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The Case for Advanced Practice Providers in Neurology



NEARLY 700 APPs, including clinical nurse specialists, nurse practitioners, and physician assistants, have joined the AAN in the past five years.

Neurologists discuss the benefits of including advanced practice providers in neurology practice.

Heidi B. Schwarz, MD, FAAN, a headache specialist and professor of clinical neurology at the University of Rochester Medical Center, said there is good reason to advocate for including advanced practice providers (APPs) in neurologic practice. For one, she said, adding APPs could help ensure that more patients have access to neurologic care — especially when a 16 percent shortage of neurologists in the United States is being forecast by 2025.

“The reality is that the population is aging and it's clear that, to meet the needs of this population, we cannot rely on neurologists alone,” said Dr. Schwarz, vice chair of the AAN Practice Committee.

APPs generally have undergone specialized education, training, certification and licensure that allows them to provide health care related services with varying degrees of independence. Some can perform certain procedures and prescribe some medications. The APP scope of practice, level of independence and authority vary by type of APP and by state.

Some neurologists have been skeptical about APPs, she noted, expressing concerns that they did not have the skills needed to care for neurology patients or would take away physicians' jobs.

Still others have said they could not trust APPs in their practice, recalled Miriam L. Freimer, MD, director of the neuromuscular division at the Ohio State University Wexner Medical Center, who participated in early meetings and discussions about expanding the use of APPs in practice.

Dr. Freimer, who went on to co-chair the APP Work Group formed in 2013, said her response then and now was that the future of medicine will require collaborative work with advance care providers.

“We are just not providing good care for all the people who need it,” she said. “If we can't open our minds and come up with alternative ways to do it, we are never going to be able to meet those needs.”


The APP Work Group developed an AAN position paper, which was approved by the Board of Directors in mid-2015, acknowledging that the use of multidisciplinary teams that include APPs offers advantages for neurology practices.

“The purpose of the position statement was to essentially educate neurologists that this is a viable model of care,” said Joseph V. Fritz, PhD, co-chair of the APP Work Group and the chief executive officer of Dent Neurologic Institute in Buffalo, NY.

The Work Group's goal is to help neurology practices move to a team-based care model, in which a neurologist leads a multidisciplinary group that treats more patients with higher quality care and greater efficiency than a physician can do alone.


DR. HEIDI B. SCHWARZ: “The reality is that the population is aging and its clear that, to meet the needs of this population, we cannot rely on neurologists alone.”

Dr. Fritz believes APPs — as well as social workers, neuropsychologists and other types of team members — are the key to reducing the serious problem of burnout among neurologists while meeting the growing demand for neurology care.

“I believe this will be the standard of care and will increase the satisfaction of all physicians within the next 10 years,” he said.

Nearly 700 APPs, clinical nurse specialists, nurse practitioners (NPs) and physician assistants (PAs) have joined the AAN in the past five years.

“I have definitely seen the pendulum swing,” Dr. Schwarz said. “I see many more people open to the resources that an advance practice provider would bring to their practice.”


Physician assistant Jessica Erfan, MPAS, PA-C, is one of about 25 APPs working with some 40 physicians at the Seton Brain and Spine Institute in Austin, TX. She has been specializing in neurology since 2006.

“I've worked in various neurology practice settings including outpatient, inpatient, and academic settings,” said Erfan, a member of the APP Work Group. “APPs are practicing in many neurology settings, including research, interventional, telemedicine, and rural practices. It's important for neurologists to realize that APPs are making contributions in neurology already but just haven't been in the limelight.”

Stuart B. Black, MD, FAAN, chief of the division of neurology at Baylor Scott & White Health in Dallas, thinks that might just be an understatement. He contends that most neurologists are not that familiar with what APPs, NPs, and PAs do, and what they can bring to the practice.

Dr. Black, also a member of the AAN Work Group, was the lead author of a paper published in December of 2016 in Neurology: Clinical Practice, which provided an overview of inpatient and outpatient models for working with advanced care practitioners in neurology practice; it was the second in a series of articles designed to educate neurologists about potential benefits related to the use of APPs in practice.

Dr. Schwarz said she can speak to the benefits. While working at Unity Health System in Rochester, NY, she had a four-month wait to schedule a new-patient visit, but that changed when she moved to the University of Rochester Medical Center in 2013. “With a nurse practitioner, the wait time went down to six weeks,” said Dr. Schwarz.

For the most part, nurse practitioners in her office treat patients independently, providing follow-up care or acute interventions for headache, such as nerve blocks or injections. One half-day each week, Dr. Schwarz and her nurse-practitioner colleague see new patients together.


DR. JOSEPH V. FRITZ believes APPs — as well as social workers, neuropsychologists and other types of team members — are the key to reducing the serious problem of burnout among neurologists while meeting the growing demand for neurology care. “I believe this will be the standard of care and will increase the satisfaction of all physicians within the next 10 years.”

“Or we see very complicated patients together because those patients are going to call in, and if I'm not available, the nurse practitioner needs to be familiar with them,” she said.

Dr. Schwarz and other practice leaders who have extensive experience with advanced practice providers shared that since APPs typically receive little or no neurology-specific training in their formal education, working in a subspecialty allows them to focus their “on the job” training, developing the skills and expertise needed to be a valuable member of the team.

Dr. Freimer first became interested in APPs by watching a colleague — a nurse practitioner who specializes in epilepsy — become an expert in her field, active in clinical research.

“I think it would have to be easier to do subspecialty APP work than general neurology,” Dr. Freimer said. “That being said, the nurse practitioner who works with me deals with 30 different neuromuscular diseases, which is a much deeper learning curve than working in a practice where the diseases are narrower and the treatments are narrower.”

An APP's scope of practice is dictated by laws that vary from state to state. And there is no “best practice” for exactly how APPs work with neurologists, Dr. Schwarz said. In her own practice, Dr. Schwarz thinks of her APPs as members of a care team.

“We play to each other's strengths,” she said. “Although I am a good physician, there are times when my nurse practitioners read the patients better regarding where they are emotionally and take the time with the patient to find out what really is going on in their lives and how that is affecting their illness. Then, as a team, we work together to craft the best approach for treating them.”

At Dent Neurologic Institute in Buffalo, NY, about 30 physician assistants and nurse practitioners work in conjunction with about 25 neurologists. The practice is organized into subspecialty areas, and APPs generally focus on follow-up care.

“The neurologist sets the plan of care and also decides which patients should go to APPs (for follow-up visits) and which should stay with the physician,” said Dr. Fritz.

As they gain experience, APPs delivering subspecialty care work more independently. “This allows the APPs to grow faster in their careers because they get really good at a particular disease,” Dr. Fritz said. “If you go to a more general neurology setting or into a hospital setting, there may be a different conclusion in terms of how autonomous the PAs and NPs can be.”

A common mistake is for physicians to delegate time-consuming tasks to an APP based on the idea that it frees up the neurologist to see more patients. APPs are well-paid professionals who can handle billable responsibilities, and failing to use them in that capacity is a bad financial move, said Dr. Schwarz.

“To have a nurse practitioner who sits there and returns patient phone calls and renews prescriptions is never going to pay for itself,” Dr. Schwarz said. “They have to see patients and be part of the provider team.”

Dr. Freimer echoes that perspective. She encourages neurologists to learn what an APP's license allows the provider to do and develop the job description accordingly. [See “Training Requirements for Advanced Practice Providers.”]

“You want an APP who can see patients independently, who can prescribe medications and look at labs and change medications accordingly,” she said. “If somebody hires a nurse practitioner to be a scribe, that person is wasting money.”


Generally, APPs include two general categories of health care providers: advanced practice registered nurses and physician assistants. Advanced practice nurses have advanced didactic and clinical education, knowledge, skills and scope of practice. They may serve in roles with anesthesia, as midwives, certified nurse practitioners, and clinical nurse specialists. Physician assistants also work as part of the medical team, and are nationally certified and state licensed to practice medicine under the supervision of a physician.

Training programs for the physician assistant, nurse practitioner, and clinical nurse specialist were launched more than 50 years ago to address an emerging physician shortage. Each of the professional designations require certification by credentialing agencies and is subject to state regulations that delineate its scope of practice.

Physician assistant training programs generally involve up to three academic years, including an average of 2,000 clinical rotation hours. A clinical nurse specialist has at least a master's degree in nursing and a minimum of 500 supervised clinical hours in a specialty such as gerontology or mental health. NPs hold either a master's or doctorate degree in nursing with at least two years of advanced education and a minimum of 500 supervised clinical hours.

Although the use of APPs is increasing in almost all medical specialties, postgraduate residency and fellowship programs are just beginning to emerge. In researching their paper for Neurology: Clinical Practice, Dr. Stuart B. Black and his co-authors found more than 700 training programs for NPs, PAs or clinical nurse specialists, but just 15 postgraduate programs, only three of which are dedicated to neurology.

“Even those APPs who have a great deal of experience and expertise (in neurology) say they want focused education on neuroanatomy, neurophysiology, and neuroradiology,” he said. “The Academy needs these people and they need to have access to training.”


• Black SB, Pearlman SB, Khoury Cl. Adding an advanced practice provider to a neurology practice: Introduction to outpatient and inpatient models Neurol Clin Pract 2016; 6:6 538–542.
    • Neurology advanced practice providers: A position paper of the American Academy of Neurology.