Physician and PA teamwork: How to determine the best role for your PA

Issue: June 2013

ByJennifer Van Atta, MS PA-C

In today’s landscape of increased costs and decreased revenues, incorporating a physician assistant into an orthopedic practice can take many shapes. Interestingly, over the years the one thing I have come to believe is that there is no singular “best practice” model. What follows are things to consider when trying to ascertain the best role for a physician assistant in an orthopedics practice.

Patients enjoy being cared for by physician assistants (PAs). Studies have shown that in general, patients feel PAs are able to take more time with them, listen well and thoroughly address their concerns. Physicians know that PAs do not replace or compete with them as a provider, but enhance their ability to provide greater efficiency and continuity of care to a greater number of patients. Physicians have found that use of a PA has translated into fewer hours in the operating room (OR), fewer hours spent rounding, fewer patient calls and more time off — all without sacrificing quality of care.

Jennifer Van Atta

The following are ways in which PAs are being successfully used in orthopedics practices. For some, I have included a few tips gleaned from personal experience.

Preoperative duties: The goal here is not only to clear the patient, but ideally to pre-empt and avoid last-minute cancellations. If the PA is familiar with and proactively addresses the thresholds of anesthesia relative to things such as, cardiac clearance, use of blood thinners, body weight, hours nil per os and preoperative discontinuance of select medications, there should be no last-minute surprises in the days before surgery.
Postoperative series, including pain management: Thought should be given to the frequency and conditions under which the surgeon will see patients postoperatively. Whatever is chosen, the groundwork should be clearly laid out from the start. For example, most patients are happy to see the PA from their surgical team in follow-up when the surgeon has already expressed a preference for the team approach and a reliance on the PA to provide therapeutic guidance, flagging any concerns directly to the surgeon. What patients care about most is getting the attention they need from someone qualified to render the service.
New patients: Histories, physical exams, ordering and interpretation of labs and imaging, and treatment recommendations are all things within the capabilities of a PA experienced in orthopedics. Many orthopedic practices use PAs as the entrance to a busy surgical practice. Patients who require immediate surgical intervention are diagnosed and prepared for surgery with the consultation of the surgeon. Patients who do not require immediate surgical intervention are treated and followed autonomously with consultation from the supervising physician.
On the job injuries (OTJIs): PAs can serve as the attending provider in an OTJI, and as such are able to see, diagnose and treat OTJIs. They can also issue work releases and modifications, and monitor treatment progress. However, there is a limit to the length of time a PA can be the attending provider, after which the PA may continue to treat injured workers under their supervising physician, who then becomes the attending provider.
Fracture care, casting, splinting and tendon repair: PAs can perform all these duties as well as closed reduction of acute fractures. They can also fabricate casts and splints, and apply and fit braces. These are things that can sometimes be done by other staff as well, and the best efficiencies of the practice need to be kept in mind.
Ultrasound, joint injections, trigger-point injections, wound closure and debridement: Contrary to what one might initially think, it is not the best use of a PA’s time and skills to do the things that provide the least revenue per visit. Patients will return for care to the team of providers they feel has given the best, most thorough and knowledgeable care. They will return to providers who have taken an interest in them, know their conditions and disease process, how far they have come in treatment options, and what the game plan of care is for the future. PAs should not routinely be asked to simply step in to do a procedure on a patient they have not been following. Patients want their providers to care for them thoroughly. PAs have full provider skills, and it is in the interest of greater patient satisfaction to use PAs at a higher capacity.

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Patient education and telephone calls: PAs are great at patient education because, as a key part of the orthopedic team, they understand presurgical expectations, anatomy, disease processes, treatment algorithms, surgical procedures and techniques, and rehabilitation expectations and protocols. They typically communicate well, and as previously noted, patients like them. Patient education is a great place to involve a PA as a member of the orthopedic care team. Whether writing protocols or simply fielding phone calls, it is important for the quality of patient care to have a member of the professional medical staff to educate your patients for consistency of information and care.
Emergency and practice call, hospital rounding, writing orders and discharging patients: Any and all of these can be incorporated into a PA’s role in a practice. Consider a team approach with the physician as lead of the team, and share the point-person responses needed for patient care.
Promotion: Community participation, athletic events, sports physicals, Saturday special clinics and community group presentations are great ways to incorporate PAs into the team model and simultaneously share your workload. PAs can educate community groups on arthritis treatment options, common shoulder injuries, and the like. There will always be people who are reluctant to schedule an appointment with a surgeon — but they are more than happy to see a PA from the same practice for an initial evaluation. There are many ways PAs can be incorporated into practice development with this approach in mind. Future patients need to know that PAs are valuable, skilled, team members who will get them to you, the surgeon, if it is necessary.
In the OR: This is perhaps the best known use of PAs, as first assists in the OR. There are plenty of roles for a PA in the OR, which will be outlined at a future time. However, consider an additional role for the PA as well — being the contact person for the OR. Having a single contact person for non-scheduling related questions and concerns can minimize confusion. A PA who knows procedural techniques, graft preferences, equipment needs, case times, etc., can be helpful both to your clinic staff and to the OR. Having one person to ask, who can always go out to get additional information, can save time and prevent the duplication of efforts.

A PA’s role in an orthopedic practice will need to be developed over time. Models delineating best practices are simply that — models. Each physician who desires to employ a PA will examine the practice goals, making decisions and developing roles to accomplish those goals. Revenue generation? Better patient care? Efficiency of clinic or operating time? One more week off per year?

Ultimately, the success of PA integration into a practice is less dependent on what the PA is doing in clinic, and more dependent on how successfully the team approach is communicated to patients. The PA’s role should be developed according to the needs of the clinic, but the success of the PA should be developed by the surgeon.

For more information:

Jennifer Van Atta, MS, PA-C, is a physician assistant at Orthopedics Northwest in Tigard, Ore. She can be reached at jenniferkvanatta@gmail.com.
Disclosure: Van Atta has no relevant financial disclosures.