SCCMPod-548: Advancing APP Careers: Models for Growth

Dr. Madden: So, hello and welcome to the Society of Critical Care Medicine podcast. I'm your host Maureen Madden. Today, I'm joined by Christopher Newman and Victoria Howard to discuss professional advancement tracks for advanced practice providers.

We'll talk about different models and how they've adapted and grown to support APP career development. Christopher Newman, physician assistant, practices in the PICU at Children's Hospital Colorado in Denver, Colorado, and is an associate professor and vice chair for clinical performance for the Department of Pediatrics at the University of Colorado School of Medicine. He helped develop the professional advancement model for his healthcare system.

Victoria Howard is also a physician assistant and is the lead APP in the division of gastroenterology and hepatology at the University of Rochester in Rochester, New York, and a clinical instructor for the Rochester Institute of Technology's PA program. She helped develop the professional advancement model for the University of Rochester Medical Center. Welcome.

Before we start, do you have any disclosures to report?

Christopher Newman: No.

Victoria Howard: No.

Dr. Madden: Okay, well, welcome. It really is my pleasure to have you both here today. APP's professional advancement tracks are a newer development in that there are several models that currently exist.

Part of what we wanted to discuss is why have these come into being, and I do know that some of it is really looking at professional advancement tracks could help with APP turnover and retention. What I'd like to do is start with you, Chris, if that's okay, and give a brief overview of the setup and the model of your APP professional advancement track.

Christopher Newman: Sure. Thanks, Maureen. Just a little bit of background because I think it's important to understand where we started.

Within the Department of Pediatrics, APPs are hired in as instructor faculty, and instructors are predominantly supposed to focus on clinical effort as opposed to our traditional promotion track faculty that are supposed to be that classic triple threat of clinical, teaching, and scholarly activity. But many of the APPs who choose to work at the School of Medicine chose it at least in part because they wanted to be part of academic medicine in some way. Our challenge was really, what do you do to recognize the non-clinical contributions of predominantly clinical faculty, and how do we give them both recognition, visibility, and support to continue their work?

The model that we developed, which we call the Instructor Recognition Program, identified that there are really three tracks that our APPs are working in, what we call clinical practice development, or teaching, or research. What we found is that while many of them are working in one of those areas in addition to their clinical responsibilities, very few of them are working across all three. We really built a system where you could receive recognition just within one of those three domains.

Because we wanted this to be more of a career-long aspirational work, we created two levels. You are either recognized as an expert or a senior expert. Our expert criteria tend to focus on active contribution to a project or a system, and our senior expert tends to focus on leading a project or change the system.

That's the basics of it. We don't adjust salary based on that. Salary is really based on your clinical role, but we do offer unrestricted CME funds that go along with some recognition that we hope will help them generate additional sources.

Dr. Madden: Okay. I have some questions just to clarify for my own knowledge, and I'm sure for the listeners.

Two elements, as people are coming into academics, as you said, and they're hired at the instructor level, does this mean, my understanding you correctly, that they don't have the opportunity to advance on the academic ladder?

Christopher Newman: Yeah. Obviously, since I'm an associate professor and began as an instructor, there is a mechanism. What happens is if you can demonstrate that you are doing significant work in all three areas and have a reasonable chance of promoting through to professor eventually, and you have support of your section, you can reclassify to an assistant professor and then begin that series, and then you're held to the same standards as any other assistant or associate or full professor.

The vast majority of APPs in our system are not working in those three domains at the level that would support promotion, but this is not a barrier. In fact, part of why we developed this program was to help coach and socialize what's required to move through promotion. All of our stuff mirrors what they would need to go through if they chose to go through promotion.

We've actually had two people through this program highlight to their section head that maybe they should be in that system and have moved over.

Dr. Madden: Okay. Excellent. That brings up another question.

How long has this program been in place?

Christopher Newman: This is year three of our pilot. We have had two complete recognition cycles and we are in the middle of our third.

Dr. Madden: Okay. Excellent. One of the other questions that originally brought up when you said unrestricted CME funds, does that mean unlimited funds?

Christopher Newman: Sure. We did not know this when we designed the program, but due to financial circumstances, the CME funds offered to our faculty broadly have been reduced, which can make it challenging to go to a conference, which can make it challenging to some of the other things you would need to do to continue the work you're being recognized for. This literally just adds a pool of money to your CME budget that you can then spend in any way that you think supports your work.

Some people have spent it to go to a conference. Others have spent it to purchase time with a biostatistician or to take a course in item writing or grant writing or things like that. It's designed so that they can say, this is what I'm going to use this money to help me get better at the work that I'm being recognized for.

Dr. Madden: Thank you for that clarification. Is this an annual type of fund that they access or is it a one-time fund? How does it work?

Christopher Newman: It's a one-time fund.

Dr. Madden: Okay. All right. So, Vicki, as we said, we know that there are different models that exist.

I'd love to hear about the model you helped develop and if you can really tell us a little bit how it differs from what Chris has put into place or how it's similar.

Victoria Howard: Sure. So, we also are sort of rebranding that what I helped to develop was a relaunched system. We had a system through our Institute of Advanced Practice Providers for many years, which has been very obtuse and kind of difficult to work through.

So, I went through it myself back in 2019 and it was very difficult in addition to clinical duties to try to get the time to figure out how to go through this. So, we were looking back at some numbers and as far as we can tell, we have someone who advanced back in 2006 with the old system. With that system, you were either baseline or level two.

For PAs and for nurse practitioners, it was level six. So, the NP and PA process was different, which was one problem that we wanted to address when we redeveloped this. And it was also not clear who to go through, how to determine steps to advance.

Not everyone was aware of the system. So, in that 2006 until 2023, it looks like about 51 people advanced, which is about three per year. And in our system, we have about 1,200 APPs.

So, that's not, you know, great awareness of this program or great access to it. So, as we started this pilot that actually began in April of 2024, what we looked at was how some other places were doing it, what we could change and how we could adapt this to our current system. So, what we came up with and what we've been using since April is now a two-tiered system.

So, that's similar to what Chris was talking about, so that we do have some capabilities to recognize earlier career APPs that we found were leaving our system because they were past their orientation, they were really contributing at higher levels, but there was no way for them to be promoted or advanced at that earlier stage. So, that level is for APPs who are three to five years in their practice. And then we have a level two, which is for those five years and more clinical experience.

And it really acknowledges an APP's total career. So, if someone was not in our system when they started, but they are now, if there have been in different roles, it's really a picture of their whole professional life and all the contributions they've done over time. It does not have to be something that is a current project they're working on.

It is, as Chris mentioned, we look at more projects and project-based. So, there are activities, a certain number of activities in six different domains that range from clinical education and scholarship, clinical practice, also citizenship and wellness, research, leadership, and professionalism. And so, within those domains, they do have to have met some criteria in all of those domains, but we wanted to find a way to recognize people who are doing all of this work that was non-clinical in addition to their clinical excellence.

And the categories are broad and the activities within each category that APPs have to check off are also very broad because we have people in many different settings. So, we wanted to make it accessible to everyone. So, I may check something off under clinical practice regarding workflow improvements, and it might be something totally different for an APP that's working at a different setting.

So, part of the process is going through with APPs as they're working through this and going over their checklist with them to make sure that everything meets criteria. At the end of this process, our APPs give a presentation. So, they give a PowerPoint presentation to their peers that they have chosen, also APPs that are currently going through the advancement process, and those that have recently gone through, and then to our SOVI Institute of APPs, some leadership there.

And so, once that presentation is done, we have a rubric, and if they pass, then they do advance to the next level. That advancement does come with the title, but also compensation. So, there's a raise involved in it.

Dr. Madden: Okay, excellent. I, again, have some questions. I find it fascinating that people are coming at this in different methods and manners, and clearly because we all practice in different environments, I can appreciate that.

Just to understand, as Chris said, this is coming from the academic side. Is yours as well coming from the academic side, or is it within the hospital or healthcare system?

Victoria Howard: Yeah, so it's the entire healthcare system. So, even though we're an academic institution, not everyone has to be involved in teaching or education outside of their clinical time. So, there is a domain within this for clinical education and scholarship, but it does not have to be involvement with, let's say, there is a nurse practitioner program involved in our School of Nursing at U of R, but we do not have a PA program.

So, the education piece of it can be through different programs. It can be through educating students that come through our system. It doesn't have to be a formal education or teaching role.

Dr. Madden: Okay, but to further clarify it, different people are hired by different entities. So, I come being hired by a School of Medicine, but yet my clinical practice clearly is in the healthcare system, which is a different entity. Is that, that's what I was trying to get at?

Victoria Howard: So, in our system, the University of Rochester umbrella, there's the medical center and then there's the university, but all of the APPs hired through our system are actually hired through the Sovie Institute of Advanced Practice Providers. So, even though I work in GI, I was hired by the Sovie Institute. So, everyone that is under that umbrella of the Sovie Institute, this applies to them no matter what their role is.

Dr. Madden: Okay, thank you for that.

So, when did you take on this responsibility?

Victoria Howard: Probably about a year before we started this pilot. So, early 2023 or late 2022, the lead APP in the Sovie Institute, the chief officer there, approached myself and a nurse practitioner and asked us if we would be willing to work on this. And the reasoning was, is that there has been feedback throughout many different sources, including exit interviews, yearly evaluations, many, many sources where people have been polled or taken surveys, the APP group, where it was brought up that the recognition system or advancement was either unknown to people or was really difficult for them to try to access.

And it's always deemed when we do surveys as one of the top two things, usually it's better market pay as number one and then advancement options as number two. So, people had a huge interest in seeing this updated. And so, with the Sovie Institute hearing all that feedback, they approached several of us, I think because we're leads in our divisions, to work on this.

And so, we set out based on a literature review that was provided to us to see what was going on in other places and then update our current system based on that. And we went through a whole process of doing some research, talking to people in other programs and what they do, collecting some focus group information from both nurse practitioners and PAs, and then using that to outline what we thought would be a good update to the program. And then we reviewed it with our leadership in the Advanced Practice Institute before then discussing it with some of the APP managers and leads and then rolling out the pilot.

Dr. Madden: Okay, excellent. Chris, can you describe how you became involved in this process?

Christopher Newman: So, while I'm no longer involved in APP leadership, I was earlier in my career and was the designated APP leader for the department. And in doing my original project, which was looking at APP clinical expectations, we interviewed over 100 APPs in our system and identified that a lot of APPs were doing this work even with no hope of recognition or advancement. We kept coming across people who were doing meaningful work.

So, in my position, I began thinking about, well, how could we recognize that? At the same time, our department had an initiative to look for ways broadly to recognize our faculty. So, I was paired with one of our business managers and the section head for rheumatology for the three of us to develop a way to recognize our instructor faculty.

And so, this was mostly my crazy ideas with two rational people helping me make it more realistic and sustainable. And we're really fortunate. We had a group of highly motivated instructors become volunteer committee members, and they've really done the bulk of the work.

And we brought on a co-chair this past year, and I'm sort of excited that next year, I will actually step away from this process and it'll become a self-sustaining process without my involvement, which I think is, for me, at least, very exciting to see that this has become something that the individuals involved want to support.

Dr. Madden: Absolutely. And when you have put so much time and energy into a process and you see it become sustainable and that you can walk away from it, certainly, you've got to have a feeling of pride and a sense of accomplishment. So, congratulations on that.

However, when you talk about some of these things, it's interesting to me, being an APP, as you both are, and we know, as you said, that you had all of these individuals already doing these different elements that you've now put a category or a title to. And we did it because the people who were doing this recognized that this was their career. This wasn't necessarily a job that they were taking on.

But yet, some of the things, and particularly, Vicki, you spoke about, you know, the wellness and when you look at the literature that came out of Ohio State University in regards to the program that they developed, that they were putting into this process recognition as a mandatory piece. And I don't know that you had stated it was mandatory, but community service wellness, doing things that were well outside their job description and that they were not being compensated for, either by financial compensation or time. So, I'd love to hear your comment on that, Vicki.

Victoria Howard: Yeah. So, you're correct. It is one of our domains.

So, citizenship and wellness can be something that they do within their role. Like, for example, some of our APPs will set social gatherings up with their APP groups or their staff. Some will do non-work-related volunteerism in their communities.

We have people who are, let's say, Girl Scout or Boy Scout leaders, or they work with youth sports, or they volunteer for a firehouse in their community. It can be patient advocacy. It can be many different things.

But we really felt that this is a voluntary program in terms of advancement. Not everybody that just meets the criteria of how many years they have been in APP will meet this criteria or want to apply or go through this process. But we do feel that the people that are doing it, for the most part, since we're very new and this is a new program, the people that have been doing this have already done all of these things.

And it's a matter of me helping them to compile it, see where things fit within the domains, and really just tell their story of their professional life and all that they've been contributing. These are very high-contributing APPs, and they do it because they've always done it, because there was a need, and they felt they wanted to fill it, and because it's of other professional goals, but overwhelmingly are happy to have some recognition for all of that. They would have done it anyways, but it's nice to shine a light on it and have people recognize them for it.

But we did feel that it is an important part of being a high-contributing member of our institution to have some focus on wellness and outreach. And so there are many ways they can do that, but it is something that everyone applying for this has to do.

Dr. Madden: I applaud both of you and your organizations that you have the insight and the forethought to think about this group of providers and how you can recognize them, but I'm sure that there were some barriers that you experienced while creating and implementing it. Could you describe some of those, Chris?

Christopher Newman: Sure. So I'll just start with the biggest one, which I don't think is unique to APPs, but really concerns anyone who works in a school of medicine but has a predominantly clinical role. Maureen, as you know, the engine of the revenue of the school of medicine is clinical practice.

Clinical practice drives the school, but prestige and reputation is tied almost exclusively to research. And so it can be really tricky for anyone with a predominantly clinical role to feel valued and recognized within a school if they are not actively engaged in high-level research. And I think that was a barrier for this program too, explaining how are we going to recognize clinically active faculty without further diminishing the value of that same clinical care?

How do we make sure that if you just want to show up and see patients and give excellent clinical care, that we really value you and you don't have to do any of these other things and we still really value you? So I think the messaging of trying to not further diminish the clinical role was really important to us. And then the other big challenge for us is we had to work within an existing system.

How do we differentiate ourselves from academic promotion without becoming a barrier to academic promotion for the people for whom it's appropriate, without blurring the lines between these two programs? I was fortunate that our academic affairs and faculty affairs teams were very involved in helping us differentiate and very supportive of the project. I'll be honest, if they had said, no, we think this infringes on our domain, we would have been dead in the water.

So I'm incredibly appreciative that they were really invested in helping us make this a separate thing that they saw value in.

Dr. Madden: Excellent. So that brings up another question that I have, that what were the resources needed to facilitate this? As you said, you were given the opportunity and told, yes, please look at this, but it's not just the personnel and your time, which they clearly carved out to allow you to work on this.

But also, Vicki, you said that they get a salary increase. And Chris, you talked about unrestricted CME funds, like that too. They put financial resources in this.

And I don't know if you could describe, was there a thought process about how they budgeted for this or how well received they anticipated this might be? So Vicki, if you would comment.

Victoria Howard: Yeah. So actually that's one of our huge barriers still. We had already a job code for level two.

So for someone going from baseline to level two, that was already approved and hammered out. And the kind of percentages of what it would be based on base pay, all goes through our SOVI Institute for Advanced Practice Providers. And so, although that sometimes is a haggling point where it was, we were trying to figure out, is that still fair?

Is there a way to change it? It's largely out of our control, but the chief APP officer is a huge advocate for this and trying to help make sure the institution is aware of how important this really is to help retain our APPs, especially our experienced APPs that are high contributors. So that piece was set.

The problem is we are still kind of haggling with HR about the level one promotion. So while we had the power to say, this is what we envision, and this is what we're going to make our professional advancement system look like, and we're going to have two levels, the tier one or the level one is still awaiting approval. And so we have several APPs who have met that criteria, have a presentation ready, and are waiting to present just for this approval, which could come in a week or a month or two months. 

So I think for us, that being out of our hands is difficult and not atypical in a large institution like this to be the kind of hang up of progress for this type of thing. Our institute recognizes that this is a big sticking point. And so I know that our chief officer is following up on this very regularly and we get regular updates, but we're just awaiting that approval.

So the biggest thing that we need to get over in terms of hurdles to move on to the next portion, we're still piloting this program and we will be probably for the next year, year and a half, and we'll continue to make adjustments, but that we need that to go through in order for our vision of this process to be able to take shape.

Dr. Madden: Yeah. And that's a rate limiting factor. And clearly, as you said, not within your ability to structure it or to approve it.

So you're kind of waiting. As I had referred earlier, the Ohio State University Wexner Medical Center and Comprehensive Cancer Center published their implementation of a professional advancement model at an academic medical center in 2020. And they talked about pretty significant financial structure associated with what they had received for their successful candidates.

They awarded a bonus at the end of the year. And what was surprising to me, it required an annual resubmission to maintain or advance within that model. Chris, how does that work within your institution?

Christopher Newman: Yeah. So first of all, I will acknowledge that this is a financial cost. We have a budget.

We had to get that budget approved. We are a public school of medicine in a state with 46th out of 50 Medicaid reimbursement. We are not a wealthy institution.

That was probably the hardest part of the project. It's why I was so fortunate to be paired with a really talented business manager who could help us craft the business case for why we were doing this. But we have thought about what does it look like long-term.

And because our program is relatively new, we haven't encountered that yet. But our plan is that eventually there will be an opportunity to re-up, if you will, in a three to five-year timeline. We're not going to look at this annually.

I think it's a very intensive process to ask people to do that annually would be more detrimental. But we are looking at once you become a senior expert, if you continue that work, how can we continue to recognize your ongoing expertise? We just have a couple of years to play with that because the first wave of people are within the first three years.

Dr. Madden: Okay. Since both of you are really on the forefront and re-looking at this process and envisioning it, you're both in pilot stages. What are some of the lessons that you've learned as you've been implementing these different models?

And would you do anything different today versus, and well, Vicki, your institution already has re-looked at it a little bit, but you personally, Vicki, you do something already different than how you structured it. So I'd ask you to go first, Vicki.

Victoria Howard: Sure. So we have plans longer-term to have a committee that helps the candidates with mentorship and review because each candidate typically, there's a lot of back and forth through the process regarding their paperwork, their criteria. They have to upload supporting documents, sort of showing what the projects they've worked on and that they, what they're counting as in this rubric.

It's a lot of work and currently it's just me doing it. So it's a little bit rate limiting in that I can only do so much. Sometimes my expertise doesn't match with what, let's say, a candidate needs.

If they need more research, that's not a huge area for me. I think if I went back and did it, we always had in our plan to establish as a second step this committee, but I think it would have been helpful to start that process a little bit sooner to get more people involved and also just make it so that we can do a little bit more work.

Dr. Madden: Okay. So Chris, your viewpoint, some of the lessons you've learned and said like next year, you're going to step away from it, but is there anything different you would have done?

Christopher Newman: Yeah, absolutely. So one lesson that we learned was this is a lot of work for the committee and so we needed a way to refresh the committee. We've been very fortunate that the people who initially volunteered have, for the most part, continued.

But one thing we discovered is we actually now invite every recognized person. We send them an invitation to join the committee or an invitation to review an applicant for next year, and we've had several of them join. So making it refreshed and growing, I think, turned out to be more critical than I would have thought because this year we had an explosion of applicants and without those additional members, I'm not sure we would have been able to evaluate them in a timely manner.

And then the second thing I learned, and our track is not exclusive to APPs. It's for all instructors. We've had some genetic counselors and we've had a social worker, but it is mostly APPs.

And one of the things we learned is that APPs tend to undervalue their work. I come from a background of billing and finance, and they tend to undervalue their work literally in the bills that they submit. But that also turned out to be something here.

We would put out a call for applications and get radio silence. But when we started reaching out to section heads to previously recognized individuals and built a way that they could nominate someone, it changed things dramatically. That what most of the people who have gone through the program needed is someone else to tell them, I think you should do this.

And then that was really all they needed. Then they submitted everything. So the other lesson I learned that I would definitely implement earlier is provide a way for someone else to encourage this individual to apply.

Dr. Madden: That's great advice. And it's great recognition on your part. When we talk about your own professional development and your career development, oftentimes the individual has to be self-motivated.

And as you said, we undersell or feel have the imposter syndrome I've talked about on a different day. So I love that you have both been a part of this process and are leading in your institutions, this recognition for APPs. I have to say the time's gone quickly and we're out of time.

So before we conclude, I just wanted to know if there's anything else that either one of you would like to say before we have to close out this session.

Christopher Newman: Yeah, I think the last thing I would say, it's not just about retention and recruitment. When I became a PA, it was mid-career. It was a second career.

I just had to sort of survive for maybe 20 more years. But we're getting people joining our profession in their early 20s who are going to spend 40 years doing this. We've got to find a way for them to grow in their career over those 40 years because I think that that's what happens.

They get stagnant. And so I really hope what these programs can offer in the future is a way to think about your career linearly and to always have something to be striving for. I think that that would make these much more satisfying careers for these people who are going to have to do it for a lot longer than me.

Dr. Madden: True. Vicki, any thoughts?

Victoria Howard: Yeah, I completely agree with what Chris just said. I think a lot of us are very self-motivated people, but we're going to be doing these things and maybe change paths even within our career. And I think a lot of this has to be to help people with their professional motivation, their satisfaction, and their professional growth over the years.

For me, this has just been an extremely enjoyable and humbling experience to get to know what a lot of people in my institution are doing and see the great work of my fellow ABPs. We are very siloed. I don't see a lot of people outside of GI and what they're doing.

And so I know what my group is doing, but then to meet with someone from hospital medicine or nephrology or cancer center and see all the amazing things that they are doing, programs they're starting, things they're offering our patients and ways they're helping the community has just been really enjoyable for me. And so even though it is a lot of extra work, I don't mind doing it because it really is great exposure. And it is motivating for me as well to just see what our group is doing and try to make it so that we're all able to advance for those new APPs that are starting, giving them more opportunities as the years go on.

Dr. Madden: I want to thank both of you for your work and your recognition of your colleagues and putting something in place to formally acknowledge their work and all that they contribute. So thank you for that.

And this concludes another episode of the Society of Critical Care Medicine podcast. If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine podcast, I'm Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC, AC, CCRN, FCCM, is a Professor of Pediatrics at Rutgers Robert Wood Johnson Medical School and a Pediatric Critical Care Nurse Practitioner in the Pediatric Intensive Care Unit at Bristol-Myers Squibb Children's Hospital in New Brunswick, New Jersey.

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