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Pediatric Orthopaedic Practitioners Society POPS

Question from POPS member Tanisha George Daugherty

Posted almost 2 years ago by Suzanne Hilt

Our department had a change in leadership and is going through a huge restructure. We have lost 10 APPs in the last 18 months and are on the verge of losing another 5. Anyone who is willing to answer my questions is greatly appreciated. As not to overwhelm my fellow colleagues, I’ll just start with our top concerns.

1. How does your department utilize the APPs?

- APP teams with 1 or more MDs for clinic and/or OR coverage. If so, in clinic are the schedules shared or concurrent? Does MD see every patient APP evaluates? Do you travel with MD to all offsite/health center locations?

- APP practices independently? If so what, what type of patients are seen? Returns only or both new and return patients?

- Do APPs run specialty clinics? If yes, what types?

- Any other models/situations/scenarios you can comment on?

2. What are the APP schedules and hours? Weekdays only? 5- 8 hour shifts, 4-10 hour shifts, 3-12 hour shifts? Nights, weekends?

Thank you so much!


Lyndsey Battaglia almost 2 years ago

I'm so sorry to hear this! I hope things improve. I am in a smaller center and have only 2 APPs in our peds division. We see patients independently which include new, follow ups, post-ops, preops, trauma and general peds ortho. We have preferences on what we prefer to see, but generally, we'll see anything that doesn't necessitate a surgeon eval only. We are attempting to develop service lines, but this is an ongoing process. Our residency program is large so there is rarely a need for OR support. We rotate inpt/outpt coverage and on outpt weeks go to a clinic a few miles away from the hospital in addition to clinics at the hospital. We don't go to outreach clinics with the MDs. Residents do not either. When covering inpt, we also see clinic pts as our inpt volume ranges between 3-15 weekly depending on cases so this gives us some down time that we fill with clinic pts. We're here 5 days a week, some days are longer, some shorter. We take inpt and community calls, but are not available on nights/weekends/federal holidays.

Hope this helps! Good luck!

Chuck Wyatt almost 2 years ago

I'm sorry to hear you guys down there are in such a tough spot especially after you worked so hard to ramp up your # of APPs over the past few years. To answer your question about clinic in my experience at Children's in Dallas the APPs run independent clinics (fracture clinics) along side an attending surgeon that is having his/her separate clinic. The surgeon becomes involved if asked by the APP. In general, operative patients are essentially referred to the attending that is in the trauma block the following day for surgery. Usually the family would not meet the surgeon until the day of surgery.

I guess I have a couple of further questions for you before giving you my thoughts about staffing your group.

1. How many full time APPs do you have assuming you don't loose anymore?
2. Do your surgeons have dedicated days of the week that they cover the OR trauma block?
3. Do your residents cover any of the inpatient duties during the weekday? Do your residents cover any of the ED call during the weekday.
4. Is your group of APPs taking any overnight call?
5. Are your APPs currently on teams with the attendings?

I could not find your # to send you a text (new phone). If you still have mine feel free to give me a shout. I am going to reach out to you at the last email that I had for you and send you my #. I am interested to see the comments from the group especially those who have multiple satellite clinics/sites.

Annie Tashjian almost 2 years ago

Wow, that is a big loss!

We have 7 Nurse Practitioners at our institution and two separate campuses. We see patients in the outpatient clinics and our Urgent Care Center. There are no inpatient population at our campus. We treat new patients, follow ups, general ortho peds , sports medicine and at times pre and post-op patients independently. We are also responsible for covering MD clinics. Each NP has a specific MD that they normally work with. When we are seeing the patients in the physician clinics, they are also evaluated by the MD.

Most of us have the 5 eight hour shift, although we put in more than 8 hours a day. I personally prefer the 4/10 or even the 3/12. The clinics do not have a night or weekend hours, but the urgent care does.
Hope this helps

Gerad Montgomery almost 2 years ago

Tanisha, sorry to hear that!
I am also in Dallas and happy to discuss with you more about how things are run at Texas Scottish Rite and Dallas Children's feel free to contact me anytime my cell number is 214-288-2066.

Kim Ingraham almost 2 years ago

I am sorry to hear about this! I can try to briefly answer your questions. We are a small Peds Ortho Division with the Ortho Department at the University of Rochester. We have three attendings, two full time PAs, two part time PAs and two full time NPs. We are not assigned to teams but all work as one big team. The PAs work Mon through Fri and run independent clinics. Everything from developmental to injuries are seen by the PAs. Including news, f/us, post ops, ed follow ups. The PAs do not take night or weekend call. The NPs take care of inpatients and help the MDs in clinic. They are also Mon thru Fri with no night, weekend call. The NPs also travel to satellite clinics with attending. One PA does independent clinic at a satellite clinic.

Carrie Chan almost 2 years ago

Hi Tanisha,

Sorry to hear about the huge turnover, it must be rough! At Stanford we have a system of organized chaos including joint venture hospitals and satellite clinics that span across 6 clinic sites and 4 hospitals that our surgeons operate at. We have 6 going on 7 (we're in the process of hiring another now) Advanced Practice Providers (4 NPs and 2 PAs) that help across the sites.

At our main hospital and clinic, we have residents, a fellow, and 1 APP who does a lot of inpatient coordination and preop organization. At the satellite clinics and hospitals where there are no residents, the other 5 APPs are involved in independent and shared MD clinics, first assisting in the OR, and managing post-op patients at the joint venture hospitals. We try to keep the APPs from traveling too much, so we base them mainly by location.

When the APPs practice independently, they see everything (new, follow-up, pre-op, post-op) and can see everything in the spectrum of peds ortho. In shared clinics, they see and send and bill independently for patients that they are comfortable doing so, but they do see more complicated patients with the MDs.

We currently work 5 8-hour days M-F, but as you might expect, we usually end up working more than 8-hour days. We additionally share call and rounding duties amongst our group, so we are on call currently approximately 20% of the time and split weekends. Sounds crazy, but it's actually quite manageable!

Hope that helps. Please don't hesitate to let me know if you have any further questions or if I can be of any more help!

Tanisha George Daugherty over 1 year ago

Thank you everyone for the feedback! I didn't realize you can see these posts without being logged in so I won't say too much more. As things continue to evolve, I may reach out individually! Thanks again!

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