Role of Advanced Practice Providers in Orthopaedic Care

Ryan Desgrange, DMSc, MPAS, PA-C

Stephanie Muh, MD, FAAOS

Dr. Muh or an immediate family member serves as a paid consultant to or is an employee of Arthrex, Inc., DePuy, a Johnson & Johnson Company, and Exactech, Inc.; has received research or institutional support from Exactech, Inc. and Smith & Nephew; and serves as a board member, owner, officer, or committee member of American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Shoulder and Elbow Surgeons. Neither Dr. Desgrange nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.

INTRODUCTION

The addition of advanced practice providers (APPs), including physician assistants (PA) and nurse practitioners (NP) within an orthopaedic setting, has proved to be invaluable in not only providing safe and reliable care, but also in driving efficiency and profitability within a practice or hospital setting. Time and research have shown that APPs are a cost-effective solution to enhancing the patient care experience and in offering an affordable solution in both an established and an expanding orthopaedic practice. Although commonly grouped together at times for administrative purposes, PAs and NPs have their own respective differences regarding education, training, scope of practice, and salary. The goal of this chapter is to provide the orthopaedic clinician or administrator with the background and information about these two professions in order to decide how to best use the APPs for their specific goals.

Within the orthopaedic practice, APPs have traditionally been used to provide inpatient hospital care, outpatient clinic care, operating room first assist, emergency room consultations, and community outreach and education, as well as possible call coverage. The needs of the specific orthopaedic practice need to be taken into consideration when deciding how to best use an APP. Although sometimes grouped into APPs with PAs and NPs, certified athletic trainers may be a useful adjunct to an orthopaedic practice to offload clinical and administrative burdens of the physician. They can be used to assist with wound management, completing office paperwork, providing patient education, fielding patient care questions, and many other tasks that are helpful to an orthopaedic practice. The focus of this chapter will be the use of PAs and NPs within the orthopaedic setting.

PHYSICIAN ASSISTANTS

PAs and NPs are being increasingly integrated in orthopaedic systems of care due to the exponentially increasing service demand by the aging population.¹ According to the 2023 U.S. News Best Jobs rankings, the PA profession ranks fourth overall behind nurse practitioner, software developer, and dentist.² PAs are educated in a manner similar to their physician colleagues with regard to the medical model of learning, where the focus is more on the pathologic and biologic components of patient health³ (Table 1). The profession began in the mid-1960s as a response to a shortage of primary care physicians. Through the Duke University Medical Center, Dr. Eugene Stead Jr chose four Navy Hospital Corpsmen who had extensive medical field training to be among the first individuals to be a part of the first graduating PA program in the United States. The PA curriculum was based on the “fast-track” training of doctors during World War II.⁴

The PA profession is a master’s level degree, with most programs lasting 26 months. Recently, hybrid tracks have allowed PAs to pursue an online learning component rather than the traditional in-person didactic route. There are currently 268 Accreditation Review Commission on Education for the Physician Assistant approved PA programs.⁵ PAs during their training complete more than 2,000 hours of clinical rotations (surgical rotation is a mandatory item). Upon successful program completion, the candidate may sit for the Physician Assistant National Certifying Exam administered by the National Commission on Certification of Physician Assistants.

Maintenance of certification is achieved by successful completion of 100 continuing medical education credits every 2 years along with passing the recertification every 10 years.⁶ Over the past few years, PA programs also have started to offer a doctorate level degree that can be completed in 1 year, typically while continuing to practice as a PA.⁷ It is an attractive emerging trend for those wanting to transition into education, administration, and leadership.⁸ PAs may also apply to various orthopaedic fellowship or residency programs in the United States to further develop their education and improve marketability for future job opportunities in orthopaedics. Most of these programs last 12 months and provide exposure to all orthopaedic subspecialties, and often include a stipend, health insurance, textbooks, meal allowance, vacation, and a certificate of completion in some programs.⁹

PAs can also obtain specialty certification (one of seven specialties) in terms of an Orthopaedic Surgery CAQ (certificate of additional qualifications) by accumulation of at least 4,000 hours of experience in orthopaedics, knowledge/skill attestation by a physician or lead PA, and successful completion of the National Commission on Certification of Physician Assistants – approved specialty examination.¹⁰ The specialty certification has been seen as a way to show competency in the specialty, justify increased pay, and expand one’s knowledge base. All PAs are required to obtain a state licensure to practice medicine; some states also require a controlled substance license to prescribe opioid medications. A collaborative or practice agreement is required for scope of practice and supervision of the PA

with a reporting physician assigned in accordance with state law or at the practice level.¹¹ PAs can write prescriptions in all 50 states, but Kentucky does not allow PAs to prescribe controlled substances.¹²

TABLE 1 Physician Assistant/Nurse Practitioner Comparison

	Physician Assistant	Nurse Practitioner
Required background before program eligibility	Bachelor’s degree with program-specific prerequisites in conjunction with generally more than 2,000 direct patient contact hours	Bachelor of science in nursing with state licensure as a registered nurse
Degree upon graduation	Master of Science as a physician assistant. Doctorate level available at some campus and online locations	Master of Science in nursing with specialty concentration focus. Doctorate level available (encouraged by American Association of Colleges of Nursing)
Program details	At least 1,000 didactic hours and a minimum 2,000 clinical hours over 24 to 36 months depending on the program	At least 500 didactic hours and 500 clinical hours over 15 to 24 months depending on the program
Accreditation	Accreditation Review Commission on Education for the Physician Assistant	Accreditation Commission for Education in Nursing Commission on Collegiate Nursing Education
Licensure	Master’s degree as PA with national certification	Registered nurse licensure as well as master’s or doctorate level nurse practitioner degree with national certification
Certification	Successful completion of the Physician Assistant National Certifying examination through the National Commission on Certification of Physician Assistants	Specialty certification from: American Academy of Nurse Practitioners American Nurses Credentialing Center
Recertification	100 hours of continuing medical education (CME) every 2 years with recertifying exam every 10 years by passing the Physician Assistant National Recertification Exam	Must be completed within 5 years every cycle with option clinical practice hours (at least 1,000) and minimum 100 continuing education hours (American Academy of Nurse Practitioners Certification Board) or sit for specialty concentration exam
Practice restrictions	Practice medicine with a practice agreement with participating physician	Depending on state regulations, nurse practitioners in almost half the states possess full practice authority. Most often work with a supervising physician
Additional specialty designation	Certificate of added qualifications (CAQ) in orthopaedic surgery recertifying every 10 years with concurrent physician assistant licensure and at least 125 continuing medical education credits in specialty during 10-year cycle	Orthopaedic nurse practitioner (ONP-C) recertifying every 5 years with concurrent nurse practitioner licensure

According to the US Bureau of Labor Statistics 2021, the median annual salary of a PA was $121,530 per year (Table 2), with an expected growth of 28% between the years 2021 to 2031.¹³ Historically, PAs in surgical specialties such as orthopaedics
have a higher salary in comparison with other nonsurgical specialties. The 2020 American Academy of Physician Assistants salary review showed that the base salary of an orthopaedic surgery PA in the 50th percentile was $120,000, with an average bonus of $7,750.¹⁴ The 2022 Physician Assistants in Orthopaedic Surgery salary survey of 1,159 of its members demonstrated that mean annual base salary was $128,585 with a mean total compensation (including bonus, office/hospital call, and other resources) of $144,282, with slight variations based on geographic location.¹⁵

TABLE 2 Physician Assistant/Nurse Practitioner Salary Demographics

	Physician Assistant	Nurse Practitioner
Overall median base salary (orthopaedic specialty)	$112,000	$113,000
Median base salary per US region (nonspecialty)
Region 1 (CT, MA, ME, NH, RI, VT)	$110,000	$115,000
Region 2 (NY, NJ)	$113,000	$123,000
Region 3 (DE, MD, PA, VA, WV, DC)	$103,205	$114,000
Region 4 (KY, NC, SC, TN)	$101,888	$110,000
Region 5 (IL, IN, MI, MN, OH, WI)	$107,000	$110,000
Region 6 (AR, LA, OK, TX)	$105,000	$118,000
Region 7 (IA, KS, MS, NE)	$102,500	$110,000
Region 8 (CO, MO, ND, SD, UT, WY)	$109,750	$113,000
Region 9 (AZ,CA, HI, NM, NV)	$117,500	$133,000
Region 10 (AK, ID, OR, WA)	$117,500	$125,000
Region 11 (AL, FL, GA, MS)	$102,750	$110,000