Becoming an AT in a Non-Traditional Setting by BranDee Gentile, MS, LAT, ATC

Athletic trainers (ATs) have been practicing in various clinical settings for decades; however, the majority of those settings are focused around orthopedics and sports medicine, which makes complete sense. A main focus of an AT’s education is orthopedic evaluation, diagnosis, and rehabilitation making it natural for ATs to lean towards a position within an orthopedic practice. However, can an AT be just as well suited in another more, non-traditional setting? Absolutely. ATs are highly qualified healthcare providers who provide a wide range of services, including preventative care, emergency care, clinical diagnosis, therapeutic intervention, and rehabilitation of injuries.

I was originally hired as the AT for a physiatrist who was practicing within a neurosurgery department at Neurological Institute of New Jersey (NINJ). Lucky for me, she previously worked with ATs during her residency giving her an understanding of our scope of practice and skill set. However, the neurosurgeons were not familiar with ATs in a clinical capacity. At the time, the NINJ had multiple ATs working in administrative positions but not in a clinical one. Finally, they agreed to hire one (me) to test the waters.

When I first joined the practice, I had to carve out a role for myself. I was the first clinical AT and I was working alongside nurse practitioners (NPs), physician assistants (PAs), residents, and neurosurgeons that had never come across a clinical athletic trainer. I was constantly explaining myself – education, scope of practice, and how I was different from nurses and medical assistants. I was asked repeatedly, “If your specialty is musculoskeletal and orthopedic injuries/rehab, why are you here?”. I quickly developed an elevator speech, but what I really needed to do was show them why I was a good fit. How could I get the nurses, the PAs, and the physicians to see that as an AT, I too belonged?

As an athletic trainer, I have a thorough understanding of anatomy, physiology, and biomechanics. I can apply clinical reasoning skills, select the appropriate assessment tests, and formulate differential diagnoses. NPs and PAs have a broad-based education throughout healthcare but have limited training in orthopedic and musculoskeletal medicine. It was this specific set of skills that I had, that differed.

Originally, my normal routine with Dr. Gyi was similar to that of the other mid-level providers. On patient days I would evaluate patients, review imaging, present to my attending, assist with in-office procedures, and develop treatment plans. On non-patient days I would handle patient phone calls, peer-to- peer discussions, disability paperwork, and various administrative tasks. Clinically, I would be the first contact a patient would have. I take a complete medical, surgical, social, and familial history. Then begin a more focused, history of present illness (HPI) and continue with a complete neurological evaluation, including cranial nerves, gait assessment, and musculoskeletal exam. Lastly, I would perform my special tests. This is what set me apart. Based on the patient’s history and complaints I could assimilate that into a detailed exam. If a patient is complaining of low back pain, was it coming from a disc? Facet joints? SI joint? Or was this referred hip pain? Was it caused by an anterior pelvic tilt, muscle imbalance, or is it a gait abnormality causing low back pain? As an AT, it was normal for me to evaluate like this instead of looking only at the patient’s chief complaint and having tunnel vision so to speak. This allowed me to present not only the HPI to the physician but also differential diagnoses and treatment plans. Prior to presenting, I would also have already reviewed any imaging that the patient had completed. Together we would formulate a treatment plan and present it to the patient. Whether that be conservative treatment, further imaging, DME, diagnostic studies, or referral to another provider.

Some of the patients we saw would require a referral to neurosurgery, which is how I ultimately became more involved with that aspect of the practice. Our neurosurgeons had expanded their outpatient hours to

satellite offices at other hospitals. Each neurosurgeon (in our practice) has a NP assigned to them; however, they do not travel. Our other hospitals had a PA based on the inpatient side, that would attend office hours when available, but the physician’s needed something more reliable. Emergencies happen and surgeries take place at all hours, so more often than not the PA would be attending to inpatient needs and unavailable for outpatient office hours.

This is where I came in. First, I started assisting the neurosurgeons in the satellite offices. Once they learned more about my skill set, and my scope of practice, I was utilized more. They saw the value in my detailed evaluations and my approach to patient care. The physician’s started to request my assistance when they had a high patient volume (in addition to their NP) and when their NP was out of the office. Eventually, it came to a point where I was no longer able to accommodate my own attending physician and the requests of the neurosurgeons; therefor the practice decided to hire an additional AT.

The addition of a new athletic trainer eased up my workload and allowed for even more expansion. I was able to participate more in the academic nature of our practice; co-authoring multiple textbook chapters, giving presentations within the community and at conferences, attending cadaver labs (with our neurosurgical residents), and acting as the clinical research coordinator for a clinical trial. Ultimately, I ended up working full-time with the neurosurgery side of the practice, and more specifically, one-on-one with the Director of Spinal Oncology. Our practice continued to hire additional athletic trainers, expanding into pain management, Otolaryngology/ENT, and neurology.

When I first began working at the NINJ, I was intimidated. Here I was, a musculoskeletal and orthopedically educated/trained AT trying to make it in the world of neurosurgery. But once I took the fear aspect out of it and thought about my education and training, I thrived in a non-traditional practice. As an AT, I am taught how to perform neurological evaluations, evaluate brain and spinal injuries, as well as joint/soft tissue injuries. Athletic trainers might not have the same extensive general medical knowledge and surgical skills that NPs and PAs have, but we have a valuable skill set which can be easily adapted to multiple settings – if we are just willing to set fear far enough aside and jump out of our comfort zone.

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