Many orthopaedic surgeons are unaware that, despite their similar-sounding names, physician assistants (PAs) and orthopaedic physician assistants (OPAs) are two distinct professions. Understanding the distinctions between PAs and OPAs, however, is important.
PAs have broad medical training at accredited programs and work in all specialties, including orthopaedics. PAs are licensed in all states and are recognized by Medicare, Medicaid, and most commercial payers. Most OPAs are trained on the job; some have previous experience as orthopaedic technologists or surgical assistants. They can be certified, but few states regulate their practice. OPA services are not covered by Medicare.
Working with physicians in all medical and surgical specialties, PAs diagnose and treat patients, order and interpret test results, prescribe medications, perform procedures, and assist in surgery. PAs must be credentialed and privileged by the hospital medical staff process to provide medical care—such as admission health and physical exams—to hospitalized patients. OPAs, on the other hand, are not eligible for hospital medical staff privileges and are not able to care for hospitalized patients without onsite, direct physician supervision.
PAs’ educational background
PAs practice medicine as members of the physician-directed team. They are trained in intensive educational programs accredited by the Accreditation Review Commission on Education for the Physician Assistant.
PA training programs are approximately 27 months long and are offered at medical schools, colleges, universities, and teaching hospitals. Organizations participating in PA program curriculum development include the American Academy of Family Physicians, American Academy of Pediatrics, American Academy of Physician Assistants (AAPA), American College of Physicians, American College of Surgeons, American Medical Association, and Physician Assistant Education Association.
All applicants to PA training programs have a bachelor’s degree and prior experience in the healthcare field. The rigorous curriculum involves both classroom and laboratory instruction in basic medical and behavioral sciences, including anatomy, pathophysiology, pharmacology, and clinical diagnosis. Clinical rotations include primary care specialties, surgery and surgical specialties, psychiatry, and emergency medicine. PA students complete, on average, 2,000 hours of supervised clinical practice prior to graduation.
The United States has more than 164 accredited PA programs; most offer master’s degrees. PAs take a national certifying examination administered by the National Commission on Certification of Physician Assistants (NCCPA), which also functions as a de facto licensing examination. All PAs must pass the NCCPA exam as a prerequisite for licensure.
To maintain national certification, PAs must complete 100 hours of continuing medical education every 2 years and pass a recertification examination every 6 years. Each PA’s scope of practice is defined by delegation decisions of the physician, consistent with the PA’s education and experience, facility policy, and state laws. Their generalist education enables PAs to work with any medical or surgical specialty. PAs who work in orthopaedics under the supervision of orthopaedic surgeons are referred to as “PAs in orthopaedics,” not “orthopaedic PAs.”
OPAs’ educational background
The American Medical Association (AMA) had accredited eight OPA educational programs prior to 1974, but has not accredited any since then. Recently, however, the University of St. Augustine for Health Sciences has announced a new 2-year training program for OPAs, accredited through the Distance Education and Training Council.
OPAs were trained as assistants to orthopaedic surgeons, with an emphasis on orthopaedic disease and injury, management of equipment and supplies, operating room techniques, cast application and removal, office procedures, and an orientation to prosthetics and orthotics.
Graduates of OPA programs are not eligible to take the NCCPA certification or recertification examinations. OPAs have, however, established a National Board for Certification of Orthopedic Physician’s Assistants and developed an exam that is administered by the Professional Testing Corporation. According to the American Society of Orthopaedic Physician’s Assistants, to be eligible to take the exam, candidates must “have a solid background with a minimum of 5 years [on-the-job training] in orthopaedic medicine….” Passage of the exam allows an OPA to use the initials “OPA-C” after his or her name.
With very few exceptions, OPA practice is unregulated. Only Tennessee has an OPA practice act. New York allows OPAs to register as specialist assistants. California allows OPAs who completed their education from 1971 through 1974 and who do not meet the requirements for licensure as PAs to provide services to orthopaedic physicians, but does not have an OPA licensing category. Since 1985, no new OPA applications have been accepted in Minnesota. No state allows OPAs to prescribe.
PAs, OPAs, and Medicare
The differences between PAs and OPAs have long been recognized by the federal government. Medicare covers services provided by PAs who are state-licensed and have passed the NCCPA certification examination. Medicare does not recognize OPAs as providers, nor are they covered by Medicare for surgical first assistant services.
As orthopaedic surgeons evaluate workforce needs for their practices, they must consider the distinctions between PAs and OPAs. They should ask themselves: What are the current gaps in care? Who will best fill those gaps? Does the practice need more providers, or does the physician need more support staff?
Scope of practice, needs of the practice and the patients it serves, and value propositions presented by each profession will help determine whether a PA or an OPA will best complement the physician’s ability to provide efficient quality patient care.
Tom Gocke, MS, ATC, PA-C, DFAAPA, is the AAPA liaison to the AAOS and vice president of the Physician Assistants in Orthopaedic Surgery. He can be reached at firstname.lastname@example.org