As a surgical PA with extensive experience in high-acuity settings, I have seen the role of the surgical Physician Assistant evolve into a cornerstone of modern operative care. Our work is far from auxiliary. It is foundational, interwoven into the surgical process at every level. In the operating room, we are not observers or mere assistants but integral agents of surgical efficiency, patient safety, and procedural success.

This article aims to dissect the surgical PA’s role in the OR with granularity that speaks directly to fellow clinicians, administrators, and surgical staff. If you’re reading this, you are likely familiar with the basics, so this is not an elementary review. Instead, we’ll explore our clinical, procedural, and administrative impact from pre-operative evaluation through post-operative care, with particular focus on intra-operative performance. My goal is to articulate our contributions with enough technical specificity to inform and enhance team dynamics, hospital policy, and advanced practice integration strategies.

The presence of PAs in surgery traces back to the late 1960s, with many early practitioners being medics and corpsmen returning from military service. Their clinical acumen and procedural confidence found a natural home in surgical settings. Over time, civilian medical centers recognized the utility of these individuals in absorbing workload, particularly as surgical complexity increased and physician training structures evolved.

The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) began recognizing postgraduate surgical residency programs in the 1990s. These programs provided a formalized pathway for PAs to receive focused subspecialty training in surgical care. Modeled after physician residency structures, they prepared surgical PAs to assist in complex procedures, support the management of post-operative complications, and contribute effectively in high-volume operating room environments under the direction and supervision of experienced surgeons.

The expansion of duty hour restrictions for surgical residents accelerated the integration of PAs into OR teams. The 80-hour workweek, mandated in 2003 by the ACGME, created critical coverage gaps that surgical PAs were ideally suited to fill. Over the past two decades, the PA role has become institutionalized in many surgical departments, not as a patch but as a permanent fixture. Today, surgical PAs work in nearly every subspecialty and are often the most consistent providers across perioperative phases of care.

Our scope of practice begins with national certification through the NCCPA and is refined by state law, institutional policy, and departmental protocols. Once board-certified, PAs must complete CME and periodic recertification. However, surgical practice is less about the license itself and more about the credentialing mechanisms in place at the hospital level.

Hospitals grant surgical privileges to PAs based on training, experience, and documented competency. Privileging committees typically require procedural logs, supervisor attestations, and completion of institution-specific credentialing packets. The result is a procedure-specific authorization list, which delineates tasks such as first-assist privileges, wound closure, central line placement, or chest tube insertion.

This scope remains under the clear and essential authority of the supervising or collaborating physician. The surgical PA functions within the clinical parameters defined by that physician, guided by established protocols and direct expectations. In the operating room, the collaborating physician plays a central role in overseeing clinical decision-making and ensuring alignment with surgical standards. Our contributions are most effective when supported by a strong and communicative collaboration, where the physician provides not only direction but also mentorship and clinical insight that enhance the quality of care delivered.

The surgical PA’s involvement often begins well before the patient reaches the OR. We are responsible for reviewing imaging, optimizing pre-operative labs, and ensuring that patient comorbidities are addressed. This phase may involve liaising with internal medicine, anesthesia, or cardiology, depending on the complexity of the case and the patient profile.

We conduct pre-operative evaluations, documenting histories and physicals with a surgical perspective in mind. This means evaluating airway status, anticoagulation risk, and identifying factors that may affect wound healing or infection risk. We are frequently tasked with obtaining informed consent under the direction of the attending surgeon. In these conversations, it’s not just about the procedure itself but about managing expectations, discussing possible complications, and reinforcing post-op planning.

Coordination with the OR team begins in earnest here. The PA ensures that necessary instrumentation is available, that pre-op antibiotics are ordered per protocol, and that VTE prophylaxis plans are communicated. We often participate in surgical scheduling and case planning meetings to advocate for efficient sequencing and patient flow.

Once in the OR, the surgical PA’s role shifts to technical execution. First-assist duties are highly variable depending on the surgeon’s preference, the procedure, and institutional culture, but there are universal constants. We are responsible for retraction, suction, hemostasis, and sometimes direct tissue handling.

In laparoscopic or robotic procedures, we are often at the bedside, manipulating trocars, assisting with camera control, and troubleshooting equipment issues. With robotic cases, PAs often assist with patient positioning, robotic arm docking, and act as the primary surgical bedside assistant.

During open cases, particularly in vascular, general, or thoracic surgery, our duties expand to include vessel exposure, vessel loops, applying bulldogs, and sometimes vascular suturing or clamping under direct supervision. Closure responsibilities often fall to the PA, and in high-volume practices, this is where we significantly affect OR turnover time. Our ability to close efficiently and safely allows surgeons to begin scrubbing for subsequent cases while maintaining procedural integrity.

Beyond hands-on surgical support, PAs manage intra-operative charting, specimen labeling, and coordination with pathology and radiology. If complications arise, we act quickly to help identify and mitigate bleeding, unexpected anatomy, or iatrogenic injury. Our continuous presence in the OR makes us invaluable during periods of high acuity.

The immediate post-op period demands rapid, accurate assessment. We accompany the patient to PACU or ICU, ensuring that handoffs to anesthesia and nursing are thorough. This includes detailing fluid shifts, blood loss, complications, lines placed, drains used, and plans for the next 12 hours.

We write post-operative orders, including fluid management, analgesia, anticoagulation, and surgical site care. Our role in managing pain has evolved with the opioid crisis, pushing us toward multimodal analgesia protocols and regional anesthesia collaboration.

In surgical services, PAs support patient care by assessing wound integrity, monitoring drain output, and identifying early complications such as ileus, infection, or hematoma. These evaluations are conducted within the care plan established by the supervising or collaborating physician. We assist in adjusting antibiotics, coordinating imaging, and facilitating timely specialty consultations based on the physician’s guidance. Discharge planning is often carried out by the PA in close coordination with the surgeon, especially during full operative days. We help ensure continuity of care by scheduling follow-up visits, preparing discharge instructions, and reinforcing the physician’s guidance on wound care and activity restrictions.

In many institutions, surgical PAs contribute beyond traditional first-assist duties by performing a range of advanced procedures that have historically been managed by residents or fellows. These include the placement of central venous catheters, arterial lines, chest tubes, and surgical drains, all carried out under the supervision and direction of the collaborating physician. Competency in these procedures represents not only technical proficiency but also a valuable support to the surgical team during trauma resuscitations and acute clinical events where timely intervention is essential.

We often manage bedside I&Ds, minor wound revisions, and percutaneous drain placements. In cardiothoracic surgery, PAs may harvest radial or saphenous vein conduits and apply endoscopic vessel harvesting techniques. In neurosurgical settings, we might assist with frame placement or perform burr hole closure.

Robotic surgery has created a new subset of procedural demands. While the attendant operates the console, the PA is responsible for exchanging robotic instruments, performing suction, clipping vessels, and manipulating ancillary tools. Our ability to anticipate surgical steps and manage the robotic arms directly affects the efficiency and safety of the case.

PAs are uniquely positioned to serve as continuity agents across the surgical team. We do not rotate in the same way residents do and are often present across multiple service lines. This consistency enables us to maintain institutional memory, reinforce standardized protocols, and identify patterns that may impact patient outcomes or process improvement.

We act as critical liaisons between scrub techs, circulating nurses, anesthesia, and the surgical attending. When equipment is missing or imaging isn’t ready, we troubleshoot without escalating unnecessarily. We also provide intra-operative updates to patient families when the surgeon is engaged in another case.

In teaching hospitals, there is ongoing debate about the role of surgical PAs relative to residents. Far from being competitive, the relationship is symbiotic when structured well. PAs can offload routine tasks, allowing residents to focus on academic learning and complex decision-making. Conversely, in non-teaching facilities, PAs fill roles typically reserved for surgical trainees, often with greater procedural repetition and confidence.

Each member of the surgical team brings distinct strengths, but role clarity is vital. While surgical NPs often excel in medical management and discharge planning, PAs are generally trained more rigorously in procedural and surgical techniques. Our education model is patterned after medical school, with an emphasis on generalist training followed by surgical specialization.

Residents, of course, are training to become surgeons, and their involvement should reflect a graduated learning model. PAs, on the other hand, offer long-term consistency and can often perform tasks more efficiently due to repetition. Surgical techs support intra-operative setup and instrumentation but do not participate in clinical decision-making or patient management.

Knowing where these roles begin and end helps reduce friction and optimize OR throughput. Interdisciplinary respect and communication are key, and surgical PAs are frequently the glue that holds this complex machinery together.

PAs play an increasingly important role in surgical documentation, not only for medicolegal accuracy but for billing and coding compliance. Operative notes must meet CMS requirements, especially when PAs are the primary first assist. Proper language around co-signature, procedural detail, and medical necessity is essential.

There is ongoing complexity surrounding incident-to billing versus shared visit billing in the post-operative context. PAs must understand the nuances of each billing pathway to ensure institutional compliance and avoid audit risk. Additionally, many of us participate in quality reporting, contributing to NSQIP, SCIP compliance, or institutional morbidity and mortality reviews.

Proper documentation of surgical start and stop times, equipment used, and intra-operative complications ensures both clinical safety and financial accuracy. We are often the ones responsible for documenting time-outs, sponge counts, and critical event timestamps.

Staying current in surgical practice requires ongoing effort. Many surgical PAs participate in postgraduate training programs, attend specialty-specific conferences, and engage in cadaver labs or procedural workshops. Our scope is evolving, and institutions must invest in our development to maintain high standards of care.

Some of us serve as preceptors for PA students or junior colleagues. Others take on formal teaching roles in residency didactics or departmental CME sessions. In advanced practices, we are credentialed in robotic systems, advanced wound care, and even bedside ultrasound.

Our ability to train others while remaining clinically sharp enhances team resilience and institutional knowledge.

Surgical PAs in cardiothoracic surgery may round in the ICU, harvest veins, and assist in complex bypass or valve procedures. In orthopedics, PAs frequently perform fracture reductions, joint injections, and assist in arthroscopy. Neurosurgical PAs may manage post-op neuro exams, ICP monitoring, and assist in spine instrumentation.

Plastic surgery PAs deal with microsurgical assistance, flap monitoring, and complex wound care. In ENT and urology, we may participate in endoscopic procedures or reconstructive cases. The core skills translate across specialties, but procedural demands and patient populations vary significantly.

Understanding the nuances of each field allows PAs to adapt quickly and provide specialized care without retraining from scratch.

Despite our established utility, surgical PAs still face institutional resistance in some environments. Credentialing restrictions, limited privileges, and underutilization persist, especially in facilities with rigid hierarchies or resident-dominated workflows.

Reimbursement remains a barrier. Medicare’s restrictive policies on PA billing under the global surgical package reduce the incentive for hospitals to hire more PAs. Advocacy for better reimbursement models is essential.

Technology will shape the next decade of surgical PA practice. From AI-assisted surgery to intra-operative imaging and digital documentation tools, our adaptability will be crucial. There is a growing need for surgical PAs to serve on quality improvement committees, EMR task forces, and institutional review boards.

The surgical PA is no longer a supportive accessory. We are indispensable participants in the surgical process, from the first clinic visit to the final follow-up. Our technical skills, clinical judgment, and procedural efficiency enhance every aspect of operative care.

To truly integrate surgical PAs into the future of surgery, we must continue to advocate for scope expansion, better reimbursement, and institutional support. As surgical complexity rises and healthcare resources tighten, PAs will play an increasingly central role in delivering safe, timely, and high-quality care in the OR.

As a surgical PA, having the right collaborative structure in place is not just a regulatory requirement; it is essential to ensuring professional security and consistent, high-quality patient care. At Collaborating Docs, we understand that the surgical environment requires more than a basic, transactional approach to collaboration. You need a physician partner who understands the complexities of surgical practice, supports your clinical role, and helps you maintain full compliance with state requirements while contributing to a dependable and effective care model.

Founded by Dr. Annie DePasquale, a Board-Certified Family Medicine physician, Collaborating Docs was built from firsthand experience with the regulatory burdens that advanced practice providers face. Since 2020, we’ve been the leading solution for NPs and PAs across the country seeking legitimate, reliable, and meaningful physician collaborations. Our network now includes over 2,000 physicians across every specialty, and we’ve facilitated over 5,000 successful collaborations.

If you are a PA working in or transitioning into surgical practice and need to meet your state’s collaboration requirements, we are here to make the process efficient, compliant, and tailored to your clinical needs. We do not just match you with any physician. We connect you with one who aligns with your surgical specialty, understands your practice model, and brings value beyond the minimum regulatory standards. Whether you are in a hospital setting, ambulatory surgery center, private surgical practice, or providing telehealth surgical consults, having the right collaborating physician can be the difference between confident practice and legal vulnerability. Let us help you establish a high-quality collaboration so you can stay focused on what matters most: delivering excellent surgical care.

Partner with Collaborating Docs today and secure a compliant, specialty-aligned physician collaborator in 14 days or less. Visit our website to get started.