Is the practice a private practice with one, two, or more physicians? Is the position hospital based and specific to a group of physicians? Is the position service centered? Are there other practitioners including nurse practitioners and/or PAs in the practice, and, if so, how many? What is their level of experience, and how long have they been a part of this group? This information is important because aside from choosing orthopaedics as your specialty, it has been shown that physician support is one of the highest predictors of PA job satisfaction.¹ Understanding the size of the practice and current involvement and retention may reveal how much support you will receive as the newest addition to the team. It may also provide some insight into your working hours. Many service-based positions are set up as shift work, for example,
7:00 a.m. through 7:00 p.m., whereas assignment to a specific physician or group will often have general hour guidelines with flexibility to the end of your work shift. Remember, it is unlikely that another will be assuming your clinical responsibilities if you work for an independent physician or group. This often means you may need to remain at work until all high-priority assignments for that day are completed. If a more reliable and predictable schedule, a service-based, shift work position may be better suited for you as you can rely on being relieved at the end of your shift.

If you will be working with more than one physician, determine their individual expectations your availability for their specific practice. Have a group discussion with all parties involved regarding expectations for your time allocation. Request that each physician outline clinical and operative schedules and indicate where your skill can be utilized. Set up a transparent schedule that can be edited and viewed by all. Once you begin to work independently in the outpatient office or on the inpatient floors, you may require less segregation of your schedule. This will benefit each surgeon’s practice by increasing your availability to their patients. In this model, you will offer outpatient appointments for each attending during the same office block.

Will your role in the practice be in the outpatient office, the operating room, and/or an inpatient hospital setting? If you will fulfill multiple roles, approximately what percentage of your time will be spent in each location? If there are multiple sites of practice (eg, surgery center, hospital-based operating room, outpatient offices), what is their proximity to each other, and how often will you commute among the sites?

Will orthopaedic residents or fellows have a permanent or temporary role in the practice? If so, will they be present in the outpatient office, rounding and managing inpatients, in the acute care clinic or emergency room, and/or assisting in the operating room? How will nonoperative clinical
responsibilities be divided? Other than the supervising physician, who is responsible for overseeing all duties? In the operating room, will the resident or fellow have priority as first assist or assume the role of lead surgeon? Is the practice volume sufficient for the PA to first assist in the operating room without compromising the learning opportunity residents and fellows? The setting of your position may determine the volume of residents and fellows present and their level of involvement in the practice. Most university teaching hospitals will have a larger volume of training physicians compared to more rural community-based hospitals. Although programs differ, institutions with an orthopaedic residency program or those that host residents annually may have less need for the PA in the operating room. If functioning as a first assist is a priority in your career, be sure to clarify this point prior to accepting a position. Please note that training physicians may be key resources to furthering your education as you train to become a skilled and experienced orthopaedic PA. Attending physicians are constantly educating young surgeons as a formal aspect of their training program. It is likely you will work as a team allowing you to absorb this information concurrently. Another perk of having training physicians at your institutions is that there will likely be cadaver labs, saw bones labs, morbidity and mortality lectures, and ongoing education lectures. If your schedule allows and you are permitted by the program director, attend these events and further your training too. Helpful hint: Many of these programs may be applied toward the continuing medical education (CME) hours that are required by the National Commission on Certification of Physician Assistants (NCCPA). With proper documentation, you can log these hours of education toward your recertification. Please see the section titled Professional Expectations for further detail.

Determine the level of additional support staff the practice? Is there a practice manager, a secretary, or a surgical scheduler?
Adequate support staff is necessary for a busy orthopaedic practice to run smoothly. Although the majority of your practice responsibilities will be clinical, PAs are often utilized to help off-load a significant amount of administrative responsibilities from the supervising physician. Establish protocols with the practice support staff for communications with patients, completion of FMLA, Worker’s Compensation, No Fault Injury, disability paperwork, completion of prior authorizations, preoperative testing protocols, medication refills, and billing submissions. Many of these topics will be covered in detail in Chapters 9 and 10.

Does the practice have clinical support staff, including medical assistants, X-ray technicians, casting technicians, or physical/occupational therapists on site?

Complete all patient-oriented documentation, including admission history and physical examinations, inpatient progress notes, discharge notes, outpatient new and established patient notes, and procedural notes (Of course this assumes you have completed outpatient office hours and rounds on all inpatients.)

Return patient and health care provider secure messages and phone calls.

Proactively call all discharged postoperative day 1 patients for follow-up, to answer any questions and to clarify postoperative instructions.

Complete medication refill requests and visiting nurse/therapist orders.

Complete pending prior authorizations and peer-to-peer evaluations.

Complete all administrative paperwork, including FMLA, WC, NFI, and disability paperwork.

Submit all surgical and clinical billing documentation.

Review surgical clearances for upcoming operations. Confirm cardiac, pulmonary, and medical clearance as well as whether the blood type and screen/cross are present in the patients’ chart if necessary. Verify preoperative images necessary for surgery are accessible or that the patient has been reminded to bring their films on the day of surgery.

Preorder imaging for patients who require routine postoperative imaging for upcoming follow-up appointments.

Complete any assigned institutional education.

At the end of the day, contact your supervising physician and support staff to verify that there are no outstanding tasks requiring completion at this time.