Surgery--the final realm of the doc alone?

[Toadkiller Dog]

I'm sure I'm not the only one here to have had this thought:

Doesn't it seem as though the areas of health care which were once reserved solely for the physician are dwindling? Nurse practitioners (and PAs) can now do nearly everything an FP/IM can do, with half the total training. CRNAs appear to be able to do pretty much all that an anesthesiologist can do (open heart, head cases, etc).

Even radiology procedures may be pawned off to "Radiology Practioner Assistants" in the near future (see the thread in the radiology forum). Gas, rads, and medicine are all interesting, but it seems very demoralizing to me as a medical student to devote eleven or twelve years of my life to gain the same rights that "mid-level" practitioners gain in five or six.

It seems surgery is the one field that no one is willing to touch yet (i.e, create a special school for). Some could argue this point, what with pseudo-docs doing some minor surgery (podiatrists, optometrists), but by and large, surgery seems to be the one field that is reserved for docs alone.

Will it, in the end, be the only thing that separates the "real" doctors (MD/DO) from other providers?

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[ESU_MD]

I did a rotation on the cardiac surgery service and was pretty surprised at what I saw.

They have nurses who are certified as first assistants who can practically do an entire CABG alone. These nurses prep the pt, open the chest via median sternotomy, take down the mammary while another nurse is either harvesting the radial and/or saphenous. I have even seen these nurses throw pursestrings in the great vessels as a final step prior to cannulation for on-pump procedures. All of this was performed with the only physican in the room being the gasman. The CT surgeon basically comes in and sews the graft in place, then leaves. The nurses finish hemostasis and close the chest- solo. Granted that CABG is practically a routine operation now, but I was still surprised the degree of autonomy these nurses had in the OR.

In their defense: (1) A skilled assistant is essential for a CT surgeon, esp in private practice (ie no residents) (2)These nurses had superior technical skills and handled the instruments and tissues like pros. (3) most of these guys knew their limits and didnt act like they could manage pts postop course.

What was surreal was seeing the surgical nurses barking orders to the scrub nurse and hollering like they were surgeons!!

It was also depressing to see these guys, some as young as 25 making great $$ and basically doing CT surgery without supervision with a 2 yr nursing degree from a vo-tech. Why should we even go to med school these days!?!

Personally I would like to have nurses and PA's around to do the scutwork and more mundane things. The problem of course is that they try to start independent practices and thats not good.

 

[Mindy]

I can certainly verify esu's story.

I also watched CT nurses do all the things described.

Also I was talking to a PA (left CT Surg for FP) who said the surgeons used to call him (in the OR) from the car to make sure the patient was closed up all right.

Makes ya wonder...

 

[womansurg]

Yeah, the nurses open and close the chest at our facility, too. At least up until this year - had to stop because of insurance reasons. Now if the junior resident is rotating through, they do it, as well as the vein harvest, the cannulation, so forth. The CT guys still do the anastomoses.

CT surgery is notorious for it's rote repetition. That's one of the major reasons why residents aren't very attracted to it as a specialty. You seem to do CABG after CABG after CABG, day after day. We only rotate for four weeks, and by the second week you never want to see another friggin' CABG as long as you live. Closing the chest at the end of the case is so laborious - you just dread it. It's easy to see why the surgeons try to pawn off these noncritical portions of the case. They know their scrub nurses - many are very good, very trustworthy, very attentive to detail, and can likely close the chest as well as they can do it themselves. God knows they get ample opportunity to teach them and assess their ability to do that particular function of the case. The surgeons are responsible for everything that happens in that case, so they make that decision knowingly.

At our hospital the insurance companies refused to cover surgeons who did this, hence the change. I'm not sure if that is a coming trend or not.

 

[Ponyboy]

I have a feeling that the last realm of physicians will be what sets them apart from mid-level practioners, their extra training in handling complex medical problems. Subspecialties where medical decision making and esoteric knowledge is the basis of practice will likely be the domain where only physicians can practice. I really can't forsee special fellowships for PA's and NP's in areas like Pediatric nephrology or pulmonology.

 

[MacGyver]

the comments on this thread are spot on.

Remember that the ONLY way that midlevels can get their grubby fingers in the docs pie is because there are surgeons out there who want to make as much money as possible and thus they let nurses/PAs infiltrate their turf.

Without doctor coooperation, CRNAs, PAs doing all this complex stuff never would have happened to begin with.

Doctors themselves are to blame for whats going to happen in future generations. Now that PAs/NPs have a foothold in previously held doc turf, they are going to continuously fight for expansion.

 

[droliver]

Originally posted by Ponyboy
Subspecialties where medical decision making and esoteric knowledge is the basis of practice will likely be the domain where only physicians can practice. I really can't forsee special fellowships for PA's and NP's in areas like Pediatric nephrology or pulmonology.

I wouldn't be too sure about that, it's an individual thing I propose. I have a friend who is a NP for the university Neurosurgery group here who functions clinically as good as most chief residents. She's an exceptionally bright young lady who can manage just about any neurosurgical realted issue off the top of her head (and do it very well) from closed head injury/ICP managment, post-op ICU care, EVD drain placement,...you name it. She even takes first call one night a week now (part of the concessions to the work hour rule for the residents to get <80 hrs). Now she doesn't have the surgical training to do many of their procedures alone, but I've watched her do trauma craniotomies with the NES chief and she does not embares herself

 

[eddieberetta]

So why do we even have medical school? Why don't we just train all the medical specialists directly out of high school (i.e. PA model) and pay them less?

 

[ItsGavinC]

Don't forget Oral Surgeons!

That is one surgical specialty that MD/DO's don't have reign over.

 

[TexPre-Med]

However M.D./D.O.'s can be oral surgeons. Two that I know of are graduating from UT Houston this year.

 

[DD214_DOC]

Originally posted by eddieberetta
So why do we even have medical school? Why don't we just train all the medical specialists directly out of high school (i.e. PA model) and pay them less?

Don't know, why don't we? You basically learn the majority of what you do during clinicals, right? The first two years is just fluff to earn you that doctorate. How much of this information do you actually use on a daily basis? Probably not a lot.

 

[Mirror Form]

Originally posted by eddieberetta
So why do we even have medical school? Why don't we just train all the medical specialists directly out of high school (i.e. PA model) and pay them less?

I admit that I'm only an MSIII, so I don't know as much about this issue as most people. But from what I've experienced, most of the NP's and PA's who do similar things as surgeons aren't competent to do this stuff when they're licensed. It's usually after having worked with a surgeon for several years that they gain that kind of knowledge and are allowed that type of responsibility. However, doctors are competent and licensed to do it as soon as they finish residency. So, you'd need to develop a whole new licensing and training program for NP's and PA's to have them actually replace surgeons and other doctors. And even then, they'd still probably have higher insurance.

 

[Gator05]

....So what do patients think about all this? I don't mind seeing a PA or an NP for routine office visits. I'll even see them for more important and complicated issues as well.

But what about in the OR? If I've agreed to let Dr. X operate on my body, shouldn't it be Dr. X doing the operating? If not, shouldn't I have explicitly agreed to let his assistants perform portions of the surgery independently?

There's also the issue of medical errors; cost cutting eventually starts causing medical errors, which serves to inflate total healthcare cost. And medical errors is a hot-button topic right now. Politicians everywhere would love to show his or her constituents that they're "saving American lives by reducing medical errors, while at the same time reducing healthcare costs by the billions". Lowering training and supervision requirements sure would be a funny way to demonstrate their committments to this issue.

 

[ItsGavinC]

Originally posted by TexPre-Med
However M.D./D.O.'s can be oral surgeons. Two that I know of are graduating from UT Houston this year.

Sure, but they've got to be dentists first. OS is a dental specialty -- and a very cool one at that!

 

[entpa]

Hi guys...stumbled across your discussion and agree with a lot of what you say. I am a PA and have been since 93'. Did a 1 yr ENT program at a AF Med Ctr and now am considered an ENT PA. As a PA I can only do what my supervising doc says I can do. Sledge is right...we gain a lot of our skills thru experience- hopefully by working with a knowledgeable surgeon/physician. I really don't know many PA's that are screaming for autonomy. Our creed if you will is to try to make our doc's life easier. Many PA's have been put in the position of having to do more by the 80 hr rule, continuity of care, etc. A good PA will know when they are pushing the envelope and defer to his/her doc. I do know some PA's that feel they are the "cats meow" and personally they scare the hell out of me! In many rural areas, PA's are the sole provider due to lack of physicians willing to work in a non-lucrative situation.
Since we don't have residents here (except FPs) I do 1st assist on thyroids/parotids/neck dissections and enjoy it but would never presume to be competent to do them solo.
If you guys are looking for a great specialty---ENT!!!!
thanks