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Diane K. Newman: Welcome to UroToday and our online medical education program. I am Diane Newman, a urology nurse practitioner, and I'm very pleased to introduce to you Rachelle Rodriguez. She is an MSN nurse practitioner and advanced practice provider and the Genitourinary Oncology APP supervisor at Moffitt Cancer Center in Tampa, Florida. And she's going to talk to us today a little bit about her role and what exactly Moffitt's doing down there in Florida. Thank you very much, Rachelle, for being with us.

Rachelle Rodriguez: Yeah, absolutely. So as you heard, my name is Rachelle Rodriguez. And I am our APP Supervisor at Moffitt Cancer Center. I've been here for seven and a half, almost eight years, all within our GU department. So I do have a good bit of experience here working in this group. I've been the supervisor for the last four and a half years.

Today, we're going to talk about Moffitt Cancer Center. We're going to talk about the demographics of what we see here and who we have working here, specifically within our GU oncology program. We're going to talk a lot about how we utilize APPs within our program, how we've used them to optimize and create additional initiatives for our patients.

We're also going to have some additional conversation about how we can continue to do this, not just here, but for APPs and urology as a whole. So when we're looking at what Moffitt is, who we are, and what we do, we have locations throughout Florida, really where we are and who we're serving, as you can see our patients throughout the entire state of Florida, and even patients from other states and even other countries.

We do see international patients who are referred here specifically. As an NCI-designated cancer center, we do get a lot of patients who are referred for our expertise. Our main center is in Tampa, Florida. That's the Magnolia campus that you see here. We have separate off-site outpatient centers in Wesley Chapel, in Tampa near the International Airport. We have our McKinley campus. We have one new campus opening in January of this coming year a little further south. And then further north, we have another location that will be opening here in January of 2026.

If we're looking at who works here at Moffitt, and then specifically who works within our program, so as you can see here, we have a lot of APPs. I think, first glancing at this, the first thing that you'll note is the volume of APPs that we have, not just in our program, but throughout our cancer center. We have more APPs than clinical faculty. Our APP group encompasses nurse practitioners, PAs, CRNAs, and AAs. Within our GU program, we have 11 surgeons, 3 medical oncologists, 1 urologist, and then we have 22 APPs. That comprises for our program just nurse practitioners and PAs. And they work in a variety of different areas.

So in our program, we have APPs who do outpatient surgery. So those APPs see patients both with their faculty, as well as independently. They run independent clinics two to three days a week. On the inpatient side, we also have APPs who specialize in surgery. Those APPs are taking care of all of our patients who have surgery. They are also seeing patients who we get consults for. They are doing everything from admissions, discharges, daily rounding. We are the boots on the ground, seeing the patients throughout the day, all day, keeping their care team updated.

We also have APPs who strictly do hospital consults. We have our surgical hospital. We also have another location, our Magnolia campus. That's where our urgent care is. That's also where our hematology and oncology programs mainly have their patients. So we see patients there. And then we have outpatient medical oncology APPs. Those APPs strictly run off of their own independent templates. So that means all day, every day, they're seeing patients independently. They are clearing them for chemotherapy. They're seeing them for continued surveillance. They're seeing them for clinical trials.

And then we also have procedural APPs. Those are more on our surgery side. They work outpatient, and they work in the OR alongside our faculty, first assisting and taking care of patients. What we have found is that our APPs do a lot better when they are able to be involved. We have specific journal clubs for APPs. We also have a specific GU APP Journal Club. We do a lot during their initial orientation with onboarding, shadowing. They get to see other aspects within our program specifically, during that onboarding phase.

We work really hard to give them a gradual ramp-up time period because they're going to learn best when they're actually seeing patients themselves and taking care of them, dealing with those issues as they come up. But to do that, they have to begin with a template. So they start off with very small templates and increase that over a period of weeks to months to get to what we look at as a full template.

During that time, they have assigned mentors who are touching base with them each day. Those are other team members from our own department. We also have created recently a GU Lecture Series. We have other APP teams that are not GU-specific, that are more surgery-specific, so general surgery. And they help us with all of our surgical patients, which means they do interact with our GU patients.

So we identified a need to really educate everybody on our GU-specific issues. So we created this lecture series. We invite our faculty to present. Currently, our general urologist does a lot of presenting for that. And then we invite APPs to present as well because we know that we have some very experienced APPs who have worked in very specialized roles, and they also have a lot of knowledge to share.

We have weekly tumor boards, and our APPs are expected to join and participate in those. We have additional educational meetings that can range from fellowship conferences or resident-led meetings where they're able to present. We have invited speakers that come and present. And for all of those, even when they're geared more towards our trainees, our APPs are always welcome and invited to join those.

We have additional resources, like a Chemotherapy Prescribing Course that is Moffitt-wide that our APPs take part in so that they're able to take care of our patients, both on our medical oncology side and even our outpatient surgery side, where we're seeing even more clinical trials and medications being managed for those patients.

And then we also have a Clinical Ladder, and that's Moffitt-wide. It's not something that's GU-specific. The Clinical Ladder for APPs is a great opportunity for all these things that we know they're doing that are extra to get recognized because they're able to utilize some of those presentations that they're doing, the Journal Clubs they're attending, to get credit to help them meet their Ladder goals.

So how else do we use our APPs to get them to increase their knowledge, but also increase their involvement within our department and outside of our department? We do a lot of initiatives and optimizations. So one of the first things I did when I began as our supervisor, we did an overhaul on our templates. So our APPs weren't really working at the top of their license, independently seeing the types of patients and the volumes of patients that they could.

So we recognized that and created new templates that maximized that. One of the ways we were able to do that was utilizing virtual visits. Our APPs in our program see about 30% to 45% virtual visits for their EPs. And that's when it's clinically indicated, but patients are able to get labs, imaging.

Whether they choose to come to Moffitt and get that done, or they have it done outside, we're still able to get those records, see those patients, communicate the knowledge that we have, and manage those patients, which is especially important when we're talking about patients who live all over the state.

We've also added more new patient visits for our APPs. So this is helping to get patients the specialized care that they're looking for in a more timely fashion by really tapping into that expertise that we know these APPs have. They've worked hand in hand with our faculty, and they are able to see these patients and have those same conversations with them.

Patients are able to get that same level of expertise, and sometimes it just means that we're expediting their care. So we're able to see them quicker, get everything that the doctor is going to need when they see them, and they're able to get a full visit that can be completed in a more timely fashion.

And then we've also got APPs who are doing procedures in the clinic. That could range from cystoscopies to prostate biopsies. Outside of the clinic, we have a lot of involvement as well. So we encourage our APPs to attend conferences, to present at conferences. We have some who have been invited speakers at different presentations.

Some are even on the board. One of our APPs on our medical oncology side is one of the FLASCO APRN Liaisons and on the board of directors in that role. We have adjunct faculty. Everybody is encouraged to be in professional memberships and to keep those current. We precept a lot of students that come through our program, both on the PA side and on the APP side. And the Clinical Ladder that I talked about earlier — they're able to use a lot of this there as well.

So when we're talking about things I've talked about today, a lot of the things that have been really important for us in really utilizing our APPs is making sure that there is a really comprehensive orientation and onboarding phase and making sure that that's solid. It's critical to the success of our APPs.

When we're looking at, how do APPs practice in a specialty when they're not really given this level of information during their programs? It is through that work that we do within our program to make sure they're trained up so that they're comfortable and confident in managing these patients.

Really making sure that our APPs are able to be involved throughout any of these processes. Whenever we're piloting something new, we look for input from our APPs. Whenever we are looking at how to design those initiatives, I look for APPs who are willing to take on a role in that. They're able to then be invested in those initiatives. And it improves overall buy-in, which improves success.

And the most important thing I think we've seen more recently as we've continued to expand and grow our department is that those education pieces that we do in the beginning really have to continue, and they have to continue throughout our program. And the best way to do that is to use our APPs. They are all experts in different areas. Our APPs work with specific faculty.

So in GU, it means we have some who may see three different types of malignancies. We have some who may just only see primarily prostate cancer. But with that, they have very specific and important knowledge. And they are all ready and willing to share it with their peers.

Diane K. Newman: Thank you so much. I mean, I'm really impressed. I mean, you have a really comprehensive educational program for your APPs. Tell me, I guess, whenever you hire, you don't have APPs that really have urology background, right? How many months does it take to onboard someone, like, what type of mentoring program, the specifics around that you have?

Rachelle Rodriguez: So I think that is a difficult question for what we do. So since I've been our supervisor, I actually counted recently, and I think I myself have hired 13 new APPs into our department. And of those specifically, two have had urology background.

One was hired into an inpatient role and had prior inpatient and outpatient background, and another one was hired into an outpatient role and had prior outpatient background. And actually, I have one more who came from another cancer center, outpatient background, but she came into an inpatient role. So she, I would say, had the most amount of base knowledge coming in.

The problem is, even if they have urology experience, since we're at a cancer center, it is still not the same as what they're seeing when they're working in a community urology office. Some of the stuff is the same. And actually, some of them have completely different knowledge, which is still useful. When they're more on the oncology side, it's not as useful in their day-to-day.

But for our APPs who are inpatient or who are seeing consults that may not be oncologic in nature, they're tapping into that other general urology experience that some of our peers have as well. But the overall pathway and what it looks like when we're onboarding someone, there's a give-and-take because we have to see fairly early on that they're going to be able to do what we need them to do.

So I have to give them a lot of education up front and have them start doing things, whether that's working on the inpatient side, working in the OR, seeing outpatients. But then I need to slowly continue to grow them. So for about the first four weeks, I usually have them in a much more shadowing role, where they're just getting a lot of exposure.

They're hearing a lot of very specific conversations with different faculty and different APPs, and they're not expected to really start doing notes or start doing all their documentation, because the important part early on is what you're hearing. Like, you need to hear these conversations to be able to understand them and really partake in them next.

And then there's that ramp-up phase that I talked about. So they start with really small templates. In general, since we have a very specialty population, our surgical APPs usually see between 12 to 14 patients per day. And on the medical oncology side, they're seeing between 10 and 12 patients per day. And those numbers are the same for virtual visits. Most of our APPs see 14 patients per day when they're doing full remote days.

And so when our new APPs — whether they're experienced or are a new grad APP — when they start seeing patients, they start at three to four patients a day. And then what I found from feedback from our other APPs is that getting through that first half of patients and working up to about six to seven patients is fairly easy. It's at that number, where that ramp-up slows down so that, even adding one patient, they get a couple days. Then we add another patient — a few more days with that.

And they work up to the low end of what their expectation is, and they stay there for their first full year. They're not expected to overbook patients. They're not expected to increase that template to full capacity their first year.

Diane K. Newman: Oh, that's really impressive. I was going to ask you how long it takes them to go onboarding. That really gets them that they are knowledgeable and really competent and feel secure in what they're doing. I was really impressed with your Journal Club. Is it run by an APP? Or tell me a little bit about that because I haven't seen that in a lot of the models that I've looked at around the country. So that's impressive.

Rachelle Rodriguez: So we have two journal clubs that are run by APPs, one that's GU-specific. So both our GU surgery, medical oncology, inpatient, outpatient, all of our APPs join that one. Now we've grown. It used to be that we didn't even have enough APPs for each one to present just once a month for the year. And now we've grown it so much so that we're able to do presentations monthly. And we're able to have a different APP sign up for each month.

And so they pick their article. They talk about it. They are usually encouraged to pick something that's very specific to what they are our own expert on. And then there's another journal club that our satellite multi-specialty medical oncology APPs run. So those are APPs who work at those various other additional sites, but they do see some urology patients from our medical oncology side. And so we're also all invited to do that Journal Club with them.

And then our Fellows have their own Journal Club. And our medical oncology team has a Journal Club as well, which the APPs are invited to. But what I found is the APPs are more willing to involve themselves and share and speak up in our APP-run Journal Club.

Diane K. Newman: Yeah, that makes sense, doesn't it? Because they probably feel more comfortable, and they can really share a lot at a different level, I think, than maybe the medical oncologists and that. What meetings, professional meetings, do you really recommend for your APPs then? Is that something that's supported by Moffitt?

Rachelle Rodriguez: Yeah, so our APPs do get — part of their package includes funds for conferences, for registrations, for travel. And they do have some days that are allocated for conferences or CME events. For our department, we have a lot of APPs that regularly attend AUA. We have APPs that regularly attend ASCO, SUO. They've done the SUNA conference as well.

And then we have some APPs who like to attend conferences that are more general, like the AANP conference or just ONS. We have some who have gone to leadership conferences if that's something they're more interested in. There's no restriction on the type of conferences they can go to.

I was actually just speaking to some of our inpatient APPs today, and we were talking about the Society of Hospital Medicine. Since we're hospitalist, we're our primary team. For our inpatients, we are the admitting team. We are the attending team. So we don't involve medicine for the care of all of our patients. So some of those other topics are just as important for our APPs.

Diane K. Newman: Well, thank you so much. I mean, this is so informative. And your model is actually one of the most comprehensive I've seen as far as your education, but also your numbers. I see that, yes, you have a large number just in oncology. But you really have a good number in urology. So I can see, too, there's a lot of probably partnerships and collaboration between them. So I really appreciate you sharing this.

Rachelle Rodriguez: Yeah, absolutely. We have significantly grown our urology department. Our physicians have grown, but our APP growth over the last five years has outpaced our physician growth.

Diane K. Newman: Wow. And I'm hearing that everywhere. I mean, it's just, we're needed. APPs are needed in urology. And it's such a nice collaborative practice with urologists, so it's nice to see your model. Thank you so much for sharing.

Rachelle Rodriguez: Yeah, you're welcome.