For many orthopedic surgeons, staffing challenges are no longer theoretical. They crop up daily in crowded clinics, operating rooms running at full capacity, and inpatient floors where documentation, throughput and patient experience are tightly intertwined.
For David Kalainov, MD, medical director of orthopedics at Chicago-based Northwestern Memorial Hospital, the impact of insufficient advanced practice provider support is felt across every corner of care delivery.
“It’s trifold,” Dr. Kalainov said. “In the surgical setting, in the outpatient office setting and in the inpatient setting.”
That reality reflects how much orthopedics has changed over the last decade. Documentation demands have intensified, quality metrics are inseparable from reimbursement, and the physician workforce shortage continues to worsen.
Advanced practice providers have become essential not just for workload relief, but for sustaining access, quality and continuity of care, Dr. Kalainov said.
Documentation and data burdens
One of the biggest shifts in modern medicine, Dr. Kalainov noted, is how central documentation has become to both care delivery and financial viability.
“It wasn’t like this one to two decades ago,” he said. “With the different forces impacting medicine, specifically the importance of documentation, we absolutely need advanced practice providers.”
APPs play a critical role in ensuring charts are accurate, complete and timely, particularly on the inpatient side. Those notes ultimately affect reimbursement, hospital ratings and data reported to Medicare Advantage and commercial payers.
As physician shortages deepen, APPs are also filling access gaps more quickly than the traditional physician pipeline.
“It’s less training to become an advanced practice provider,” Dr. Kalainov said. “Getting more advanced practice providers out there more quickly is a doable thing, as opposed to training physicians, which is a bit more time-consuming.”
The outpatient bottleneck
In the clinic setting, the absence of consistent APP support directly affects how many patients surgeons can see and how quickly.
Ideally, Dr. Kalainov said, each surgeon would work closely with a dedicated APP who understands their practice patterns and workflow. Without that model, efficiency suffers.
“It does impact the ability to maximize my efficiency and my ability to see a higher volume of patients,” he said.
APPs allow surgeons to focus on new and complex cases by managing postoperative visits, which are often bundled into global payment periods and not independently billable.
“When you’re working side by side with your advanced practice provider, they can help you see the post-op patients,” Dr. Kalainov said. “So you can spend more time seeing a new or established patient.”
That division of labor is essential for maintaining access in a system in which demand continues to outpace capacity.
Supporting inpatient continuity
The impact of APP shortages becomes even more pronounced on the inpatient floor.
At Northwestern, orthopedic census typically runs around 35 inpatients during the week, many of them joint replacement patients moving quickly through short hospital stays. When staffing drops, the ripple effects are immediate.
When APP coverage dropped to just one provider at Northwestern, the combination of documentation requirements and bedside care quickly became unmanageable.
“It was not possible without getting more resident and fellow involvement, pulling trainees away from clinic and the operating room to focus on floor coverage,” Dr. Kalainov said.
Advanced practice providers, he emphasized, are the continuity of care on orthopedic units. They coordinate with nurses, social workers, primary care physicians and subspecialists, ensuring patients move efficiently through their hospital stay while maintaining satisfaction and safety.
“They know what’s going on with these patients,” he said. “They get everything coordinated and get the patient through the hospital experience as efficiently as possible, and with high patient satisfaction and family satisfaction.”
Education, not replacement
In academic settings, APPs do not replace residents; rather, they enable better training.
Residents rotate frequently, often every six to eight weeks, which can disrupt continuity. APPs bridge those gaps, preserving institutional memory and practice nuance while allowing trainees to focus on education.
“They provide the continuity that residents can’t always provide,” Dr. Kalainov said. “That allows residents to learn, be in the operating room, be in clinic, not necessarily being pulled away to document stuff in a chart.”
Importantly, he stressed, APPs are not simply absorbing undesirable tasks. They are highly trained professionals engaged in their own ongoing education, working as part of a collaborative team.
“It’s a symbiotic relationship,” he said. “It’s divisional labor, doing things that let residents do what they need to do, and APPs do what they’re hired and responsible for doing, while learning and developing at the same time.”
Integrating value-based care
As healthcare shifts further from the fee-for-service model, APP support becomes even more critical.
“In order to play value-based care correctly, it’s all quality measurements,” Dr. Kalainov said. “Outcomes, safety, quality — those are the numerator in value.”
APPs directly influence patient experience measures, discharge efficiency, responsiveness to patient needs and overall care coordination, all factors that drive quality scores and reimbursement.
“They positively influence all of that,” he said. “It’s not just about dollars. Those measures are reflective of providing valuable care, and valuable payment and ratings.”
What needs to change
Looking ahead, Dr. Kalainov believes the most impactful change is structural, not incremental.
“You need to hire,” he said plainly.
More specifically, he advocates for a consistent one-to-one physician-APP model whenever possible, supported by additional advanced practice providers for inpatient and ambulatory surgery settings.
“Practicing medicine is a lot like dancing,” he said. “You’ve got your partner, you know each other, and you can be super efficient when you operate in that fashion.”
That rhythm is difficult to achieve when APPs are constantly reassigned or stretched across multiple physicians.
“When someone learns your patterns and you learn their patterns, that’s when you really operate efficiently,” he said.
In an era defined by access constraints, workforce shortages and value-based accountability, Dr. Kalainov’s message is clear: Advanced practice providers are no longer optional support staff. They are foundational to how orthopedic care is delivered and how it will survive and scale in the years ahead.
As pressures continue to mount, the systems that recognize that reality and invest accordingly may be best positioned to deliver high-quality, sustainable care.
