Military creates new "doctoral" residency program for PAs

first of all, that's crazy. i don't understand. explain.

second, thank you. unfortunately the link doesn't work since we don't have PA sign-ons

Taurus said:

Looks like the surgeons will have to start looking over their shoulders. Doing their own cases is the next step.

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There are at least a few articles I've come across over the years of ancillary staff performing operations and their outcomes. In short ancillary staff have poor outcomes even when trained by a surgeon and then left to operate independently.

I don't think we've progressed to the point in American healthcare where the surgeon, of all physicians, will be replaced by a mid-level practitioner. If it does come to that, great! I can then start up my band again...

Castro Viejo said:

There are at least a few articles I've come across over the years of ancillary staff performing operations and their outcomes. In short ancillary staff have poor outcomes even when trained by a surgeon and then left to operate independently.

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PAs have had an optional "residency" for a while, usually a one year deal in surgery. Not a degree program.

do you have any of those references? i didn't realize anything was published. i did a quick search but didn't find anything. thanks.

gasnewby said:

PAs have had an optional "residency" for a while, usually a one year deal in surgery. Not a degree program.

do you have any of those references? i didn't realize anything was published. i did a quick search but didn't find anything. thanks.

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Yes but those residencies were not to practice independently, but more as an on the job training for very specific specialties. I seem to remember hearing about an Ortho spine residency in Michigan.

DrDawg said:

Yes but those residencies were not to practice independently, but more as an on the job training for very specific specialties. I seem to remember hearing about an Ortho spine residency in Michigan.

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yes, seen them for CT as well...are these new residencies really intended for independent practice? (i was too lazy to register, so i could view that link from the OP)

gasnewby said:

yes, seen them for CT as well...are these new residencies really intended for independent practice? (i was too lazy to register, so i could view that link from the OP)

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No independent practice. Most of the "residencies" (a poor term - the preferred term is post-graduate PA program) are meant to rapidly acclimate new graduate PAs to specialty practice. Ortho probably has the most but CV has quite a few. There are a lot of practices that use PAs to take the vein for grafts. With the use of endoscopic harvesting a lot of practices do not have the time to train PAs in these procedures hence the post graduate programs. For a more complete list of post graduate PA programs:

http://www.appap.org/

David Carpenter, PA-C

Taurus said:

Looks like the surgeons will have to start looking over their shoulders. Doing their own cases is the next step.

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MacGuyver, is that you?

Yeah the official party line is that this is not for independent practice. Of course check back in 5 years and then lets see what their stance on this is.

This is the first residency program for PAs that gives them a doctoral degree.

According to their commander, they're "not supposed" to call themselves doctors. We'll see how that works out, I seriously doubt he's going to monitor them or track them down and make sure they arent using that title. He's simply saying that to smooth over any ruffled feathers by the MDs on the base. Then in 10 years when this blows over and their grads start using the "doctor" title he'll say "oops, the cat's out of the bag now, there's nothing I can do to stop it"

This is yet another step on the pathway to independence.

gasnewby said:

PAs have had an optional "residency" for a while, usually a one year deal in surgery. Not a degree program.

do you have any of those references? i didn't realize anything was published. i did a quick search but didn't find anything. thanks.

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I'll have to dig around. The most recent one I thumbed through was from just several months ago. I don't know it off the top of my head, unfortunately.

It was in England. Some surgeon "trained" several surgical nurses to perform Lichtenstein-type inguinal hernia repairs independently and then looked at outcomes compared to his experience and that of surgical residents. I don't know the specifics (i.e., length of training, number of cases, what the exact outcome measures were, etc.), but the outcomes were that the nurses had poor, poor outcomes and the surgical residents were closer to his own results. Far from scientific but interesting nonetheless to me. I guess you can't teach just any monkey how to operate.

All I want to know is how does malpractice work with those folks? And with NPs that practice independently. Do they both take on the same amount of malpractice insurance as a physician doing the same job? If their PA's outcomes are truly bad, then the malpractice settlements will weed the bad one's out. Hopefully.

Castro Viejo said:

It was in England. Some surgeon "trained" several surgical nurses to perform Lichtenstein-type inguinal hernia repairs independently and then looked at outcomes compared to his experience and that of surgical residents.

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yes, i've heard of that study, i forgot...hernias aren't always so simple!

Looked for that hernia study but couldn't find it. Seems like a lot of studies have been done examining NPP in "surgical abortions" though, and various GI procedures like liver biopsy, and flex sig

Hey maybe in ten years we can all join anesthesia in the Doctors lounge and watch CNN and sportscenter while everyone else is doing the work, popping into several OR's every so often.

DrDawg said:

Hey maybe in ten years we can all join anesthesia in the Doctors lounge and watch CNN and sportscenter while everyone else is doing the work, popping into several OR's every so often.

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i resent that. sometimes we watch cheesy reality shows.

gasnewby said:

i resent that. sometimes we watch cheesy reality shows.

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"Who Wants to be a Millionaire?" isn't cheesy...

Neither is watching "Live! with Regis and Kelly."

Taurus said:

You guys have to use your imagination and try to project what could happen.

DrScPA won't change the surgery culture tomorrow. It may take decades. However, I could see this scenario happening. Midlevel surgeons like DrSciPA's do the straight-forward cases like lap choles and appy's. Maybe they even work up the cases themselves. You'll have a surgeon who floats between OR's in case the midlevels need help. It'll be similar to how the anesthesiologists float between OR's while CRNA's manage the anesthesia.

What would be the driving force behind this? Money of course. More cases can be done. Fewer surgeons you have to hire. The dirty little secret in medicine is that most of it is routine. It's true for FP and it's true for surgery.

Sounds implausible? I'm sure the anesthesiologists 40 years ago thought the same way about CRNA's. I'm sure the internists 40 years thought the same thing about NP's. Now you have all of these midlevel groups who create pseudo-doctorates for themselves, doing junk research to show equivalence, and then pushing for independence from physicians.

Someday, DrScPA's will publish an article claiming that there is no difference in outcomes between a surgeon and DrScPA's for simple surgeries like lap choles and appy's.

Were the surgeons laughing when the interventionalists first came on the scene too? "They're not real surgeons". Look at what interventional rads and cards has done to CT surgery. Now you have interventional GI, neurology, nephrology, etc. Interventionalists and DrScPA's will be able to do what they do because surgeons will be around to act as back up when they get into trouble.

I wouldn't get so complacent. Learn the lessons from history so you don't repeat them.

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You really need to understand surgery. Surgeons don't get paid for the easy 95%. They get paid for recognizing the other 5% of the cases and dealing with it appropriately. Lap choles can be anything but easy. We see a fair number of CBD injuries. As a PA who works in surgery, I can tell you that this is the part of the PA profession that has the least amount of independence. Almost everything that we do in the OR is under direct supervision. The work that we do on the floor has less supervision but much more than when I worked in medicine. I can't predict what medicine will look like in 40 years. We may not even have physicians, but I can tell you that the DScPA has nothing to do with independence. It simply recognizes that the areas that the Army has interest in training PAs in (EM, Occ med, surgery, and Ortho) are being expanded by adding a research component to the current post grad program. You can try to read more into it, but thats really all that it is.

David Carpenter, PA-C

Taurus said:

You guys have to use your imagination and try to project what could happen.

I wouldn't get so complacent. Learn the lessons from history so you don't repeat them.

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So what would you like us to do?

Burn down all the PA schools in protest?

In all seriousness though, yes, a lot of what we do is routine but the old saying goes, "there are no simple surgeries, just simple surgeons," is true. Repairing inguinal hernias may not seem like a big deal, but tell that to the plaintiffs in malpractice lawsuits who claim they can't feel their inner thigh, scrotum, or even have "relations" without pain. If the PAs want to take on this kind of responsibility, and there's some malpractice carrier who's willing to cover them, and some hospital somewhere who's willing to put its neck out on the line, let them. By the way, since PAs can't technically practice without direct supervision by a licensed physician, who's gonna be the surgeon volunteer to allow his good name to be put on the line? I like PAs and some of them are my friends, but I sure as hell am not gonna sit back and supervise them operating.

I think the American public is still mystified enough that they generally see the physician as where the buck stops, even if they use an NP as their primary caretaker. I jsut can't imagine this same group, who seems to crowd EDs all the time saying, "My NP gave me this medication (Reglan) because I was complaining of nausea (secondary to SBO), why do I feel worse now?" submitting themselves to be cut by anyone other than a highly trained surgeon.

If what you describe happens, then shame on us as a profession for allowing it to happen, because we'd be the ones called upon to train them to perform "routine" operations. The ACS and surgeons all over the country would be the ones who finally put the knife into the back of the profession, not PAs, NPs, or other non-surgeon interventionalists.

I can only see this kind of thing happening in some far away place (as in outside the US in some third world country) where surgeons are in short supply, but even then, what other country in the world has PAs or mid levels? And what humanitarian organization, even if only for medical relief, would advertise that they're sending "PA surgical assistants" with research doctorates to operate on the world's poor? I'd imagine that to be a PR nightmare!

But maybe I'm short sighted...

Castro Viejo said:

So what would you like us to do?

Burn down all the PA schools in protest?

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Thats a start. Seriously though, what I'd like is for surgeons to wake up and smell the coffee. PAs and NPs both want independence in every area of medical practice (including surgery) and they are going to try and sucker surgeons into helping them along that path by approving BS "supervision" requirements like letting PAs or NPs do the surgery solo while the surgeon is "supervising" from a remote location.

If it can happen to the anesthesiologists, it can damn sure happen to the surgeons too.

If the PAs want to take on this kind of responsibility

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Oh I think thats already been well established

and there's some malpractice carrier who's willing to cover them

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I dont think thats a big hangup. Malpractice carriers routinely cover docs who have been sued dozens of times, and they dont seem to be concerned about it at all

By the way, since PAs can't technically practice without direct supervision by a licensed physician, who's gonna be the surgeon volunteer to allow his good name to be put on the line?

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Oh I'm pretty sure there are a few greedy surgeons out there who would love to try this. Think about the potential upside for the "pioneering" surgeon/PA team who tries this. Why be stuck with one measly $150 hernia repair for every 2 hour time slot when you can bill for 3 hernia repairs simultaneously by "remote supervision" while you personally do a 4th? Thats a quadrupling of income overnight. You dont think there are a few "enterprising" surgeons who would try that out? I think they'd scurry out of the woodwork like cockroaches if that kind of opportunity presented itself.

Surgeons interested in doing this are probably not as widespread as the CRNA/MDA collusion, but enough to get the ball rolling.

I like PAs and some of them are my friends, but I sure as hell am not gonna sit back and supervise them operating.

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Kudos to you sir. I hope all your surgeon colleagues feel the same way, but sadly it wouldnt surprise me at all to them stab the profession in the back.

If what you describe happens, then shame on us as a profession for allowing it to happen, because we'd be the ones called upon to train them to perform "routine" operations. The ACS and surgeons all over the country would be the ones who finally put the knife into the back of the profession, not PAs, NPs, or other non-surgeon interventionalists.

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Damn straight, this is spot-on. Every midlevel/allied health community (even the NPs) has had EXTENSIVE help from MDs to get where they are today in terms of autonomy and independence. Hell, the freakin PA concept was invented by an MD.

Personally, I think its time for MDs to ban all working relationships with NPs and force them to practice solo in the wilderness with no collaboration. But sadly, too many MDs are continuing to sell out the profession becuase they see $$$ by hiring NPs

MacGyver said:

Thats a start. Seriously though, what I'd like is for surgeons to wake up and smell the coffee. PAs and NPs both want independence in every area of medical practice (including surgery) and they are going to try and sucker surgeons into helping them along that path by approving BS "supervision" requirements like letting PAs or NPs do the surgery solo while the surgeon is "supervising" from a remote location.

If it can happen to the anesthesiologists, it can damn sure happen to the surgeons too.

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Perhaps I'm mistaken, but I thought an Anesthesiologist couldn't supervise several CRNAs working at the same time. In other words, you can't run four or five rooms staffed by CRNAs and one Anesthesiologist running around between all of them. Even in ambulatory surgery centers.

I agree with you that it's a potential issue in the future, but I just doubt any surgeon would voluntarily train a PA to do what he does. We don't have a track record of this kind of thing and PA "surgical residency programs" are nothing more than mini-internships.

"...However, I could see this scenario happening. Mid level surgeons like DrSciPA's do the straight-forward cases like lap choles and appy's."

I am not sure surgery=anesthesia, no offense to anesthesiologist. Watched all the intubations and gen anesthia, you have time to correct mistakes and problems.

In surgery, you hit something and it bleeds like hell. Or can't recoginize something and you cut it. You are sooo screwed. No time to call me away from my reality shows. You better know how to fix it. I have seen this with the best of surgeons.

Also, I would say 75-90% of the time cases are straight forward. But, 10-25% surgery is so unpredictable, and scary. I have seen very experienced attendings out for 10-20 yrs, have crazy apps and scary lap choles and weird hernias. Even, they say what the he** or ****.

Everything looks easy when you start out as a student or jr resident, but when you see more and more; you see more and more ways you can kill a person.

Castro Viejo said:

Perhaps I'm mistaken, but I thought an Anesthesiologist couldn't supervise several CRNAs working at the same time. In other words, you can't run four or five rooms staffed by CRNAs and one Anesthesiologist running around between all of them. Even in ambulatory surgery centers.

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yep, they can supervise (up to 4?) crnas and take care of emergencies in the pacu.

Anyway PA postgrad programs have been around for a while, and I don't think they have caught on because its so easy to get on the job training. I mean go to Duke and learn to assist, and do EVH and get $40k a year or go directly to work for $75k and likely be pulling close to 100K by the end of the year. Decide you don't like your job. Quit, you likely have already received 4-5 offers from other docs in your hospital

Neither hernias and choles are "simple cases." Anyone who has actual done enough of them knows that. Everything in surgery is always easier than it looks. I've seen lives ruined by "simple choles" gone wrong. All it takes is for one move to be off and you have a CBD injury and the pt is as sick as can be. Hernias can also get you into a lot of trouble as well.