iceman55

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Quick question guys,

So I ended up on this site, http://www.pac.ca.gov/supervising_physicians/faqs.shtml#14 , that belongs to the Department of Consumer Affairs Physician Assistant Board. In the FAQs section under can a PA perform surgery? it says:

"14. Can a PA perform surgery?
Yes, if the supervising physician has delegated the PA authority to do so in writing. A PA may perform surgical procedures under local anesthesia without the personal presence of the supervising physician. A PA may perform surgical procedures requiring other forms of anesthesia only in the personal presence of the supervising physician. A PA may act as first or second assistant in surgery under the supervising of the supervising physician."

Is the "catch" here local anesthesia? meaning simpler cases that PAs and residents can do w/o supervision from the attending surgeon?

Sorry, excuse my ignorance if am completely off.

I understand that PAs/NPs commonly first assist in surgery, but how often would one (as a PA) get the chance to lead the surgical team w/o the presence of the surgeon?
 

core0

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Quick question guys,

So I ended up on this site, http://www.pac.ca.gov/supervising_physicians/faqs.shtml#14 , that belongs to the Department of Consumer Affairs Physician Assistant Board. In the FAQs section under can a PA perform surgery? it says:

"14. Can a PA perform surgery?
Yes, if the supervising physician has delegated the PA authority to do so in writing. A PA may perform surgical procedures under local anesthesia without the personal presence of the supervising physician. A PA may perform surgical procedures requiring other forms of anesthesia only in the personal presence of the supervising physician. A PA may act as first or second assistant in surgery under the supervising of the supervising physician."

Is the "catch" here local anesthesia? meaning simpler cases that PAs and residents can do w/o supervision from the attending surgeon?

Sorry, excuse my ignorance if am completely off.

I understand that PAs/NPs commonly first assist in surgery, but how often would one (as a PA) get the chance to lead the surgical team w/o the presence of the surgeon?
Surgical Procedures have a pretty broad definition in this case. The question involves local anesthesia. So if someone was placing sutures in the ER or Office that would be covered. If someone was taking out AKs under local that would be covered. I guess technically if you could figure out how to do open heart surgery under local anesthesia and the supervising physician signed off on it then yes theoretically a PA could lead the surgical team. Generally the "surgical team" consists of the PA and occasionally an MA to help.
 

emedpa

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PAs at many places(rural e.d.s and ICUs for example) do procedures with procedural sedation without a doc present.
many surgical PAs also start cases with only a crna in the room(open the chest, harvest vein, etc) before the doc comes in to do their part. those folks are under general anesthesia and there is no doc at the bedside. IR PAs do quite a bit without docs around as well(ct/fluoro/ultrasound guided biopsies, etc).
I think the literature is slow to catch up with reality sometimes.
 

Winged Scapula

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You know SDN has lost its volume of users when a thread about PAs doing surgery doesn't start an immediate flame war....
Give us some time; some of us just got home.

After all, unlike PAs, we don't clock out at 5 pm. ;)
 

emedpa

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Give us some time; some of us just got home.

After all, unlike PAs, we don't clock out at 5 pm. ;)
hah! this PA works 60+ hrs/mo more than the docs in his group for around 1/3 the salary....they work 12-14 eights...we work 16-20 tens....and some of us work almost exclusively 12s and 24s....
 
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wjs010

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Winged Scapula

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hah! this PA works 60+ hrs/mo more than the docs in his group for around 1/3 the salary....they work 12-14 eights...we work 16-20 tens....and some of us work almost exclusively 12s and 24s....
Are we really going to get into a discussion regarding the number of hours that EM physicians and PAs work, here in the surgical forums?

Not only is it irrelevant to the discussion at hand, my 72-year-old mother works more hours per week than the average EM physician.
 

emedpa

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FINE, I don't know too many surgical PAs( and I know a bunch) who work bankers hours. most put in 12+ hr days with many working 80 hrs/week. I know your original comment was light-hearted. I just don't think it is fair to portray pas that way to medstudents here who might not know better. most pas in practice work their asses off. it isn't a lifestyle job by any means. I'm not discounting the time put in by surgeons either. as a group they are probably the hardest working docs in the hospital.
 

wjs010

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FINE, I don't know too many surgical PAs( and I know a bunch) who work bankers hours. most put in 12+ hr days with many working 80 hrs/week. I know your original comment was light-hearted. I just don't think it is fair to portray pas that way to medstudents here who might not know better. most pas in practice work their asses off. it isn't a lifestyle job by any means. I'm not discounting the time put in by surgeons either. as a group they are probably the hardest working docs in the hospital.
Being a PA isn't a lifestyle job?
 

Pir8DeacDoc

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If you're working 80 + hours a week as a PA on traditional PA pay, then you're a fool. I worked with a lot of PA's at my hospital during residency across a variety of services and they would either come in early and make rounds and leave by 1-2 or go the the OR as first assist an leave when the surgeon left, without doing any rounding etc. No way in hell I ever saw a PA work 80 hours, not even close. Certainly not average 80+, that's crazy talk.
 

wjs010

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If you're working 80 + hours a week as a PA on traditional PA pay, then you're a fool. I worked with a lot of PA's at my hospital during residency across a variety of services and they would either come in early and make rounds and leave by 1-2 or go the the OR as first assist an leave when the surgeon left, without doing any rounding etc. No way in hell I ever saw a PA work 80 hours, not even close. Certainly not average 80+, that's crazy talk.
Yea I mean I thought that was the main reason one would go into PA, FOR the lifestyle
 

emedpa

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Yea I mean I thought that was the main reason one would go into PA, FOR the lifestyle
HARDLY. people go to pa school because they either want to get to work sooner, avoid scary prereqs, or think they will have more free time once they are working. these are all bad reasons. sure, pa school is shorter and folks get into the job market sooner but many find they are putting in lots of hrs when the docs in the practice are at home.
docs hire PAs to do the work they don't want to do at the times and places they don't want to do it so they can be home with their families.
that means nights/weekends/holidays/early am rounding, late night first call to the er, wound clinic, inner city, rural, wound clinic, HIV clinic, std clinic, prisons, etc.
 
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emedpa

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If you're working 80 + hours a week as a PA on traditional PA pay, then you're a fool. I worked with a lot of PA's at my hospital during residency across a variety of services and they would either come in early and make rounds and leave by 1-2 or go the the OR as first assist an leave when the surgeon left, without doing any rounding etc. No way in hell I ever saw a PA work 80 hours, not even close. Certainly not average 80+, that's crazy talk.
most of the surgical PAs I know who work in community facilities without residents do early am rounds, spend the day in clinic or the o.r. or both then take frequent first call to the floor and the icu (one of my friends is on Q3 night call with 2 other PAs). most of the time they don't need to call in the doc and the rest of the surgical team at night, they just deal with the issues themselves. another of my friends is on a transplant team. he has to go pick up and babysit the organ anywhere in the country, bring it back to his home facility then first assist in the transplant procedure. his days are 12-16 hrs on a regular basis. another friend works at a facility where the pas run the surgical floors and the unit 24/7(they are the only surgical housestaff-no md residents). they call the surgeons in only if a pt needs to go the the o.r.
there is a pa surgical residency there and many pas stay on after graduation:
Q: What makes the Norwalk/Yale Residency stand out?

A: Many factors combine to make the Norwalk/Yale Residency so effective. The clinical aspect is enhanced by the fact that PAs constitute the entire surgical house staff at Norwalk Hospital. The attending physicians on the teaching staff have personally chosen to take part and are dedicated to the educational process. Staff PAs also provide didactic and clinical instruction and consciously serve as role models. The importance accorded to the PA role is built into the Department of Surgery’s very structure, and is recognized throughout the institution.
 
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emedpa

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my 72-year-old mother works more hours per week than the average EM physician.
probably true. most em docs work cush schedules. I don't know any that work more than 35 hrs/week on a regular basis.
 

Winged Scapula

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FINE, I don't know too many surgical PAs( and I know a bunch) who work bankers hours. most put in 12+ hr days with many working 80 hrs/week. I know your original comment was light-hearted. I just don't think it is fair to portray pas that way to medstudents here who might not know better. most pas in practice work their asses off. it isn't a lifestyle job by any means. I'm not discounting the time put in by surgeons either. as a group they are probably the hardest working docs in the hospital.
I agree that it is important to present a realistic post training lifestyle to medical students and others who may be interested.

It's just as important to recognize that there are a myriad of practice types with different responsibilities and work hours.
For example, like the others above, when in training, I never saw a PA work more than 40 hours per week. As a matter of fact, we had a great deal of trouble with them on CT and trauma surgery as they would refuse to come in for rounds prior to 7 AM, would never stay past 5 PM, would not work weekends, and for the short period that we added them to the call schedule, consistently told the nurses to call the resident and refused to come see patients or do anything else that was expected of them outside a routine shift.

But in a busy community practice I often see the urology and orthopedic PAs in the hospital early in the morning and late in the evening as well as on weekends. As a matter of fact, even in my lifestyle special day, our PA frequently works 10 hour days. But she constantly complains that she works much much more than her family medicine colleagues and makes less. Frankly I'm not sure who would pay more than $100,000 a year to work less but that's what she tells us. I've seen others in family medicine practices to work 8 to 5 with 90 minute lunches daily.

So it's important to recognize that its not all rainbows and unicorns or canaries in coal mines.
 

emedpa

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Fair post.
I think it is likely we are seeing the 2 extremes for how surgical PAs are used. at places that train md surgical residents, the PAs likely take up slack but don't do the heavy lifting because the residents do. at community facilities without md residents the PAs end up doing a lot more and working longer hrs.
100K in FP for PAs would not be unheard of for a senior PA but it's not the norm by any means. surgical PAs in most situations should make considerably more and a senior surgical pa might might 2x what an entry level fp pa makes.
 
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thedrjojo

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The question at hand is it appropriate for PA's to be doing these procedures unattended? Within a limited scope, I see little issue with it. These minor procedures (suturing, I&D's, skin tags, etc) that are usually the intern level stuff or really could be done by a medical student, there is no issue with it. Conversely, something that the PA has gotten extensive training and experience in and is the entire scope of the practice essentially (like the Cardiac PA whose entire job basically consists of vein harvests, +/- opening the chest), these are again things I am ok with. Limited scope here though, but when you get to more complex things like a hernia (which can be done under local so in theory could be done by a PA based on the OP), the number of surgical PA's with the experience necessary to be doing those unattended will be almost non-existent
 

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Limited scope is key and experience in the procedures is expected. If it were possible for a PA to get a more broad scope and perform more advanced procedures, with significantly less training than someone who has completed a residency and is BE/BC, then we would alter our surgical training to reflect that. With less hours already in surgical training, it is tough to get our MDs trained with a broad experience. I have no problems with PAs doing procedures, but in my experience this is quite limited to either simple procedures or one or two more advanced with supervision.
 

ESU_MD

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probably true. most em docs work cush schedules. I don't know any that work more than 35 hrs/week on a regular basis.
ER docs have a nice schedule and lifestyle, but they also make less money than surgeons. I bet they don't care they make less either when they are off at home without a pager!
 

emedpa

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ER docs have a nice schedule and lifestyle, but they also make less money than surgeons. I bet they don't care they make less either when they are off at home without a pager!
Not much less...this salary survey has the difference at about 30k/yr which means the em docs are likely making more hourly if you consider 35 vs 50 hr workweeks:
http://www.medscape.com/features/slideshow/compensation/2012/public
the same survey also finds 54% of em docs satisfied with their jobs vs 46% for surgery
 

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Not much less...this salary survey has the difference at about 30k/yr which means the em docs are likely making more hourly if you consider 35 vs 50 hr workweeks:
http://www.medscape.com/features/slideshow/compensation/2012/public
the same survey also finds 54% of em docs satisfied with their jobs vs 46% for surgery
I don't doubt that EM physicians make more "per hour" when compared to their GS colleagues. While I can't speak for the compensation for EM, that listed for GS is laughably low (except perhaps in academics).
 

wjs010

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I don't doubt that EM physicians make more "per hour" when compared to their GS colleagues. While I can't speak for the compensation for EM, that listed for GS is laughably low (except perhaps in academics).
What do you think is the real number for GS? I'm curious because my brother is a pvt practice GS in Dallas and I don't wanna ask what he makes
 

Winged Scapula

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What do you think is the real number for GS? I'm curious because my brother is a pvt practice GS in Dallas and I don't wanna ask what he makes
IMHO the number is closer to high 300/400 but will vary geographically. Expenses also vary: your brother likely pays 1/3 of what I do in malpractice given Texas tort reform.
 

wjs010

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IMHO the number is closer to high 300/400 but will vary geographically. Expenses also vary: your brother likely pays 1/3 of what I do in malpractice given Texas tort reform.
Well damn he sounded disappointed in his pay but sounds to me like he has it made. So you're saying there's less malpractice insurance in Texas across all specialties? Why don't you move to Texas? I feel like moving to Texas now and I'm in Louisiana. Lol
 

Winged Scapula

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Well damn he sounded disappointed in his pay but sounds to me like he has it made.
Keep in mind that those numbers are highly variable; however, my comment above still stands: $250K for PP General Surgery is low IMHO with several states (not including Texas however).

As far as "got it made", a general surgeon works pretty hard and should be compensated for it. Your brother may also have a a student loan debt to deal with which can be substantial.

So you're saying there's less malpractice insurance in Texas across all specialties?
I'm saying that malpractice insurance rates tend to be less in states with tort reform, like Texas.

Why don't you move to Texas? I feel like moving to Texas now and I'm in Louisiana. Lol
Uhm...have you *been* to Texas? Then again, if I lived in LA I'd consider Texas as preferable as well. ;)

I don't care for Texas, would prefer to live closer to my family in California, and I'm a full partner in a practice in AZ so leaving isn't like quitting a job at Burger King.
 

Winged Scapula

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Arizona is intriguing. What is it like.
Its a big state and that's a big question. Anything specific you'd like to know?

- weather: very hot, dry heat in PHX and surrounding areas; snow in higher elevations
- political climate: conservative with liberal gun possession laws; expect that everyone is packing a concealed sidearm
- community: large and growing; family and gay friendly. Lots of professional sports. Lots of outdoor activities. Good foodie scene. Homes expensive compared to midwest, but cheaper than coasts.
- medical community: very skewed toward private practice; few specialists given size of town.
 

wjs010

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Its a big state and that's a big question. Anything specific you'd like to know?

- weather: very hot, dry heat in PHX and surrounding areas; snow in higher elevations
- political climate: conservative with liberal gun possession laws; expect that everyone is packing a concealed sidearm
- community: large and growing; family and gay friendly. Lots of professional sports. Lots of outdoor activities. Good foodie scene. Homes expensive compared to midwest, but cheaper than coasts.
- medical community: very skewed toward private practice; few specialists given size of town.
this is not much different than TX, save the snow. :D
 
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Winged Scapula

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this is not much different than TX, save the snow. :D
I beg to differ. Texas is much more humid, especially Houston. I was miserable there doing a rotation because of the humidity.

The scenery is Arizona is almost, without fail, much more pleasant than Texas.

Arizonan Mexican food >>>>> Tex-Mex

Texas also has Texans. I've never met a group of people so slavish in their love of their state and possessing such a sense of superiority as Texans. ;)
 

wjs010

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I beg to differ. Texas is much more humid, especially Houston. I was miserable there doing a rotation because of the humidity.

The scenery is Arizona is almost, without fail, much more pleasant than Texas.

Arizonan Mexican food >>>>> Tex-Mex

Texas also has Texans. I've never met a group of people so slavish in their love of their state and possessing such a sense of superiority as Texans. ;)
Haha. I agree about the humidity. I guess I have a different view because I like Dallas. But yea it is annoying to be from Louisiana , especially now that everyone associates it instantly with duck dynasty
 

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Being a PA isn't a lifestyle job?
Not the surgical specialty PAs where I work. They are on the same hours as the attendings, often 70 hours a week, all so they can barely crack 6 figs. They don't take call like the attendings, but they are present on weekends, so it's kind of a wash. Then there's the hospitalist PAs, which do the same 7 on, 7 off 12 hour shifts for about half of what we pay the physician hospitalists. Maybe if you're in FM or urgent care it's a lifestyle job, but PAs in most of the hospitals around here have a lot expected of them, both in time and in services, and they aren't exactly compensated a lot for what we ask of them.
 

SeekerOfTheTree

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Not the surgical specialty PAs where I work. They are on the same hours as the attendings, often 70 hours a week, all so they can barely crack 6 figs. They don't take call like the attendings, but they are present on weekends, so it's kind of a wash. Then there's the hospitalist PAs, which do the same 7 on, 7 off 12 hour shifts for about half of what we pay the physician hospitalists. Maybe if you're in FM or urgent care it's a lifestyle job, but PAs in most of the hospitals around here have a lot expected of them, both in time and in services, and they aren't exactly compensated a lot for what we ask of them.
Trauma PAs at my shop work 3 12s a week and moan about it. I know about six if them that do this. GI PA does 40. ER PA that's 14 10s and can't think of anymore I know.
 
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SeekerOfTheTree

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Trauma PAs at my shop work 3 12s a week and moan about it. I know about six if them that do this. GI PA does 40. ER PA that's 14 10s and can't think of anymore I know.
I am just curious, what are we asking of PAs that they should be compensated more for?
 

Winged Scapula

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Not the surgical specialty PAs where I work. They are on the same hours as the attendings, often 70 hours a week, all so they can barely crack 6 figs. They don't take call like the attendings, but they are present on weekends, so it's kind of a wash. Then there's the hospitalist PAs, which do the same 7 on, 7 off 12 hour shifts for about half of what we pay the physician hospitalists. Maybe if you're in FM or urgent care it's a lifestyle job, but PAs in most of the hospitals around here have a lot expected of them, both in time and in services, and they aren't exactly compensated a lot for what we ask of them.
There's no doubt that many physician assistants work long hours and on weekends especially in the surgical specialties.

However I'm not sure that it's relevant to state that they work the same hours as the attendings but make half of what the physicians do. That seems to imply that the reason for a physician's reimbursement is solely based on the hours worked.

Without rehashing old arguments I would state that it needs to be considered that the knowledge base and skill levels of the attending's exceeds that of the PA as well as the medical legal liability.

Frankly I often encourage students to consider going to PA school because for the amount of time invested in the education the salary is pretty darn good. There arent many 25-year-olds out there that can earn a six-figure salary.
 

Mad Jack

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There's no doubt that many physician assistants work long hours and on weekends especially in the surgical specialties.

However I'm not sure that it's relevant to state that they work the same hours as the attendings but make half of what the physicians do. That seems to imply that the reason for a physician's reimbursement is solely based on the hours worked.

Without rehashing old arguments I would state that it needs to be considered that the knowledge base and skill levels of the attending's exceeds that of the PA as well as the medical legal liability.

Frankly I often encourage students to consider going to PA school because for the amount of time invested in the education the salary is pretty darn good. There arent many 25-year-olds out there that can earn a six-figure salary.
I wasn't implying they deserved to make as much as those they were working under, just saying that the hours and pay kind of don't compensate for the awful lifestyle.
 

Winged Scapula

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I wasn't implying they deserved to make as much as those they were working under, just saying that the hours and pay kind of don't compensate for the awful lifestyle.
Fair enough.

I guess I would venture that for the minimal additional education required, that even at 70 hrs per week (which many white collar jobs also entail and most PAs jobs don't), a 6 figure salary is more than adequate compensation.
 
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SeekerOfTheTree

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Fair enough.

I guess I would venture that for the minimal additional education required, that even at 70 hrs per week (which many white collar jobs also entail and most PAs jobs don't), a 6 figure salary is more than adequate compensation.
Completely agree with this.
 

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hah! this PA works 60+ hrs/mo more than the docs in his group for around 1/3 the salary....they work 12-14 eights...we work 16-20 tens....and some of us work almost exclusively 12s and 24s....
Let me get this straight. You work 50 percent hours and you STILL make only 1/3 the salary of an EM doc? Dude, you picked the wrong career!