PAs scope in surgery

[MacGyver]

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Found this on another board. Are these people lying or have surgeons really started "assisting" PAs with the PA as the primary surgeon?

I've done chest tubes, open cardiac massage, 1st assist c-sections, primary surgeon on open tibal ligations with surgeon 1st assisting me.

I have worked in CT-Surgery for almost three years now and I have had the opportunity to do a lot of cool things along the way. The coolest things I have done are as follows: I did pericardial window as the primary operator from the Surgeon's side with a Surgeon assisting me. I have done a sternal debridement and rewiring as the primary operator with a Surgeon assisting me. Once I did an Emergent bedside Thoracotomy for a patient that dissected his Thoracic Aorta after Aortic Valve surgery (pt died almost immediately after), I did an Emergent Bedside Re-Sternotomy for a patient in Cardiac Tamponade after surgery (she lived). I did an Emergent Femoral Cutdown to Crash on Bypass during a redo CABG after the RV was lacerated while opening up the sternum.

Out of OR: Chest Tubes/Central lines/Para/thoracentesis/complex laceration repair, Ventriculostomy, minor biopsies, removal of indwelling lines, Incision & drainage, PEG, etc...

In the OR:

General: Open appy (primary surgeon), Lap Appy (primary surgeon), Lap chole (everything but clipping the cystic artery), Excision of minor soft tissue masses, hemorrhoidectomy (internal & external), creation of colostomy, reversal of colostomy/ileostomy, Modified Radical Mastectomy (except for skeletonizing the axillary vein), Sigmoid colon resection, Gastric Bypass (open - everything but the creation of the gastric pouch & the final gastric anastamosis), needle localized breast biopsy, sentinel lymph node biopsy, Below knee amputation, above knee amputation, sural nerve & muscle biopsies, insertion of Mediport/removal of mediport, tracheostomy

Neuro - craniotomy (I opened to the Dura, neurosurgeon dealt w/ the mass & then I closed); Insertion of vagal nerve stimulator, open/close on lumbar laminectomy (everything but the actual laminectomy)

Plastics: Breast augmentation, breast reduction, harvested TRAM flap, blepharoplasty, minor local flap closures, harvest full thickness/split thickness skin grafts, abdominoplasty (most of these cases I was the primary surgeon on my side of the patient)

Vascular: Vein Harvesting, closing primary wounds, not really all that much as a primary here (I still haven't gotten around to getting Loupes)

working Family practice I was trained to do vasectomies with a family practice doc - ended up doing 40 on my own (with the doc in the next room) before I left that assignment.

In the civilian world working ortho - I first assist several different docs, some have me doing more than others. Everything from helping with the approach to actually making the cuts during the total joint arthoplasty. Most of the guys have me close after the case - some will have me close with them - ie they throw the pop-offs & I tie & cut. During ACL cases, I'll help harvest the graft, then take it to the back table and prepare it for the doc.

It's probably during the bigger late-night trauma cases where I get to do the most - I've been the primary on IM rodding of the femur & tibia (with the doc assisting) I've done a complete DHS case (dynamic hip screw for an Intertroc hip fx - again with the doc assisting).

I have been working in CV Surgery for almost 15 years. I routinely perform endoscopic vein and radial artery harvests, close chests from chest tubes up, I am the bedside surgeon for all robotic mitral valve repair cases, among other things. The coolest thing I have done is bring our patient back to the OR for poor hemodynamics post CABG and pre tamponade. I opened the patient, evacuated the clot, and repaired a bleeder on one of the anastomosis. Only then did my surgeon come out of his other case and look over my shoulder for report, then said nice job, close him up and left. I am sure there are many rewarding surgical areas but CV is my favorite.

primary on lap chole, alot of first assist on mastectomies, colectomies, reanastamosis, primary on ports, perm caths, first assist on hearts(cabg) finish once proximals are complete, simenofistulas. I got out of surg though for the easy life. no more 3 am phone calls, no more 20 hour days, now i have more family time and more money to do it with!

Notice also that they refer to themselves as "surgeons" now, not just assistants.

Sounds to me like some of you surgery attendings are selling teh soul of the profession so you can pull in 400k instead of "only" 350k

 

[Chronic Student]

I get the idea that you really lose sleep over this.

Anyway, to answer your question and I hate to say we may actually agree here. PA's are not surgeons and should NEVER call themselves as such. Surgical assistant yes, but I would never even consider calling myself an assisting surgeon, that is BS.

That having been said, I have been allowed to put in ventrics, put in subarachnoid bolts, place burrholes and my SP is training me to do sural nerve bx's, muscle bx's and carpal tunnel releases. Always under his direct supervision and never without him gowned/gloved and at my side and never assisting, but guiding.

When I was doing my neurosurgical rotation the PA's would actually take trauma patients to the OR, get exposure and turn flaps, but they were not allowed to go past the dura per institutional policy.

In other specialties like CT surgery the PA's do vein harvests, may get exposure and close. I'm not sure about cannulation, etc.

In the end we may be well trained and experienced technicians, but not surgeons. When complications arise and they will if you do anything long enough, then I think that the difference is obvious. The simplest operations can have complications and when the s**t hits the fan is when the PA falls short.

Just my personal opinion.

-Mike

 

[moquito_17]

Someone asked me to post to this thread, so as an orthopaedic surgeon, here are my thoughts:

I can’t speak to the general surgery or CT surgery parts, but the orthopaedic procedures that the poster quoted are not unreasonable to let an assistant do. Some of them we often let the medical student do. For example, to ream a femur, the most important part is the starting point. After that, reaming is just passing drill bits over wires. Not hard at all. For a total joint, the cuts come off a template, so this is not hard either. The hard parts are deciding what templates to use, interpreting the fits, appropriateness of choice and making intraoperative modifications. An assistant can never be trained to do this—this requires a different level of training and understanding.

Often, it is the Attending Surgeon, acting as an ‘assistant’ who is really in charge. All of the listed scenarios sound like that. Think about this—if I tell you exactly where to cut, what to cut, how to sew it and what modifications to do in order to adjust, who is the surgeon? You because you cut, or me because I: 1) knew what to do where and 2) knew that anything you did, if you messed it up I could fix it?

 

[beastmaster]

If there's a PA, med student, and resident assisting a surgical case, what is the difference in their respective roles? Or is it atypical for all three to be working on the same case?

 

[deleted6669]

Found this on another board. Are these people lying or have surgeons really started "assisting" PAs with the PA as the primary surgeon?


DUDE....you need to get another hobby besides bashing pa's. if you don't like pa's, don't hire one...end of story.....

 

[deleted6669]

Found this on another board. Are these people lying or have surgeons really started "assisting" PAs with the PA as the primary surgeon?


DUDE....you need to get another hobby besides bashing pa's. if you don't like pa's, don't hire one...end of story.....

IN THE MEANTIME THERE ARE LOTS OF JOBS LIKE THIS FOR US TO TAKE INSTEAD OF LISTENING TO YOUR WHINING....
TITLE: Physician Assistant- Peds Cardiothoracic Surgery
TAGLINE: Be at the heart of it all. Come and join our winning team at Rainbow Babies and Children's Hospital and take your career to a new level!

LOCATION: Cleveland, Ohio FULL TIME/PART TIME: Full Time
CLIENT: University Hospitals Health System
REGULAR/TEMPORARY: Regular
POSTED: 10/23/2006 EMPLOYMENT/CONTRACT WORK: Employment
REPLY SENT: NO VISA WAIVER AVAILABLE: Not specified


DESCRIPTION:
Rainbow currently has an immediate opening for a Surgical PA in Pediatric Cardiothoracic Surgery. The Pediatric Cardiothoracic Surgery Department at Rainbow Babies & Children's Hospital is seeking a motivated, self-directed and energetic PA to join its team. You will become part of a multidisciplinary team that includes 2 other PAs. Responsibilities include rounding on patients to determine and implement daily care plans, monitor patient status and implement therapeutic interventions, first assist in the Operating Room, take in-house call in the Pediatric Intensive Care Unit, and assist with outpatient follow-up care. As needed and desired, you can assist in the instruction of students and residents and participate in clinical research.
This is an exciting opportunity for a PA who is eager to learn, works well in a team setting, enjoys responsibility, and has an interest in pediatric cardiovascular disease. Experience in Surgery and Pediatrics is preferred. Educational needs and on-the-job training will be provided. PA-C and hospital credentialing required.

and this one....
TITLE: Physician Assistant, Cardiac Surgery
TAGLINE: University of Chicago Hospitals
Section of Cardiac & Thoracic Surgery

LOCATION: Chicago, Illinois FULL TIME/PART TIME: Full Time
CLIENT: University of Chicago Hospitals
REGULAR/TEMPORARY: Regular
POSTED: 10/23/2006 EMPLOYMENT/CONTRACT WORK: Employment
REPLY SENT: NO VISA WAIVER AVAILABLE: Not specified


DESCRIPTION:
The Physician Assistant, 1st Assistant (PA) is a member of the cardiac surgery team who is qualified by academic and clinical education to provide healthcare and patient services that may additionally include educational, research and administrative activities under the direction and supervision of the section's cardiac surgeons.

The PA has acquired the knowledge, skills and judgment necessary to assist the surgeons through organized instruction and supervised practice. The PA will take patient histories, conduct examinations, diagnose and treat illnesses, order and interpret laboratory tests and assist during complicated medical procedures and surgeries.

Other duties include independently coordinating conferences in conjunction with members of other multi-disciplinary teams at the University of Chicago Hospitals, coordinating the Cardiac Surgery Clinic, organizing the medical evaluation for patients, and maintaining database information, scheduling surgical procedures in the general operating rooms, evaluating patients for eligibility for entry into research protocols, collecting data for research protocols, participating in the evaluation of protocol data, and interfacing with industry and/or research organization representatives regarding patient entry, data collection and patient follow-up relative to the research endeavor.

Qualifications:
- Completion of an accredited physician assistant educational program
- Certification by the National Commission on the Certification of Physician Assistants (NCCPA)
- Current and/or eligibility for State of Illinois licensure/registration

 

[droliver]

That someone can be trained thru repetition to do a mechanical task should not come as a surprise. I think CTVS & ortho/neuro have been the fields in my observation that delagate a lot of the gruntwork to their allied health provider subordinates. I've worked with nurses (not even PA level degree) in Plastic surgery, burns, and neurosurgery whom I thought were as good (or better) then many surgeons' technique.

I get the impression though that there is going to be increasing blowback on this due to liability issues for both the provider & institution. Scope of practice has been a prominent feature of an increasing number of multi-million dollar verdicts. The VA system has already signifigantly tightened up their rules for this & I've seen the issue of unsupervised NP/PA doing surgery (usually closing) come up at department meetings in 3 different hospitals debating this.

There really is no defense you can offer if some catastophic complication occurs and the surgeon of record is not physically present. I think this changing climate is most likely to affect some of the more liberal CTVS practices involving closing the chest and such.

 

[SLUser11]

DUDE....you need to get another hobby besides bashing pa's. if you don't like pa's, don't hire one...end of story.....

He's not really bashing anybody......he's just asking a question.

I've worked with PAs more as a student, but I specifically remember a CT surgery PA that was the surgeon's right-hand man, seeing consults, managing ICU patients, etc. In the OR, he was the FIRST ASSIST, opening the chest, helping to cannulate, harvesting veins, closing the chest. I thought he was excellent at his job, and I think his responsibilities were appropriate.

But, the PA is always going to be an assistant and a skilled technician, nothing more. I find some of those stories MacGuyver posted to be BS simply because the surgeon has no motivation to teach PAs to do the critical part of surgeries (be primary surgeon) since they will never do the surgeries alone. More likely the PAs are naive to the surgeon's true involvement in the case.

PAs are extremely helpful in some situations, and don't know their boundaries/limitations in others. I've read on this forum about situations where their role and the resident's role clash, and the PA draws off of job experience and the limited realm of their duties to be more of an expert than the resident.

There are other situations where PAs go to school and train to do lots of things, and then become scutmonkeys for paperwork/dictations/etc., or even just glorified secretaries.....which is I THINK how us residents prefer it since we're territorial......I think there can be a happy medium.🙂

 

[Chronic Student]

I think that EMEDPA is referring to the numerous posts that MacGyver has written in the past.

This is the latest in a long line of them, do a search.

This was actually one of his more benign threads and we sort of agree, for once.

BTW, the vast majority of PA's do know when they are in over their head. Otherwise, we would have left a trail of dead people over the last 30+ years that we've been in healthcare. It is the really bad PA's that give the rest of us a bad name.

I also agree that you're entitled to your opinion, but when you say that a PA will never be more than a skilled technician, I would beg to differ. We just might deserve a small modicum of repect and we are capable of thought and are not automatons.

-Mike

He's not really bashing anybody......he's just asking a question.

I've worked with PAs more as a student, but I specifically remember a CT surgery PA that was the surgeon's right-hand man, seeing consults, managing ICU patients, etc. In the OR, he was the FIRST ASSIST, opening the chest, helping to cannulate, harvesting veins, closing the chest. I thought he was excellent at his job, and I think his responsibilities were appropriate.

But, the PA is always going to be an assistant and a skilled technician, nothing more. I find some of those stories MacGuyver posted to be BS simply because the surgeon has no motivation to teach PAs to do the critical part of surgeries (be primary surgeon) since they will never do the surgeries alone. More likely the PAs are naive to the surgeon's true involvement in the case.

PAs are extremely helpful in some situations, and don't know their boundaries/limitations in others. I've read on this forum about situations where their role and the resident's role clash, and the PA draws off of job experience and the limited realm of their duties to be more of an expert than the resident.

There are other situations where PAs go to school and train to do lots of things, and then become scutmonkeys for paperwork/dictations/etc., or even just glorified secretaries.....which is I THINK how us residents prefer it since we're territorial......I think there can be a happy medium.🙂

 

[SLUser11]

I also agree that you're entitled to your opinion, but when you say that a PA will never be more than a skilled technician, I would beg to differ. We just might deserve a small modicum of repect and we are capable of thought and are not automatons.

-Mike

I didn't mean that as an insult.....I said assistant and technician. As I said in my post, there are alot of clinical situations where PAs are invaluable members of the health care team. I give PAs much respect, but ultimately your title and level of training forces you to be always the bridesmaid, never the bride.

 

[Chronic Student]

Sorry, just touchy. It just seems like I got more respect as a scrub tech than I do as a PA and you are so right about always the bridesmaid and never the bride. In fact, I think I've used that exact phrase before.

There are a few people around who make out PA's to be the enemy and I really don't feel like that reflects the way things really are.

In real life, my doc and my patients love me and I really think that I make his and their lives much easier and I don't want to take over his job and I know my limitations.

It just seems that all I've been hearing lately is that midlevels are the ultimate evil, want to run docs out of the business and that we have littered the landscape with corpses from not understanding basic pharmacology and missing every single dx that is not OM or a URI.

Rant over, just had to vent.

-Mike

 

[toxic-megacolon]

Notice that PAs who do invasive procedures say "I GOT to do this" or "She LET me do that"

That's the difference.

MDs shouldn't be jealous, or even annoyed--Do you really want to be a surgical intern/junior resident the rest of your life? Your main job would be pre-rounding, cross cover, and someone else would decide when you "get" to do something. And of course, when patients think about who "did" their surgery, they assume it was the attending surgeon, not the resident or PA, even though the attending might have been scratching his butt in the Dr's lounge 90% of the case.

 

[tussy]

Be cautious whenever you hear someone saying "i got to do X in the OR" whether it be a resident, med student, nurse or PA. Most of the time they think they were doing the case but in reality it was the attending exposing and leading it thru the steps. Had he not been there then they most likely would not have been able to do the procedure.

I trained in a program that gave residents a lot of autonomy in the OR. I remember the first time the attending left me alone in the OR with a medical student to do a hernia. A procedure i had "done" many many times before. Well, suddenly it was not so simple. I realized how much the other person was "doing" and I struggled to expose the tissues and get the procedure done.

Being a surgeon is more than just doing the surgery. Working the patient up, discussing options and good decision making are the much more difficult parts. This is what takes 5 years of surgical residency to learn. Nobody is going to replace us there. And, as long as we are deciding who gets an operation then we will decide who does the surgery.

We don't have PAs where I work, but i think it would be great to have someone to do all the scut that nobody else wants to do; especially the stuff that takes some skill and intellectual thought. As long as the "midlevels" know their place and limitations then i think it's a great concept.