Do you currently have a mid-level provider?

Yes, we have two mid-level providers, they are both physician assistants.

How many years have you had a mid-level provider working within your practice?

We began to use mid-level providers in our practice about 10 years ago.

What circumstances made you consider adding a mid-level provider versus adding an additional physician provider?

In considering how to bring additional value to the practice, we needed more providers to help manage patients in our office.  We had a growing practice, and the in-office visits were increasing at a rate that was pushing out new patient visits beyond what we felt was acceptable.  We also wanted the providers that were managing patients here to have the same care philosophy as the other ENT partners. We felt like it was a real opportunity to expand our availably, reduce our wait times and patient frustration with getting access quickly and most importantly, we wanted to be able to train the mid-level providers ourselves.  Physician assistants aren’t usually specialized, so the opportunity to train them to our care model, align them with our guidelines & best practices and ultimately, position our provider team to be an extension of us as physicians.

In what capacity do you use your current mid-level providers?

Our physician assistants were hired with the intention for them to develop their own patient base and manage their own caseload. We wanted our patients to have greater access to our practice and to us as ENT providers.

Is there a selection criterion that you use when considering a mid-level provider in your practice?

There are many considerations when selecting any provider for your practice.  For us, we wanted someone that was eager and motivated to learn, open to additional training, and had a great work ethic. Being able to train “on the job” for a mid-level within the practice allows for molding the care delivery model to one that is consistent from one physician to the other when they are practicing with more than one physician.  It allows for standards to be established that are consistent to the office and patient need, not just to the interest of the physician partners. 

Are there any limitations to the types of patients that you direct toward your physician assistants?

How a mid-level provider is used within a practice can vary greatly based on the specialties of the training physicians as well as other medical providers on the care-team, for instance, audiology and speech pathology. In our case, our PA’s have built their own patient load with reoccurring patients while assisting with practice growth by taking on new ENT patients, just as a physician partner would be expected to manage their schedule.  We utilize our mid-level providers for most office-based procedures; however, we do put limits on some patient types, for example: airway obstructions and nose bleeds; but the limitations of each mid-level provider may vary based on their area of interests as well as experience, eye-hand coordination, and depth perception, as these are requirements when working in the ear, especially as microscope use is typically required.  

What type of on-boarding process and training do you use when introducing mid-level providers to the specialty of ear, nose and throat?

How training is approached is determined initially by the experience of the mid-level provider. We were fortunate the first PA we added at our location had been working in the ENT specialty for some time prior to joining our practice.  We were able to take the experience that she had from her prior employment and build on it.  We focused more our assuring she was comfortable with the fundaments and then moved toward the care philosophy we have established for our practice. Our second PA came aboard without any experience in ENT.  However, she had great familiarity with us as a practice, as she had worked on the administrative side of our practice as she was working on her PA degree.  This gave us great comfort in hiring, as we already knew her, loved her work ethic and knew she would be open to our training and practice care philosophies.  She was already a great fit with our team and our patients.   

Is there a difference in microscope training skills for a mid-level provider versus an ENT resident?

As medical residents, most of your learning begins in the cadaver lab as well as working with patients in surgery.  This is very different than the physician assistant that learns these skills on alive, alert patients. It takes practice to work under a microscope, but with a planned approach, “see one, do one, teach one” allows for direct and ongoing oversight until the mid-level provider has mastered the microscope.

How do you feel the mid-level provider brings value to your practice?

Adding mid-level providers to our practice allowed us to provide more comprehensive care and follow-up with our patients. Our patients often recommend our PAs as a primary provider to friends and family. This speaks to the quality of care our mid-level providers give to our patients.

When considering the different patient types and procedures that a PA can manage in your office, what do you consider in the training process as it relates to liability?

Just as physicians, mid-level providers may have skills that align with different types of procedures and treatments within the office.  There are some limits we set for treating patients initially, airway obstructions and nose bleeds to mention a couple examples.  Deciding how a PA will be used in a physician practice is determined by the skills of the provider, as well as the comfort of the physician that is supervising. They do ultimately work as a team.

While excellent clinicians will always be in high demand, the definition of excellent is expanding far beyond having top-notch, specialty-based capabilities.   Most young healthcare providers have the technical knowledge and quickly develop the clinical skills they need for their role; however, many even more experienced professionals continue to need training when it comes to complex problem solving, teamwork, conflict management, business understanding, communication and leadership, known as behavioral or soft skills. These skills are harder to acquire and are learned through life and work experience versus a textbook. 

All medical providers deal with many challenges every day.  The real-life situations involve trying to adapt to constant change, prioritizing our time, learning to listen & collaborate in a team and understanding how to communicate our ideas, findings, and recommendations in a compelling way. However, most of us were never truly taught how to properly go about handling these situations. Even in other professions, roles that require high social skills like sales, leadership, project management, and marketing have seen an increased focus on the importance of heightened behavioral skills.  In 2020, healthcare providers managed changes from the in-person, traditional care model to more non-traditional professional and patient care environments, like telemedicine and remote practice. During this time, they discovered or were reminded just how important the ability to empathize, actively listen, communicate and collaborate is to the success of the patient. A basic lesson: it is never too late to work on your communication skills.

Numerous research studies have shown that no matter how knowledgeable a provider might be, if they are not able to open communication channels with other medical colleagues, their teams and patients, they may be of no help to anyone.  A patient’s perception of the quality of the care they receive is highly dependent on the quality of the interaction with their healthcare provider.  Yet, communication training for physicians and other providers historically has received far less attention in training and mentorship programs. 

Here are six reasons why communication skills really matter for providers.

• The history-taking aspect of a patient interview is critical to diagnostic decisions. When multiple providers are involved in the same patient visit, the opportunity for incomplete data and interruptions is higher, which can compromise the information.
• A patient’s adherence to recommendations is directly impacted by effective patient-provider communication.  There are examples of this in every medical specialty; motivational interviewing was grown out of this basic concern. 
• Patient satisfaction is impacted by realistic expectations, having the opportunity to express their ideas & concerns, the length of their appointment, the provider team in which they have interacted with and their perception of continuity of care among many others.  Communication lives at the core of each of these elements. 
• Patient Safety requires that all the members of a health care team communicate effectively, or medical errors increase, and patient care often suffers.
• The leading cause of most malpractice claims is a breakdown in communication. CRICO Strategies reviewed 23,000 medical malpractice lawsuits filed between 2009 and 2013.  Communication failures were a contributing factor in over 30% of those cases.
• Overall healthcare team satisfaction is impacted when providers do not feel supported, valued, and listened to in the work environment.  The quality of communication breaks down further when working relationships are not maintained.  There is a direct relationship between the provider’s satisfaction and their ability to build rapport with their patients.

There are strong relationships between a provider’s communication skills and a patient’s capacity to follow through with medical recommendations. The clinician’s ability to listen and empathize can have a significant impact on patient outcomes and satisfaction. Further, communication among providers & their teams influence working relationships, job satisfaction and can easily impact patient safety. Keep in mind, just like technical training and book knowledge, softer skills, like communication, can be improved upon through practice.

By: Patricia Ramos, AuD

Working in ear, nose and throat (ENT) involves interfacing with many providers; physicians, mid-level providers like physician assistants (PAs) and nurse practitioners (ARNPs), speech pathologists, and physical therapists to mention a few.  These providers make a tremendous impact on the practice, opening appointment options, improving triage and expanding the overall capacity to deliver care.  PAs and ARNPs are a welcomed addition into the provider team and the patient care partnership, particularly when it comes to audiology. 

If you have been to a physician lately, you know that many specialties are using mid-level providers, both as primary providers, as well as collaborative partners with the physician.  As an audiologist, the mid-level provider can be an incredible partner in the hearing health care journey.  On a day-to-day basis, we support many aspects of the ENT specialty, often simply because when there is more than one physician, there is more than one professional interest.  Many ENTs manage a general practice, seeing patients with symptoms that span the general specialty, however, similar to audiology, most still have a favorite area; allergy, sleep, rhinology, cosmetics, otology and head and neck surgery, to mention a few. 

The mid-level provider may have an area that they are more interested in as well, but what many will tell you is they are typically trained as generalists.  If they choose to go into a specialty area, the more narrow, focused training and experience happens on the job. Audiologists have a unique opportunity to work with mid-level providers, and as you’ll learn from our PA interviews this month, learning the ENT and audiology specialty requires commitment; not just the procedures that need to be mastered, both in the office and sometimes even in the OR, but hearing science, audiology and hearing rehabilitation are areas where their knowledge also mostly is honed by one the job experience and through their partnerships with their audiology providers. In our interviews, both providers pointed out how important the relationship between providers is to the overall care of the patient.  They also discussed the need for on-going education within the specialty, and especially around audiology diagnostics, surgical and non-surgical interventions for the treatment of hearing loss, tinnitus and dizziness. 

We developed a mid-level provider audiology training program to introduce our PA and APRN providers to a deeper understanding of the audiology specialty. We’ve found that our audiologists also benefit greatly from understanding the physician assistant approach to the patient.  The heightened communication and overall collaboration to care improves the patient experience, practice efficiencies and our patient outcomes.   Another benefit the audiology team has noticed is that our mid-level providers tend to have more time to spend with a patient during their visit and are often more easily able to work patients into their schedules on short notice.  This improves our ability to manage a patient’s needs within one appointment.  We find that working closely with our PAs and APRNs really aligns our counseling messages, and the few extra minutes they spend enables them to help reinforce audiological recommendations.

Understanding how providers have been trained, working together to expand each other’s knowledge and really focusing on how to manage the patient as they are passed from one provider to another and back to another again is good work that is well worth the effort between healthcare professionals.  One of the most important things that can be done in an environment where many providers are involved is to get to know each other a little better, focus on expanding our on-the-job training all with the hope that it improves the providers, the overall patient journey and ultimately, creates the best outcome for our patients. 

Check out the infographic from the American Academy of PAs to learn more!