Peer Reviewed

The Role of Advanced Practice Providers in Vestibular Healthcare

By Maria Machala, MS, NP

I hear it all the time from my patients. Long wait times, numerous consults, tests, and opinions, and no definitive answers. Dizziness has become chronic and debilitating, and it seems there is no end in sight. There are a few well-defined categories of dizziness, but none of these diagnoses really encapsulate their symptoms, and therefore no clear path forward is recommended. Each specialist has found inconclusive results and deemed the cause to be outside of their specialty. No wonder patients often become anxious and discouraged. I feel very grateful to be able to offer answers, treatment options, and hope to these patients.

Why is evaluation and management of dizziness tough for health care providers? The answer is multifactorial. Our balance system is very intricate – proprioception, vision, inner ear, and brain need to work in harmony. These individual organs are well-managed by subspecialists, but when it comes to putting it all together, no one seems to be talking.

“Dizziness,” the word itself, is also complex, at least when it comes to listening to patients’ symptoms. It can be used to describe lightheadedness, imbalance, vertigo, wooziness, unsteadiness, floating, feeling “off,” etc., the list goes on and on. A patient may use a word that seems to best describe what they are feeling, however it might have a different meaning to the provider. This can lead down a road of diagnostic testing that is far off from elucidating the cause.

I am a nurse practitioner, and I have been fortunate to work with some of the best neurotologists that have had an integral part in shaping what we know about the vestibular system. I have learned so much from them, the elaborate anatomy and physiology of the inner ear and neural pathways, how to order and interpret diagnostic tests, and how to provide care for these complex patients in a thoughtful and compassionate way. These incredible physicians are also very busy surgeons placing cochlear implants, resecting skull base tumors, performing microscopic surgeries in the middle ear for hearing loss and chronic infection, and more. The vast number of vestibular patients creates a deficit of physicians who can manage them.

That is where advanced practice providers (APPs) come in. The role of the APP was born out of the imbalance between physicians and the number of patients needing care. The nurse practitioner (NP) role was created in 1965 by Henry Silver, MD, and Dr. Loretta Ford, an acclaimed nursing leader at the University of Colorado, due to insufficient pediatric primary care. It is based on the nursing model which focuses on holistic, patient-centered care. The physician assistant (PA) program was also started in 1965 by Dr. Eugene A. Stead Jr. at Duke University in North Carolina. Again, this was in response to a shortage of primary care providers, and the program was modeled after fast-track training for doctors during World War II. Today, as knowledge about the human body and medicine increases exponentially, the need for primary care providers and specialists also increases. NPs and PAs, collectively known as APPs, have the unique opportunity to care for patients who do not fit into any one specialty, as formal training is broad, but the “on-the-job training” is meant to be catered to what the particular needs of the practice are.

Dizziness is one of the most common chief complaints in primary care and emergency care and has causes that span specialties, so there isn’t one specialty that can fully manage all patients with this complaint. APPs often have shorter wait times, can determine the appropriate workup that is needed, and either manage the patients themselves or can get them in with a neurologist or otolaryngologist in a timely manner. Having an APP vestibular specialist can expedite care and cut down on health care costs by avoiding unnecessary consults and testing. This would help to relieve the heavily burdened clinics in neurology, ENT, and primary care. The benefits would extend not just to patients, but to physicians and our healthcare system in general. As an APP, it is highly rewarding to be able to care for these patients and provide them with the hope and care that they had been so desperately searching for.

To conclude, I encourage patients to seek out MDs or APPs who are truly passionate about caring for those with vestibular disorders. These can be found in the VeDA directory. I encourage APPs with an interest in vestibular disorders to partner with other vestibular APPs, physicians, audiologists, and physical therapists; we learn best from each other. I encourage MDs to invest in your APPs who not only can provide exceptional care, but who also allow for you to efficiently provide care to patients who require your expertise.

National APP Week is September 25-29, 2023