Implementation of a postgraduate dermatology fellowship program for nurse practitioners

Supplemental Digital Content is Available in the Text.

ABSTRACT

Transition to practice programs (also referred to as fellowship, residency, or postgraduate training programs) for nurse practitioners (NPs) are becoming more popular, especially in specialties such as dermatology. A nationwide shortage of dermatology clinicians, which had led to long appointment wait times and inadequate patient access to care, has led to more NPs practicing dermatology to help meet the demand for care. New graduate NPs may struggle in their transition to practice, and fellowship programs have been shown to support NPs as they transition from novice to expert. In this article, the University of Rochester Medical Center shares its experience in developing, implementing, and managing a postgraduate dermatology fellowship program for NPs.

Introduction

Dermatology is a medical specialty that includes more than 4,000 diseases of the skin and cutaneous adnexa with many subclassifications of disease (Ferreira et al., 2021). The most common dermatological problems are acne, atopic dermatitis (eczema), hair loss, psoriasis, rosacea, and skin cancer, which impose a substantial disease burden and have a high economic impact (American Academy of Dermatology [AAD], 2021). There is an ongoing shortage of physician dermatologists and a high demand for dermatologic care, resulting in an inadequate supply of care and long appointment wait times (Tsang & Resneck, 2006).

Skin disease is a leading cause of health care burden in the United States and affects nearly 85 million Americans (Laughter et al., 2020; Lim et al., 2017). The increasing nationwide incidence and prevalence of chronic disease related to an aging population do not spare specialty fields, such as dermatology, as the prevalence of most skin diseases increases with age (Lim et al., 2017). In the United States, 50% of individuals older than 65 years (the Medicare population) have one or more skin disease(s). By 2030, this group is projected to grow by 30 million individuals with continued growth through 2050, likely leading to substantial increases in the burden of skin disease (Lim et al., 2017). In 2013, 26% of Americans sought treatment for at least one skin disease, and the average person was treated for 1.6 skin diseases, with a cost of $75 billion to the health care system (Edison & Brod, 2017). The prevalence and cost of skin disease are comparable with or exceed cardiovascular disease and diabetes (Lim et al., 2017). As the population ages and the burden of skin disease grows, wait time for a dermatology appointment also increases. A significant problem for the dermatology specialty in the United States is offering adequate access to patient care (Kamangar et al., 2015).

Wait time for a dermatology appointment varies within the United States by geographic region and often exceeds 45 days (O'Brien & Chong, 2016; Resneck et al., 2014), even for patients with urgent problems such as changing skin lesions that could be cancerous (Tsang & Resneck, 2006). In the United States, there are only 3.4 dermatologists per 100,000 persons and substantial geographic disparities in the distribution of dermatology clinicians (Glazer & Rigel, 2017). Most dermatology clinicians practice near big cities or academic medical centers (Feng et al., 2018). Wait times for a dermatology appointment are growing and are longer for patients with Medicaid/Medicare than with commercial insurance (Creadore et al., 2021; Oostrom et al., 2017).

Efforts to address this problem have included increasing the number of nurse practitioners (NPs) in dermatology (Bobonich & Nolen, 2018). In 2015, the employment of NPs and PAs by dermatology practices had increased to 46% from 28% in 2005 (Ehrlich et al., 2017). Despite this increase in the number of NPs in dermatology, there are limited opportunities for NPs to obtain formal postgraduate training in dermatology (Bobonich & Nolen, 2018). To address the barrier of access to care for patients in the Western New York region, the University of Rochester Medical Center Dermatology Department (URMC) started a 2-year transition to practice program for NPs in 2017. The URMC is a quaternary medical center in the Western New York region and is the largest academic medical center in New York State outside of New York City. The name of “nurse practitioner fellowship in dermatology” was adopted. The first cohort consisted of two trainees. The purpose of the program was to increase NP knowledge in dermatology when transitioning from novice to expert in a highly structured, supervised training program. In the URMC program, NP trainees are referred to as “NP fellows.” In the literature, fellowship programs are interchangeably referred to as residency programs and fellowship programs. Transition to practice (TTP) encompasses both terms. In 2010, the Institute of Medicine (IOM) Future of Nursing report called for greater attention to the transitional period from new graduate to practicing clinician to help bridge the gaps between graduation and expert proficiency in a specialty practice area. This need is emphasized in studies where novice NPs express feelings of self-doubt, incompetence, and role ambivalence during their transition into the workforce (Faraz, 2016) and the desire for transition assistance and postgraduate residency programs (Hart & Bowen, 2016). In addition, NPs and PAs perform more biopsies than dermatology physicians to diagnose a malignant neoplasm, which may contribute to increased costs and increased morbidity (Nault et al., 2015).

Nurse practitioner role transition is supported by mentorship, social support, finding meaning in work, job satisfaction, and work-life balance (Faraz, 2019). Before 2010, NP TTP programs in primary care and mental health started to appear (Bush & Lowery, 2016), and this trend has been increasing (MacKay et al., 2018). Most NP TTP programs are in primary care settings (Zapatka et al., 2014), although fellowship programs have also appeared in critical care (Meissen, 2019; Zhou & Pathak, 2021) and in other specialties (MacKay et al., 2018). Approximately 10% of primary care NPs complete some form of postgraduate training, and these graduates are more likely to report enhanced confidence in an independent role, greater practice autonomy, increased team collaboration, increased job satisfaction, and decreased intent to leave compared with those without formal postgraduate training (Park et al., 2022).

Program leadership

The URMC NP Dermatology fellowship was developed by the chair of dermatology who recognized the need for more high-quality dermatology care providers in the Western New York region. A medical director who was supportive of the mission of the fellowship was identified. At the time, there were no NPs practicing within the department. Initially, key stakeholders, including attending physicians and administrative leadership, were involved in discussions of starting the program. The primary role of the chair was to identify key stakeholders and obtain support for the program. The medical director and chair initially interviewed candidates with several attendings and identified evaluation methods. This is consistent with evidence from other TTPs, 84% of which reported that physician and administrative support were facilitators to program implementation (Kesten & El-Banna, 2020). The URMC program would not have been formed if not for the representation of the attending physicians and support from department and medical center leadership. The existing Grand Rounds, Journal Club, and ongoing resident education lectures were pivotal because they provided existing educational opportunities for the NPs to participate in.

Logistics: Pay, credentialing, benefits, and privileges

To foster a collegial working environment, NP fellows were offered a salary similar to that of physician residents. Salary was selected by considering that of a medical intern, medical resident, registered nurses within the medical center, and salaries offered by other dermatology NP fellowship programs. A salary of $60,000 for the first year and $70,000 for the second year was selected. The NP fellows received full-time benefits, and each fellow received a $1,000 stipend to attend one national conference each year of the 2-year program. In addition, each fellow received reimbursement for one professional organization's membership fees, and all professional licensing.

To be eligible for the fellowship, each NP fellow was required to undergo the same credentialing and onboarding process as other NPs within the organization. This included passing their boards, obtaining state licensure, and completing the credentialing and clinical privileging process. Due to the time needed for this process, graduates from May 2017 batch or before were considered for the first cohort. Nurse practitioners were required to obtain their own National Provider Identifier (NPI) number and Drug Enforcement Administration (DEA) number to allow them to write prescriptions for both noncontrolled and controlled substances. In addition, New York state law requires that each NP who has completed less than 3,600 clinical practice hours must enter a written collaborative practice agreement with an attending physician. Once this threshold is met, NPs may practice with full practice authority.

In 2017, The Dermatology Certified Nurse Practitioner (DCNP) examination blueprint was used to develop competencies and determine which clinics it would be most appropriate for the NPs to participate in. In 2018, the competencies for dermatology NPs (Bobonich & Nolen, 2018) were used to ensure that the program was meeting all expected competencies for dermatology NP practice.

Program structure

The program aims to educate postgraduate NPs in general medical dermatology. Fellows may observe cosmetic clinics but do not perform cosmetic procedures. Over a 24-month period, fellows are immersed in dermatology through a mix of approximately 80% clinical and 20% didactic instruction. Nurse practitioner fellows rotate through specialty clinics, including but not limited to those for connective tissue disease, psychodermatology, psoriasis, cutaneous lymphoma, hair loss, vulvar dermatoses, blistering dermatoses, pediatric dermatology, and urgent dermatology clinics. Fellows initially work in parallel with dermatology physician residents under the guidance of a board-certified dermatologist. Eventually, fellows start to see patients in their own independent clinics, with a board-certified dermatologist and/or dermatology-certified NP on-site.

Ideally, each NP fellow begins their training at the beginning of the academic year with the new cohort of physician residents. This time has reduced patient loads, direct mentoring, tutorials in the use of the electronic medical record, increased ancillary support, and foundational dermatology education, which allows a smooth and successful introduction to clinic. However, NPs have successfully started in the program on a rolling basis, bolstered by extra faculty tutorials covering basic knowledge. The program consists of a 5-day work week with daily morning lectures, clinic, and allotted time for independent study. In each clinic, the NP fellows participate in direct patient care, including history taking, assessment, disease management, and procedures. Lectures feature instruction from both physician and NP trainees, physician attendings, and guest lecturers. In addition, fellows participate in monthly Journal Clubs and Grand Rounds with residents and attendings.

The first 6 months of the training program solely consists of supervised clinics with attendings. Following this period, attending physicians evaluate trainee readiness to start a limited number of unsupervised independent clinics with straightforward follow-up patients (such as warts and acne). The proportion of independent clinics to supervised clinics and complexity of diseases treated increases as the program continues. At the end of the 24-month period, 50–75% of clinics are independent. On successful completion of the 24-month program, the NP fellow has fulfilled the 3,000-hr practice requirement to be eligible to sit for the DCNP examination and is sponsored by the department to do so.

Recruitment and interviewing

An essential part of the program's success came with choosing the right candidates. Each year, one to two NPs are enrolled into the program. Recruitment consists of online advertisement through professional NP organizations, the URMC Dermatology website page, and social media interest groups.

Once individuals apply to the program, they are first screened by the University Advanced Practice Provider Leadership office to ensure that they meet minimum requirements for NP employment. These requirements include (1) being a master's or doctorally prepared new graduate or early career NP, (2) having New York state NP licensure eligibility, (3) having a complete application with at least two letters of recommendation from a clinical educator or colleague, and (4) possessing a family nurse practitioner (FNP) certification and state licensure by the agreed upon start date. The FNP credential is considered necessary because patients throughout the lifespan are seen at all the URMC Dermatology clinic locations. Once initial screening is complete, resumes from appropriate applicants are sent to the department hiring committee to be selected for interviews. This committee consists of the department of dermatology chair, the medical director, the lead NP, and a second-year NP fellow. A single interview is conducted with each candidate by the committee, and a collaborative decision on admission to the program is made after all chosen applicants are interviewed.

Curriculum

Competencies for dermatology NPs were published by Bobonich and Nolen (2018), and these competencies were used to establish competencies for the URMC program (Table 1). The academic curriculum mirrors that of the physician residency except for cosmetic dermatology, dermatopathology, and Mohs surgery. These exclusions are largely based on Bobonich and Cooper's 2012 Delphi Analysis that showed that those skills are not highly ranked in importance for the core curriculum of entry-level dermatology NPs. Nurse practitionerss must achieve competency through direct supervision in each of the basic dermatology procedures in Table 1 before they are allowed to perform them without direct oversight. The NP fellows are required to read chapters of a dermatology textbook each week and attend didactic lectures 5 days a week, for 1 hr per day. They are also required to present dermatopharmacology lectures twice per academic year to attendings, NP fellows, and residents, with an attending content expert present. Nurse practitioners fellows are encouraged to propose presentations on topics of individual interest, which in the past have included topics such as ethnic hair care and use of oral contraceptive pills for the treatment of acne. The NPs present to attendings, other NP fellows and residents, which adds to the diversity of learning within the department and has been well received by physician colleagues.

Table 1.

Procedural competencies for dermatology NP fellows

Procedure	Number Required to be Performed Competently Under Direct Supervision
Intralesional injection	4
Shave biopsy	4
Punch biopsy with placement of sutures	4
KOH prep for detection of fungi	2
Electrodessication and curettage	4
Liquid nitrogen cryotherapy	4

Note: The NP fellow is required to perform each of the above procedures competently under direct supervision before they are allowed to perform any procedure with solely on-site (indirect) supervision for the remainder of the program. Each NP fellow is required to log each procedure performed, with sign-off by the attending. NP = nurse practitioner.

Meeting compliance requirements for billing

The structure of the NP training program requires a close working relationship with supervising attending physicians while NPs build clinical skill. Because NP trainees are already licensed to practice independently when admitted to the program, it is necessary to properly document shared visits when the NP sees a patient with an attending, and the billing requirements for a shared visit are met. Our institution uses the EPIC electronic medical record. To facilitate proper documentation of shared visits, specific dot phrases were created within EPIC to ensure that the role of the attending MD was documented appropriately.

In the case of small procedures, the attending MD actively participates in each until the required number for on-site supervision has been completed (Table 1) Attending MDs are additionally paid a stipend in consideration of their supervisory effort.

Quality and research

Participation in research to inform clinical practice has been identified as an integral part of the NP role (Ryder et al., 2019). Nurse practitioner fellows are given the opportunity to participate in research initiatives within the department, which includes participating in the department-wide quality improvement team, serving as subinvestigators in the clinical trials unit (CTU), being encouraged to pursue their own research interests, and participation in research projects with clinical faculty.

Currently, all NP fellows participate in the CTU for 1 day each week. During this time, trainees learn foundational translational research skills. They are then able to serve as subinvestigators for sponsored and investigator-initiated clinical trials. Tasks involved in this role include assessing participant eligibility through medical history and physical examination, completing validated clinical evaluation scoring systems for specific diseases (e.g., Eczema Area and Severity Index), and maintaining study compliance and regulatory documents. This opportunity supports NP fellows' knowledge of dermatologic diseases, future treatments, and exposes trainees to career opportunities in research and pharmaceutical industries.

Commitment to stay

Recruitment and retention and retention of NPs after postgraduate training is crucial. Benefits of increased recruitment and retention have been identified by other organizations that implemented NP TTPs (Kesten & El-Banna, 2020). The URMC has also experienced these benefits, with enrollment in the TTP increasing exponentially from 2017 to 2021, and 100% of graduates continuing to work for the department for 18 months or more beyond fellowship completion. On successful completion of the program, trainees may be offered full-time medical staff positions in the dermatology department.

Evaluations

During the program, the progress of each fellow is evaluated on an ongoing basis. Fellows receive feedback from physician attending after clinics. Nurse practitioners performance is also evaluated by faculty every 6 months using a modified scale, which was adapted from one published by Turiansky and Loo in 2014, with added procedural milestones (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JAANP/A263). Every 3 months, fellows are evaluated by faculty using the NP Training Program Interim Assessment Scale (Figure 1). Fellows are expected to meet milestones as they progress through the program. If concerns regarding the progress of the fellow arise, they are addressed immediately. Finally, an annual evaluation is completed.

Figure 1.

Nurse Practitioner Training Program Interim Assessment Scale. This figure is a Likert-type rating scale used by faculty to assess nurse practitioner fellow progress intermittently throughout the fellowship within the domains of patient care, medical knowledge, practice-based learning and improvement, professionalism, and systems-based practice.

On completion of the URMC NP dermatology fellowship, NPs expected to become certified in dermatology and are sponsored by the department to sit for the DCNP examination. The DCNP examination is a 175 multiple question examination that assesses the NP's ability to evaluate, diagnose, and treat dermatological conditions. Successful passing of this examination indicates expert knowledge in general dermatology care. As of January 2023, 100% of graduates have passed the DCNP examination on the first attempt.

Access to care

Since the inception of URMC's fellowship, access to care has been positively affected. The presence of a NP trainee allows attending physicians to see one additional patient in each half-day clinic block. Unsupervised, independent NP clinics resulted in an average of 2,859 more patient visits each year, from 2017 to 2023. An independent NP clinic in this setting is defined as one where the NP sees patients alone; however, a board-certified dermatologist is present in the office and can be brought in to see the patient if the NP believes an interdisciplinary approach is necessary and will benefit the patient. The number of patients seen each year by NPs is expected to rise over time as the program expands.

Controversies

There is still much to learn about TTPs. To the authors' knowledge, no studies or organizations provide an accurate number of all existing TTPs or comprehensively describe the characteristics of these programs. Without this information, stakeholders have a limited understanding of the value of these programs for current and future NP education and practice. This is exemplified by a 2014 NP Roundtable publication that stated that “additional, postgraduate preparation is not required or necessary for entry into practice” (Meissen, 2019). Studies that have examined the effectiveness of TTPs show that they result in improvement in preparedness to practice (Parkhill, 2018; Schofield & McComiskey, 2015). Although important, improved preparedness may not be enough to convince stakeholders to implement these programs. The documentation and standardization of TTP programs and outcomes is vital for the continued growth and acceptance of these programs.

Conclusion

In conclusion, URMC has successfully implemented a NP dermatology fellowship program, which has increased access to care for patients and successfully prepared NPs to become certified in dermatology, with a 100% DCNP examination pass rate on the first attempt. The program successfully runs in tandem with the physician residency program, and the program has been accepted by attendings and residents. The program successfully retains trainees after completion, with 100% continuing employment for at least 18 months after the completion of training.