I graduated as part of Class of 2011 with the University of Wisconsin, Madison and moved to Toronto after marrying my husband who works as a chiropractor in Markham. I have now lived in Ontario for 6 years. It took me approximately 4 months to find my first job as a Physician Assistant in Ontario.
That first position was in an Emergency Department. I enjoyed this experience, however I left the position once I was offered a permanent position in General Surgery at Toronto General Hospital, where I worked for just under 2 years, until I found my dream job and niche with Orthopedics.
Prior to my PA education, I was a radiologic and CT technologist. I made the decision to proceed with PA school with the intention of becoming an Orthopaedic PA. Outside of clinic, I have two children, ages 2 and 4 years. We enjoy camping, hiking, biking and pretty much anything outdoors. My husband and I have a health and nutrition business that we both are so very passionate about. We like to participate in competitive sports, racings, jogging, swimming, and high intensity interval training (HIIT).
My work schedule
When I was first hired I predominately looked after the care of inpatients, outpatient fracture clinic, and perioperative care.
- Inpatient and ward responsibilities include daily rounds, review of vitals and blood work. If any medical conditions arise, it is my responsibility to contact other services for consultations. Daily Orthopaedic testing and examinations to include neurovascular status, wound care, hemodynamics, and mobility.
- Fracture Clinic – Acute Orthopaedic injuries such as fractures, and soft tissue injuries that present in the ER are usually referred here for ongoing treatment and management. If I have free time, or the Orthopaedic Surgeons are backed up I will help with procedures such as joint aspirations and injections.
- Operating Room – PAs also function as surgical first assists in the OR. However, we have identified that my time is best served looking after inpatients, orthopaedic consultations, and shoulder center. Ispend 2 hours per month of assisting in the OR, and this is only when they absolutely need my help.
- Orthopaedic On-Call – I am first call for Orthopedics during the hours I am working and triage all consults. The most common consults from the ER are open fracture, hip fractures, post op complications, and septic joints. Common inpatient consults I see include septic joints, diabetic limbs, or severe joint pain not yet diagnosed.
- Shoulder Centre (Outpatient Orthopaedic Clinic) – Referrals that are sent from family physicians to be seen by a shoulder specialist are referred to the Shoulder Centre, where I work as part of a team of 6 health care providers. I explain a little bit more below.
- PA Student Curriculum – In addition to my clinical responsibilities I have also assisted my supervising Physician with teaching and precepting second year PA students completing their clinical clerk rotation in Orthopaedics.
Working in the Shoulder Centre
Our Orthopedic team has developed a new model of care called the Shoulder Centre. This is a big addition to my skill set, in addition to inpatient care and consultations. Gratefully, I have been assisting in the development and implementation of the Shoulder Centre Program. We have 6 providers at our Ajax/Pickering Shoulder Centre with 1 champion Medical Doctor in Port Perry. Shoulder care is very underserved in our communities. There is a gap between primary care practitioners and Orthopaedic specialists, in terms of shoulder treatment. Specifically when we need to see patients and what we need from primary care practitioners. Often times there are so many patients in the community that suffer for years with shoulder pain and bounce back and forth between x-rays, ultrasounds, MRIs and doctors without any sound diagnosis or treatment plan.
Our surgeons created an Intelligent e-referral tool so we can obtain the information we need from primary care to triage the patient to the right provider at the right time. The referrals come into a central referral and they are reviewed by our shoulder surgeons and coded appropriately. Between the six providers, the coded referral goes to the appropriate provider. Referrals that have a high likelihood of requiring surgery go to the three Orthopaedic Surgeons and wait less time. The referrals that likely do not require surgery or need further testing are divided amongst the PA and two Non-surgeon Medical Doctors.
In preparation for seeing and assessing patients at the Shoulder Centre, the Orthopaedic Surgeons trained me quite extensively. This was a 3-6 month training period with direct supervision, workshops, injection clinics, and learning labs. We created a very thorough and complete set of medical directives to encompass all my shoulder centre skills.
I now see a certain subset of non-surgical shoulder patients completely independent if their conditions are covered by the umbrella of medical directives that we have established. These are cases that I am comfortable managing, and are often seen repetitively. I perform AC Joint injections, subacromial and glenohumeral injections, prescribe anti-inflammatories and physiotherapy. I spend a lot of time teaching the patients about their condition and they are often so happy to have a better understanding. Yet mostly they are happy to be heard and have somebody that wants to help them. I spent approximately 16 hours per week at the shoulder centre.
Common conditions I see at the shoulder centre include:
- Adhesive capsulitis (frozen shoulder)
- Subacromial impingement
- Rotator cuff tears, acute and subacute
- Periscapular pain
- Rotator cuff and biceps tendonitis
For the patients that I see independent of my supervising physician, there is no Orthopaedic Surgeons fee billed to OHIP for this patient. The patients I see are solely charged the hospital visit. Therefore, my care is a 25% saving the health care system. The disconnect is that I am employed by the hospital, and the hospital does not perceive this cost savings.
This system has really helped cut down wait times significantly for surgery. Previous wait times to see a surgeon specialist for a shoulder condition went from 3 month or more wait to 2-4 weeks for a surgical consultation. With the start of the Shoulder Centre, the hospital has opened more OR time, which also improves wait time to date of operation by 4-6 weeks.
Feedback about the addition of an Ortho PA
There has been nothing but positive feedback about the services and consultations I provide in the hospital setting.
The PA role has been extremely well received by the ER staff, nursing staff on the surgical ward, and the multiple health care providers that I provide consultations for. My supervising physicians are 100% on board with working alongside a PA.
Working with Nursing – Before I started working, nurses would often talk about how many times they would have to page surgeons waiting for orders and how often admission were delayed due to on-call surgeon being busy in ORs. They were so thankful to have someone there to help them provide excellent patient care. When I arrive at the start of my shift, and they often have a list of things they would like to have done for improved patient care.
Consulting with different Specialty Physicians – I carry a cell phone with me at work, and am often available to anybody whenever they need an Orthopaedic opinion. The Emergency physicians are extremely appreciative to seek opinions. If they have patella fracture or quadriceps tear that requires an urgent Orthopaedic opinion they are able to get a quicker response with the PA. The same goes with our Internists.
We recently went to the Canadian Orthopaedic Association conference in Ottawa last June and presented three abstracts, one of which was a study on the PA role in the Shoulder Program at Lakeridge Health. This presentation was so well received, we had 5 or 6 Orthopaedic Surgeons ask us questions after the presentation about how to get a PA in their organization after hearing how the role has been utilized.
Advice for PA students interested in Orthopaedics
If it’s inpatient management –
- Know the most common post-operative complications that can occur in (1) the first hour, (2) first 24 hours, and (3) in the first week.
- Wound care and orthopaedic physical assessment knowledge is of utmost importance for inpatient management.
For surgery –
- Look up and know what to expect in the case before you even go into the operating room, that way you know and can recognize the anatomy.
- Sterility and common operating room policy and procedures.
Professionalism and Learning –
- Employers like to see learners take initiative, so be proactive and prepared. Know what your role is going to be and have clear expectations.
- Don’t be afraid to jump right in and starting showing your independence. Get in there and ask to do more. That’s the only way we can get ahead in our profession, we need to ask to see more and do more.
Tips for Orthopaedic Surgeons looking to work with a PA
PAs are educated in the same/similar medical model as a physician, however it is a more accelerated program. They require more precise on-the-job training.
Training a new PA grad is very similar to training an early/junior resident. If it is a PA that is new to an Orthopaedic practice or organization, the expectation is to train the PA in diagnostic imaging, Orthopaedic testing, developing a diagnosis and implementing a plan of care. Guide them to resources that they can use to learn. As mentioned before, I attended learning workshops and labs with the Orthopaedic Surgeons.
Have any questions for Kimberly? Let us know in the comments below!
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