Jan 29, 2015Doctor’s Orders
Working alongside physicians in a clinical setting isn’t exactly what athletic trainers are trained for. But more and more are finding the role of physician extender to be the right career move.
By Kenny Berkowitz
Kenny Berkowitz is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].
After becoming a certified athletic trainer in 2002, Ned Tervola spent the next two years at the Detroit Lakes (Minn.) School System, where he was responsible for the care of 500 athletes competing on 20 teams. There was more than enough work to keep him busy, but Tervola still found himself thinking about the next stage in his career.
“There were times when I felt completely bored,” says Tervola, MA, ATC, who now works as Physician Extender at Sports and Orthopedic Specialists in Edina, Minn. “And that’s what drove me to find something that would be more challenging from both a professional and academic standpoint. I wanted to be pushed harder and feel fulfilled. I’m now in the middle of my third year here, and life is significantly different.”
Five mornings a week Tervola works in the clinic, where he assists eight orthopedic specialists and sees between six and 12 patients in a typical four-hour shift. Working closely with the physicians, he takes patient histories, assesses injuries, discusses treatment plans, develops home exercise programs, schedules ancillary procedures, coordinates rehabilitation strategies, completes medical dictation, conducts research, and works as a liaison to allied health professionals in the area. Then, after a short lunchtime workout, Tervola spends his afternoons as Assistant Athletic Trainer at Macalester College, where he provides hands-on care in the athletic training room and primary coverage for volleyball and baseball.
It’s not exactly what he trained for in graduate school, but Tervola is glad he made the change. “The biggest advantages for me have been working closely with our physicians and having the opportunity to learn a little more each day,” he says. “At a busy clinic like this, there’s more responsibility placed on me, and my assessment skills have grown by leaps and bounds.
“When some athletic trainers hear I’m working as a physician extender, they assume I’m just running around re-stocking examination rooms or shuttling patients from one place to another,” continues Tervola. “It’s considerably more challenging than that, and when I tell them I’m actually doing physical examinations, they’re intrigued and want to hear more about it.”
A DAY’S WORK
Like Tervola, more and more athletic trainers are finding employment as physician extenders. According to the latest statistics, there are close to 1,000 certified athletic trainers currently working in the role. They may balance part-time clinical work with an outreach position at a local high school or college. Or they may work full-time in family medicine, primary care sports medicine, orthopedics, osteopathics, pediatrics, physiatry, occupational medicine, or chiropractic care.
Less than a decade after the NATA officially recognized the position–and began actively promoting it as a viable alternative to the traditional setting–there’s still wide variation in responsibilities from one work site to another. However, Jim Raynor, MS, ATC, Administrator at St. John’s Sports Medicine in Springfield, Mo., argues that being a physician extender is essentially the same role that athletic trainers have always played, even if they don’t realize it.
“Too many athletic trainers don’t understand they’re already working in the physician extender model,” says Raynor, who supervises athletic trainers at three outpatient clinics. “They’re already acting as physician extenders in the athletic training room, whether they’re at a high school, college, or clinic. Every time they evaluate an injury or treat an athlete, they’re working as an extension of their team physician, and functioning under a physician’s protocol. We’ve just never identified an athletic trainer this way.”
In a typical day at St. John’s, physician extenders alternate between assisting physicians and taking care of their own patient load. They may have scheduled follow-up appointments on injury rehabilitation progress, or be called to join a physician in diagnosing or treating a patient.
Over his nine years working as a hands-on physician extender, Raynor encountered a wide variety of issues. “I worked on a broad range of problems, from the traditional football athlete with a blown out knee to the female athlete who didn’t realize she was pregnant to the boy who refused to play baseball because his dad was pressuring him too much,” he says.
“For example, the female athlete originally came in for a pre-participation physical,” he continues. “The doctor did the medical component and I took care of the parts related to history, nutrition, and sport readiness. When I asked her questions related to eating disorders and amenorrhea, she realized she hadn’t had her menstrual cycle in three months. I consulted the doctor, who ordered the pregnancy test, and lo and behold, this girl was pregnant. That incident really sharpened my awareness of issues we don’t usually see in a school athletic training room.”
Raynor describes his clinics’ philosophy as a collaboration between physicians and athletic trainers. “Because the physicians are confident in the skills and abilities of our athletic training staff, we’ve been given a lot of professional discretion in what we do,” he says. “That’s made us better athletic trainers because we have to be sharp to work with the physicians here.”
At the University of Wisconsin Health Sports Medicine Program, athletic trainers have been working closely with physicians for more than 20 years. Joe Greene, MS, ATC, Supervisor of Athletic Training Services, oversees a staff of three athletic trainers who work in the clinic full-time and 15 athletic trainers who divide their days between the clinic, the university athletic department, and high school teams in the surrounding area.
When his athletic trainers work as physician extenders, they essentially escort patients during their entire visit to the clinic. “They take a thorough history for each patient who comes in the door, present the case to one of our physicians, walk patients down to X-ray for testing, write referral forms, fit durable medical equipment, and create a medical record of every visit,” Greene explains. “They do a great deal of patient education, spending the one-on-one time with them that’s central to patient satisfaction. Their last question to a patient is always, ‘Are there any more questions you have about your visit?’ Getting that kind of attention is an important part of why our patients feel they’ve been taken care of so well.”
REAPING THE BENEFITS
In a 2004 study conducted at UW Health Sports Medicine, the benefits of the physician extender model came through loud and clear. Working closely with athletic trainers, primary care providers were able to see 10 to 20 percent more patients, and orthopedists were able to see 15 to 30 percent more patients. Athletic trainers provided care for one-third of the patients at the clinic, spending an average of 25 minutes with each one and improving the clinic’s productivity by an average of 10 additional patients a day.
“Based on the data presented, our sports medicine clinic throughput would suffer without the assistance of athletic trainers,” Greene wrote in the study’s conclusion. “The value of athletic trainers was also reinforced by interviews with physicians, who strongly believed that their clinics could not support current volume without the three assistants… Physicians also felt the cost/benefit ratio of hiring an athletic trainer was very favorable and that the athletic trainers’ skills and knowledge in regards to sports injuries and rehabilitation was irreplaceable.”
Another study, conducted at Emory Sports Medicine Clinic by Brian Franklin, MS, LAT, and Forrest Pecha, MS, ATC, CSCS, OTC, found a 25-percent improvement in both the number of patients seen and the amount of revenue produced. “Working with an athletic trainer is going to increase a physician’s productivity and allow him or her to see more patients in a day,” says Franklin, Director of Reimbursement Services at Ossur, a prosthetic design company. “It provides an assistant who can educate patients, answer questions during or after an office visit, and free the physician to spend more time caring for each patient.”
The benefits to athletic trainers working within the model are equally clear. The most obvious one is financial, says Franklin, who estimates the starting salary for a physician extender is in the $32,000 to $42,000 range, compared to $20,000 to $30,000 for an athletic trainer beginning work in the traditional setting. On top of that, physician extenders at some clinics may also be eligible for bonuses based on increasing a practice’s productivity.
Another plus is the schedule. “The quality of life issues related to the physician extender role are extremely big positives,” says Greene. “It allows us to work a 9 to 5 day, which is very amenable to athletic trainers trying to balance work and a home life.
“I was a high school athletic trainer for 11 years, and there were times during the school year when I worked four evenings a week plus weekend coverage,” continues Greene. “It was fun to work in that capacity, but as I moved through life, there were too many times I couldn’t be home. When I began working as a physician extender, I had a couple of young kids at home, and now I have a third. Making that change was a quality of life decision that allowed me to be home around 5 o’clock each night and spend time with my family.”
Other benefits of working as a physician extender are more subtle. “Many of us really enjoy the constant contact and close communication we have with doctors,” Greene says. “We get to know our physicians on a personal level, which helps build our working relationship and create a very satisfying work environment.”
There are also opportunities for advancement. “A physician extender is a highly respected position, and once you perform well in the clinical capacity, physicians will start looking at you as a possible clinic or practice manager,” Greene says.
For Tervola, one unexpected plus is the ability to help orthopedists prepare conference lectures. “I’ve been reviewing literature and readying presentations for two of our shoulder specialists,” he says. “Helping with a lecture for the 2007 American College of Sports Medicine Conference was uniquely challenging for me because I haven’t done much academic research since I finished graduate school five years ago.
“The clinical experience is what originally drew me to this position,” continues Tervola. “But it’s also worked out well for my career plans. Having this research experience has made me think more about going back to school for further education.”
Like Tervola, Greene feels changed by his experience at UW Health Sports Medicine and is currently pursuing a master’s degree in healthcare administration. “Working as a physician extender has spurred an interest for me in higher levels of administration, because I’ve seen areas where I could really make a difference,” he says. “It’s opened up doors for me, as well as for a lot of other athletic trainers who have pursued advanced degrees after working in this role.”
As interest in the physician extender model grows, so do educational opportunities related to it. There are currently fellowship programs to develop athletic trainers into effective physician extenders at Emory Sports Medicine & Athletic Training, the New Hampshire Musculoskeletal Institute, and the Steadman-Hawkins Clinics in Vail, Colo., and Greeneville, S.C.
In the last three years, Emory has graduated 10 athletic trainers from its fellowship program, helping place them in clinical positions around the country. “Our fellowship teaches athletic trainers all the tasks that can be done in a physician’s practice,” says Pecha, Director of Athletic Training Services and Clinical Coordinator at the clinic. “As part of the curriculum, they spend time with musculoskeletal radiologists, learning how to recognize problems through an understanding of MRIs, CTs, and X-rays. They attend summer school with residents, going through gross anatomy, didactic sessions on specific musculoskeletal injuries, clinical diagnoses, and even surgical approaches. They participate in grand rounds with full privileges at the university hospital and scrub for 250 cases in the operating room, where they drive the scope, prep grafts, retract tissue, and suture, as well as observe operations.
“Through work in the OR, they gain a better understanding of anatomy and biomechanics,” he continues. “They do their own evidence-based outcome studies. And all the time, they’re refining their clinical exam skills, studying the practice model, and learning to work with durable medical equipment. Really, we’re training them to be the ideal physician extender.”
At UW, Greene is scheduled to launch a new fellowship program in 2008, based in part on the Emory model. “There’s a growing set of tools you need to be an effective physician extender,” says Greene. “Some of these skills aren’t necessarily taught in an undergraduate or even a graduate program in athletic training, including musculoskeletal radiology, general medical conditions related to orthopedics, fitting casts and durable medical equipment, and training in the operating room. If athletic trainers can gain that diverse skill set, there’s a strong likelihood they’re going to be considered for physician extender positions.”
Many athletic trainers are also creating opportunities for themselves by working with local physicians to establish new physician extender positions in family practice, pediatrics, and sports medicine clinics. In these situations, Greene suggests approaching physicians you already know and work well with.
“Many of these clinical positions started because the athletic trainer was working with a team physician who was covering the local high school,” says Greene. “If you already have a strong relationship, you’re in the perfect place to ask that physician, ‘Have you ever thought of utilizing someone like myself to help care for patients in your clinic?'”
Raynor agrees. “If a doctor trusts you and respects the work that you do, he or she is going to be open to hearing your proposal,” he says. “But if you’re considering becoming a physician extender, you’d better be good at what you do. Because when you’re working as a physician extender, you don’t have the luxury of making mistakes. If you’re going to be an asset for the physician, you can’t miss a step.”
To market yourself to a physician, you’ll also need to construct a persuasive argument about the benefits of the position. “The greatest selling points are quality of care and efficient management of resources,” says Raynor. “For example, if a patient comes in with a swollen knee, it will take about 30 to 45 minutes for a physician to do a comprehensive job of evaluating and managing the injury. In the meantime, there’s a growing line of patients in the waiting room, which is why most orthopedists can’t afford to conduct a complete workup. That’s where we can offer the most help–by doing that complete workup.
“The physician extender model gives doctors the time to see all their patients, decrease exam and waiting room time, and stay on schedule, while giving patients the kind of one-on-one attention they really need,” he continues. “That’s a huge benefit for both revenue and patient satisfaction.”
When deciding who to approach, Raynor recommends the busiest physicians in town–the ones who serve the youngest, most active population, and have the longest waiting times. “Those are the physicians who need your help the most because you’ll be able to make the greatest improvements in their patient satisfaction,” he says.
Some physicians will want to know details and see research. In these cases, it helps to provide studies about how patients want opportunities to ask questions and hands-on attention. “Then, put together some numbers that demonstrate you’d be able to make the office work more efficiently,” says Raynor. “For example, if you can increase the office’s caseload by two or three patients a day, you’ve more than paid for your hiring.”
Raynor suggests the NATA Web site as the easiest place to find the data you need for a successful pitch. Along with providing resources for athletic trainers that outline the demands of the position, the site offers potential employers cost/benefit analyses, information on patient satisfaction rates, and research on the topic. In one study, a part-time athletic trainer working in an orthopedic practice created $28,000 in billable charges over the course of a year. In another study, one full-time athletic trainer added $82,000 in billed charges to a sports medicine practice.
“The amount of detail you need in your pitch will vary depending on the doctor’s personality and the work setting,” says Raynor. “Some doctors are global thinkers who want to look at the big picture but not the little details. Others will want to know exactly how much it’s going to cost and whether everything is going to work out financially. But any successful pitch will cover both quality and efficiency of patient care.”
INTO THE FUTURE
From his position in the industry, Franklin sees the physician extender role expanding to more athletic trainers. “In the future, we’re going to see more physicians capitalizing on this role, not just in orthopedics and primary care sports medicine, but in pediatrics and occupational medicine,” he says. “For example, there will be more athletic trainers working as certified orthopedic technologists, which are sometimes called cast techs.
“You’ll also see more athletic trainers implementing outcome studies,” Franklin continues. “You’ll see more athletic trainers working as liaisons to attorneys, workman’s comp adjusters, and nurse case managers. On the administrative side, more athletic trainers will be assisting with precertification or preauthorization of surgical procedures. And as more clinics decide to run their durable medical equipment in-house, athletic trainers will be the ideal people to facilitate these programs.”
For Raynor, one of the physician extender model’s most significant benefits is its ability to bring athletic training to a new population of both athletes and non-athletes. “Without question, the physician extender model is the strongest one we have for the future,” he says. “Because our profession has a finite scope of dealing only with particular types of patient issues, we need to keep creating environments where we can make a difference.
“We need to hold onto the things that work but always search for better ways,” continues Raynor. “We need to think outside the box and ask ourselves, ‘Why do we do what we do?’ We need to be careful not to limit ourselves to musculoskeletal issues, because there’s a huge umbrella of concerns to be treated within sports medicine. The physician extender model allows athletic trainers to work closely with physicians, and as we move forward in healthcare, that relationship is going to be one of our greatest assets. Strengthening that bond is the future of our profession.”
Sidebar: NOT FOR EVERYBODY
In his earlier years as a physician extender, Joe Greene, MS, ATC, Supervisor of Athletic Training Services at the University of Wisconsin Health Sports Medicine Program, believed the job was right for every athletic trainer. “I used to think this position would be attractive to everyone,” says Greene, who supervises three full-time and 18 part-time physician extenders. “Why wouldn’t every athletic trainer want a more regular schedule? Why wouldn’t they want to be paid more?”
But as he’s seen more people go through the transition, Greene has changed his mind. “A lot of athletic trainers go into the profession because they want to work with teams–that’s the exciting part of the job for them,” says Greene. “But in the physician extender role, we treat a different set of patients and injuries. We’re not working with athletes all the time, and although we see a large number of athletes, there are also a lot of patients who are just trying to stay active.”
Even when the tasks feel similar, athletic trainers who choose to work as physician extenders should prepare themselves for a significant transition. There is far less contact with teams and young athletes, less direct involvement in injury rehabilitation, fewer opportunities to focus closely on athletic performance, and little of the camaraderie that comes from being part of an athletic department.
Greene suggests fully examining your reasons for wanting to switch before you do. “Before you make that leap, you need to investigate it first and consider what you really enjoy doing the most,” he says. “My best advice is to shadow a physician extender. Spend a day or two observing them at work and their interactions with the physicians. If working closely with physicians isn’t right for you, then neither is this role.”
For additional information and resources on working in the physician extender role, visit the NATA’s Web site at: www.nata.org/employers/index.htm.
To download the UW Health Sports Medicine study, “Athletic Trainers in an Orthopedic Practice,” go to: www.nata.org/employers/hosp-clinic/athletic_therapy_today.pdf.