Midlevels doing surgery solo

[ESU_MD]

just supervising a bunch of rooms. After all, he would be available if trouble happens. Once that happens, it's just a skip and a throw before they next ask for autonomy in surgery.

actually, ortho guys do this frequently on their cases. midlevel opens, closes. doc puts the joint in and bounces rooms.

I used to be paranoid that nurses, PA's, etc. are going to "take over", until I got over my own inferiority complex. A midlevel cannot, and will NEVER be able to totally independently do what a board certified general surgeon can do.

Ironically, most midlevels DO NOT WANT to do what surgeons do solo.

and yes there are a few militant ones out there that want to take over and practice medicine without going to medical school.

the vast majority are just trying to make a living and enjoy their line of work.

As for me, I would not want a CRNA answering to me during the operation, but I don't mind nurse anesthesia in general. IF they can be independent, then fine- thats an issue for the anesthesia community to address. As long as they are compentent who cares?

Nor would I mind having a good PA who could open the belly, get the exposure, call me in for the critical part and then close while I go to another room. Its probably OK for routine cases.
What surgeon like opening and closing skin and fascia?

Yes as physicians we have to keep an eye on what midlevels are doing, but As surgeons, we have bigger issues to worry about than CRNA's and PA's taking over.

---

Members don't see this ad.

 

[Castro Viejo]

Nor would I mind having a good PA who could open the belly, get the exposure, call me in for the critical part and then close while I go to another room. Its probably OK for routine cases.
What surgeon like opening and closing skin and fascia?

The surgeon whose patient now has a enterocutaneous fistula from the small bowel that got snagged on closing.

Again, I suppose it's a remote possibility, but I generally agree that it's somewhat far-fetched and I think General Surgery and Surgeons in general have bigger problems than mid-levels revolting against our machine.

If you think about it in liability terms (there goes that New York-training in me again!), I can't see how any surgeon would leave even opening and closing a belly to a mid-level. Some attendings can't even let a Chief Resident do it!

As a Surgeon I'd be more worried about GI guys trying to take over NOTES, VIR/Cardiology taking over endografting, Optometrists taking over some operative stuff from Ophthalmology, Podiatrists taking lower extremity orthopedic stuff, Dentists taking over Head & Neck, etc.

 

[deleted6669]

when clinton had his cabg a few yrs ago guess who assisted?
yup, a staff ct surgery pa.....
http://forums.studentdoctor.net/showthread.php?t=150224&highlight=CLINTON

 

[Dr.Millisevert]

As a Surgeon I'd be more worried about GI guys trying to take over NOTES, VIR/Cardiology taking over endografting, Optometrists taking over some operative stuff from Ophthalmology, Podiatrists taking lower extremity orthopedic stuff, Dentists taking over Head & Neck, etc.

Do you differentiate between single and dual qualified OMFS guys? What about a surgeon who has both an MD and DDS?

Who would you prefer reparing your pan facial fractures? someone who graduated from dental school and then spent 4-6 years doing nothing but facial surgery and has logged thousands of similar trauma cases... (not to mention orthognathics and who knows how the jaws and teeth should come together properly).. or would you prefer someone who completed medical school and then maybe say did plastics and spent most of their time dealing with burns, boobs, etc.. and maybe had done half or 1/3 the number of facial, H/N cases?

Oral and Maxillofacial surgery is a surgical specialty which requries many years of residency training. (even as a general dentist you are allowed to do minor oral surgery). This is nothing like optometry. You can't really group these two together. Sorry.

Btw: We had a doctor who had already completed 2 years of general surgery already who was in my dental class because they then wanted to be able to pursue Maxillofacial surgery training.

 

[Tristero]

Yes, I am into research. SHOW ME the cases you are talking about. SHOW ME the ASA viewpoint. I am well aware of who the AANA is and who they represent. I am also well aware that there is a difference in a legal brief and a practice act. But if we are discussing legal liability here, I think written briefs from med mal lawyers is more useful that a vague, unnamed reference to an anonymous "I once saw this one case..." followed by "yeah me too..." posting on the SDN Anesthesia board is a bit more useful.

You spewing off all this nebulous "CRNA's suck" and "PAs suck" and "NPs suck" is of no utility and has no more basis than these patients we have all encountered who hate ALL doctors and think ALL doctors are greedy, incompetent, uncaring and rich a-holes who are only out to make their next buck. I'm sure you don't like being held accountable for every physician in every specialty's previous errors and misdeeds, so why do you do the same to midlevels?

BITSY, go eat a dried placenta!

 

[Castro Viejo]

Do you differentiate between single and dual qualified OMFS guys? What about a surgeon who has both an MD and DDS?

Relax. I wrote DENTIST, not OMFS. I give props to the OMFS guys, especially the ones who've gone through programs that require an MD. Sheesh. Most of the OMFS guys here would beat me up if I referred to them merely as dentists (which I do just to screw with 'em...).

Who would you prefer reparing your pan facial fractures? someone who graduated from dental school and then spent 4-6 years doing nothing but facial surgery and has logged thousands of similar trauma cases... (not to mention orthognathics and who knows how the jaws and teeth should come together properly)..

Clearly the OMFS guy. I never said anything to the contrary. Just not a plain old dentist.

or would you prefer someone who completed medical school and then maybe say did plastics and spent most of their time dealing with burns, boobs, etc.. and maybe had done half or 1/3 the number of facial, H/N cases?

By the way, I love the community OMFS guys who do boob jobs. That's really swell of them to do that.

Oral and Maxillofacial surgery is a surgical specialty which requries many years of residency training. (even as a general dentist you are allowed to do minor oral surgery). This is nothing like optometry. You can't really group these two together. Sorry.

True. Dentists do train in dental school to do various minor oral surgery things. I know. I was referring to the General Dentist who does major oral surgery things in their little operatories.

Btw: We had a doctor who had already completed 2 years of general surgery already who was in my dental class because they then wanted to be able to pursue Maxillofacial surgery training.

Word up. A few of my fellow interns were OMFS program people. Solid guys. Really smart.

 

[Dr.Millisevert]

Relax. I wrote DENTIST, not OMFS. I give props to the OMFS guys, especially the ones who've gone through programs that require an MD. Sheesh. Most of the OMFS guys here would beat me up if I referred to them merely as dentists (which I do just to screw with 'em...)

Ok, just trying to clearify. OMFS doing H/N makes sense. General dentist doing H/N surgery doesn't make sense. Sorry for the confusion.

By the way, I love the community OMFS guys who do boob jobs. That's really swell of them to do that.

Sarcasm noted. Don't worry, I agree with you... I really have a problem with this myself. I do feel cosmetic facial surgery is fine (esp as we are exepected to know this for our board cert exams) and is well within our scope. However, even though we may learn how to do H/N recon cases using pec flaps, etc. This does not mean we should be doing boob jobs. I would like to apologise on behalf of anyone in my specialty who does this and/or markets themselves in this way. (It is a very small minority thank god).

True. Dentists do train in dental school to do various minor oral surgery things. I know. I was referring to the General Dentist who does major oral surgery things in their little operatories.

Well.. maybe that depends on what you consider major or minor. General dentists are able to do the easier dental implant cases and surgically remove uncomplicated partially erupted wisdom teeth, etc. However, no general dentist I know would be attempting any major facial or H/N surgery unless they have undertaken the appropriate 4-6 years of OMFS residency.

 

[Werry]

when clinton had his cabg a few yrs ago guess who assisted?
yup, a staff ct surgery pa.....
http://forums.studentdoctor.net/showthread.php?t=150224&highlight=CLINTON

And I'm sure he did a very good job holding the heart and squirting saline. Please, Columbia barely lets the fellows even do anything.

 

[Castro Viejo]

(It is a very small minority thank god).

Not in New York they ain't...

 

[Dr.Millisevert]

Not in New York they ain't...

Most are members of the ABCS http://www.americanboardcosmeticsurgery.org/fellowship_route.php
and the ACS and have usually completed 2 years of full body fellowships and are legally licensed to provide these procedures and prob have completed enough cases and are competent. (However, I'm not supporting this)


Like I said before.. I disagree with this practice among my collegues. I do feel that OMFS are the best when it comes to the face.. but if an omfs wanted to do boobs, I would prefer that he/she finish a plastic surg training program.

sorry.

 

[deleted6669]

And I'm sure he did a very good job holding the heart and squirting saline. Please, Columbia barely lets the fellows even do anything.

and opening and closing and harvesting the vein.....

 

[Leforte]

I do feel that OMFS are the best when it comes to the face..

I would agree that OMFS are the best at mandible pathology/orthognathic surgery, but we ENTs, too, do 4+ years of facial fractures that you referred to. On top of the 75+ free flaps, 150+ thyroids, 80+ parotids and 300+ modified/radical neck dissections our service covers per year, plus the cosmetic cases - Be careful when claiming to be "best" in a specific part of the body - especially when there is overlap from other fields.

But I agree, OMFS is a great field and many are excellent surgeons.

To the original topic - I'm not worried about midlevels taking over surgery. Surgeons are far too territorial . Yes, some open/close/harvest veins/etc - but at the end of the day, this is R1/R2 level stuff. If they can claim to be competent, one could argue that surgery only requires 2 years of training - and I think we can all agree that will never happen. Heck, OR nurses can get First Assist qualifications (and do in the private practice hospitals) - doesn't mean they are suddenly surgeons.

 

[VFTW]

The bottom line is this: surgeons should choose a state to practice in which the state regulations are clear and unequivocal that CRNAs are 100% independent providers. Any state practice act which states that CRNAs are "part" of the healthcare team means that the surgeon is liable for their incompetence.

.

 

[Dr.Millisevert]

I would agree that OMFS are the best at mandible pathology/orthognathic surgery...

Be careful when claiming to be "best" in a specific part of the body - especially when there is overlap from other fields.

But I agree, OMFS is a great field and many are excellent surgeons.

I apologise for that. (I was comparing plastics and maxillofacial when I made that comment because of their increased case logs of facial procedures.) However, I would group OMFS and ENT together in that respect in comparison to plastics when discussing which specialty is more experienced in the Head and Neck. (I would personally equally usually prefer an ENT over plastics to reconstruct my face for that reason.)

I agree.. ENT also has many aspects to the Head and Neck to which their trainees are much better at than Maxfacs. Both fields have overlap quite a bit but do have their respective strengths.

 

[Tristero]

Jeez Millesevert,

For a resident you sure are biased! As a medical student I have extensively worked with all three services OMFS, ENT, and plastics. I would never make the broad, sweeping generalizations regarding expertise in a certain aspect of the body.

Even though I'm going into plastics thats one reason I believe in ENTs and OMFS doing facial cosmetics as well. I don't, and I don't think many plastic surgeons, feel that they have particular ownsership over an organi system.

That being said, I have met plastic surgeons more skilled in head and neck than OMFS/ENT, and of course vice versa. Getting in discussions about who is more qualified to perform certain procedures is pointless unless patient safety is truly a concern. And between plastics, ENT, and OMFS, it isn't.

I say let the best surgeons duke it out for procedures, regardless of their field, as long as patient safety isn't compromised and they have a reasonable amount of exposure during their training.

 

[Dr.Millisevert]

That being said, I have met plastic surgeons more skilled in head and neck than OMFS/ENT, and of course vice versa. Getting in discussions about who is more qualified to perform certain procedures is pointless unless patient safety is truly a concern. I say let the best surgeons duke it out for procedures, regardless of their field, as long as patient safety isn't compromised and they have a reasonable amount of exposure during their training.

I agree that surgeons are human and individuals and everyone is different. However, surgery is a procedural based skill set. "USUALLY" the surgeon who has "done the most" of a particular type of procedure is the one who would be considered "more competent" at that procedure. In this way you can say.. one trained in a particular specialty may be more suited to work on a particular part of the body or to do a particular procedure. Again, however.. everyone is different.. and different residency programs at different locations focus on different things. I agree I was making generalisations based on the focus of training on average. sorry.

peace.

 

[Taurus]

Yes, I am into research. SHOW ME the cases you are talking about. SHOW ME the ASA viewpoint. I am well aware of who the AANA is and who they represent. I am also well aware that there is a difference in a legal brief and a practice act. But if we are discussing legal liability here, I think written briefs from med mal lawyers is more useful that a vague, unnamed reference to an anonymous "I once saw this one case..." followed by "yeah me too..." posting on the SDN Anesthesia board is a bit more useful.

Oh, I found a case for you where the surgeon is sued along with CRNA, even though the death was clearly anesthesia-related.

Woman sues hospital, doctor over husband's death after surgery

 

[droliver]

I agree that surgeons are human and individuals and everyone is different. However, surgery is a procedural based skill set. "USUALLY" the surgeon who has "done the most" of a particular type of procedure is the one who would be considered "more competent" at that procedure.

So we can all agree that oral surgeons are the surgeons most qualified to pull your wisdom teeth

 

[Leforte]

So we can all agree that oral surgeons are the surgeons most qualified to pull your wisdom teeth

Yep - no problem with that statement. Personally, if I was in OMFS, I'd set up a sweet Wizzy practice. Let others fight it out for the cosmetic stuff, etc.

As an interesting point, starting this year, Medicare allows physicians to bill for dental extraction codes. We have been doing it recently for complex facial fractures, composite resections, etc, that require the extraction. Before, when I was yanking them out (and it was an non-reimbursed part of the case for the attending), I would comment on how if we were MD/DDSes, that one tooth would pay more than the mandible repair, since you could bill both dental and medical codes. I'm curious what the Medicare reimbursement is....

 

[Dr.Millisevert]

So we can all agree that oral surgeons are the surgeons most qualified to pull your wisdom teeth.

Yes, oral and maxillofacial surgeons would usually be most qualified to pull your wisdom teeth.

Yep - no problem with that statement. Personally, if I was in OMFS, I'd set up a sweet Wizzy practice. Let others fight it out for the cosmetic stuff, etc.

As an interesting point, starting this year, Medicare allows physicians to bill for dental extraction codes. We have been doing it recently for complex facial fractures, composite resections, etc, that require the extraction. Before, when I was yanking them out (and it was an non-reimbursed part of the case for the attending), I would comment on how if we were MD/DDSes, that one tooth would pay more than the mandible repair, since you could bill both dental and medical codes. I'm curious what the Medicare reimbursement is.....

Is the medicare coded reimbursement as much as the dental coded reimbursement? I'm curious about this as well. If you get more information about this can you please post it on here? Thanks!

 

[M.Furfur]

Are you talking about putting the trocars in or actually doing the dissection, stapling off the appendix, and essentially doing the case?

If it's the former that happens in most private practice/community hospital settings. Our CV service has PAs opening and closing the chest, harvesting the vein, etc. If it's the latter, then that's something I've heard of, read stuff about on the internet, but I've never seen it in real life nor do I really believe it exists.

Kind of like the female orgasm.

well if this is happening or if this is the future, then what is the purpose of working your A$$ during undergrad to get into med school. Then have to do another 4 years of school and 5-6 years of training if anyone with 2 years of training can do your job?

What's the solution, go to Canada?

 

[DrDre311]

I agree that surgeons are human and individuals and everyone is different. However, surgery is a procedural based skill set. "USUALLY" the surgeon who has "done the most" of a particular type of procedure is the one who would be considered "more competent" at that procedure. In this way you can say.. one trained in a particular specialty may be more suited to work on a particular part of the body or to do a particular procedure. Again, however.. everyone is different.. and different residency programs at different locations focus on different things. I agree I was making generalisations based on the focus of training on average. sorry.

peace.

At my med school there was no OMFS program so plastics and ENT alternated face call. Our trauma center is insanely busy. I don't know actual case numbers, but I'm sure the plastics residents got more facial fracture cases per unit time than the OMFS residents do at my current institution. I'm not knocking OMFS at all, but plastic surgeons aren't slouches either. If you want to judge a surgical specialty by the sheer volume of training, then by that logic an ENT-trained plastic surgeon would be the most competent HN surgeon. However, the relative domain of a given specialty varies from hospital to hospital and program to program, and I personally really like working with OMFS. It isn't necessary to have a pissing contest about who's better at procedures in which our respective fields overlap.

 

[Plastikos]

At my med school there was no OMFS program so plastics and ENT alternated face call. Our trauma center is insanely busy. I don't know actual case numbers, but I'm sure the plastics residents got more facial fracture cases per unit time than the OMFS residents do at my current institution. I'm not knocking OMFS at all, but plastic surgeons aren't slouches either. If you want to judge a surgical specialty by the sheer volume of training, then by that logic an ENT-trained plastic surgeon would be the most competent HN surgeon. However, the relative domain of a given specialty varies from hospital to hospital and program to program, and I personally really like working with OMFS. It isn't necessary to have a pissing contest about who's better at procedures in which our respective fields overlap.

I agree. At my med school ENT/OMFS/Plastics rotated face call. At my residency, there are no omfs or ent residents, so we do all the faces, but not many mandibles. Each institution is different and will give you your own view, but each field has its strong points. I have thoroughly enjoyed my ENT/OMFS rotations, and every omfs guy i have ever worked with since med school was top notch and i really respect them in general. I feel they are treated a little differently because outside of plastics, most doctors dont interact with them enough to appreciate what they do/know. Why they throw away the dentist lifestyle and becomes MDs will always puzzle me though.