Physician assistants in orthopedic practices can expand the scope and depth of care

Introduction

It was my pleasure to put this Round Table discussion together with five outstanding physician assistants (PAs). Most of you probably know how specialized some orthopedic PAs are and how much they can add to our field. I hope the insights shared in this discussion will stimulate some of you to consider working with a PA in your practice setting.

As I travel around the country and visit various orthopedic organizations, I am always impressed with their role PAs have in orthopedic patient care. They take great pride in their work and profession. One thing I learned through the course of this discussion is the proper terminology for these professionals: Singularly they are a physician assistant and the plural form is physician assistants. It is not correct to refer to them as a physician’s assistant or physicians’ assistants.

Douglas W. Jackson, MD
Chief Medical Editor

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Douglas W. Jackson, MD: What are the prerequisites and qualities you look for in candidates to become a physician assistant?

Roy Guizado, MS, PA-C: There are approximately 140 PA programs in the United States: 82% award a master’s degree upon program completion, 12% offer a bachelor’s degree and the remaining offer an associate degree or a certificate of completion.

The prerequisites and qualities for potential physician assistants (PAs) can vary from institution to institution. However, PA programs are looking for people who know about the profession and are willing to undertake a labor-intensive curriculum in order to successfully pass the national PA board examination.

Common prerequisite courses include anatomy, physiology, microbiology, chemistry, advanced mathematics, statistics, genetics, and English. Some programs require previous patient experience, while other programs require community service hours.

Most master-degree granting institutions require a bachelor’s degree prior to entering PA school.

Jackson: How successful are your graduates in finding positions after graduation?

Guizado: Most graduates have engaged in networking while being a student on clinical rotations, which assists in job placement. The United States Bureau of Labor Statistics projects that the number of PA jobs will increase by 27% between 2006 and 2016. It also predicts that the total number of jobs in the country will grow by only 10% during that period. In 2007 CNN.com and Forbes.com ranked the PA profession as the fourth fastest growing occupation. The outlook of the profession is very positive and as a result, PA jobs are available for graduates.

The national board examination required of all PA graduates is based in primary care, which is the basis of the PA education curriculum. PAs can specialize in two manners: after completing PA school, a graduate can enroll and complete a post graduate program for a particular specialty, or the graduate PA can align with a specialized physician who is willing to mentor him or her in the physician’s area of expertise.

Currently, there are no exams for specialty practice. To specialize in the two manners presented allows for PAs to easily move from one specialty to another, which increases their utility in medicine. In the near future there will be optional specialty exams for PAs in surgery, emergency medicine, and dermatology. There may be other optional specialty exams in the future as well.

Jackson: Share with us your role as an orthopedic PA in your practice setting.

Peter Bos, PA-C: My role as an orthopedic surgery PA at the Mayo Clinic is to assist the surgeon and the fellow/resident in all aspects of patient care. Clinically, this includes pre-, intra- and postoperative care.

For preoperative care, my role includes: performing a history and physical exam on new patients; making an appropriate assessment and plan for the patient, including a diagnosis, and presenting the information to the surgeon. If surgery is decided for the patient, I provide appropriate preoperative planning, templating, and admission notes/orders.

In the operating room, I assist the surgeon or surgical team in any way possible to complete our objective for each surgical case.

In the postoperative care setting, I assist with inpatient care responsibilities and see patients back in the clinic at appropriate follow-up intervals. If the surgeon is away, I am able to work in the musculoskeletal clinic where I see patients with a range of orthopedic problems including shoulder, hip, knee, painful total joints and acute injuries. These patients are referred to this clinic from other departments within Mayo and I see and treat them exclusively.

Anthony R. Gauthier, PA-C, ATC: My role in a large, private clinical practice is to improve the continuity of care for our patients. There are many facets that allow me to accomplish this — through my initial contact obtaining a new patient’s history, assisting in surgery or performing the postoperative follow-up. When the patients can recognize that the partnership between a physician and the PA is a team approach, they feel confident in the treatment plan and appreciate the quality care.

John Larinto, PA-C: My role as a PA in a large hospital system encompasses a wide variety of orthopedics, but is primarily focused in sports medicine. I am in the office setting usually 3 days a week seeing initial consults for new injuries, routine follow-ups, pre- and postoperative patients. Routine office procedures include joint and soft tissue injections and irrigation and debridements.

I average 2 days per week in the OR, primarily assisting on sports medicine cases. My duties also include rotating first call responsibilities on evenings and weekends managing orthopedic inpatients, emergency room consults for orthopedic trauma and performing closed reductions of fractures and dislocations under the supervision of an attending orthopedic surgeon.

John Mohnickey, PA-C: My role is that of first line evaluation for our orthopedic practice. I see a mix of new patients from ages 6 months to 102 years old, existing patients with new complaints and nonsurgical follow-ups in our prompt clinic.

I believe a PA’s role in a prompt clinic is to decompress the surgeon’s clinic by providing workups of potential surgical patients while treating the nonsurgical patients. Presently we see 20 or more new patients and 20 or more follow up patients per day which includes fracture care.

Jackson: How specialized are you in terms of the orthopedic care you perform?

Bos: I am extremely specialized at Mayo. We have world-renowned lower extremity adult reconstruction specialists, some with a focus on young patients. I have to be an extension of these services and am therefore required to maintain a specialized knowledge base on the procedures performed. This allows me to talk intelligently to patients while educating them on their surgery and recovery aspects of the procedure.

In the clinic, we often see patients who are referred from other orthopedic surgeons with complex problems that require an expert surgical familiarity with each case and procedure to be performed. This necessitates I be well-versed in preoperative planning and operative assisting needs of each case.

All the PAs in orthopedics here work with a highly specialized orthopedic surgeon. This is the nature of a tertiary care facility and the services that are provided by the department of orthopedic surgery. Since I primarily work with one surgeon on a daily basis, it is imperative that I understand the specific orthopedic disease processes, focused examinations, appropriate work up of the patient and operative vs. nonoperative treatment options for these patients.

Larinto: The role of an orthopedic PA can vary significantly in the Kaiser Permanente system, depending upon the needs of the specific medical center. At Kaiser Permanente in Orange County, our PAs work in subspecialty groups such as hand, foot and ankle, sports medicine, total joint reconstruction, trauma, and pediatrics. We have the luxury and benefit of having 19 fellowship-trained orthopedic surgeons. This increases the opportunity for our PAs to specialize and draw from a vast knowledge base to provide the highest quality of care across all subspecialties.

Mohnickey: Since graduation my training and experience has been both surgical and clinical. I have worked with patients from all walks of life, including professional, college and high school athletes. This allows me to better inform our patients of treatment options with expected outcomes. Over the years I have been blessed by forward-thinking physicians who have allowed PA services to evolve in their practices.

I think a well-trained PA translates to patient confidence and physician trust.

Jackson: What advice can you offer to a physician considering working with a PA?

Bos: My advice to a physician would be to develop a model that works best for his or her practice and that adopts the skill sets of a PA that maximize efficiency and productivity. This model can be developed cooperatively with the physician and PA if desired.

It is critical that the physician recognize the PA’s orthopedic knowledge base. From there, certain aspects of the physician’s surgical practice can be engaged in the PAs duties and obligations to the service and the surgical practice. This ensures that the practice runs smoothly and to his or her preference.

My goal would be to have the surgeon appreciate the competence and abilities of an orthopedic PA. This would ensure that the PA would be an effective extension of the surgeons practice and would be able to follow through with the specific surgical principles.

My advice for the surgeon is to utilize the PA in a way to unload him or her of some routine clinical practice responsibilities that a PA is capable of doing. This would improve productivity and create a rewarding sense of duty.

Gauthier: Physicians should educate themselves on the PA profession and think about their expectations of a PA in their practice and what qualities a PA can add to the practice. Try to find applicants who had orthopedics as their clinical rotation elective, completed an accredited PA orthopedic fellowship, or has previous work experience as a certified athletic trainer. Recommended resources are the American Academy of Physician Assistants and the Organization for Physician Assistants in Orthopedic Surgery.

Guizado: If a physician is considering to employ a PA in a practice, it would be a good idea to contact a local PA program and become a preceptor. This will empower the physician to make a direct impact on a student’s education while allowing the physician to evaluate a student for possible employment.

PAs appreciate the relationships they forge with supervising physicians to provide the best patient care. A PA-physician partnership will be a rewarding adventure for the PA, physician and patients.

Larinto: I believe the key ingredients of a successful physician-PA partnership are mutual respect, open communication, sharing common goals for providing the utmost quality patient care and building a thriving practice together. The PA is an extension of the physician, which increases efficiency and gives more opportunity for growth of the practice. This also allows for greater patient satisfaction by spending more time with each patient and increasing access to medical care. A successful partnership can be personally, professionally, and financially beneficial for the physician and the PA.

Mohnickey: In our practice model, the walk-in clinic has not been as effective as a quick-access clinic with same-day scheduled appointments by both physician-referral, ER and direct patient calls.

The physicians believe in the concept. By giving autonomy to the PA you must realize you are not losing patients by not seeing them. You are actually increasing the number of new patients into your practice who have been evaluated and prepped for surgery.

The PA and the physician must have a clear understanding of shared plans of care so that treatment options are identical. The physician must realize that a PA in this setting are the front door to their practice and are the first impressions and the last impressions that the patient will remember.

Physician and PA must have an open line of communication to review questionable cases, treatment options and office issues including digital X-ray and off-site review by the supervising physician.

My supervising physician, Michael C. Kolczun II, MD, taught me one fundamental truth that must take place with PAs: That care delivered by a PA is no less than would be delivered by the physician. I believe this is the cornerstone of practice is being carried forward today by Brian Sims, MD, and Keith D. Bjork, MD, and that is what makes our prompt center so successful.

For more information:

• Peter Bos, PA-C, can be reached at the Mayo Clinic, 200 First St. SW E14B, Rochester, MN 55905; e-mail: Bos.Peter@mayo.edu.
• Roy Guizado, MS, PA-C, Chair, Physician Assistant Education, Associate Professor, PA Education, can be reached at 309 E. Second St., Pomona, CA 91766; 909-469-5445; e-mail: roygpac@westernu.edu.
• Anthony R. Gauthier PA-C, ATC, can be reached at Memorial Orthopaedic Surgical Group, 2760 Atlantic Ave. Long Beach, CA 90806; 562-0424-6666; e-mail: agauthie@gmail.com.
• John Larinto, PA-C, can be reached at Kaiser Permanente, Anaheim Medical Center, 441 N. Lakeview Ave., Anaheim, CA 92807; 714-279-4000 e-mail: John.T.Larinto@nsmtp.kp.org.
• John Mohnickey, PA-C, can be reached at Amarillo Bone and Joint Clinic, 3501 Soncy Road, Ste. 129, Amarillo, Texas 79119; 806-468-9700; e-mail: amherst-5@hotmail.com.