The Development of an Advanced Provider Fellowship Program

Lahey Hospital and Medical Center (LHMC) was founded in 1923 by renowned general surgeon and teacher, Frank Lahey.

Today, it has grown into a large tertiary care teaching hospital that continues to serve Boston and the surrounding communities. It has continued to host a number of residency programs and fellowships, with many faculty members holding teaching appointments at area medical schools, including Tufts University, Harvard University and Boston University. The hospital has grown exponentially over the past decade and has expanded to include a number of outpatient offices, as well as community hospitals.

The Pulmonary and Critical Care Department (PCCM) at Lahey operates throughout the entire hospital system and currently provides staffing to four different intensive care units.
With the rapid expansion of the hospital system came an immediate need to increase the number of advanced practitioners (APs) to ensure continued high-quality care throughout all the intensive care units. Prior to this period of growth, PCCM leadership had become an early adopter of, and advocate for, the role of advanced practitioners in Critical Care Medicine. With the urgent need for more staff to care for the ever-expanding hospital system, advanced practitioners were recognized as a vital component to adequately staffing the intensive care units, while continuing to provide continued high level of care.

Over the next few years, the Department of Pulmonary and Critical Care Medicine saw the number of advanced practitioners double.

The Pulmonary and Critical Care Medicine (PCCM) department undertook the unique challenge of hiring and successfully training each new member of the Critical Care team to become productive and self-sufficient providers. Although there was an orientation plan in place for new graduates, the orientation process was re-shaped with each new graduate that was hired, ultimately taking on a more structured approach that included specific learning modules and key objectives that each AP was required to complete prior to moving out of the orientation phase.

Teaching, ongoing education and evidence-based practice are highly regarded among the PCCM group and creating a formal fellowship program was a long standing goal for a number of the critical care APs.

As the orientation and training of new PCCM members became more streamlined, serious consideration was given to the development of a fellowship program. Members of the PCCM team began to meet regularly to develop a formal fellowship curriculum and in January of 2018, the first PCCM fellow started the program.

The fellowship is primarily based in the Medical Intensive Care Unit, which is staffed by an established advanced practitioner team and physician.

The fellow operates similar to a staff AP and is expected to examine, present and care for patients as if they are the sole provider. Increasing autonomy and patient responsibilities occurs gradually as the fellow becomes more proficient. The fellow works full time, alternating between 3 and 4 shifts per week, each 13 hours and works every sixth weekend and some overnights to ensure a well rounded staffing model. The fellow is provided with additional education opportunities and is encourage to attend the PCCM Fellow lectures, as well as the critical care resident lectures.

The fellow also has the unique opportunity to rotate with various specialty/consult services including Nephrology, Infectious Disease and Palliative Care. The fellow also rotates in a teaching ICU and works alongside internal medicine residents for a number of weeks. Towards the end of the fellowship, the fellow is given the opportunity to rotate in a community hospital setting and spends some time at Beverly Hospital and Winchester Hospital, which are two community hospitals that are part of the Lahey Health system.

We asked Elizabeth Woods NP, to describe her experience as the first AP fellow at Lahey for this blog post and her commentary was truly humbling and is shared below…

“Being the first Pulmonary/Critical Care AP Fellow at Lahey Hospital & Medical Center has been an absolute privilege. It was clear from the beginning that the AP team at Lahey was familiar with training new graduates, and that there was a working system in place to provide the support and education necessary to foster the advancement of a newly graduated advanced practitioner into a valuable member of the team. I had only had a month of Critical Care experience prior to starting the fellowship and had decided that a fellowship would give me the opportunity to decide whether Critical Care was the right area for me to pursue in my career.”

The fellowship allowed me the unique opportunity to work full time in the medical intensive care unit

Gradually becoming familiar with the role of a Critical Care AP, honing skills, and building upon knowledge that is best taught on the job. This experience alone has provided me with more confidence and understanding than I ever imagined I would have gained from a 12-month fellowship, but the additional learning opportunities–200+ hours of lectures focused on Critical Care medicine, rotations with specialty services, and time in the simulation lab learning about ultrasound and procedures–have afforded greater insight into the nuances of Critical Care that I would never have realized so early on in my career otherwise.

The opportunity to work alongside such a highly functional and well established advanced practitioner group was invaluable for me, as I was able to see advanced practitioners working to their full capacity while caring for very complex and critically ill patients. With only two months left in my fellowship, I am grateful for every day that I have been able to learn from my colleagues and immerse myself in the learning opportunities and management of patients in the ICU. It is hard to believe that just ten months ago I had very little critical care experience, and now I am independently working in the MICU with a full patient load. I have no doubt that this fellowship had given me a solid foundation that will benefit me for the rest of my career as an acute care nurse practitioner. Not only has this past year given me the confidence and competence to pursue any area of medicine, but also the passion and determination to continue caring for complex patients in the ICU”.

Timothy Noland PA-C, Brittney Wilson PA-C and Elizabeth Woods NP.

Brittney has been a PA for 3.5 years at Lahey Hospital in the PCCM department. She loves teaching and hopes to continue her involvement with the AP fellowship process!