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Advanced Degree Practitioners Partner with Physicians to Provide Quality Care

New York (May 24, 2010)

Increasingly, physicians in hospitals and in private practice are calling on the skills and expertise of healthcare professionals with advanced degrees and medical training to assist them in providing quality and personalized healthcare for their patients. Known as "physician extenders," these healthcare providers include physician assistants and nurse practitioners that function under the supervision of a physician but may diagnose, order tests, develop treatment plans, and write prescriptions.

"Our nurse practitioners and physician assistants are critical to our practice," says David P. Roye, Jr., MD, Chief of Pediatric Orthopaedic Surgery at NewYork-Presbyterian Morgan Stanley Children's Hospital. "Our physician assistants and nurse practitioners are healthcare providers. They see and take responsibility for the physical examination, diagnosis, and treatment of patients with Orthopaedic disease. They are very experienced, well-trained and have a role that's not unlike a non-operative orthopaedic surgeon.

"The education of a nurse practitioner is similar to that of a physician provider - not as in depth and not quite as long - however, they study physiology, anatomy, disease processes, pharmacology and their clinical practice as nurse practitioners is indeed clinical practice," continues Dr. Roye.

Physician assistants (PAs) also play an integral role in the orthopaedic surgery team. "Our PA oversees our club foot clinic and makes sure that the casts are applied properly, that the follow-up is done and that care is delivered efficiently and well. She also has responsibility for running our clinical team, which includes two medical assistants and two nurse practitioners."

Advanced Training Required

Nurse practitioners have completed a registered nursing degree as a part of a bachelor's degree, plus a master's degree. A nurse practitioner is state-licensed and may be certified in a specialty area, such as family health, orthopaedics, oncology, or pediatrics. They provide a broad range of services, focusing on patients' conditions, as well as the effects of illness on the lives of the patients and their families. Their core philosophy is individualized care, emphasizing prevention, wellness and patient education, and counseling.

Nurse practitioners may also advance in their education and training to become a doctor of nursing practice (DNP). "That level of expertise is really quite amazing in terms of diagnosing not only orthopaedic problems, but also the medical problems that may be associated with it, for example, knowing how to care for a child who has cerebral palsy with pulmonary and some gastrointestinal issues, or knowing how to care for patients who have post-surgical infections or post-surgical complications, or orthopaedic management by bracing. These providers become more and more expert as they go on in their education," says Dr. Roye.

Physician assistants are state-licensed and certified to practice everything from basic primary care to specialty procedures under the supervision of a physician. PAs deliver a broad range of comprehensive medical and surgical services and conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and prescribe medications. The typical PA training program is 24 to 32 months long and requires at least four years of college and some healthcare experience prior to admission.

"PAs are more technical in their training," says Dr. Roye. "Some of the PAs in cardiac surgery actually assist in the operating room and take care of the patient's pre-operative, intra-operative and post-operative care."

A Holistic Approach

According to Dr. Roye, nurse practitioners pursue a more holistic approach in caring for patients than many surgeons. "There is a philosophical alignment that's a little different in nursing than in medical clinical practice," he says. "In nursing it's more holistic. It's looking at the patient as a whole, considering all of the patient's issues and problems and how the family and environment are impacting on the patient's illness. I think that in many ways the NP can often arrive at a better treatment plan because of this personalized holistic approach."

Michael G. Vitale, MD, MPH, Associate Chief of Pediatric Orthopaedic Surgery and Chief of the Pediatric Spine Service at Morgan Stanley Children's Hospital, agrees. "Nurse practitioners and physician assistants are generally very effective in coordinating the complex medical and social needs of many of our patients," he says. "They are available all the time to our patients, when, as surgeons, we can't be immediately available. I think they improve our quality of care, and they improve patients' access to subspecialty care."

A number of the children who come to the Department of Orthopaedic Surgery have conditions that do not require surgery. "The vast majority of children who have a gait disturbance like flat feet, toe walking, bow legs or knock knees are really just exhibiting normal developmental issues," says Dr. Roye. "Once we have ruled out other things and made sure there are no neurological or structural boney problems, what the parent then needs is reassurance. The nurse practitioner or physician assistant is the perfect provider for this family because he or she will talk to the family, do the complete exam, do the teaching and provide the reassurance that will get the family past this and allow them to be happy and know that their child is normal."

Improving Quality and Access to Care

Drs. Roye and Vitale both stress the vital partnership of physicians and physician extenders that ultimately results in improved quality of care. "We have a collaborative relationship with our nurse practitioner and physician assistant colleagues," says Dr. Vitale. "I think this partnership will grow over time. It's good for patients, and it is certainly helpful for physicians in allowing us to focus on our specialty."

"NPs and PAs improve the quality of care we provide to our patients because of the time they can spend with them," adds Dr. Roye. "That time is really critical and looking at that patient as a whole and also understanding the educational needs of the parent is so important."

Faculty Contributing to this Article:

David P. Roye, Jr., MD, Chief of Pediatric Orthopaedic Surgery at NewYork-Presbyterian Morgan Stanley Children's Hospital, and the St. Giles Professor of Pediatric Orthopaedic Surgery at Columbia University College of Physicians and Surgeons

Michael G. Vitale, MD, MPH, Associate Chief of Pediatric Orthopaedic Surgery and Chief of Pediatric Spine and Scoliosis Surgery at NewYork-Presbyterian Morgan Stanley Children's Hospital, and the Ana Lucia Associate Professor of Clinical Pediatrics and Orthopaedic Surgery at Columbia University College of Physicians and Surgeons

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