The great PA debate: Should spine surgeons hire them?


Here six spine surgeons discuss the pros and cons of hiring physician assistants.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What do you wish you had known about hospital employment before taking up that option?


Please send responses to Anuja Vaidya at by Wednesday, March 30, at 5 p.m. CST.


Question: The demand for physician assistants is growing. Would you recommend hiring a PA? Why?


Brian R. Gantwerker, MD, The Craniospinal Center of Los Angeles: In a word, no. I think the more directly involved we are with patient care, and the less we give into the urge for the "more is more" mentality, we can deliver on the promise of better patient care. As we distance ourselves from our patients, I feel it leaves a potential space for the government and insurance companies to intercede more and more in that relationship. They do have incredible value, though, in some practices and when supervised and carefully trained they can be a valuable asset.


Richard Kube, MD, Founder, CEO, Prairie Spine & Pain Institute (Peoria, Ill.): Yes, if you can support them. If you have the ability to truly develop an extender of yourself, it is quite valuable on many levels. PAs are potentially so much more than someone to help you round and do scut work you wish to avoid. If you are willing to take the time to train and mentor those individuals, you can increase the volume your practice is able to handle as well as develop added service lines for your practice. Those added lines are not only a benefit to your patients, by incorporating more of their care under one roof, but you also have added financial verticals for the business.


Raymond Hah, MD, Assistant Professor, Clinical Orthopedic Surgery, Keck Medicine of USC, Los Angeles: A well-trained physician assistant extends the capability of a surgeon to help more patients and help them more thoroughly and completely. By working in conjunction with the surgeon, the physician assistant can properly triage acuity of care, increase the surgeon's efficiency and offer an additional level of care in both the hospital and clinic settings.


Michael Duffy, MD, Texas Back Institute, Plano: Hiring a physician assistant has both positive and negative implications. In regard to lifestyle and time management, there is no question that a qualified PA can make the doctor's life much more manageable, especially in surgical specialties. I use the word "qualified" because there is definitely a downside to hiring the wrong PA; however, the vast majority of PAs are qualified.

From a financial standpoint, PAs can improve the bottom line if the physician has a busy surgical practice. Typically the PA can bill between 15 to 20 percent of what the surgeon bills for in certain cases. Each orthopedic subspecialty has different definitions of a case that can have an assistant fee. For certain subspecialties, such as hand surgery, it may make less sense to have a PA in the OR due to a limited number of reimbursable cases.

Training a PA can be onerous as well, in the beginning, even more so when the PA has previously worked for another surgeon with a different practice style. Usually, the training period takes up to six months until a PA is able to have more autonomy.

In the office, PAs are quite helpful in lessening the burden of paperwork and dictation. Follow-up and maintenance office visits take up significant time for a physician and having a PA allows the physician's clinic to make more appointments for new patients who may need surgical interventions.

Determining when it is time to hire a PA is basically a mathematical equation. When the cost is relatively neutral, the benefits of a PA definitely outweigh the negatives.


Mark Nolden, MD, NorthShore Orthopaedic Institute, Chicago: Physician assistants are invaluable. They've been part of our team for the past decade and have enhanced the patient experience. They are the bridge between the clinic and surgery.

We have higher patient volumes because of their ability to treat the patient everywhere surgeons do. They're in the clinic setting with me and the patient, helping to come up with a treatment plan. They are part of the educational and preparation process for patients. They scrub in with me in the OR, and do rounds at the hospital. They are very knowledgeable and an excellent resource for consistency.

They are a valuable set of eyes and ears that every spine practice should have a part of their team.  


Thomas A. McNally, MD, Director, Chicago Spine Center at Weiss Memorial Hospital: Yes, I would recommend hiring physician assistants. They have become valuable members of our healthcare team. A team approach is required in caring for spine patients. PAs add different viewpoints as they bring their own life and work experiences to the discussion as well as their own skill set and mindset. As residents have worked fewer hours in the hospital setting over the past decade, the PA's presence has been needed more and more. They are appreciated partners in the continuity of care between the clinic setting and OR. It's a real collaborative effort which benefits the patient.


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