Case 39: The Value, Development and Management of GI Advanced Practice Provider Fellowships

August 13, 2026

APP Angle. Resources for APPs.

Question

Which of the following statements about the Advanced Practice Provider (APP) workforce pipeline are true?

  1. APPs will enter the workforce in 5-fold greater numbers than physicians from 2023–2033
  2. 29.8% of early-career APPs change practices within 3 years
  3. APP turnover costs range from $85,832 to $114,919 per episode
  4. APPs in smaller practices with fewer colleagues have higher turnover
  5. All of the above
Show Answer

The correct answer is E, All of the above.

The Challenge

Your GI division has had three APP departures in 18 months. Each vacancy takes an average of six months to fill, and newly hired APPs require an additional 6 months of informal onboarding before they can practice with any degree of independence.1-2 During these gaps, physician workload increases — endoscopy schedules tighten, clinic wait times grow, and inpatient consult response slows.3 Remaining APPs absorb extra coverage, accelerating burnout and raising the risk of further turnover.4

Meanwhile, your division struggles to recruit subspecialty-ready APPs because few training pathways exist; most new graduates require extensive on-the-job training that pulls physicians away from clinical duties.5 Your department chair asks for a sustainable solution — not just another job posting, but a strategy that addresses the root causes: lengthy onboarding, limited subspecialty readiness, inconsistent training, and weak retention. You propose a structured GI APP fellowship program.

Why It Matters: The Workforce Case

  • APP workforce growth is projected to far outpace physician growth from 2023–2033, yet subspecialty-trained APPs remain scarce.6
  • NP numbers grew 49.4% and PA numbers 73.9% between 2016–2022.7
  • 14.4% of early-career APPs change practices within 1 year; 29.8% within 3 years.1
  • APPs who leave tend to be in smaller practices with fewer colleagues — highlighting the importance of team structure and professional development.8

The Cost of APP Vacancies

  • Across published studies in various specialties, average onboarding duration for non-fellowship-trained APPs ranges from 25 to 26 weeks, with total vacancy costs (including lost revenue) reaching up to $361,714 per APP while direct turnover costs alone range from $85,832 to $114,919 per episode.1,3,9
  • Indirect costs compound direct losses: lost clinic/endoscopy revenue, reduced patient access, increased physician burden, and remaining staff burnout during prolonged vacancies.4

APP Fellowship Program Structure

  • Duration: 12 months
  • Format: Accept both NPs and Pas
  • Core Rotations (4-12 weeks): General GI, hepatopancreatobiliary, hepatology, inflammatory bowel disease, inpatient consults, esophageal
  • Subspecialty Rotations (2-4 weeks): Motility, nutrition, pelvic floor therapy, GI psychology, multidisciplinary clinic, endoscopy
  • Didactics (4-8 hours/week): Weekly didactics through American College of Gastroenterology (ACG) Education Universe platform, weekly division grand rounds, teach back lunch and learn sessions, shared foundational content with hospital medicine APP fellowship
  • Evaluations: Quarterly milestone grid structured from ACGME core competencies, pre/post confidence survey, mini-CEX bedside evaluation, end of rotation fellow evaluation (completed by preceptor), end of rotation preceptor evaluation (completed by fellow)
  • Assessment: End of rotation fellow self-assessment, end of rotation exam for core rotations
  • Completion: End of fellowship comprehensive exam, exit survey
  • Other: Mentorship curriculum and Quality Improvement/Education project submitted for publication at the end of fellowship

The Team

  • Program Director (PD): Senior APP or physician; owns curriculum, evaluation, and accreditation compliance
  • Medical Director: Senior APP or physician providing clinical oversight and serving as program champion
  • Associate Program Director (APD): Seasoned GI APP supporting day-to-day operations, mentorship, and remediation
  • Clinical Preceptors/Faculty: GI physicians and experienced APPs who provide direct clinical supervision, procedural training, and competency assessment; serve as rotation-specific evaluators and role models
  • Office of Advanced Practice (OAP): Institutional infrastructure for credentialing, professional development, and workforce strategy

Program-Level Metrics

  • Fellow retention rate post-graduation: Percentage of graduates retained within the institution or GI division at 1, 3, and 5 years — directly reflects program ROI and culture.
  • Time to independent practice: Weeks from hire to practicing without direct supervision.
  • Vacancy cost avoidance: Estimated dollars saved per hire cycle by reducing onboarding duration and turnover.
  • Patient access metrics pre/post implementation.
  • Clinical productivity at 6 and 12 months post-graduation:  wRVUs, patient encounters, panel size, wait-times, compared to non-fellowship-trained APP hires at the same time points — demonstrates accelerated ramp-up and validates the training model.

Key Takeaways

  • GI APP fellowships address a critical workforce pipeline gap and reduce costly turnover.1
  • Strong leadership (PD, Medical Director, APD, OAP) is essential for program success. Effective programs require clearly defined roles.5
  • ACGME competencies provide a rigorous, validated assessment framework. Competency-based medical education (CBME) places learners at the center of training.10
  • Structured training improves both APP and physician satisfaction.
  • Measurable outcomes validate program investment.1
  • When fellowship graduates reach independence faster, stay longer, and generate clinical revenue sooner, the program transforms APP staffing from a recurring cost center into a sustainable workforce strategy.5

References

  1. Lackner C, Eid S, Panek T, Kisuule F. An Advanced Practice Provider Clinical Fellowship as a Pipeline to Staffing a Hospitalist Program. J Hosp Med. 2019;14(6):336-339. doi:10.12788/jhm.3183
  2. Newton L, Sulman C. Implementation of a phased onboarding program for novice advanced practice providers. Int J Pediatr Otorhinolaryngol. 2025;193:112363. doi:10.1016/j.ijporl.2025.112363
  3. Li X, Patt E, Koehn M, et al. Throughput Benchmarking and Throughput Variance Analysis to Evaluate the Efficiency of an Outpatient Endoscopy Unit. J Med Syst. 2026;50(1):101. doi:10.1007/s10916-026-02427-9
  4. Lee AI, Masselink LE, De Castro LM, et al. Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support. Blood Adv. 2023;7(13):3058-3068. doi:10.1182/bloodadvances.2021006140
  5. Klimpl D, Franco T, Tackett S, et al. The Current State of Advanced Practice Provider Fellowships in Hospital Medicine: A Survey of Program Directors. J Hosp Med. 2019;14(7):401-406. doi:10.12788/jhm.3191
  6. Bureau of Labor Statistics. Occupational Outlook Handbook. Published 2024. Accessed January 6, 2025. https://www.bls.gov/ooh/
  7. Rotenstein LS, Apathy N, Edgman-Levitan S, Landon B. Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings. JAMA Netw Open. 2023;6(6):e2318061. doi:10.1001/jamanetworkopen.2023.18061
  8. Hyman MJ, Litwack K, Quallich SA, et al. Turnover Among Early-Career Advanced Practice Clinicians. JAMA Netw Open. 2025;8(4):e255407. doi:10.1001/jamanetworkopen.2025.5407
  9. Gheihman G, Vgontzas A, Paulson J, et al. Integrating Advanced Practice Providers in an Academic Department of Neurology. Neurol Clin Pract. 2021;11(6):462-471. doi:10.1212/CPJ.0000000000001077
  10. Cooper D, Holmboe ES. Competency-Based Medical Education at the Front Lines of Patient Care. N Engl J Med. 2025;393(4):376-388. doi:10.1056/NEJMra2411880

Author

Catherine (Cate) Brady, MPAS, PA-C

Catherine (Cate) Brady, PA-C, MPAS, is an Assistant Professor at the University of Colorado Anschutz Medical Campus and a practicing physician assistant specializing in gastroenterology. She serves as Medical Director of the Advanced Practice Provider (APP) Gastroenterology Fellowship, where she focuses on APP education, workforce development, and training in complex digestive diseases. Her academic interests include APP fellowship development, competency-based education, and improving access to high-quality GI care.

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