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You Must Be Present to Win

December 6, 2021

December 2021

Sandy Kurtin, PhD, ANP-C, AOCN
Hematology/Oncology Nurse Practitioner at the University of Arizona Cancer Center and an Assistant Professor of Clinical Medicine and Adjunct Clinical Assistant Professor of Nursing at the University of Arizona

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Building AP Presence in Collaborative Groups, Professional Organizations, and the Workplace

 

Maintaining visibility in collaborative groups, professional organizations, and the workplace is crucial for advanced practitioners (APs). ASH Clinical News Associate Editor Sandy Kurtin, ANP-C, PhD, AOCN, invited Amy Pierre, RN, MSN, ANP-BC, and R. Donald Harvey, PharmD, BCOP, FCCP, FHOPA, to speak about their experiences. Ms. Pierre is a clinical director in the Research Oncology Division at Flatiron Health, a cancer technology company. Dr. Harvey is director of the Phase I Clinical Trials Unit and medical director of the Clinical Trials Office at the Winship Cancer Institute and professor at Emory University School of Medicine.

 


Dr. Kurtin: As APs, we interact within our institution in several ways – participating in research, offering input on programmatic strategies and transforming practice to integrate best practices. Becoming a leader in this way requires visibility and involvement, but people need to know who we are and why our work is important. To start, can you both talk about your roles at your respective institutions?

Ms. Pierre: At Flatiron, I provide clinical and research leadership both within and outside the company, ensuring quality and translating real-world data insights into better outcomes for our patients. This includes offering input on how data sets are developed and used, critically thinking about scientific problem sets and their interpretation and working collaboratively to move real-world evidence forward. In addition to my role at Flatiron, I maintain a clinical appointment at Memorial Sloan Kettering Cancer Center as an oncology nurse practitioner, where I see outpatients in the myeloma and lymphoma division.

Dr. Harvey: At the Emory University School of Medicine, as a faculty member, I guess you could say I’m a pharmacist in a physician’s world. We work to advance the care of cancer patients through clinical trial research every day. For research purposes, I’m a pharmacologist/pharmacist, and we see patients at our Phase I Clinical Trials Unit at the Winship Cancer Institute daily.

Dr. Kurtin: Amy, do you feel that integrating APs into practice is a priority at your institution?

Ms. Pierre: I would say APs are valued for our expertise in patient care and are represented throughout the organization in leadership. We have our own reporting structure and operate as a separate entity from nursing and medicine. We have several AP-run clinics, including a high-risk breast cancer clinic, survivorship clinics, and symptom care clinics. APs serve on councils and participate in AP grand rounds, newsletters, a journal club, mentorship programs, and a clinical ladder that’s currently in development. In addition, we have AP merit-based financial awards and an AP conference.

At Flatiron, APs are most certainly a priority. In the research organization where I reside, APs work right alongside our medical directors and non-clinical staff, including software engineers, product managers, and quantitative scientists. Most importantly, we have our own crucial roles and responsibilities that complement the work of our fellow medical directors. For example, I have clinical expertise in hematology/oncology. Another medical director has expertise in gastrointestinal oncology. Another AP has experience in breast medical oncology. Another medical director has expertise in radiation oncology. We all bring our own unique visions to the research organization, all of which are valued.

Dr. Kurtin: Don, can you talk about how your role evolved and was fostered at Emory?

Dr. Harvey: At Emory, like other institutions, physicians have historically been the team leaders in cancer. Over the years, many of our physician colleagues have recognized the value that each of our disciplines brings to the team. For me, that evolved from a working relationship with physician Fadlo R. Khuri, MD, when I moved to Atlanta. At that time, I was at Grady Memorial Hospital and he was here at Emory. Dr. Khuri had trained at MD Anderson Cancer Center, where pharmacists have had a long history of working directly in patient care alongside physicians. We developed a tight relationship in patient care at Grady. When he began creating a phase I program here at Emory, he reached out to me and said, “I think you can do this.”

While I realized that I didn’t have the formal training to do it, I jumped in anyway. There’s mentorship and then there’s sponsorship. Mentorship is helping someone else to open doors. Sponsorship sometimes means knocking those doors down and pushing the person through the doorway. Dr. Khuri basically paved the way for me to come in as a non-physician leading a research program and growing a clinical trials program. I’ve been fortunate to have little pushback in my efforts to build and expand our clinical trials footprint within Emory. For us, it has been a team approach across the board.

The first hire I made here was an AP. Since then, we have both evolved in our roles. We eat, drink, and breathe clinical trials work. Our physician colleagues have multiple responsibilities beyond their trial work, clinics, inpatient service, etc. – so our expertise and focus are critical. As APs we bring different, unique perspectives to the table. These days, I think this information and role are clearly needed, particularly for pharmacists, because there are so many new agents out there.

I believe the future of cancer care depends upon integration of APs across the board. We have fewer physicians coming out of residencies and going into hematology/oncology. Patients are living longer thanks to better therapeutics. Physicians alone can’t bridge that gap – everyone needs to get involved.

Dr. Kurtin: It’s such a dynamic process. The landscape has changed entirely in the 37 years I have been practicing. Thinking back to my early career in myeloma, we were lucky to have people live a year or two at most with melphalan and dexamethasone. Now, the trade-off of having so many available options is that patients can get to their 14th or 15th line of therapy, these patients are very complex and require not only interdisciplinary collaboration, but continuity. APs are critical for continuity of care.

Don, how did you create or build your presence in the cooperative groups at your organization?

Dr. Harvey: My good friend at Johns Hopkins and I elbowed our way into some areas, and have been welcomed in others, as we try to demonstrate the value of pharmacists in thinking about trial design, execution, and conduct. I was mentored and sponsored by Suresh S. Ramalingam, MD, FACP, FASCO, executive director at the Winship Cancer Institute.

Within the phase I program, we work with a couple of entities at the National Cancer Institute (NCI), such as the Organ Dysfunction Working Group and the Experimental Therapeutics Clinical Trial Network (ETCTN). One of my favorite things to see lately has been the evolution of the NCI and specifically the Cancer Therapy Evaluation Program (CTEP) and their decision to allow APs to order study agents. This is a big step for the NCI, which is historically a very physician-focused institution.

Dr. Kurtin: It’s a great deal of responsibility, but it is a huge step. We want more patients on clinical trials, which necessitates a more integrated, efficient process with more clinicians to absorb and facilitate all that complex but critical work.

Dr. Harvey: That’s right. It’s the only way we grow in what we do. I doubt we would have been able to do all the work in clinical pharmacology trials in our phase I program without a pharmacist running it. An AP taking the lead on the drug interactions and food effects studies means our physician colleagues have more bandwidth for more therapeutically based trials.

Dr. Kurtin: Amy, can you talk a little bit about your perspective on how APs build their presence? How do you do that in your organization? Who are the people that you believe are critical to building that presence and increasing visibility?

Ms. Pierre: Frankly, I think the best way to build your presence is to educate anybody who has interest in learning what an AP is, how unique we are, and what we do in our care of our patients. This can be done by explaining and introducing yourself to patients directly. Anytime somebody asks me what I do, I take that great opportunity to explain how wonderful our work is. Making our presence known outside of where we work can also be done by joining professional organizations and committees and attending conferences.

There are so many ways to educate everyone about APs and build our presence.  Hematology/oncology APs are unique in that we are specialists who take care of patients during the scariest times in their lives. Patients rely on us the most, because we typically see them from diagnosis onwards, building a strong rapport through clinic visits for treatment and symptom management. Not many specialties have that opportunity for frequency and care, so we need to continue to advocate for ourselves and educate others.

Dr. Kurtin: I agree. I have taken the initiative to get involved and be that AP voice, joining projects and advocacy groups outside of work. There’s an essential need for an expanded, well-trained expert group, an interdisciplinary health care team, as our roles become more complicated. Were there any periods of time when you experienced pushback? How did you overcome those barriers?

Dr. Harvey: The responses are varied. I have heard, “Stay in your lane, that’s not your purview.” In that case, speak with the person about their concerns and try to understand why they have that perspective. Also, engage others who know your work, who are in similar positions, and have the same background as the people who are questioning what you can do. It’s important to have advocates willing and able to help others understand the value of our skillsets.

As APs in leadership positions, we have a responsibility to ensure that when we are asked to participate, we give our best efforts. We’re not just doing it for us and for patients, we’re doing it for others in the field, for those who will come after us.

Dr. Kurtin: If you keep knocking on the door, you will see progress over time. With any role I’m involved in, I take very seriously that I am not just representing myself, but our profession and any other organization that I’m a part of. Serving as that example is critical, as is mentoring others to bring them along. How about you, Amy?

Ms. Pierre: I have a little bit of a different perspective. I have found myself in situations where the organizations I’ve worked at are clamoring to have APs do more. It’s the opposite of pushback and that can be positive or negative. I’ve seen a shift in clinical practice as patients with cancer are both becoming sicker and living longer. I’m seeing institutions offload more responsibilities and workload onto the AP from other clinicians, which means they accept our value, but provides new challenges as well. In those situations, we need to be clear about what is feasible to avoid burnout of the AP.

Many APs leave the field because of burnout or lack of career growth and professional development opportunities. Advisory boards have estimated that an AP position vacancy can cost an institution upwards of $1,500 per day. If we show how important it is to retain our staff and avoid burnout and continue to advocate for the importance of the AP role, we will continue to grow as a profession.

In terms of pushback, I’ve learned that if you demonstrate and show data and evidence, it’s hard to argue with tangible data.

Dr. Kurtin: The Advanced Practitioner Society for Hematology and Oncology has developed a professional development and leadership committee to focus on just what Amy described: what are the metrics, and how do we measure and support productivity – not by using a physician model, but a model that is tailored to the diversity of the role of the AP? This will require establishing national benchmarks that incorporate all facets of the AP role required to effectively support a hematology/oncology practice beyond individual visits. The things that you can’t crunch into a patient visit are essential to an effective and cost-efficient practice. There’s a great deal of work ahead, but at least we’re beginning that work.

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