#44 APPs in the ICU
The critical care landscape is a dynamic one, filled with team members with all sorts of backgrounds who have various skill sets and experiences to bring to the table. In this episode of Critical Care Time we focus on the role NPs & PAs - sometimes referred to collectively as APPs - play in the ICU. To help us explore this we sat down with Gary Macy of Duke University a Critical Care NP in their Neuroscience ICU who has many years of experience working as an ICU NP. During our discussion we explored numerous topics such as the concerns regarding education, "turf wars" and what integrative models might best serve our patients. Give us a listen and let us know what you think!
Episode Summary
In this episode of Critical Care Time, we explore the evolving role of Nurse Practitioners (NPs) and Physician Assistants (PAs) - collectively referred to at times as Advanced Practice Providers (APPs) - in the ICU. We had the pleasure of hosting Gary Macy, a seasoned critical care nurse practitioner at Duke University’s Neuroscience ICU, to discuss the integration of NPs and PAs into the critical care environment.
Together, we explored:
The history and career pathways of APPs in intensive care.
Common terminology and the ongoing debate over titles like "mid-level provider" and "clinician."
The role of APPs in critical care, including autonomy, scope of practice, and team dynamics.
The controversy surrounding independent practice for APPs.
Successful models of collaboration between physicians and APPs.
The impact of APPs on patient care, nursing culture, and ICU workflow.
The future of APP education and potential workforce challenges.
This conversation is timely, thought-provoking, and essential for ICU teams navigating the shifting landscape of multidisciplinary critical care.
Key Takeaways
✅ APP can be a confusing term! Gary advocates for - whenever possible - just using the terms NP and PA. There is no shame in those titles, no reason to confuse patients. To that end, using the term “doctor” in a clinical setting is very confusing to patients as well if the doctor is not an MD or DO (in the United States). If people would just call themselves by their appropriate title, it would likely be less confusing for all parties involved!
✅ NPs and PAs are a vital part of ICU care teams – Their presence improves continuity, efficiency, and can improve patient outcomes. This is especially true in teaching centers where the resident/fellow physicians may rotate quite often and thus, NPs and PAs can provide vital institutional and logistic/procedural memory that pays dividends. The important roles that NPs and PAs place amongst the critically ill has been recognized by a number of interprofessional organizations, most recently CHEST who has announced a formalized education and validation program for NPs and PAs just a few days ago!
✅ The debate over APP independent practice – With 27 states now granting full practice authority to NPs, what does this mean for inpatient and critical care medicine? It probably means that critical access hospitals or remote locations that did not have intensive-care trained boots on the ground, might now be able to make that happen. No one has a crystal ball, and while cost-savings may be appealing, it does not appear like the future of critical care medicine is one where physicians are marginalized and NPs and PAs are the sole practitioners throughout US ICUs.
✅ Collaboration >>> competition – The best ICU models foster a collegial relationship between physicians and PAs/NPs, enhancing both patient care and job satisfaction. One model we discussed is where the attending physician relies upon NPs or PAs as trusted, experienced force multipliers - allowing the attending to leverage their indispensable skills to affect the care of more patients than they could affect on their own.
✅ The future of NP and PA education – Quality matters. There are concerns about program standards, barriers to entry, and competency upon graduation. While there may be a valid argument for NPs being able to receive their degree without having worked as bedside RNs, we all agree that real, clinical experience is a must. In 2025, having elements of asynchronous or on-line education is completely reasonable and frankly, necessary in many cases for all types of education. However, there is no place in modern medicine for any clinician who has not had many hours of practical, bedside patient-care experience if the expectation is that they will care for critically ill patients.
✅ Addressing the "Turf War" – The growing need for ICU clinicians suggests a shared workforce, rather than direct competition, may be the best path forward. There is no way to tell what the future holds with certainty and cost-savings will certainly be a factor. That said, logic and history dictates there is enough work to go around and that patients benefit the most when NPs, PAs and physicians work together in complementary roles, leveraging their unique skillsets in the best interest of patients.
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