How the University of Wisconsin expanded access to pediatric care

Ken Noonan, MD

A decade or so ago, I often wondered about the division of labor in treating pediatric musculoskeletal conditions. As a pediatric orthopaedic surgeon, I often saw children in clinic who had simple problems that could be treated nonsurgically or who were normal, despite their parents’ concerns.

One day, after seeing 60 patients in clinic, the pediatric resident on rotation with me noted that most of the children we saw had easily diagnosed conditions and would never require surgery. This visionary, whose name I’ve since forgotten, opined that most of these patients did not need a surgeon and could be managed by a well-trained pediatrician.

At that moment, I realized that my pediatric surgery colleagues had fellowship-trained pediatric neurologists, cardiologists, gastroenterologists, and renal specialists to manage nonsurgical conditions—but pediatric orthopaedic surgeons had no such partners. We alone “owned” the pediatric skeleton and were the final experts on all physiologic and pathologic skeletal issues in the child.

Orthopaedic surgeons and their nonsurgical colleagues in other anatomic specialties have established working partnerships. Rheumatologists have long managed arthritis prior to joint replacement, and physical medicine and rehabilitation (PMR) specialists are important for screening and managing back pain prior to referral to spine specialists. Perhaps the most obvious surgical/nonsurgical partnership exists in sports medicine with fellowship-trained adult and pediatric primary care providers who come from family medicine, general medicine, and pediatric backgrounds.

On the surface, a pediatrician with sports medicine training could be an ideal partner for a pediatric orthopaedic surgeon. But pediatricians receive little training in primary pediatric orthopaedics and are uncomfortable managing the patients with buckle fractures and knock-knees who populate pediatric orthopaedic clinics. The recent interest in concussion management programs is also taking time away from musculoskeletal issues.

A new fellowship
Thus began the drive to develop a nonoperative pediatric orthopaedic (NOPO) fellowship. For the last 10 years, the University of Wisconsin department of orthopaedics has supported a 1-year fellowship to train graduates of U.S. pediatric or PMR residencies in tertiary pediatric orthopaedics. During this year, they learn how to diagnosis, treat, and refer patients with musculoskeletal conditions. Importantly, they learn whom they can manage and who needs referral for possible surgical intervention.

Fellows spend time working in the pediatric orthopaedic, spine, sports medicine, and neuromuscular multidisciplinary clinics. They are also exposed to radiology, rheumatology, and other related specialties. Because many will return to their home programs after training, each fellow receives an education tailored to the clinical needs that await him or her.

Where do these graduates work and whom do they treat? NOPO specialists work in close partnership with physicians and staff in surgical pediatric orthopaedic practices. They are facile at management of newborn pediatric foot deformities, including Ponseti casting for clubfoot. They learn to manage children with hip clicks or instability with nonsurgical methods and to refer patients to a surgeon for definitive treatment. They are taught observational gait analysis and physical examination so they can evaluate and treat physiologic and potentially pathologic lower limb deformity. Initial evaluation and management of torticollis, back pain, kyphosis, spondylolisthesis, and orthotic management of scoliosis is within their expertise.

We know that experienced nurse practitioners (NPs) and physician assistants (PAs) are just as good—and perhaps better—at reducing and managing pediatric trauma than are orthopaedic residents in training. Our NOPO graduates can help determine who needs surgery and who can continue to be managed by advanced practice providers (NPs and PAs).

Because many NOPOs are affiliated with academic centers, they are often called upon to develop outreach clinics to screen patients. They are popular teachers and mentors with their pediatric colleagues, helping to narrow the knowledge gap, which has led to the onslaught of inappropriate referrals.

Many large pediatric orthopaedic referral bases have developed a diverse team of registered nurses, residents, certified athletic trainers, NPs, PAs, and surgeons. NPs and PAs can provide treatment for simpler fractures, in-toeing, out-toeing, and postoperative care. But nonsurgical physicians play an important role for families or referring doctors who demand that the patient see a specialist.

Sharing the load
In encounters with patients who have clearly nonsurgical conditions, the NOPO specialist works hand-in-hand with pediatric orthopaedic surgeons. Because the NOPO specialist can diagnose any level of pediatric pathology, he or she can manage the bulk of these patients and refer those that require further consultation and likely surgical intervention. Pediatricians may refer even more patients to the NOPO, because their comfort level with orthopaedics is low and they trust like-minded colleagues with specialty training.

We have also noted “new roles” for pediatric orthopaedics, and pediatricians with orthopaedic training are best to lead these initiatives. Childhood obesity is an epidemic that has long-term health implications and risks for early mortality. Yet the morbidity is present immediately, with increased musculoskeletal pain, functional limitations, and surgical conditions such as Blount’s disease and slipped capital femoral epiphysis.

NOPO specialists understand the nutritional and activity constraints of childhood and adolescent development. Adding orthopaedic pathology to their knowledge base enables them to start programs to curb this epidemic.

Children with special needs such as cerebral palsy and spina bifida deserve to play. The current NOPO director at the University of Wisconsin department of orthopaedics, Blaise Nemeth, MD, has instituted a fitness and sports program for these children. His expertise in pediatrics, fitness, and orthopaedics has enabled children in Sit-Ski programs to compete regularly in cross-country ski races.

Finally, poor pediatric bone health, osteoporosis, and rachitic conditions are often seen in patients with fractures and deformities. A NOPO specialist with an interest in this field would be uniquely qualified to diagnose and manage the pathology.

Summary
NOPO specialists trained at the University of Wisconsin have been able to decrease waiting lists, open field clinics, and develop niche practices that have improved access for children with pediatric orthopaedic issues. NOPO colleagues have taught me as much about pediatrics as I have taught them about orthopaedics…and the children have benefitted.

The successful pediatric practice requires a team approach. Registered nurses are needed to encounter and triage and teach patients. Medical students, orthopaedic residents, scribes, and certified athletic trainers can improve clinical throughput; NPs and PAs can diagnose and treat simpler problems. NOPO specialists can see patients referred from nonsurgeons and refer those who need surgery to pediatric orthopaedic surgeons who can perform these procedures.

In this model, every team member performs to the height of his or her training, and surgeons stay in the operating room doing what only they can do.

For more information, contact me (noonan@ortho.wisc.edu) or Dr. Nemeth (nemeth@ortho.wisc.edu).

Ken Noonan, MD, is an associate professor at the University of Wisconsin and coprogram director of the Nonoperative Pediatric Fellowship.