Origins of the APP EM Internship
The physician shortage has had a significant effect on hospitals’ ability to staff adequately, especially in rural areas. As we’ve discussed previously, even the highest functioning rural hospitals are one provider resignation away from a shortage. As a clinician-led emergency and hospitalist provider staffing and management organization, we at Aligned Providers Wyoming have seen firsthand the financial stress that staffing challenges can have on hospitals––and the communities they serve.
To address the shortages––while ensuring maximum patient safety–– we have developed an advanced practice training program that equips providers with rigorous classroom and didactic instruction. Under the supervision of seasoned teachers and physicians, our APPs receive specialized guidance in responding to emergency situations. They not only learn how to treat high-acuity patients, but then go on to independently lead healthcare delivery in remote areas (with on-call support).
In this blog, the first of a two-part series, we will share a history and overview of the program. We explore why it’s so vital for APPs to have access to specialized emergency medicine training that can benefit the rural communities they serve. While the root causes of the physician staffing crisis are complex and challenging to solve for, we see this training as a sustainable way of responding and avoiding interruptions in care. This series will provide insight into a clinical training model that can empower APPs while helping to alleviate staffing concerns in rural facilities, thus setting the stage for rural hospitals to achieve long-term success.
The Evolution of APW’s APP Training Program
“As a newly minted APP, you don’t know what you don’t know,” says Joann Bourlier-Childress, founding director of Aligned Provider Wyoming’s advanced practice provider training program, and longtime Board Chair. As a physician assistant from Western Nebraska who has specialized in critical access medicine for over 20 years, she is referencing the fact that many recent physician assistant and nurse practitioner graduates haven’t had much exposure to emergency medicine or rural care.
“The thing is, that if you haven’t seen it, you don’t know how to treat it. You might not realize it’s even a thing.” She goes on to explain: “When we began working in Cheyenne in 2016, we were finding that many brand-new APPs (PAs and NPs) came out of school without hands-on experience.”
This was the concern that led Bourlier-Childress and the cofounders of APW, Dr. Lawrence Bean and Dr. Eugene Gicheru, to start the APP training program in 2017. In 2019, Zach Bjore, an experienced physician assistant and professor, was brought on as co-director of the program. Conducted at Cheyenne Regional Medical Center, the program sought to equip providers with the skills they would need to treat patients independently, while benefiting from the oversight of physicians that only a major hospital like CRMC could provide.
Over the next several years, the program evolved and graduated numerous groups of APP interns, who gained direct experience not only in the ER, but in the hospital medicine program, and urgent care. As the program grew, so did APW, expanding its contracts to rural facilities across the state. After recognizing the need for specialized staff training in Wyoming’s most central facility, Joann and the team wondered, What were smaller sites seeing in other rural states? And how could they better serve these communities?
As Dr. Lawrence Bean puts it, “In Cheyenne, we were so successful in developing and recruiting talented APPs that we had more providers than shifts available. We quickly realized what an amazing resource this was in a region with many understaffed rural hospitals. The decision was made to expand our mission and dedicate ourselves to helping other underserved communities across the state.”
Central to this mission? Rigorously training advanced practice providers to treat high-acuity patients in emergency departments and to work independently in rural areas, where direct EM physician care is difficult (if not impossible) to find. According to one of the leaders behind the program, “Rural communities should have the same type of care that all of the urban areas have, with highly skilled people.”
Overview of the APP Rural Emergency Medicine Training Program
Over the last 7 years, Aligned Providers Wyoming has expanded to include Nebraska. They now help staff 15 sites across both states. As the APP training mission has evolved, so has its program. In 2023, Zach Bjore took over as director of the program, building on Joann’s leadership. Since then, the class grew from training a single intern every six months to training 6 interns who stay for a minimum of 12 months.
“We’ve had so many more applicants than that,” Joann Bourlier-Childress shares. “But we’ve found that 6 was the right number for each of them to have an exceptional experience.”
Since its inception, the program has graduated about 20 physician assistants and nurse practitioners, who are now qualified to treat in rural settings. Several now run hybrid ED and HM programs independently, working in remote areas around the region, which we discuss in part 2.
The APP Internship: A Step-by-Step Breakdown
When choosing interns, the team conducts a comprehensive vetting process. Applicants are typically physician assistants and nurse practitioners. Some are recent graduates, eager to get started. Others are already practicing but looking to branch out into the field of emergency medicine, or gain more experience. In this early process, Zach reviews past coursework, assesses technical skills, and of course gauges applicants’ interest in rural and emergency health. In addition to these metrics, it is important that applicants are a good fit for the APW culture, aligned with similar values of transparency, service, and continuous growth.
“They should be lifelong learners,” says Zach, who asserts that potential providers need to bring resiliency and flexibility, two key factors in rural medicine. When he meets with them (both at the start of the program, and later, when conducting oral exams), he wants to hear how they work through a problem. “We want to know how they think,” he explains.
Joann seconds the importance of adaptability in training for emergency medicine. Regarding the early days of COVID, for example, she notes how often the protocols were changing. “What worked yesterday might not work today,” she says. “You always need to be treating with evidence-based medicine.”
Once accepted, interns follow this curriculum:
- 30-36 hours/week of didactic clinical education with preceptor
- 8-10 hours/week of classroom instruction
- Education in simple and advanced procedures
- EKG interpretation course and emergency radiology course
- Procedures designated for passing ACLS/PALS/ATLS certifications
- Critical care procedures like cardiac arrest intervention, paracentesis, lumbar puncture, pericardiocentesis, cricothyrotomy, and ER/OR intubations
- Written and oral exams
- Trips to neighboring remote hospitals with preceptor to gain in-person practice
- 1-1 mentoring with Cheyenne Regional Medical Center physicians
- Simulation laboratories to practice critical care procedures
At the heart of the program is the didactic education, which sets providers up to be able to quickly identify a differential diagnosis. “We want them to note which patient needs immediate care and critical thinking. For example, what to do in a stroke, sepsis, or other high-mortality illnesses,” says Joann. “It is absolutely vital in rural healthcare to be able to discern who can be treated on the spot and who needs to be transferred to a larger hospital.” In other words, the team wants APPs to be able to triage patients at a glance.
“Our didactics go by chief complaint,” says Zach. “For example, they may come into the emergency room with chest or abdominal pain. But as Joann mentioned, you don’t know what you don’t know, and that’s what we’re trying to solve for. So, we’re trying to encourage them to think about all these differential diagnoses so that they don’t miss something.”
For the cases demanding immediate action, the training program wants APPs to be able to practice emergency procedures like a cricothyrotomy (inserting a tube through the airway) in a patient with a life-threatening emergency. The trainers note how critical this is to providing care in rural America. They are considered “high risk” but “low frequency.” As Joann puts it, “Those cases might not come in that often, but when a patient walks in with that need, you better know what to do and how to do it.”
Under Zach Bjore’s leadership, it’s a priority for students to practice these procedures. He has implemented a simulation lab where the goal is for providers to practice so often that the procedures become muscle memory.
“What Zach and I found was that the interns needed more time to see more patients…. There are procedures that you will only feel comfortable with after performing them in person,” said Joann. This was part of the logic driving the recent shift in the program length—from an initial 6 months to its current 12-month duration.
Given the variety of cases that could come into the ER at Cheyenne, some interns had a full experience at 6 months, while some were not yet confident in their skills. This prompted the programming team to do two things.
First, they gave new grads the opportunity to practice over a full year, doubling the amount of didactic and clinical guidance they received in person from physicians at Cheyenne Regional Medical Center. Second, the objective has been to implement a simulation lab where providers can practice procedures in a standardized way. With a full year program, preceptors have plenty of time to assess each provider’s level of competency and where they might need more training.
Ensuring Quality in Rural Emergency Medicine
This highlights a key characteristic of the program—its commitment to quality. Not only are the leaders dedicated to continuously expanding the program, but they are also very serious about only graduating interns who are completely confident can hold their own in a rural environment. “We want them to be better than we are,” quipped Bourlier-Childress. “At APW, we don’t want them to be afraid. We want them to be confident, to have access to everything they need to help them manage anything that walks through the door.”
As we’ll discuss in our next blog, the thoughtfully designed nature of APW’s training program sets it apart. In the midst of concerns about the ongoing rural health crisis and the physician shortage, the APW team is taking action to respond to systemic limitations in the healthcare industry. The goal is to help practitioners function at the top of their license, in a manner that is safe and supported.
Ultimately, this is for the benefit of both the practitioners themselves, and the patients in rural communities who might otherwise be left without care. Read on to hear the firsthand experience of an intern and why being able to do this is only growing in importance.
About Aligned Providers Wyoming
At Aligned Providers Wyoming, we are dedicated to transforming healthcare delivery through a patient-centric approach that prioritizes compassion, excellence, and innovation. Our mission is to revolutionize the healthcare industry by fostering a culture of empathy and commitment, ensuring that every patient receives the highest standard of care.