Invited Review
Evolving Unique Roles of Spine Advanced Practice Providers (APP)
Nicholas Eley, PA-C
Virginia Mason Franciscan Health Seattle, WA
Nicole Vivelo, ARNP
Virginia Mason Franciscan Health Seattle, WA
Michelle Gilbert, PA-C
Virginia Mason Franciscan Health Seattle, WA
Hannah Boudreaux, PA-C
Virginia Mason Franciscan Health Seattle, WA
Kellen Nold, PA-C
Virginia Mason Franciscan Health Seattle, WA
Jean-Christophe Leveque, MD
Virginia Mason Franciscan Health Seattle, WA
Philip Louie, MD
Virginia Mason Franciscan Health Seattle, WA
Introduction
Since their conception in the mid 1960s, advanced practice provider (APP) roles have evolved due to changes in health care delivery needs and workforce availability. APPs play a vital role in the delivery of spine care in inpatient and outpatient settings. As a group, however, they are often overlooked when discussing dynamic trends in spine care. Our neurosurgery/orthopedic spine department at Virginia Mason Medical Center employs many APPs that have key clinical and academic roles. While other surgical services in our hospital utilize residents, the neurosurgery/spine service does not have any resident coverage and instead relies upon this APP team. Over time, our APPs have developed unique roles. What follows are comments from individual APPs, describing their unique rules. While each of these APPs brings their own unique experience to the job, together they foster engagement, collegiality and loyalty; average tenure is greater than five years and with multiple providers having worked for longer than 10 years in the department.
Topic: Active participation in research studies with podium presentations and manuscript authorship
Nicholas Eley, PA-C
The last several years have seen increased rates of burnout amongst APPs and physicians alike. Since provider engagement is a proven antidote to burnout, several of us have chosen to engage by becoming involved in ongoing research efforts. Using us as a local resource not only helps to increase engagement but also results in the feeling of being a true stakeholders in our department’s successes on regional and national levels. I have personally experienced the satisfaction of a poster presentation, and have been a first-author on a publication in a major spine journal. With a new original study pending publication and multiple publications as first and second author submitted this year alone, I have been provided with an opportunity for continued education, career development and a feeling of accomplishment. I have also become an example for other APPs who are looking to provide meaningful contributions to published medical knowledge. Being deeply involved in our research and academics program has helped to increase my level of engagement in the clinic and in the operating room as I can see the direct impact of my work on improving the care of our spine patients.
Topic: ARNPs that serve as first assists in the OR regularly (and the path to get there)
Nicole Vivelo, ARNP
Many in the medical field remain unaware of the potential of utilizing an advanced registered nurse practitioner (ARNP) in surgical settings. The use of ARNPs in outpatient settings or hospital-based services is relatively routine, yet there is a lack of clarity regarding the steps necessary to become first assistants in the operating room. Some states explicitly permit NPs to function as first assistants while others require additional steps or have specific limitations. I chose to pursue certification through the National Institute of First Assist, as this certification is widely accepted within the healthcare industry and satisfies most state requirements. Each hospital may have its own rules as well. At Virginia Mason, my certification did not automatically result in credentialing committee approval for first assist privileges Through effective leadership and advocacy, I was able to obtain approval for my certification and formalize the process for future ARNPs who meet the institutional requirements. I have a gratifying level of autonomy as an ARNP and first assist in the operating room. As a new graduate it is crucial to educate potential employers about one’s skill set, scope of practice, and their relative advantages. This proactive approach can pave the way for NPs to contribute significantly in the dynamic environment of surgical practices.
Topic: Leading large multidisciplinary conferences and quality improvement initiatives
Michelle Gilbert, PA-C
I have a unique role in our department as the lead clinical coordinator for our complex spine program. Part of my time is allocated to direct ambulatory care of spine deformity patients with the remainder allocated to administrative coordination of our pre-operative pathway and running our multidisciplinary conference. After a patient is evaluated for consideration of complex spine surgery, I prepare a summary of their case to be presented at our monthly multidisciplinary conference. I obtain history, imaging, and additional medical data as well as coordinate referrals for preoperative neuropsychological evaluation. This conference has been an integral part of the Seattle spine team approach since 2014, as part of an effort to reduce postoperative complications, and enhance patient selection and preoperative optimization. Additionally, having a highly qualified APP rather than a surgeon managing the conference results in cost saving to the institution. One of the key aspects of my role is to provide follow-through on the recommendations from the conference. This role goes beyond care coordination. As a clinician, I can independently evaluate the patient, interpret results, and provide timely communication, all of which improve patient satisfaction and service line efficiency. This role has been an antidote to burnout for me. I have found purpose in feeling connected to my work. Through my expertise and the environment of mutual respect which we have cultivated in our program, I have also gained autonomy, which is a critical aspect of job satisfaction for an advanced practice provider.
Topic: Serving in system-wide and societal leadership positions early in their career
Hannah Boudreaux, PA-C
APPs now practice in almost every area of medicine alongside our physician colleagues and as independent practitioners, yet frequently are not equally represented in leadership roles within their institutions. In many hospital systems, APPs make up a large portion of the total providers but historically have lacked a pathway into organizational leadership roles. As a new physician assistant (PA) coming into a large system at the beginning of my career, I was determined to create such a path. I applied to and graduated from the Provider Leadership Academy, a provider development program offered through our larger organization, CommonSpirit. As I became more involved with system-wide clinical improvement committees, I was asked to serve on our national Advanced Practice Leadership Council as a representative of the Pacific Northwest. At our institution, I run quarterly meetings for our large APP group to ensure our group is current on organizational updates and provide a space for any APP-specific issues to be discussed. Early in 2023, our hospital leadership expanded our Medical Executive Committee (MEC) to include an APP seat. I took the opportunity to apply and now serve as the first APP on Virginia Mason’s MEC. Most recently, with unwavering support from our current leadership, I introduced a policy for formal APP leadership within Virginia Mason and was named the first Chief of Advanced Practice. Moving into leadership roles can be daunting without an obvious ladder and I would urge others to explore any development opportunities and engage with your leadership team to understand how APPs can contribute to the larger provider-driven voice.
Topic: Balancing surgical skill development and working alongside trainees
Kellen Nold, PA-C
Having worked at Virginia Mason Franciscan Health for over 10 years I have witnessed both my surgical skill and clinical abilities increase substantially. Our position as a large hospital without a neurosurgical or orthopedics residency has allowed our APP group to step into a role more analogous to an experienced resident rather than being regulated to a typical first assist role. From the APP perspective, education starts with senior members, both APP and MD, mentoring newer colleagues to ensure their career is advancing in technical skill, understanding, and knowledge base. Outside of the hospital system, inclusion in activities such as journal clubs, conferences and CME further enhances the education of the entire team. These opportunities have resulted in increased surgical skill, increased responsibilities in the operating room, improved job satisfaction and less turnover among staff. All practitioners a benefit from this training as it allows for better skill-task alignment, freeing up a surgeon’s valuable time. Greater autonomy allows more items to be delegated to the APP team both in and outside of the operating room, including APP-independent exposure and closure and skilled assistance during instrumentation and positioning. Consultations and rounding are handled by the APP team and reviewed with the on-call attending. While our complex spine fellows initially often have worries about the effect that APPs may have on their training, they typically find that an experienced APP team is extremely efficient, especially in their early months, with the team acting as a valuable resource and knowledge base to ensure continuity of care.
Conclusion
Philip Louie, MD and JC Leveque, MD
We have presented here some unique roles that APPs can fill within a surgical spine practice. While initially created decades ago as an “assistant” position, and often still used as merely an extra set of hands in the OR/clinic, the concept of APPs as “physician extenders” has gained more traction in recent years. With training, time and support many of them are able to take on autonomous roles that allow that extension far beyond the operating room, including research, clinical coordination and leadership or administrative positions. In an era that demands increased output with reduced resources, these individuals are a critical part of the medical team. Their success is dependent on physician mentorship and a willingness on the part of surgeons to welcome them as partners. We hope that these examples will resound with others in the spine community and provide inspiration for models of practice development.
Author Disclosures
N Eley: Nothing to disclose
N Vivelo: Nothing to disclose
M Gilbert: Nothing to disclose
H Boudreaux: Nothing to disclose
K Nold: Nothing to disclose
JC Leveque: Consulting: ATEC (B), Axis Spine (B); Scientific Advisory Board: SI-BONE (B); Speaking and/or Teaching Arrangements: NuVasive (B, Paid directly to institution/employer).
P Louie: Board of Directors: AOSpine (Travel Expense Reimbursement, Advisory Committee); Consulting: Alphatec (B), Surgalign (B, Paid directly to institution/employer), Viseon (B, Paid directly to institution/employer); Fellowship Support: AOSpine (C, Paid directly to institution/employer).