PA cramping my style...

[deleted6669]

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Yes, because the attending is qualified, trained and experienced.

and the pa who was trained by the surgeon and performs the procedure the vast majority of the time including endoscopically is not? as in my post above- if it's good enough for a former president it's good enough for anyone.....

 

[McGillGrad]

and the pa who was trained by the surgeon and performs the procedure the vast majority of the time including endoscopically is not? as in my post above- if it's good enough for a former president it's good enough for anyone.....

You do not have the education to compare yourself to a resident, yet you want the same responsibility? It doesn't work that way. Know your role and act accordingly. Your skills do not supersede the education of physicians, to whom you assist.

 

[deleted6669]

You do not have the education to compare yourself to a resident, yet you want the same responsibility? It doesn't work that way. Know your role and act accordingly. Your skills do not supersede the education of physicians, to whom you assist.

some of the best surgeons in the country would disagree with you.
get over yourself.

 

[McGillGrad]

some of the best surgeons in the country would disagree with you.
get over yourself.

They would disagree with the fact that you have less education than a physician?

 

[deleted6669]

They would disagree with the fact that you have less education than a physician?

no, they would affirm that the fact that the composition of their team and care of the pt is more important than the training of residents....there is a reason many of the top surgeons in the country work with pa's. they trained them, they know them and they trust them. someone who has been a ct surgical pa for years has assisted thousands more surgeries than a resident and knows the particular way their surgeon likes to do each procedure and how they react to different contingencies. I have a friend who is a residency trained ct surgical pa who has worked with the same surgeon for 25 yrs. his surgeon would not trade him for another surgeon under any circumstances.
I'm not saying training residents isn't important. I'm just saying some folks prefer working to teaching and those folks work with pa's because they are fast, predictable, and efficient.
folks who like to teach as a priority probably work more with residents than pa's or use pa's only for floor work, admission h+p's, rounds, discharge summaries, wound checks, clinic f/u, etc.
lots of current surgeons received at least a part of their training from pa's on surgical teams.
I don't work in surgery but do train med students, fp, im, and em residents and have for many years including writing their rotation evaluations.

 

[JeffLebowski]

no, they would affirm that the fact that the composition of their team and care of the pt is more important than the training of residents....there is a reason many of the top surgeons in the country work with pa's. they trained them, they know them and they trust them. someone who has been a ct surgical pa for years has assisted thousands more surgeries than a resident and knows the particular way their surgeon likes to do each procedure and how they react to different contingencies. I have a friend who is a residency trained ct surgical pa who has worked with the same surgeon for 25 yrs. his surgeon would not trade him for another surgeon under any circumstances.
I'm not saying training residents isn't important. I'm just saying some folks prefer working to teaching and those folks work with pa's because they are fast, predictable, and efficient.
folks who like to teach as a priority probably work more with residents than pa's or use pa's only for floor work, admission h+p's, rounds, discharge summaries, wound checks, clinic f/u, etc.
lots of current surgeons received at least a part of their training from pa's on surgical teams.
I don't work in surgery but do train med students, fp, im, and em residents and have for many years including writing their rotation evaluations.

Cripes - no one's discounting the role of good PA's in an appropriate capacity, and we keep saying it over and over - good PA's in an appropriate capacity are extremely valuable. Stop pretending like we think we're better than you, we don't. We just want you to function within the bounds of your (appropriate) capacity, and we don't want to miss out on valuable cases or see the expansion of midlevel autonomy to include the entirety of our jobs, when we know there's a darn good reason we have much more training.

And you should be good at what you do. If it were my job day in and day out to assist in the more basic aspects of surgery for "many years" with the same attending, yeah I'd make a good team with him too.

 

[Rendar5]

Cripes - no one's discounting the role of good PA's in an appropriate capacity, and we keep saying it over and over - good PA's in an appropriate capacity are extremely valuable. Stop pretending like we think we're better than you, we don't. We just want you to function within the bounds of your (appropriate) capacity, and we don't want to miss out on valuable cases or see the expansion of midlevel autonomy to include the entirety of our jobs, when we know there's a darn good reason we have much more training.

And you should be good at what you do. If it were my job day in and day out to assist in the more basic aspects of surgery for "many years" with the same attending, yeah I'd make a good team with him too.

I'm not sure I think that harvesting saphenous veins or being first-assist in a surgical case is really taking over our jobs or preventing residents from learning. The only thing doing that is the attending at a teaching hospital preventing resident learning by not allowing their participation in academic cases. not a PA doing their job and us freaking out that they're stealing our jobs. The issue of this really should be a teaching attending acting like a private attending.

Seriously, why are we freaking out that PAs are ruining our experiences or overstepping their bounds when that hasn't really happened too much in these instances. (and yeah, some PAs in this thread are being a bit defensive, but so are we).

 

[deleted6669]

I'm not sure I think that harvesting saphenous veins or being first-assist in a surgical case is really taking over our jobs or preventing residents from learning. The only thing doing that is the attending at a teaching hospital preventing resident learning by not allowing their participation in academic cases. not a PA doing their job and us freaking out that they're stealing our jobs. The issue of this really should be a teaching attending acting like a private attending.

Seriously, why are we freaking out that PAs are ruining our experiences or overstepping their bounds when that hasn't really happened too much in these instances. (and yeah, some PAs in this thread are being a bit defensive, but so are we).

thank you.
until the day pa's start doing valves and emergent caths, etc(the day after hell freezes over) you guys will always have a job.

 

[JeffLebowski]

I'm not sure I think that harvesting saphenous veins or being first-assist in a surgical case is really taking over our jobs or preventing residents from learning. The only thing doing that is the attending at a teaching hospital preventing resident learning by not allowing their participation in academic cases. not a PA doing their job and us freaking out that they're stealing our jobs. The issue of this really should be a teaching attending acting like a private attending.

Seriously, why are we freaking out that PAs are ruining our experiences or overstepping their bounds when that hasn't really happened too much in these instances. (and yeah, some PAs in this thread are being a bit defensive, but so are we).

I agree, it really hasn't been my experience that PA's get in the way of a resident's training, and usually enhance it. These discussions always get blown out of proportion when people's egos get involved. However, I meant what I said about each of us knowing our place and think that remains relevant. I like PA's. The PA's I've worked with at academic institutions have been real assets to the team and to the faculty and residents alike. I dislike these ridiculous pissing matches.

 

[lapelirroja]

You guys are literally physician's assistants.

Yeah, not so much. We are Physician Assistants, we do not "belong" to anyone. We learned that in PA School 101, and anyone who said that in an interview was rejected. In ideal MD-PA teams, the PA is definitely not serving as the MD's personal assistant but as an associate in a collaborative effort. You can have whatever opinion you want about PAs but at least get the name right...

 

[JeffLebowski]

Yeah, not so much. We are Physician Assistants, we do not "belong" to anyone. We learned that in PA School 101, and anyone who said that in an interview was rejected. In ideal MD-PA teams, the PA is definitely not serving as the MD's personal assistant but as an associate in a collaborative effort. You can have whatever opinion you want about PAs but at least get the name right...

Wow.

 

[McGillGrad]

Wow.

Yeah, I know. This is the same logic that allowed janitors to become custodial engineers.

 

[Rendar5]

Yeah, I know. This is the same logic that allowed janitors to become custodial engineers.

*palmface*
Are you trying to start a flamewar?

 

[njbmd]

One of the attending surgeons at the hospital I'm rotating at has a PA who scrubs in on most of his cases. Usually they are simple things like PEG tubes, trachs, I&Ds, etc, but anyways this PA pretty much does the whole case while the attending "supervises." Meanwhile theres usually a surgery intern and a medical student (me in some cases) scrubbed in who would like to get our hands dirty too since we're still learning obviously. Its kind of annoying because a resident and medical student are expected to cover all the general surgery cases and then follow the patients afterwards - even in the cases where the PA does everything in the OR. Furthermore when there is something to follow up on (i.e. a CXR too look for a pneumo after mediport insertion) the PA doesn't follow up at all. I realize that he is a "mid-level provider" but you gotta reap what you sew. Basically it annoys me because this guy is done with his training already yet when there are ppl scrubbed in who are still training (students/residents) he completely disregards them. Anyone else have a problem like this? And, if so, how do you deal with it? From what I can tell there are no other surgeons at this teaching hospital who have PAs that come in and do this.

The OP clearly did not intend for this thread to degenerate into a PA versus physican flamefest. Please respect the OPs intentions and confine your comments to the OPs original question (posted above) which was how he/she could get more hands-on experience with procedures when his/her role was limited on an attending's service that utilized PAs to do procedures that he/she would like to have a shot at performing.


If you feel the need to respond to a particular poster, then do so with the PM function if your response does not relate to the original question.

 

[stankem]

Yeah, I know. This is the same logic that allowed janitors to become custodial engineers.

I love this guy.

 

[IMDoc607]

Agree with the above posters- as a med student, you have no say.

I disagree. A med student is paying to learn and if he/she is not learning then they have the right to say something. I understand there is a heirachy in medicine, but we need to learn.

 

[Rendar5]

I disagree. A med student is paying to learn and if he/she is not learning then they have the right to say something. I understand there is a heirachy in medicine, but we need to learn.

Learning doesn't mean you have to do the actual more advanced procedures. On surgery there is no need for your education to actually do vein harvesting or anything more than sutures. If you do get to do it, you can count yourself lucky.

 

[njbmd]

I disagree. A med student is paying to learn and if he/she is not learning then they have the right to say something. I understand there is a heirachy in medicine, but we need to learn.

Learning doesn't mean you have to do the actual more advanced procedures. On surgery there is no need for your education to actually do vein harvesting or anything more than sutures. If you do get to do it, you can count yourself lucky.

Attending physicians who have residents and medical students are expected to teach them and abide by the guidelines that are set in place by the rotation director or residency program director. If the learning environment is not working for student (or resident), they do have the right to voice their concerns to the rotation coordinator/program director.

Medical students are expected to learn how to perform procedures more than "just sutures". Good clinical rotations make sure that they get plenty of "hands on" experience. As a medical student, you are not just there to hold a retractor but to get some procedures and practice. The OP is very correct in wanting to get procedure experience that he/she can take into residency. If this isn't happening for them, then the next step (after asking the attending if they can get more hands on) is the residency coordinator who can shift them to another rotation or take care of the problem.

If an attending's service is not providing adequate teaching to residents and medical students, they may not participate in having house staff. In that case, they can hire PAs/NPs to take up the slack. Housestaff and students are not there for extra bodies but are there to learn. If there is no teaching and plenty of "scut", then they need to be elsewhere.

 

[Rendar5]

Attending physicians who have residents and medical students are expected to teach them and abide by the guidelines that are set in place by the rotation director or residency program director. If the learning environment is not working for student (or resident), they do have the right to voice their concerns to the rotation coordinator/program director.

Medical students are expected to learn how to perform procedures more than "just sutures". Good clinical rotations make sure that they get plenty of "hands on" experience. As a medical student, you are not just there to hold a retractor but to get some procedures and practice. The OP is very correct in wanting to get procedure experience that he/she can take into residency. If this isn't happening for them, then the next step (after asking the attending if they can get more hands on) is the residency coordinator who can shift them to another rotation or take care of the problem.

If an attending's service is not providing adequate teaching to residents and medical students, they may not participate in having house staff. In that case, they can hire PAs/NPs to take up the slack. Housestaff and students are not there for extra bodies but are there to learn. If there is no teaching and plenty of "scut", then they need to be elsewhere.

What OR procedures should the students be taught to do in a surgery rotation when the resident is there as first assist (I ask this seriously, as it's not my experience that there is more for the med student to be doing regularly when there are residents there too)? Now non-OR procedures sure, definitely more things to learn and do in a surgical rotation.

 

[PUPPYBOY3765]

I see absolutely nothing wrong with the quote you got all defensive about:
some PA's are scary. Or perhaps I should say that it's sometimes scary the leeway that attendings give their PA's. For having only two years of post-graduate school/training, they are sure allowed to do a lot.

This is one person's opinion based on one person's experience. The fact is, this opinion and experience is not rare because the fact is that some attendings do give too much autonomy to PA's (according to accepted standards of practice and you know...the law).

Unless your contention is that PA's should be able to do whatever they want, you can't argue this point. There is a line that shouldn't be crossed, and some people cross it. That's not good. PA's are fantastic resources in the appropriate capacity, and potentially dangerous/scary beyond that capacity.

Edit: on a related note, is anyone else sick of midlevels on SDN getting all huffy and defensive any time someone suggests they're in any way less than a doctor? They do this constantly - someone says something pretty harmless (and pretty true) like the above quote, and some PA or NP or whatever comes in and gets all defensive...saying simultaneously making a big scene about how they KNOW they aren't a doctor but then extol how thin the line is between them and a doctor and how they're so super competent at pretty much everything.

Look at the posts above, and look at a LOT of the posts from medical students - everyone saying "listen, as a medical student/resident you have to know your place and don't get too big for your britches" and guess what? We all agree - as medical students/residents we are inferior to attendings and should know our place. Everyone's on board. There's a team, there's a hierarchy, there's a training and experience difference, and we respect that. But suggest to a midlevel that they should "know their place" and all of a sudden you're an elitist arrogant jerk. We should all know our place, and that means being honest about where the line is. The quote you got all defensive about is an example of someone (attending & PA alike) violating that line.

Yeah, I am glad that this was brought up. It happens over and over and over and over and over. It is so disgusting! And I am a former PA.

 

[PUPPYBOY3765]

Education takes priority. Med students pay big bucks to learn. Whether at a teaching hospital or community hospital, if an attending takes students and residents, they need to be teaching.

 

[njbmd]

What OR procedures should the students be taught to do in a surgery rotation when the resident is there as first assist (I ask this seriously, as it's not my experience that there is more for the med student to be doing regularly when there are residents there too)? Now non-OR procedures sure, definitely more things to learn and do in a surgical rotation.

Actually, I am the "first assistant" on most my cases and the resident/fellow is doing the case for the most part unless its something that specifically needs my hands. I allow medical students to close skin (under resident supervision while I am in the OR). Since I am a vascular surgeon, most of the residents who operate with me are at the senior level (PGY-4 and 5, fellow) which means that they get the "hands on" for the most part. A resident doesn't need to be a first assistant, they need to learn how to operate and are given as much autonomy as their skill level will allow as long as I am present. I am happy to fill in the role as first assistant.

If it's a case where it's just me and a medical student (vein procedures and insertion of mediports or permacaths with the C-arm), I will actually allow them to do much of these procedures and again, close. (Most residents get plenty of "hands on" experience on my service). If there is a junior resident doing a vascular access procedure with me, then the medical student gets "bumped". Still, the PAs don't trump the housestaff on my service in terms of doing procedures because the education of residents, fellows and students is of paramount importance in my practice which is an academic teaching practice.

 

[Rendar5]

Actually, I am the "first assistant" on most my cases and the resident/fellow is doing the case for the most part unless its something that specifically needs my hands. I allow medical students to close skin (under resident supervision while I am in the OR). Since I am a vascular surgeon, most of the residents who operate with me are at the senior level (PGY-4 and 5, fellow) which means that they get the "hands on" for the most part. A resident doesn't need to be a first assistant, they need to learn how to operate and are given as much autonomy as their skill level will allow as long as I am present. I am happy to fill in the role as first assistant.

If it's a case where it's just me and a medical student (vein procedures and insertion of mediports or permacaths with the C-arm), I will actually allow them to do much of these procedures and again, close. (Most residents get plenty of "hands on" experience on my service). If there is a junior resident doing a vascular access procedure with me, then the medical student gets "bumped". Still, the PAs don't trump the housestaff on my service in terms of doing procedures because the education of residents, fellows and students is of paramount importance in my practice which is an academic teaching practice.

Gotta say I'd have enjoyed my surgery rotation a lot more if I had you as an attending. Very different experience from what I went through.

 

[lapelirroja]

ugh. delete.

 

[MattD]

I'm sure his response stoked his ego and made him look cool in front of his students, but did he really do the right thing by the patient? The patient consents to what is done in the OR, not the other way around. I'm not saying this really happens, but the attending is actually supposed to explain the roles and get consent for a med student to participate in care in any way.

So can I take this lecture to mean that when you were on your surgery rotation you made a point of talking to each patient you'd be in the OR with and letting them know you were a medical student, what your role would be, etc? And if they patient seemed uncomfortable, you volunteered to just stand back and watch, right?

I'm sure when your attending goes for major surgery he doesn't want the intern first assisting or the med student closing his wounds. It's common sense. I'm not willing to take on extra risk in something as risky as surgery. Med students can interview me and look in my ears all day long, but I'll be damned if they'll be up to their elbows in my abdomen or sewing me shut while practicing sterile technique for the first or second time.

So again, on your surgery rotation, did you decline to scrub any cases so that you wouldn't wind up "up to your elbows in someone's abdomen" while practicing sterile technique for the first or second time? Seems rather hypocritical if you were willing to subject a patient to your incompetence, but not to subject yourself to someone else's. If you do truly believe that medical students shouldn't be involved in operating, when IS the proper time? If medical students don't operate, well gee, that means it will be the INTERN'S first time practicing sterile technique when he/she operates. Maybe no one should operate until they are a senior resident. Attending? Eventually, every surgeon has to have their first time placing knife to skin, and someone is going to have to be that person's first patient. What is the appropriate timing in your mind? And what makes you so much better than others that you feel you are above being the first patient?

 

[cpants]

So can I take this lecture to mean that when you were on your surgery rotation you made a point of talking to each patient you'd be in the OR with and letting them know you were a medical student, what your role would be, etc? And if they patient seemed uncomfortable, you volunteered to just stand back and watch, right?

Actually, yes. I did make a point to speak to almost every patient I scrubbed in on and explained what my role would be. There were a few times when the patient was uncomfortable, and I did not scrub in. This is appropriate and what you are supposed to be doing as a student. However, the responsibility does rest with the attending to get consent and make sure these things are explained.

So again, on your surgery rotation, did you decline to scrub any cases so that you wouldn't wind up "up to your elbows in someone's abdomen" while practicing sterile technique for the first or second time? Seems rather hypocritical if you were willing to subject a patient to your incompetence, but not to subject yourself to someone else's. If you do truly believe that medical students shouldn't be involved in operating, when IS the proper time? If medical students don't operate, well gee, that means it will be the INTERN'S first time practicing sterile technique when he/she operates. Maybe no one should operate until they are a senior resident. Attending? Eventually, every surgeon has to have their first time placing knife to skin, and someone is going to have to be that person's first patient. What is the appropriate timing in your mind? And what makes you so much better than others that you feel you are above being the first patient?

I didn't say I think it's inappropriate for medical students or junior residents to scrub...at all. I do, however, think it's every patient's right to refuse to have trainees operate on them. Knowing the risks, and having been through the process, I wouldn't want a medical student scrubbed on my surgery. They are welcome to watch. You may think that's hypocritical, and it may be. I don't apologize for it, however. Every patient, including me, should be able to know who will be performing invasive procedures on them and make the decision for themselves. I don't resent it when a patient says they don't want me involved in their care. I understand it, and I walk away.

 

[njbmd]

My patients do not have a choice in terms of medical students of residents being "scrubbed" on my cases. They are well aware of being treated in a hospital that teaches residents and medical students. When they come to my office for their first evaluation, they are told of the role of medical students and residents. If they refuse, they are directed to the community hospital and to another attending physician.

My role as an academic surgeon is to explain the presence of everyone on the team and everyone who will be in the OR on the day or surgery. If you, as a resident or medical student, assisted in the work-up of the patient in my clinic, you will be scrubbed in the OR for the case. This is not a point for debate between myself and the patient. My practice is academic and I operate in a teaching hospital. The same works for student physician assistants too as they are part of my teaching service.

 

[psipsina]

What OR procedures should the students be taught to do in a surgery rotation when the resident is there as first assist (I ask this seriously, as it's not my experience that there is more for the med student to be doing regularly when there are residents there too)? Now non-OR procedures sure, definitely more things to learn and do in a surgical rotation.

At my institution medical students often get to do more than just retract and close skin. I've gotten to open, drive lap cameras and endoscpes, throw sutures for anastomoses (including vascular), practice bovie technique, use the harmonic scalpel etc. There have of course been super intense cases where I have just watched and retracted and cut suture but my attendings and residents use safe calm moments in the OR to teach us technique as well. They start small and let students prove that they are able to take instruction well etc and then they give you a bit more each case. I've actually had residents apologize when they think I didn't get to do anything "cool" in a case. I think as important as the floor management etc is its also important to explore whether or not you like participating in the OR, as thats a big part of the decision to go into surgery.

 

[cpants]

My patients do not have a choice in terms of medical students of residents being "scrubbed" on my cases. They are well aware of being treated in a hospital that teaches residents and medical students. When they come to my office for their first evaluation, they are told of the role of medical students and residents. If they refuse, they are directed to the community hospital and to another attending physician.

My role as an academic surgeon is to explain the presence of everyone on the team and everyone who will be in the OR on the day or surgery. If you, as a resident or medical student, assisted in the work-up of the patient in my clinic, you will be scrubbed in the OR for the case. This is not a point for debate between myself and the patient. My practice is academic and I operate in a teaching hospital. The same works for student physician assistants too as they are part of my teaching service.

I think that's a fair and professional policy. Your patients still have a choice, and that choice is to go to another surgeon if they don't want students involved. Surgery is a contract between patient and surgeon, and both parties have to agree on what procedure will be performed by whom and under what circumstances. Many academic physicians are not as absolutist as you about having students involved, but I appreciate your educational spirit. You have every right to run your practice the way you want to run it.

 

[kdburton]

My patients do not have a choice in terms of medical students of residents being "scrubbed" on my cases. They are well aware of being treated in a hospital that teaches residents and medical students. When they come to my office for their first evaluation, they are told of the role of medical students and residents. If they refuse, they are directed to the community hospital and to another attending physician.

My role as an academic surgeon is to explain the presence of everyone on the team and everyone who will be in the OR on the day or surgery. If you, as a resident or medical student, assisted in the work-up of the patient in my clinic, you will be scrubbed in the OR for the case. This is not a point for debate between myself and the patient. My practice is academic and I operate in a teaching hospital. The same works for student physician assistants too as they are part of my teaching service.

Haha I was rotating at a well-respected cancer institute and when a women requested no students be involved to one of the attending surgeons on the breast service the conversation went like this:

Woman: So can I request that no students or residents be involved in any part of my case?

Surgeon: Sure you can request that.

Woman: Then I'd like for you to be the only one doing my surgery.

Surgeon: I'm sorry then you're going to have to go someplace else.

Woman: I thought I could request no students/residents?

Surgeon: You can request it, but I'm just refusing your request.