thing that’s been really good for our patients to know that they’re, you know, supported in that way too so –

Speaker:  Yeah, that’s funny because sometimes we can get around some of the imaging because I know we’ve had cases, especially with the teams, the way the teams work, you know, if the nurses are talking to the patient and we think that they have a clot in their arm or they’re having issues breathing, we can send them for a chest X-ray or may sure they don’t have a pulmonary embolism and bring them right back in here after imaging is completed so that Candace has all the information she needs to be able to make an information without keeping them out. So, that’s been nice too.

Speaker: You know, we keep talking about keeping patients out of the hospital, and that is ultimately our goal but sometimes patients do end up in the hospital and that’s okay. You know, we like to assess them and see if it’s appropriate for them to go to the hospital and sometimes it really is. Sometimes patients are too sick to stay out of the hospital, but the good thing is if they do go to the hospital a member of our team is there in the hospital. So, Stafford Hospital, Spotsy Hospital [phonetic] and Mary Washington Hospital, our doctors cover all three, even on weekends. During the week the APPs are at Mary Washington Hospital.

And so, it’s nice for the patients to see a familiar face and know that, you know, we’re looking out for them, we know what’s going on. Because a lot of times these patients when they’re going through active treatment, they see us a lot more than they see their primary care provider, and so we kind of take over that role even for just when they’re going through chemo. And so, to see us and say, oh my gosh, thank you for coming to see me, like I hear that all the time. You came out of your way to come see me. And it means so much to them, and it’s nice for us too because we know them, and we can make sure that they’re getting the care that they need.

Vaughn: Yeah, I can’t tell you the times that I’ve had patients just come up to me and they’re so appreciative of our ability to kind of almost use our own surveillance clinic as an urgent care clinic to a degree to avoid them going to the hospital and like you said, Candace, there have been a few times where patients had like a fever or infection. They’ve been able to come here for antibiotics for a couple days just to make sure they’re doing okay, and we’ve been able to kind of ward off an admission that’s been and they’re just – I mean it’s just – it means a lot to them to spend time with their family at home and not having to go to the hospital.

Speaker:  Right.

Vaughn:  Also, I know when I’m on a call at night and if I get called about a patient who has a fever, not doing great, it’s just such a luxury to have them come first thing in the morning.

Speaker: Yeah, they trust us to like make the right decisions. I mean from any scale of anything, you know, they – and sometimes patients will just walk into the Surveillance Clinic and say I have an infection in my toe and my doctor gave me this medicine, but I want to make sure it’s okay with Dr. Vaughn.

Speaker: I have to say okay, let me look at it, you know. I’ll come back. And I did talk with Dr. Vaughn and he said it’s fine, so you know, it’s like they really just trust us to, you know, that we have their best interest and I think just the bottom line is we’re here for them. We’ve developed things within the practice to, you know, do that for them.

Vaughn:  I think patients, you know, will 1, when the go into the Emergency Room or they go see other – what we do is just so complex and the medicines change, I just – it’s hard to keep updated. I think other providers have a hard time with that that it’s just nice when we can kind of take care of our own cause I think if they’re in the Emergency Room it’s just sometimes it’s so complicated, what’s wrong, they’re going to be admitted for at least observation. So, we’re able to hopefully keep them out, and it means a lot for the patient to stay out of the hospital.

What do you guys think? I mean I – how do you guys keep up with the amount of kind of new stuff that keeps coming up, and I think as a physician there is about every week there’s a new medicine coming up, there’s a new immunotherapy agent coming up, a new indication for when to use it. How do you guys keep up? I mean I know we try a lot.

Speaker: A lot of reading and a lot of – yeah, and I honestly think again, it’s cream of the crop in this group. I really mean that. I think that you have to be willing to learn every day something new and, you know, you can never go by what you learned 10 years ago because it might have completely changed based on the medications that are out there, you know, and I think a lot of education, self-educating, educating the nurses. I think that’s a big role. Educating the patient supports.

And I think one of the things that I love about this practice, and I wish we could do it more often, but I know schedules are so tight, right, because we have a lot of patients, but I love when we do our, you know, our docs get together with the APPs and we do some education. Yeah, those are fun. But I think that’s really important is just staying on top of things.

Vaughn: Right. It’s a lot. I mean it’s a lot not only to manage the patients, but then new stuff comes up; of course, that’s something we always try to do is be advanced enough to provide the immediate sort of updated care to our patients, right? I know we have clinical trials here. We’re always kind of pushing down a little bit to say what’s the best thing for our patients in the community.

Speaker:  And I think we do a great job of that because I mean I think, you know, we’re in Fredericksburg. We’re not in New York City, we’re not in Boston, we’re not in Richmond, you know, we’re not in D.C., but I really do think we are always there and we always have, when something comes out that’s new, we’re on it, you know, and we get in the computer system fast enough and we get things moving and we have the availability to give our patients like top of the line updated thing quickly, you know.

Speaker:  And I think there’s a really good just culture of education, and I think we share it with one another. That’s one of the nice things too, physicians and APPs really, you know, with one another. So, I think that helps a lot and it’s not unusual for [inaudible 34:50] to say hey, did you see, you know, there’s new, you know, drugs or whatever, new gene mutation that was just found. You know and so that’s helpful.

Speaker: We all have different backgrounds too, so it’s like I did a lot of time in interventional radiology so, you know, I even had some of the doctors asking me like can you do this in IR, you know, and I’m like oh, yeah, you know, to have some of that knowledge or like patient comes in with a leaking G tube or something, so I can kind of like, you know, offset some of the gaps in other people’s knowledge and the same with like Linda. She has like a broad knowledge of pulmonary that I’m not great with.

Speaker:  I think my favorite cause I hadn’t been in the practice very long and I diagnosed a patient with aortic stenosis, like we were about to treat his lymphoma and I’m like, you know, this is a really bad murmur, like it’s pretty severe, and he went on to have a [inaudible 35:40] before he got treated. It was kind of fun.

Speaker: So, oftentimes I think we pride ourselves on the fact that a drug may be approved on a Tuesday and we may have a patient in the office on Friday getting that new drug. Our patients are huge proponents of that. They’re always very excited to try something new and from our standpoint it’s a huge learning curve. So, you know, before I do the chemotherapy education appointment I’m learning all about that new drug that likely has never been given in the office before.

We’re also educating the nurses and the other office staff of, you know, new things that have come out, what to look for as far as side effect profile, what to expect with the patient going forward, and I think it takes the whole team being on top of things and just continually learning. And that’s what makes it exciting and fun.

Vaughn: Well I do see you guys do; I mean you guys do play off each other very well, constantly helping each other out. I think that’s one of the things, and so like rewarding seeing, you know, and I’m sure just passing on information. And I guess I have to add sometimes I know, and you guys can speak more on this, but you know, sometimes if you’re busy maybe you guys can help each other out in the clinic. I know handing off in the hospital rotations can be tough if you’re rounding that afternoon, but it seems the camaraderie is so strong amongst you guys.

Speaker: I think the learning aspect of things, like constantly learning. I think that’s like really what appeals to all of us too. I mean we kind of like that’s a, you know, when I finished school, I was like I just don’t want to go somewhere and feel like bored, you know, and I think that’s what’s again intriguing about it too. It keeps us all sort of on our toes and constantly –

Speaker: Uh-huh.

Speaker: Cause we’re sort of on the front lines. I mean really, like when you start a new drug, you know, it may be the only patient in our practice that’s on that medication, but we’re going to be probably the first ones that see them with the first side effects.

Speaker: If we learn about the drug, teach the patient.

Speaker: Then when they ask me how many other patients do you have on this, and I say you’re the only one. But you know, sometimes it’s approved like two days before.

Speaker: And that goes back to the patients too cause they’re like oh okay, cool. They’re fine with that, you know. Sometimes you’re like well we’re going to be learning together and they’re like okay.

Speaker: And I think part of the reason that they think that is because there is a relationship and so they’re okay when you pull up the, you know, the latest information on that new drug and review it with them.

Speaker:  And they like it. They’ll say, you know, I’m the only one on this drug, you know, and they like kind of like that too.

Vaughn:  Well it’s true. I mean I think again it shows the rapport you guys and all of us have with our patients, how comfortable they are and willing to, you know, go on this journey with us, you know, as their provider, so it’s rewarding, and that’s – I think that’s what keeps me going every day is there’s something new out there and you’re never stagnant for sure.

Speaker: Never for sure.

Vaughn: And you got to keep learning which is exciting. Also, I think one of the things we try to, as we mentioned a little bit about hospital, cause your role is not only in the office; you guys do go to the hospital, so you get also it’s a different type of medicine sometimes in the hospital rounding, but it does allow patients are in the hospital, it allows sort of continuity when they’re discharged that you guys are able – and one of the things I really love is if a patient of ours is in the hospital we’re able to see them out of the hospital so quickly so they can kind of stay on schedule, you know, their medications can be reconciled cause, you know, things can definitely get out of whack, so I think there’s this kind of nice little checks and balances when patients are discharged.

Speaker:  And so, one of the nice things that we have here is the survey [inaudible 39:23] clinic which is kind of the unique thing that sets us apart I believe and essentially what it is is a nurse practitioner and we have right now two or three medical assistants, actually two medical assistants and one LPN, so a nurse if there. And we see essentially every patient that comes through that’s just for labs. We do a lot of blood work follow-ups for patients on treatment and patients that are just inactive follow-up, so if they’re just coming in for labs that day they come through surveillance. If they touch, you know, the MA touches them or the LPN and they say I’m having this issue or I have this concern, if it’s something that they can address then certainly they do and they’re really good at that.

But if it’s something they really feel like they need to see a provider for they have really good clinical judgment and, you know, they – they just take it and run with it and they’ll, you know, sort of – we have protocols in place for, you know, fever and for different things, and they’ll just kind of start that process and put them in a room and, you know, give me a little heads-up on what’s going on and I’m right there to see the patient. So, we do that for anyone coming in for labs. We do that for really for anybody that’s on active treatment that just even if they walk into the office, and we usually encourage them to try to talk to the nurses first just because if there’s any, like Danielle said, any testing that needs to be done beforehand we can sort of facilitate that, but certainly if they feel that they just need to walk in here and be seen, they can do that.

We also, you know, I’m also available for our patients that, along with Danielle, that are here for infusions that have issues, you know, prior to treatment or need to be seen urgently on the site, you know, whether they’re getting their treatment or any reactions or any other issues. It’s just really nice to have a provider available to see those patients because, you know, most of the time our physicians, you know, are pretty scheduled up and most of our nurse practitioners are and PAs so to have somebody just with the flexibility and the schedule to just see people, you know, on an as needed basis, and, you know, we see any number of people in a day.

Most days it’s like nine to 10 patients. Today it’s 16, you know, so it’s ramping up and it’s evolving, but we try not to turn anyone down if it’s something we can help them with, you know. We try to at least get the process started. So, if a patient’s on treatment and they have a concern, like I said, typically we have them, you know, call the nurses. We have a team set up. They should have that information. That’s given to them on the day of their, you know, teaching appointment and they have the direct extension to speak wit the nurses. Usually the nurses will sort of triage that stuff and try to get them in, but like I said, if they have a concern, if they’re, you know, feeling anything really.

Speaker: If they have, you know, if they have a new symptom of illness, they have a cough or they are nauseated or they’re, you know, having excessive diarrhea or they have a rash or any of those things, you know, we see on a daily basis. It’s basically anything.

Vaughn: Yeah, but what’s great is we have the labs right there. You can run the labs real quick. We can give IV antibiotics, so it really is – can be hopefully turned around pretty quickly in the office.

Speaker: We had a patient walk in once. Remember, she had a bruise on her leg, and it seemed so minor to us, it’s a bruise on her leg, but she was on chemotherapy and she was worried that her platelets were low so with the one bruise on her leg just panicked her, so she actually walked in here and we were able to see her and comfort her and get her labs back within eight minutes so that we told her her platelets were normal and she was going to be okay, and that for the patient is huge.

And I think a lot of it, one of the good, like best things about Surveillance is that some of these patients, they just sort of think everything is related to their chemo and a lot of them don’t sort of report some of their side effects and symptoms that they’re having and having them come through Surveillance for labs and having someone kind of assessing them, we’ve picked up a lot of those patients that were just literally just coming in for labs but they actually had something like major going on and the MAs and the nurses were able to pick that out and say like oh gosh, you know, like and they can be seen, whereas they wouldn’t have been seen before. They would just be at home thinking everything is related to their treatment and normal.

Vaughn: From when I started over again it’s been over 10 plus years since we’ve sort of integrated APPs into HOAF. I mean I think it’s been a steep upward climb, positive upward climb, of course. What do you think your roles are going to be in the future? What may grow?

Speaker: I think we’re going to continue to – I think our practice is going to continue to grow. I think, you know, we’re going to have a lot of new drugs on board, new different treatments that are not chemotherapy, per se, but you know, other modalities, if you will. So, I think we’re going to see that, and I think we’re going to continue to expand our role. I think for me personally, I plan on being here until I retire. I’d like to continue to see, you know, with the nursing staff cause part of my role, as you know, is to oversee infusion and our oral pharmacy and our IV medications as well.

So I see patients in clinic on Wednesdays and acute issues as well, but I also run the nursing team and the pharmacy, so I’d like to continue to see good education for all of our staff from the medical assistants, nursing, all the way up, you know, and continue, you know, our camaraderie and our culture of sharing and knowledge.

Speaker:  And I’d like to see us also I think we will be – my vision is that we’ll be able to integrate a palliative kind of, which I think we do a lot of that already but do even more of it cause I think there’s a lot of that that can be done even by the infusion nurses.

Speaker:  I’m ready with my paint brushes.

Vaughn: No, I agree. We’ve been – I’ve been kind of preaching that for awhile. It’s like kind of bringing these other aspects of therapeutics into the office cause I think the holistic approach is helpful to a lot of patients. I think art therapy, that’s awesome, I’m so excited, you know, music therapy, yoga. There’s a lot of things –

Speaker: Reiki therapy.

Vaughn: Yeah, so that’s why I think that is just going to help having that side of our therapeutics here at HOAF, but I agree, I think one of the things, at least when I look at it is, you know, as our sort of models are changing how we treat patients more in sort of targeted direction and immunotherapeutic direction, we have to be, you know, side effects, things are different now that we have to look for. And I think that’s always something that all of us are going to have to continue to stay abreast of is the new treatments, new side effects, how to maintain, you know, [inaudible 45:50].

Speaker: Especially the oral ones. I mean I think that remains a huge challenge, how to manage those and, you know, help the patients manage them and take them appropriately at home. That’s a huge role for an APP, I think.

Vaughn: Yeah, and maintaining I think, you know, you touched on it. I think sometimes you guys are sort of the liaison to kind of educating the nursing staff cause they’re on the front lines a lot. We like to know when – cause they – if they don’t understand a symptom or understand a problem, it may not come to our attention, so I think our nurses are unbelievable, but we can always continue to improve on education.

Speaker: Yeah, and I think we have to for the changes every day. I mean I think our email boxes are full by with just new things that are being approved or, you know, indication of change, so yeah, it’s important.

Vaughn: You know, you guys are awesome, and I speak for all the other doctors. I mean a patient today just asked when am I going to see Liz again. I feel like I’m already kicked aside so, you know what you guys have been able to provide for the care of our patients here and so I’m just thankful. Hopefully, we’re a template for other practices, you know, nationally that can bring in an APP and to show how well it can keep the continuity of care going and really provide a great quality of care. So, thank you guys.

Speaker:  Well thank you and we like working with you guys too.

Vaughn: Well thank you guys for joining me on the podcast today.

Speaker:  It’s our pleasure.

Speaker: Thanks for having us.

Thanks for listening to Cancer Shop Talk, Behind the Diagnosis. If you enjoyed our show and want to know more, check out HOAFredericks.com or leave us a review on iTunes. Join us next month when we go behind clinical trials and research at HOAF.