Physician assistants are surgical residents. Shameful.

[anonperson]

It is also a matter of efficiency. I need an assistant when I’m doing a robotic case. My partners and I often assist for each other. This is fun, but a huge loss of productivity. My partner may bill 4 RVUs for a 3-4 hour case when instead they could have seen 15 patients in clinic. If I had a well trained PA for that purpose I would happily use him or her and a program that trains PAs to be good first assistants is fine by me.

Efficiency is fine. I use PAs for my bedside assist on robotic cases and think using a physician as an assist for most robotic cases isn't needed.

A well trained PA is fine but the program in question talks about teaching intracorporeal knot tying. Not sure why this would be the case.

And knot tying is even easier robotically than with conventional laparoscopy.

The main thing I have an issue with is scope creep. It starts off small but can get out of control quickly.

I know certain specialists feel they are immune to mid level encroachment due to the complexity of operating in general.

But I would say the same thing about anesthesia. Intubation, spinals, epidurals, etc are still complex procedures in my eyes but CRNAs are doing all of these things.

Physicians cannot continue to give up turf. It hurts the profession.

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[DoctwoB]

Efficiency is fine. I use PAs for my bedside assist on robotic cases and think using a physician as an assist for most robotic cases isn't needed.

A well trained PA is fine but the program in question talks about teaching intracorporeal knot tying. Not sure why this would be the case.

And knot tying is even easier robotically than with conventional laparoscopy.

The main thing I have an issue with is scope creep. It starts off small but can get out of control quickly.

I know certain specialists feel they are immune to mid level encroachment due to the complexity of operating in general.

But I would say the same thing about anesthesia. Intubation, spinals, epidurals, etc are still complex procedures in my eyes but CRNAs are doing all of these things.

Physicians cannot continue to give up turf. It hurts the profession.

Meh I think that is a distinction without a difference. Is passing a suture laparoscopically or a robotic instrument more or less dangerous then tying one of the 3-0 silk pops I use on the second layer of a bowel anastomosis? Because the former makes me more nervous, as I directly observe the latter. The key point is that I am supervising, not the exact technical task.

 

[anonperson]

Meh I think that is a distinction without a difference. Is passing a suture laparoscopically or a robotic instrument more or less dangerous then tying one of the 3-0 silk pops I use on the second layer of a bowel anastomosis? Because the former makes me more nervous, as I directly observe the latter. The key point is that I am supervising, not the exact technical task.

Can they both incur risk? Sure, but things like intra corporeal suturing and knot tying require more skill. Passing a suture through a trocar requires one to have good vision and not be a goofball with the needle.

My issue is at some point, we can be supervising a mid level performing a fairly challenging part of a case. That can grow.

Early anesthesiologists were supervising CRNAs induce/intubate a patient. At some point, CRNAs decided that they knew enough to function on their own. We know that this isn't the case but there are now several states where they can be independent.

There was a maybe a month or two ago about Upenn publishing a study about non radiologists trained to read chest x-rays. I think the conclusion was they did an adequate job. It caused a huge uproar (rightly so) because it is conceding turf. We have enough to worry about without training our "replacement."

Are well trained surgical assists needed? Yes. The main issue is where the line is drawn as to what they can do.

 

[nymedstudent874]

the only profession i can think of where attending's actively try to sabotage their own profession and trainees is medicine. wake up people. NPs/PAs are essential in todays healthcare system and we all know that, they serve a vital role in coordinating care, dealing with patients, etc. Just like dental hygienists do in dentistry, but do you ever see a hygienist doing anything other than cleaning teeth? never. The dentist comes in every time and checks your teeth anyway to make sure that YOU as a consumer know that the he/she is the dentist, the person in charge. Now on this thread we have people advocating for teaching what essentially are people who opted to not go to medical school and residency and go straight to the operating. Want to teach? Teach residents, medical students- encourage the next generation. Instead what I usually see happening is attendings creating PA mini-me's of themselves out of selfishness.

 

[Dr.LeoSpaceman]

Are well trained surgical assists needed? Yes. The main issue is where the line is drawn as to what they can do.

I don't know that anyone--at least in this thread--disagrees with this.

I just have an issue with the "slippery slope" discussions when I've honestly seen no evidence of said slope in surgery specifically. Yes, it happened in anesthesia, psych, EM and wherever else. When people say it may be a different story in surgery, we get called naïve. But to this point, I've yet to hear of a first hand account of a surgeon allowing a PA/NP to perform a critical portion of an operation without direct supervision by the attending. If I have to stand there while they do something, it's not selfish since I'm not deriving benefit. I can't be doing something else that's revenue generating at the same time.

For example, PAs have seemingly been harvesting vein for CABGs for quite some time. If the slippery slope was a foregone conclusion, shouldn't we expect that PAs somewhere would be sewing the grafts so the cardiac surgeon could run multiple rooms? If we don't, doesn't that lend some support to the idea that there is something inherently different about surgery that limits the ability to cede responsibility to a PA/NP when you aren't physically present?

 

[anonperson]

I don't know that anyone--at least in this thread--disagrees with this.

I just have an issue with the "slippery slope" discussions when I've honestly seen no evidence of said slope in surgery specifically. Yes, it happened in anesthesia, psych, EM and wherever else. When people say it may be a different story in surgery, we get called naïve. But to this point, I've yet to hear of a first hand account of a surgeon allowing a PA/NP to perform a critical portion of an operation without direct supervision by the attending. If I have to stand there while they do something, it's not selfish since I'm not deriving benefit. I can't be doing something else that's revenue generating at the same time.

For example, PAs have seemingly been harvesting vein for CABGs for quite some time. If the slippery slope was a foregone conclusion, shouldn't we expect that PAs somewhere would be sewing the grafts so the cardiac surgeon could run multiple rooms? If we don't, doesn't that lend some support to the idea that there is something inherently different about surgery that limits the ability to cede responsibility to a PA/NP when you aren't physically present?

The slippery slope has started across the Atlantic...

Meet the nurse who will soon perform surgery on patients alone

Unlike other nursing roles, a surgical care practitioner is involved with the patient every step of the way

www.google.com

Specialist nurses trained to take over surgical service from doctors | Nursing Times

Cardiac rhythm specialist nurses at University Hospital Southampton NHS Trust have undergone extensive training to implant devices in patients with heart

www.nursingtimes.net

Nurses 'will be trained to perform surgery' in bid to slash NHS waiting times

NURSES are to be trained to perform certain surgeries as part of new plans to halt a rise in NHS waiting times. The plans will see nurses given the option to take a two-year course to qualify as &#…

www.google.com

This is all for cost cutting. Not patient safety.

Mid levels aren't going to eliminate the need for physicians. But I can easily forsee a scenario where a mid level is performing a "straightforward " surgical procedure leaving the complex stuff to a physician.

I don't think any specialty is immune. It won't happen in one fell swoop, just a gradual chipping away.

You just listed several specialties that are dealing with this very issue. I for one am concerned for the future.

 

[Dr.LeoSpaceman]

The slippery slope has started across the Atlantic...

Meet the nurse who will soon perform surgery on patients alone

Unlike other nursing roles, a surgical care practitioner is involved with the patient every step of the way

www.google.com

Specialist nurses trained to take over surgical service from doctors | Nursing Times

Cardiac rhythm specialist nurses at University Hospital Southampton NHS Trust have undergone extensive training to implant devices in patients with heart

www.nursingtimes.net

Nurses 'will be trained to perform surgery' in bid to slash NHS waiting times

NURSES are to be trained to perform certain surgeries as part of new plans to halt a rise in NHS waiting times. The plans will see nurses given the option to take a two-year course to qualify as &#…

www.google.com

This is all for cost cutting. Not patient safety.

Mid levels aren't going to eliminate the need for physicians. But I can easily forsee a scenario where a mid level is performing a "straightforward " surgical procedure leaving the complex stuff to a physician.

I don't think any specialty is immune. It won't happen in one fell swoop, just a gradual chipping away.

You just listed several specialties that are dealing with this very issue. I for one am concerned for the future.

Somehow I don't consider NHS policy as generalizable to the US.

And doesn't anyone else see how circular this conversation is?

Person 1: We should have defined roles for NP/PAs.
Person 2: [describes role-appropriate activity for PA/NP]
Person 1: Don't you know that if we let PAs/NPs do things they'll soon take over?

First they'll come for our sebaceous cysts. Next thing you know, they'll be doing our Whipples.

 

[HighPriest]

NPs will eventually start doing surgery. Period. Cost cutting is the rationale, but it’s allowed primarily because physicians let these things happen. We have no organizational body whatsoever that looks out for us on the national scale. AMA and your academy (any academy) has their head so far up their @$$ that is almost works against us rather than for us. I wouldn’t give them a penny to piss on my shoes. No one is in the cages in Congress, state or federal swinging for physicians in any meaningful way, but I guarantee to you that that is where the nurses are tying our nooses. Hospitals can shoot for cost savings all they want, but they have to operate within the law. We all know that NPs simply do not have the education or experience to do what we do. Training course or not. So it is not in the patient’s best interest to have NPs operating on them. Period. Laws protecting patients are pretty commonplace. This could be stopped. But it won’t, because we don’t care enough to organize. We’re fat and happy. And yeah, hospital lobbies throw a lot of fat around, but it’s irrelevant because we don’t even try.

 

[anonperson]

Somehow I don't consider NHS policy as generalizable to the US.

And doesn't anyone else see how circular this conversation is?

Person 1: We should have defined roles for NP/PAs.
Person 2: [describes role-appropriate activity for PA/NP]
Person 1: Don't you know that if we let PAs/NPs do things they'll soon take over?

First they'll come for our sebaceous cysts. Next thing you know, they'll be doing our Whipples.

Somehow I don't consider NHS policy as generalizable to the US.

And doesn't anyone else see how circular this conversation is?

Person 1: We should have defined roles for NP/PAs.
Person 2: [describes role-appropriate activity for PA/NP]
Person 1: Don't you know that if we let PAs/NPs do things they'll soon take over?

First they'll come for our sebaceous cysts. Next thing you know, they'll be doing our Whipples.

Per the articles,

"removal of hernias, benign cysts, and some skin cancers"

"possible skin grafts and flap reconstructions"

That sounds like more than a sebaceous cysts removal.

I don't think the argument is circular. I completely disagree with mid levels trying to learn this type of Surgical procedures.

This is the fundamental problem. The role of the midlevel is to hold the camera/retractor/ pass suture/close skin (even that I don't like to do) etc. Anything beyond that is ceding ground in my opinion.

They won't come for Whipples. But they will come for low hanging fruit in straightforward cases in patient's with no comorbid conditions.

Maybe it's just me, but it is nice to do a straightforward case on a healthy-ish patient. Ask me how I felt doing a hysterectomy on a patient with 4 prior c sections and a BMI of 40 vs a hysterectomy on a Virgin abdomen with a BMI of 22.

 

[anonperson]

NPs will eventually start doing surgery. Period. Cost cutting is the rationale, but it’s allowed primarily because physicians let these things happen. We have no organizational body whatsoever that looks out for us on the national scale. AMA and your academy (any academy) has their head so far up their @$$ that is almost works against us rather than for us. I wouldn’t give them a penny to piss on my shoes. No one is in the cages in Congress, state or federal swinging for physicians in any meaningful way, but I guarantee to you that that is where the nurses are tying our nooses. Hospitals can shoot for cost savings all they want, but they have to operate within the law. We all know that NPs simply do not have the education or experience to do what we do. Training course or not. So it is not in the patient’s best interest to have NPs operating on them. Period. Laws protecting patients are pretty commonplace. This could be stopped. But it won’t, because we don’t care enough to organize. We’re fat and happy. And yeah, hospital lobbies throw a lot of fat around, but it’s irrelevant because we don’t even try.

This is the problem. Some physicians are more than happy to sell out their profession. Mid levels can't learn surgical techniques without surgeons teaching them.

 

[HighPriest]

This is the problem. Some physicians are more than happy to sell out their profession. Mid levels can't learn surgical techniques without surgeons teaching them.

That is true. And those of us who wouldn’t do it aren’t willing to take the time or lose the income to stop them. I’m guilty too. There’s plenty of “just get what I can and get out before the roof falls in” attitude.

 

[adenocard]

 

[HighPriest]

View attachment 338662

Pfft. I got a guy in El Salvador who can do that and he had no medical training.