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 the 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
|Round Table Participants
Douglas W. Jackson, MD
Long Beach, Calif.
Peter Bos, PA-C
Department of Orthopedic
John Larinto, PA-C
Physician Assistant II,
Orange County, Calif.
Anthony R. Gauthier, PA-C, ATC
Memorial Orthopaedic Surgical Group
John Mohnickey, PA-C Physician
Prompt Orthopedic Clinic
Roy Guizado, MS, PA-C
Assistant Education Associate Professor, PA Education
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
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
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
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
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
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:
- 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:
- 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: firstname.lastname@example.org.
- John Larinto, PA-C, can be reached at Kaiser Permanente,
Anaheim Medical Center, 441 N. Lakeview Ave., Anaheim, CA 92807; 714-279-4000
- John Mohnickey, PA-C, can be reached at Amarillo Bone and
Joint Clinic, 3501 Soncy Road, Ste. 129, Amarillo, Texas 79119; 806-468-9700;