Advanced practice providers (APPs) are increasingly valued — and needed — in rheumatology practices, yet some rheumatologists report that retaining nurse practitioners (NPs) and physician assistants (PAs) can be challenging.

Medscape Medical News spoke with Janine Shinn, MPAS, PA-C, a board-certified PA who has been working in rheumatology since 2014, about how she was trained and onboarded, why she has no plans to leave rheumatology, and the advice she has for rheumatologists who are seeking long-lasting partnerships.

Shinn practiced for 12 years at Rheumatology Associates in Dallas and joined the North Texas Center for Rheumatology, also in Dallas, at the end of 2025. The conversation has been edited for length and clarity.

Why did you choose rheumatology?

I went to the UT Southwestern Medical Center PA school, which provides some training in rheumatology. (This is not always the case in APP training.) And during my internal medicine hospital rotation, I had a couple of rheumatology patients. Both experiences were interesting, so when it came time to choose an elective, I chose rheumatology and worked at Rheumatology Associates in Dallas with Stanley Cohen, MD. I found it fascinating.

About 8 weeks after I completed my rotation there, they reached out to me about a job opening.

How were you trained and onboarded? What did you like about the process? And what did you find most challenging?

Dr Cohen was the major force in training me. I started by seeing new patients. I was well trained to do a history and physical exam, and if I missed something, Dr Cohen would tell me when I presented the patient to him. Then we’d meet together with the patient to ask any additional questions and discuss a management plan.

Little by little, I then began to shadow Dr Cohen and another physician on follow-up visits. I learned to ask the right questions. And after several weeks, I began to see follow-up patients on my own, consulting with the physician when I had any questions.

There is a huge learning curve in rheumatology, and it can be very intimidating. And for me, it was even more challenging because I was a new PA as well. But the physicians I worked with never made me feel as if I was wasting their time with a question. I never felt denigrated for not knowing something. They were always supportive.

In addition to training on the job, I also took an online training program for fellows offered by the American College of Rheumatology. The practice absorbed this cost. It was not taken out of my continuing medical education budget.

It wasn’t until 2 years in, approximately, when I felt I could see every patient without needing to consult with the physician. I’d still ask questions occasionally to Dr Cohen, who often sees particularly complex patients referred to him by other rheumatologists.

Can you describe your relationship with the physicians you’ve worked with, and what has made you feel valued and respected?

At Rheumatology Associates in Dallas, for both of the physicians I worked with, the patients were the physician’s patients, but they sometimes saw me, and I would do whatever the physician would do: perform assessments, adjust medications, order tests, etc. I like patient relationships, and it gave me confidence to hear that sometimes patients requested follow-up visits with me.

Practicing as a PA has required a balance of confidence and humility. You have to have confidence in your own ability, and the physician has to have confidence in you. At the same time, you need to have the humility to know what you don’t know. Asking questions has to be recognized by the physician as a good thing and not be penalized. This not only builds confidence for the PA, but the physician, in turn, knows that you won’t overstep your abilities.

This is the kind of relationship I’ve had. I was trained to learn, and there were no repercussions for asking questions or for being corrected. There has been mutual respect.

Rheumatologists not uncommonly speak about challenges with retaining APPs. What would you like rheumatologists to appreciate about how PAs and NPs can be successfully integrated and retained?

First and foremost, it is important for physicians to have realistic expectations for how much an APP knows and how quickly they can ramp up. It took me 2 years. Some practices want you to be there in 2 months, and I just don’t think that’s realistic.

It’s also important to discuss at the start the intended scope of practice and the envisioned range of responsibilities. I’ve seen PAs surprised by responsibilities or tasks that they weren’t at all expecting. Likewise, having a mechanism for ongoing feedback, maybe a monthly or quarterly meeting between the APP and physician, may help prevent any pent-up frustration from building.

Especially in the beginning months and years, being able to access the physician with questions is invaluable. If practices can build flexibility in the physician’s schedule so they can be available for consultation right when questions arise, this will work best for the patient and for the PA to be able to learn.

And again, mutual respect is super important. APPs who feel respected and valued are more likely to stay. They can be empowered as reliable partners. When physicians convey to patients their confidence and trust in their PA — by saying ‘I trained her, and I have confidence in her’ or ‘I’d like you to see my PA next time, I trust her’ — it can be really helpful for getting patients on board to see the APP and for fostering long-term relationships.

We hear all the time that once patients see an APP, they like the experience because the NP or PA spends more time with them. Practices can use this to their advantage — generating goodwill with patients — by guarding against making APPs’ schedules too tight. A few extra minutes with a patient can make a difference.

Finally, the compensation model matters. I’ve worked both as a salaried PA with a bonus structure and on an relative value unit basis, and I much prefer a salary-based model. Being paid based on only billable work can create situations where the APP has to push back when asked to take on non-billable tasks. I prefer not to be in that situation; I want to be able to take on tasks that the physician needs help with.

Many PAs today have a base salary, and there’s a trend toward a productivity bonus of some sort. This is a good model that helps to prevent conflict in the APP-physician relationship.

Why have you stayed in rheumatology and not pivoted to another specialty? And what qualities should a rheumatology practice look for in hiring an APP for the long-term?

My husband’s nickname for me is ‘the investigator.’ This helps explain why rheumatology is a good fit for me. There is no organ system that isn’t affected by rheumatic diseases, and there’s little you don’t need to think about. In addition to the detective work, I also like the patient relationships very much. And, again, there has been mutual respect and support from the physicians I’ve worked with.

To enjoy rheumatology, an APP should have a love of learning and initiative. I’d advise rheumatologists to look for an APP candidate who is poised to be proactive and think ahead about things like implementing clinical disease measures for monitoring, or screening patients who might be in high-risk categories — such as for interstitial lung disease in rheumatoid arthritis or nephritis in lupus — or coordinating with an interdisciplinary team. An APP should also be a team player. People who can’t get along well with others will not do well in this role.

Shinn had no relevant financial relationships to disclose.