When is surgery's turn coming?

[M.Furfur]

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Nurses already started Dermatology, Emergency, IM, Cardiology.... residencies.
http://health.usf.edu/nocms/nursing/AdmissionsPrograms/dnp_concentrations.html
Nothing can stop them from starting a surgery residency and then keep adding hours on it so they can do many procedures.

 

[Bond8204]

Specialization like that is laughable. I kind of get nurses and PA's trying to cover the primary care gap, but at some point, if you want to practice medicine, why not just start programs... in medicine?

 

[skiz knot]

500 clinical hours / 80 hour resident work week = 6.25 weeks. What surgical intern gets to function independently after 6.25 weeks?

 

[45408]

500 clinical hours / 80 hour resident work week = 6.25 weeks. What surgical intern gets to function independently after 6.25 weeks?

Exactly. Surgeons have between 18-30,000 hours of training. I can't imagine we'll ever see an NP doing a Whipple, and even if they went for something easier, I'm pretty sure they would still want a surgeon as their back-up. I also think it might be hard to find a surgeon willing to do that...

 

[Herman Bloom]

You guys are taking a huge leap here assuming that NPs are pursuing true "residencies" in the same sense that we do them. Come on: do you really think that nurses who have completed cardiology "residencies" actually practice cardiology? You know they don't.

Most NPs and PAa are happy with the scope of their practice and are willing to forgo the higher salaries enjoyed by physicians in exchange for less responsibility, better hours, and diminished liability. Don't make something out of this concept that really isn't there.

 

[M.Furfur]

You guys are taking a huge leap here assuming that NPs are pursuing true "residencies" in the same sense that we do them. Come on: do you really think that nurses who have completed cardiology "residencies" actually practice cardiology? You know they don't.

Most NPs and PAa are happy with the scope of their practice and are willing to forgo the higher salaries enjoyed by physicians in exchange for less responsibility, better hours, and diminished liability. Don't make something out of this concept that really isn't there.

That's what they are asking for. If they were happy with their scope they wouldn't be pushing for legslation to expand their scope in 28 states.

You can chose to bury your head in ths sand. But mark my words, it is only a question of time before they start claiming surgical procedures under their scope...

 

[bronx43]

The bigger threat for surgical fields comes from surgical PAs.

 

[Winged Scapula]

You guys are taking a huge leap here assuming that NPs are pursuing true "residencies" in the same sense that we do them. Come on: do you really think that nurses who have completed cardiology "residencies" actually practice cardiology? You know they don't.

Most NPs and PAa are happy with the scope of their practice and are willing to forgo the higher salaries enjoyed by physicians in exchange for less responsibility, better hours, and diminished liability. Don't make something out of this concept that really isn't there.

Nurses are already doing scopes in some areas and as noted above, they are expanding their scope of practice in many arenas.

No one here thinks their residencies are anywhere close to what we do. The problem is:

1) DNPs think they are
2) the public will think they are once the DNP start referring to themselves as Board Certified Doctors who have finished a residency in specialty X

They want to practice medicine without doing the work. I strongly feel this will take a legal challenge to the Board of Nursing in those states to prevent them from practicing medicine. The day those 28 states gave them independent practice rights and prescribing rights was the day we started digging our own graves.

I used to think that PAs were different; now with the knowledge that many are supporting a title change to Physician Associate, I find it not too ridiculous before they start trying to usurp other rights.

 

[filter07]

http://www.generalsurgerynews.com/index.asp?section_id=77&show=dept&article_id=14767

It’s clear that Congress needs to be repopulated with a totally different species, and as a modest proposal, may I suggest replacing the lawyers in Congress with doctors. I can assure you, it isn’t partisanship that renders Congress dysfunctional. Our current crop hides behind ideologic commitment only to disguise their lack of fluency with issues, particularly health care. Good people with conflicting ideologies can always find common ground to solve common problems.

Doctors. I know you. I know you well and I think you’d do a better job than those “fighting for me” right now in Washington. Granted, most of you don’t have the money, time, inclination, or hair or tan for that matter, to get there, but things could change. They must change or we will continue to suffer from a stalemate in Congress over important issues like health care.

 

[JelloBrain]

Nurses are already doing scopes in some areas and as noted above, they are expanding their scope of practice in many arenas.

No one here thinks their residencies are anywhere close to what we do. The problem is:

1) DNPs think they are
2) the public will think they are once the DNP start referring to themselves as Board Certified Doctors who have finished a residency in specialty X

They want to practice medicine without doing the work. I strongly feel this will take a legal challenge to the Board of Nursing in those states to prevent them from practicing medicine. The day those 28 states gave them independent practice rights and prescribing rights was the day we started digging our own graves.

I used to think that PAs were different; now with the knowledge that many are supporting a title change to Physician Associate, I find it not too ridiculous before they start trying to usurp other rights.

Please don't flame me for saying what I am about to say. These are just my opinions based on being part of the healthcare (surgical) system in India, UK and USA (fringes currently). I feel all this started from when the western world decided to do away with the hierarchy of healthcare. The hierarchy exist(ed) for a reason-the best and the brightest go on to become doctors (usually). Go to any school-No school topper would say "I'll be a nurse or a PA when I grow up". So this day was about to come from the time we as doctors agreed to regard nurses as parallel healthcare providers. Inch by inch they have started encroaching on our turf! Now when we are on the verge of being smothered, we are starting to panic!

Doctors started selling out when they would rather have a PA/Surgical assistant help them in surgery for a quicker turn-over (dictated by OR nurses again!) rather than take the time to go over a case slowly with a junior doctor (resident). Seriously! The assistant's job should be to assist/fill gaps when no doctor is around to do mundane things like paperwork, not do the best jobs out there in lieu of a trainee surgeon.

I had heard of 2 nurse practitioners in UK, one with his own carpel tunnel clinic and OR, and one who exclusively did knee arthroscopies (neither where I trained). I had argued many times with my trainers/mentors about how could they justify this when even the juniormost resident can do the same, yet s/he has no such freedom-The response would always be: "That is the only thing this person would do for the rest of his/her life, whereas you are getting trained for bigger/better things!"

That may well be true for most of us, but there are some doctors out there who might start out wanting to be surgeons then realize they are not that committed/capable/whatever. Wouldn't it be a better option to track them in this manner-do one procedure only for your entire life, rather than giving such chances to nurses?

Alternately, one of the main negatives against IMGs is their poor communication skills, but majority of the previously trained surgeons have excellent surgical skills. Wouldn't tracking them in the above manner be a better option-they do some training equivalent (in hours) to a nurse practitioner's to get them used to USA's system, and get a limited license to practice one procedure-thus keeping surgical practice in the surgeon's world, providing much-needed service to patients while also addressing AMG/IMG residency issues. Meanwhile they can have a NP/PA who can handle paperwork and communication to satisfy patients' comforts as well. I have a feeling a lot of IMGs would be more than happy with this arrangement. At least they have done the work of becoming doctors, rather than nurses who would never become one (majority) even if they tried!

Instead of doctors in each specialty trying to live in their own bubble world of "this wouldn't happen to us", wouldn't it be better if we all came together as doctors (regardless of where internationally we trained from) to stop the force of nursing power sweeping through our ranks and decimating us?

Hoist someone on your shoulder for a little support, and it is not long before they start to pee in your ear! Now that nurses have peed in our right ear and PAs close to peeing in our left ear, we are wondering where to go and what to do with wet ears!

 

[Winged Scapula]

Doctors started selling out when they would rather have a PA/Surgical assistant help them in surgery for a quicker turn-over (dictated by OR nurses again!) rather than take the time to go over a case slowly with a junior doctor (resident). Seriously! The assistant's job should be to assist/fill gaps when no doctor is around to do mundane things like paperwork, not do the best jobs out there in lieu of a trainee surgeon.

That may work in academics but what are those of us in private practice supposed to do? I don't have residents unless there is someone rotating with me as an elective. So I am forced to hire a surgical assist.

However, in academic medical centers I TOTALLY agree. If you are using a PA/RNFA in the OR, then residents should not be rotating on your service. This was a major problem we had with CT during residency - eventually they pulled us off the service because the CT surgeons refused to give up their PAs and NPs.

I agree that surgeons need not be so complacent. We were complacent when:

- work hour reform was talked about; it was forced on us because we refused to participate
- 90 day global period; it was forced on us because we refused in force to discuss the issues surrounding this
- encroachment of midlevels; it will be forced on us and you will see nurses doing surgical "residencies" because we refused to think it could happen to us or were greedy and failed to support our brothers in other fields. As you know, if you refuse to help me, when it comes your turn, you may not expect any help. We should be supporting our FM colleagues, our anesthesia brothers, etc. because who will help us when we need it?

 

[JelloBrain]

Oops! I forgot about private practice scenarios. But again what I propose about using IMGs as surgical assistants should be a better choice than NPs or PAs. At least foreign doctors have done the hard work and gained the right to be called doctors, and passed the USMLE as well.

This would be a great choice for a lot of IMGs/FMGs who are unable to get into a residency cycle after cycle and/or those who have already trained in their native country and don't want to be a resident again. If as some say the NP/PA pay is 180k, it's still great compared to the uncertainty facing IMGs and way better than resident/postdoc salaries.

It is high time us doctors come together, forgetting differences of specialty, state of practice, country of training, etc. to fight this encroachment before it's too late. United we stand, divided (or indifferent) we fall! Never under-estimate the opposition and get complacent. Once we start letting the mid-levels secede from under our wings, the invasion is going to continue till we become extinct.

 

[MossPoh]

So how many deaths or complications would it take over a set period of time for them to realize how idiotic this is? I've never had a problem with NPs or PAs, but seriously, if you aren't happy with what you are doing then go to medical school. It is pretty damn selfish and ignorant of you to think you can master (or become proficient in) something in a fraction of the time as someone else. I find it amazing that they'd so willingly risk someone's health and life because they have an inferiority complex with what they are doing. I wonder if the politicans so happily going along with this would send their loved (or go themself) to one of these people.

 

[notinkansas]

When I was in my surgical residency, there were a couple of problems. The NPs on one service tended to wind up scrubbing in the OR for add on cases from the ED, instead of the intern. Intern was on the floor doing floor work. R2 carried the consult pager and saw the pts in the ED, then communicated with chief and attending. NP trots around all day following attending. So NP knows when case goes and scrubs. Intern doesn't know when case goes, unless R2 or chief lets them know.

Second issue was on cardiac surgery. RNFA did all the saphenous vein harvests. I decided to try to be humble and ask if she would teach me how to do it. Response: "No, you won't be on the rotation long enough to learn how"

I believe it is just a matter of time before the midlevels try to get credentialed to do "simple" cases. They will probably cite "success" in these other "residencies" as reason to move forward. They already run a lot of ICUs with minimal supervision, place lines and chest tubes. And in non teaching institutions they are often active assistants in cases. And, sadly there will probably be surgeons willing to teach them.

 

[Encephalectomy]

Do you guys think that the medico-legal circus we have here in the US might protect surgeons and other high-risk specialties from midlevel encroachment? Obviously I'm not a fan of the malpractice/lawsuit situation, but it seems like it might work towards surgeons' benefits here.

One of the surgeons at my school loves the expression 'the only way to have 0 complications is to have 0 operations'. If the NPs and PAs are operating, they are going to have complications and I have to imagine that a complication at the hands of an undertrained person is easy pickings for the lawyers. Also given the malpractice climate it seems like it would be suicidal for a hospital to grant privileges to an NP/PA to do any sort of operation. Maybe this is just wishful thinking on my part?

 

[Hyperlite2011]

I used to think that PAs were different; now with the knowledge that many are supporting a title change to Physician Associate, I find it not too ridiculous before they start trying to usurp other rights.

I agree that if a PA wants to take on the role of a physician, he/she should quit and go to med school. However, most PAs I know are very happy with their scope of practice. These same PAs support changing their title from Physician Assistant to Physician Associate, not because they are trying to usurp other rights, but because the title Physician Assistant is pretty inaccurate.

Yes, if they are in the OR they will be assisting, but PAs see their own patients in clinic and sometimes are hired independently by hospitals. They are just required by law to have a physician available to call if they run into a problem. On a side note, I would wager that at graduation there are a lot of PAs that have the same working knowledge as many medical students - the real difference is in the post-graduate training.

Now, going back to the name change... imagine that you have graduated from PA school and maybe have a few years of job experience under your belt. You go into the exam room and a misinformed patient sees "Physician Assistant" and reads "Medical Assistant". The patient then demands to be seen by a doctor because, well, who wants treated by the assistant whose job description consists of taking blood pressure and chief complaints?

This is why I agree with the name change. I don't think there is anyone out there who thinks a PA is the equivalent of an MD, and if a PA is trying to take on the role of a physician then that's an issue between that PA and his/her employer.

 

[Encephalectomy]

The patient then demands to be seen by a doctor

This is not a problem. The reason they sought medical care was most likely to see a doctor and get their opinion on and/or treatment for a problem they are having. So being offended that they demand to see a doctor once they realize that a PA is not a doctor doesn't seem to make a lot of sense.

 

[Hyperlite2011]

This is not a problem. The reason they sought medical care was most likely to see a doctor and get their opinion on and/or treatment for a problem they are having. So being offended that they demand to see a doctor once they realize that a PA is not a doctor doesn't seem to make a lot of sense.

The point I was making was that many people confuse "Physician Assistant" with "Medical Assistant" when there is a very big difference in their respective roles. Also, I agree it shouldn't be an issue if a patient wants to be seen by a physician. However, in many cases a physician may not be in the clinic with the PA - they just have an understanding that if the PA needs the physician's help, he/she will be available. This could simply mean that the physician will need to answer a phone call.

 

[core0]

snip
I used to think that PAs were different; now with the knowledge that many are supporting a title change to Physician Associate, I find it not too ridiculous before they start trying to usurp other rights.

I'll point out a couple of things. The initial name for the profession was physician associate. The name was changed in many programs at the insistence of the AMA in the 1970s. However there are a few programs where the degree has been physician associate all along. The problem is that the term is too generic. While most physicians understand the difference between a MA and PA many other organizations don't. The US department of labor under reported PA salaries for years because they could not differentiate between MAs and PAs in their salary surveys for years. This had a real effect on PA salaries. It also makes it easier for hospitals to lump us into non licensed practitioners and restrict our practice contrary to what our supervising physicians would want.

Furthermore this is not a new issue. I've been a PA for nine years and this will be the third time that this has been brought before our house of delegates. If you study PA history there were similar resolutions dating back to 1987 and reference to the name in the 1970's. There are two reasons that you are aware of it now. One is the internet. The second is a number of senior PAs have decided this is the proper time to press the issue. The reasons are somewhat complex, but relate to the fact that health care in undergoing profound change. Other groups are using this change not only to advance their causes but also using the PA name to limit the role of PAs in health care. This is no different than the discussion of the use of "Doctor". As PAs have become more successful other groups are using our success to advance their causes (RPAs and OPAs) by usurping the title. On the other hand groups are deliberately using the name to limit the PA profession by confusing the title with medical assistant.

PAs deliver around 10% of the health care in the US. They are trained in a medical model and only work with the supervision of a physician. The term assistant was perhaps more appropriate in the 1960's when PAs worked under delegated practice acts under direct supervision of a physician. In the current model where physicians carry their own medical license and frequently operate under the general supervision of a physician, associate is a more appropriate term. The origin of the word speaks to the unique partnership that PAs form with physician. Any change in title does not change the unique dependent nature that PAs have with their supervising physicians.

Personally, I was neutral on this subject, but after credentialing with a hospital and having to fill out the Medical Assistant test for privileges I have come to believe that changing the name will help us make changes in regulation that prevent our supervising physicians from utilizing us to our full potential.

David Carpenter, PA-C

 

[Winged Scapula]

Oops! I forgot about private practice scenarios. But again what I propose about using IMGs as surgical assistants should be a better choice than NPs or PAs. At least foreign doctors have done the hard work and gained the right to be called doctors, and passed the USMLE as well.

This would be a great choice for a lot of IMGs/FMGs who are unable to get into a residency cycle after cycle and/or those who have already trained in their native country and don't want to be a resident again. If as some say the NP/PA pay is 180k, it's still great compared to the uncertainty facing IMGs and way better than resident/postdoc salaries.

I agree that its a reasonable solution but you perhaps don't understand how surgical assists are hired. A surgical assist has to have operating privileges. You can be employed by a surgical assist company, a physician (ie, one's own PA/RN) or have independent surgical assist privileges. I use the former mostly which consists of RNFA, CSA and MDs of various skill levels.

In addition, I have a friend who left her surgical practice and now does surgical assisting. I would love to use her more often - but here is the problem and why its relevant to the use of IMGs/FMGs. She cannot assist me at some local hospitals because she is no longer board eligible. The standards for physicians who have completed training is stricter than for others. If you have not completed a residency elsewhere (ie, outside the US), you might still be eligible but frankly an IMG/FMG who has never done a residency and hasn't been in the OR is probably more of a hindrance than a help. The surgical assist companies do have some requirements for number of hours in the OR that just graduated medical students might not possess. I would be willing to train someone and agree that it is a possible solutions for IMGs/FMGs that can't get a residency, but surgical assisting is pretty popular and I'm not sure they would be able to compete or get privileges.

CoreO/Dave - thank you for your input. Can you specify how the changes will allow supervising physicians to use PAs to their full potential?

I admit that when I wrote the above I was angry - over the DNP thing and with our *own* PA who is getting on my last nerve.

 

[core0]

I agree that its a reasonable solution but you perhaps don't understand how surgical assists are hired. A surgical assist has to have operating privileges. You can be employed by a surgical assist company, a physician (ie, one's own PA/RN) or have independent surgical assist privileges. I use the former mostly which consists of RNFA, CSA and MDs of various skill levels.

Actually if you look at the first and last groups they are probably credentialed the same. To have any privileges to assist you have to a sponsoring physician at the hospital with operative privileges who is ultimately responsible for the first assist. Usually the companies pay a retainer to the physician or they have a relationship with the surgeon who brought them in because they needed an assist. This is also why JC hate the concept. JC hates it because there have been numerous issues where when there were problems with conduct the physician of record would claim that they were not there and the physician who was doing the surgery would claim they were not responsible. Basically there is no real accountability (although the liability goes to the surgeon using them). CMS has chosen to deal with the issue by not reimbursing non-NPP/Physicians. Their view is that they are paying the assist fee to provide for the surgery and aftercare. Therefore they are not interested in paying providers that cannot provide aftercare (they ignore NPPs and physicians that are only assisting).

In addition, I have a friend who left her surgical practice and now does surgical assisting. I would love to use her more often - but here is the problem and why its relevant to the use of IMGs/FMGs. She cannot assist me at some local hospitals because she is no longer board eligible. The standards for physicians who have completed training is stricter than for others. If you have not completed a residency elsewhere (ie, outside the US), you might still be eligible but frankly an IMG/FMG who has never done a residency and hasn't been in the OR is probably more of a hindrance than a help. The surgical assist companies do have some requirements for number of hours in the OR that just graduated medical students might not possess. I would be willing to train someone and agree that it is a possible solutions for IMGs/FMGs that can't get a residency, but surgical assisting is pretty popular and I'm not sure they would be able to compete or get privileges.

I'm not sure how the staff bylaws work where you are but most places I have worked at the BC clause only applies to surgeons with full operative privileges. There is usually a way to apply for assist only privileges (ie not privileged for the actual surgeries just the assist). In Denver the malpractice carrier would allow surgeons to assist at very favorable rates after they retired. There were several surgeons who continued to assist for a few years after "retirement". If the bylaws don't allow this you could talk to the medical president about changing the bylaws for this exception. The argument would be this allows you to choose the most qualified assistant.

CoreO/Dave - thank you for your input. Can you specify how the changes will allow supervising physicians to use PAs to their full potential?

I admit that when I wrote the above I was angry - over the DNP thing and with our *own* PA who is getting on my last nerve.

For example I work in surgery and in the inpatient setting I can write for schedule II's. However, when I discharge a patient since I work in a state where I cannot write schedule II's I either have to find a resident who does not know the patient to write it or track down an attending to sign the scrip. If everyone is in the OR then the patient sits until they get out. My job is to discharge the patient when appropriate but I don't have all the tools to do it.

You can find tons of examples that are the result of archaic rules. For example there is a federal rule written in the 1980's that only a physicians can order respiratory therapy services. In most cases this language was updated but somehow this was missed. This led to JC ruling that the services could not be provided without a co-signature. In some hospitals the co-signature can be applied later. In others the order will not process without the co-signature. So in the small ER I moonlight I can go to the PIXIS and get the albuterol and do the neb myself or write an order for the RN to do the neb. What I cannot do is write a respiratory therapy order for a neb. Fortunately this is being change but its just an example of what we have to navigate that generally does not effect physicians.

David Carpenter, PA-C

 

[basupran]

On a side note, I would wager that at graduation there are a lot of PAs that have the same working knowledge as many medical students - the real difference is in the post-graduate training.

PA schools-2 years
Medical School-4 years.

Some of the clinical knowledge is close (ie first line tx for HTN)- but med students typically spend more time on the underlying causes. I wouldn't say that they have the same working knowledge. Recent med grads are better at some things while recent PA grads are better at other things.

 

[Winged Scapula]

Actually if you look at the first and last groups they are probably credentialed the same. To have any privileges to assist you have to a sponsoring physician at the hospital with operative privileges who is ultimately responsible for the first assist. Usually the companies pay a retainer to the physician or they have a relationship with the surgeon who brought them in because they needed an assist.

I will defer to you on whether this is true or not, but I would have no idea who the "supervising physician" is, as when using an employee of the surgical assist group, I have never been asked to sign any paperwork accepting sponsorship. OTOH, I have done so for a PA who wanted to work as a surgical assist and agreed to sponsor him.

This is also why JC hate the concept. JC hates it because there have been numerous issues where when there were problems with conduct the physician of record would claim that they were not there and the physician who was doing the surgery would claim they were not responsible. Basically there is no real accountability (although the liability goes to the surgeon using them). CMS has chosen to deal with the issue by not reimbursing non-NPP/Physicians. Their view is that they are paying the assist fee to provide for the surgery and aftercare. Therefore they are not interested in paying providers that cannot provide aftercare (they ignore NPPs and physicians that are only assisting).

Yep - fortunately, I have a very small Medicare population. However, when the group does send a non-NPP/MD/DO to assist on this cases, they just "eat" the charges for goodwill on getting more of my cases.

I'm not sure how the staff bylaws work where you are but most places I have worked at the BC clause only applies to surgeons with full operative privileges. There is usually a way to apply for assist only privileges (ie not privileged for the actual surgeries just the assist).

Nope - here, even for surgical assist only privileges, at some hospitals you are required to be Board Eligible. When my friend told me this, I didn't believe it (it took her awhile to tell me, as I didn't know she wasn't BC, let alone BE anymore, so she was embarassed until I guess I hounded her so much she finally broke down and told me). I verified this with the credentialing office that a physician applying for surgical assist privileges who has *completed a residency* is required to be Board Eligible for those privileges *at those facilities*. Full surgical privileges requires Board Certification. The reason I brought it up was because I recognized that it was probably unusual but its out there and people need to know about it.

 

[Llenroc]

I blame the Germans.

 

[core0]

I will defer to you on whether this is true or not, but I would have no idea who the "supervising physician" is, as when using an employee of the surgical assist group, I have never been asked to sign any paperwork accepting sponsorship. OTOH, I have done so for a PA who wanted to work as a surgical assist and agreed to sponsor him.

It all depends on the state and hospital credentialing. Here for example to assist I would need to have the physician on my license as an alternate supervising physician and be credentialed under that physician in the hospital system. Other hospitals you just have to have a license (or not for UAP) and be credentialed under a physician. I would guess that if you have a system you can look up credentialing information you could find it out. But as you pointed out its mostly academic.

Yep - fortunately, I have a very small Medicare population. However, when the group does send a non-NPP/MD/DO to assist on this cases, they just "eat" the charges for goodwill on getting more of my cases.

Thats the case most places. I was a tech at a trauma center where the assist companies told the hospital they wouldn't cover medicare/caid cases without a supplement. The hospital paid them $10/hr skin to skin for the cases.

Nope - here, even for surgical assist only privileges, at some hospitals you are required to be Board Eligible. When my friend told me this, I didn't believe it (it took her awhile to tell me, as I didn't know she wasn't BC, let alone BE anymore, so she was embarassed until I guess I hounded her so much she finally broke down and told me). I verified this with the credentialing office that a physician applying for surgical assist privileges who has *completed a residency* is required to be Board Eligible for those privileges *at those facilities*. Full surgical privileges requires Board Certification. The reason I brought it up was because I recognized that it was probably unusual but its out there and people need to know about it.

That's interesting. I know that hospitals have really been hammering the BC/BE rules recently but that sounds a little extreme. It may be that they are worried about letting a non BE physician operate at all. In theory they could claim after say five years of assisting that they have sufficient training to get full privileges since they are licensed. Kind of a slippery slope type of theory. As I alluded to before in theory any part of the bylaws is changeable but it depends on the political system in place. I'm not completely up on BE rules for surgery. How could you complete a residency but not be board eligible (unless it was time limited)?

David Carpenter, PA-C

 

[Winged Scapula]

I'm not completely up on BE rules for surgery. How could you complete a residency but not be board eligible (unless it was time limited)?

David Carpenter, PA-C

It IS time limited.

I believe you have 5 chances in 5 years after graduation from residency to get the ABS certification. If you fail to become BC in that period of time there is a process for becoming BE again - used to have to do a "super Chief" remediation year, but now I think you can do some coursework, readings etc. (because who the heck would leave practice and face the embarassment of doing a remedial year?).

So my friend either never took the exams or failed to pass - not sure which (and don't want to embarass her by asking) and has been out of training for at least 7 years, so is no longer BE.

There are several local hospitals which require BC within a certain timeframe from original granting of privileges if not at time of application (for those who are more than a few years out from training). It is pretty strict here, it seems.

I actually learned something new today as well - I was printing my certificate off the ABS website (I'm applying for privs at a new hospital) and it says in the text that the ABS does not recognize the term BE. Not sure if that's new or we've always just been using it incorrectly.

 

[JelloBrain]

Wow! What an interesting catch-22 situation. If someone has already completed a residency they will be competent in the OR, but held to higher standards, hence they cannot be surgical assistants (SA), even if they are willing to accept the 2nd tier (compared to a surgeon) life of SA. On the other hand, a newly minted doctor-AMG/IMG/FMG, whatever, will be green in the OR, so no one wants to take the time to train him/her.

I understand time is money, but seriously, this is no reason to bail out on our brethren and let allied health staff take over. Any person who has finished medical school and internship would be a better assistant than any one who has gone to NP/PA/RNFA/whatever school! Surely the credentialling companies and hospitals know this? If not, doctors need to emphasize this and lobby for protection of our turf. Otherwise the day is not far away when every Tom/Dick/Harry would call themselves doctors after a few hours of online training!

 

[Winged Scapula]

Wow! What an interesting catch-22 situation. If someone has already completed a residency they will be competent in the OR, but held to higher standards, hence they cannot be surgical assistants (SA), even if they are willing to accept the 2nd tier (compared to a surgeon) life of SA. On the other hand, a newly minted doctor-AMG/IMG/FMG, whatever, will be green in the OR, so no one wants to take the time to train him/her.

I understand time is money, but seriously, this is no reason to bail out on our brethren and let allied health staff take over. Any person who has finished medical school and internship would be a better assistant than any one who has gone to NP/PA/RNFA/whatever school! Surely the credentialling companies and hospitals know this? If not, doctors need to emphasize this and lobby for protection of our turf. Otherwise the day is not far away when every Tom/Dick/Harry would call themselves doctors after a few hours of online training!

That is HIGHLY debatable.

One of the assists with this group I used completed THREE years of a surgical residency. Nice guy but his skills suck. He's worse than the Family Medicine physician, any of the CSAs or RNFA. Many surgical programs do not get their interns in the OR to do much more than retract. As much as I want to support our fellow physicians, I will not do it because they are inherently better assistants after medical school (+/- internship) than someone who has completed a surgical assisting course. There's just no comparison in the majority of cases. Perhaps your misinterpretation comes in the assumption that these surgical assists have no extra training? All of the RNs and CSAs have completed training in surgical assisting - the MDs have not (which is why the FM is not very good, the retired OB has good thought processes and attention to detail but his suturing is not what I would expect, and the former surgical resident is just not very good at all-but spends his time telling me how great I am so is fun to have around ; ) ).

 

[JackADeli]

...Any person who has finished medical school and internship would be a better assistant than any one who has gone to NP/PA/RNFA/whatever school! Surely the credentialling companies and hospitals know this? ...

Absolutely WRONG statement and/or generalization. Such a statement demonstrates a real lack of understanding and/or experience.

There are numerous academic attendings, board certified, etc.... I wouldn't want to operate on Sadam Hussein! There are numerous medical students that work/assist better in the OR then senior surgical residents. Not all individuals are equal just because of length of training. Being a good assistant is different then being the primary operator. It is often the case that residents are NOT trained to be good assistants. You can see this with numerous attendings. They go to the otherside to "assist" while you are trying to do a lap-chole.... and it's torture. You wish the attending would scrub out and allow the trained assistant to take over and actually "help a surgeon".

With increasing work hour regs/etc... programs can not spend residents time with them serving as assistant for long periods/large numbers of cases.

...RNs and CSAs have completed training in surgical assisting - the MDs have not...

Correct.

 

[core0]

It IS time limited.

I believe you have 5 chances in 5 years after graduation from residency to get the ABS certification. If you fail to become BC in that period of time there is a process for becoming BE again - used to have to do a "super Chief" remediation year, but now I think you can do some coursework, readings etc. (because who the heck would leave practice and face the embarassment of doing a remedial year?).

So my friend either never took the exams or failed to pass - not sure which (and don't want to embarass her by asking) and has been out of training for at least 7 years, so is no longer BE.

There are several local hospitals which require BC within a certain timeframe from original granting of privileges if not at time of application (for those who are more than a few years out from training). It is pretty strict here, it seems.

I actually learned something new today as well - I was printing my certificate off the ABS website (I'm applying for privs at a new hospital) and it says in the text that the ABS does not recognize the term BE. Not sure if that's new or we've always just been using it incorrectly.

The whole BE thing came out from ABMS several years ago. I think it was related to the maintenance of certification when they started to require re certification. I've seen physicians use board qualified instead of BE recently but that opens a different can of worms.

David Carpenter, PA-C

 

[JackADeli]

It IS time limited.

...If you fail to become BC in that period of time there is a process for becoming BE again - used to have to do a "super Chief" remediation year, but now I think you can do some coursework, readings etc...

I don't know if there is a "non-clinical" remediation policy/protocol. I vaguely remember reading the pamplet for the examination process and eligibility criteria. It mentioned something to the effect of not recognizing a straight additional clinical year.... and did mention something that you would have to contact the ABS for "remediation" and/or meeting their guidelines for additional training and testing. I got the impression they were being more strict on allowing additional testing opportunities.

...There are several local hospitals which require BC within a certain timeframe from original granting of privileges if not at time of application (for those who are more than a few years out from training). It is pretty strict here, it seems...

Yep, this is more and more common practice. Hospitals are requiring this. A good portion of this is do to liability and/or malpractice coverage. It is very common to say no to folks that can't get boarded or fail to get boarded. Some hospitals may allow you to continue if you fail to meet their deadline... but that keeps you/physician under their yoke and/or almsot continuous probation. Another reason for this requirement is business/marketing. Look up almost any hospital and they brag about "all" their physicians are board certified. This is especially true in more high profile specialties at a "medical center"

...I actually learned something new today as well - ...the ABS ...says in the text that the ABS does not recognize the term BE. Not sure if that's new or we've always just been using it incorrectly.

That is interesting as most of the surgery jobs posted in the journals will say as requirement "BE/BC". Granted, the written exam is technically called "qualifying" and the oral exam is the "certifying" examination..... I am not sure all the semantics around ABS statement in these regards.

 

[JelloBrain]

Quote: Originally Posted by JelloBrain
...Any person who has finished medical school and internship would be a better assistant than any one who has gone to NP/PA/RNFA/whatever school! Surely the credentialling companies and hospitals know this? ...

Absolutely WRONG statement and/or generalization. Such a statement demonstrates a real lack of understanding and/or experience.

There are numerous academic attendings, board certified, etc.... I wouldn't want to operate on Sadam Hussein! There are numerous medical students that work/assist better in the OR then senior surgical residents. Not all individuals are equal just because of length of training. Being a good assistant is different then being the primary operator. It is often the case that residents are NOT trained to be good assistants. You can see this with numerous attendings. They go to the otherside to "assist" while you are trying to do a lap-chole.... and it's torture. You wish the attending would scrub out and allow the trained assistant to take over and actually "help a surgeon".

With increasing work hour regs/etc... programs can not spend residents time with them serving as assistant for long periods/large numbers of cases.

Quote:Originally Posted by Winged Scapula
...RNs and CSAs have completed training in surgical assisting - the MDs have not...

Correct.

I am sorry that I did not have a bigger grasp on the training of surgical assistants (SA). I thought SAs learnt on the job too for the most part. I also compare things to my own training and limited experience. I had 3 SAs in our cardiothoracic department in UK who were considered quite good. But in less than 6 weeks after my joining the dept. as a junior resident, I was teaching them better surgical techniques and training them how to train my other colleagues better. Soon I was in-charge of OR/ICU/Clinic/Ward schedule for 6 residents and the 3 SAs. I guess I just assumed doctors take over as they are better. 😳

Another experience of mine was during my previous neurotrauma postdoc in USA where I worked on a large animal model. My tech, who has more surgical experience than my age, used to do a cut-down for arterial line placement in the groin while I did the neurosurgical part. I didn't think much of it till we started survival sesisons-the animals started getting massive groin seromas. She was not closing all the spaces layer by layer-I showed her how to on a couple-they were perfect. Anyways I scrapped that and started doing percutaneous line placements. My point is a monkey can do a procedure, but you have to be a doctor to recognize problems and figure out what went wrong and how to rectify it. So wouldn't you rather have another doctor as your assistant (if available) for an extra pair of eyes rather than someone who has been robotically trained to assist only?

I know surgeons come in all calibers. I was under the impression that those who were not good enough to be primary/independent surgeons could fulfil their passion by at least becoming surgical assistants. I was always told only a good assistant goes on to become a better surgeon as they anticipate and prepare for the surgeon's every move, thus thinking through the entire process for which you have to have full knowledge of the procedure step-by-step. I am surprised to learn that SAs have that kind of knowledge.

Oh well! I cannot win the argument of how use of allied healthcare staff is affecting the training of future doctors. My suggestions were just to help protect our entire profession from invasion. All I can do is continue with my commitment to training and education of future generation of surgeons. 🙂

 

[Hyperlite2011]

PA schools-2 years
Medical School-4 years.

Some of the clinical knowledge is close (ie first line tx for HTN)- but med students typically spend more time on the underlying causes. I wouldn't say that they have the same working knowledge. Recent med grads are better at some things while recent PA grads are better at other things.

True. But first off, PA school is typically 2.5-3 years depending on the program. And some of our first year courses (like microbiology) are prerequisites for PA school.

All I'm saying is that just about all of my medical knowledge right now is from my clerkships (and maybe a few trivia facts from step I). PA students generally experience a similar clinical year setup and use the same textbooks. My experience so far has been that PA students and med students are on a similar playing field at this stage in their careers. If med students do have an advantage, I think its mostly due to our having just studied a massive amount of preclinical information for the boards.

Since every med/PA school is different, it is hard to make a blanket statement... however, I would still bet money on med students and PA students having a very similar working knowledge at graduation. I still stand by my statement that the big difference between doctors and PAs is residency.

 

[Chemdocx]

This topic gives me heartburn. I didn't say anything but was a little ruffled when I was on a service for a month doing floor work, seeing consults, putting out fires and the PAs would go in to close the chest, harvest veins etc. without letting me know. My chief kind of rolled with it and only towards the end of the month did he have them page me. Everyone needs to get along these days, and residents can't really tell PAs/NPs employeed by the hospital what to do at our institution...i.e. you can't say go away, I'm paging my intern to close.

The PAs thought was that if they could be proficient in these skills at an academic center they then could land a nice private practice job. I get that, no real problem.

However, in short, I think surgeons at all levels should take care of their own first with respect to training and privelages. Even if it does involve re-inventing the wheel on a monthly basis. I also still think that surgeons have alot of say at higher levels who and who doesn't have the right to cut. I think that influence should be utilized to preserve the selective and rigorous nature of the field.

 

[JelloBrain]

Everyone needs to get along these days, and residents can't really tell PAs/NPs employed by the hospital what to do at our institution...i.e. you can't say go away, I'm paging my intern to close.

However, in short, I think surgeons at all levels should take care of their own first with respect to training and privileges. Even if it does involve re-inventing the wheel on a monthly basis. I also still think that surgeons have a lot of say at higher levels who and who doesn't have the right to cut. I think that influence should be utilized to preserve the selective and rigorous nature of the field.

Wow! This is scary that the primary surgeon on a case can't/won't pick who opens and closes. IMO, the PAs/NPs/SAs whoever should only assist in cases when there is no junior doctor available to do so. When would the juniors learn the basics of positioning the patient, prepping the correct field, layout of surgical instruments, etc.-all of which should be known well before they learn to cut and close!

I completely agree that surgeons have the power to change these ridiculous rules; however most of the ones who have the power are complacent as they have escaped this take-over and so are not doing anything to protect their legacy for future generations. Invading the patient's body (for their benefit) should be an earned privilege of the best and the brightest who are willing to undergo the rigors of training, and not just anyone who wants the glory without paying their just dues in the form of blood, sweat, tears, and long hours!

Instead of selfishly thinking about short-term profits, if we want continuous sustained interest (over the next 100-200 years) in our profession and be able to recruit the crème de la crème of the intellectual society, we need to raise back the boundaries between doctors and allied health care professionals. As an analogy, if we all had always worried about the impact on environment our over-consumptive wasteful life would have, we wouldn't have to worry about global warming, and celebrate "earth day" today!

The only way (as I see it) to end this coup (for want of a better word) is for all doctors across USA to unite as one regardless of specialty and refuse to employ any NP/PA/others who want to practice outside the scope of their training or with minimal supervision. It will be difficult initially, quite inconvenient even for a while, no doubt, apple carts will be upset everywhere, but it will (attempt to) maintain the sanctity of our profession.

Of course the 50 states of the "United" States of America don't seem united in anything other than geography. So I don't expect any united action of solidarity happening anytime soon, but one always hopes.....

 

[dilated]

True. But first off, PA school is typically 2.5-3 years depending on the program. And some of our first year courses (like microbiology) are prerequisites for PA school.

Since every med/PA school is different, it is hard to make a blanket statement... however, I would still bet money on med students and PA students having a very similar working knowledge at graduation. I still stand by my statement that the big difference between doctors and PAs is residency.

PA school is not "typically 2.5-3" years. It's funny to see this number continually inflate with time. First people were claiming "at least 2 years", then it made it to "2 to 2.5" and now it's up to 3. Pretty soon PA school will be from "two to ten years", I guess. The reality is that the programs in my home town are 27 months and a five year BA/PA degree straight from high school (!) respectively. I have yet to see statistics suggesting that they're outliers.

If you really didn't get anything extra in your 48 months versus the PA's 27 months, I would have to say that the fault lies with you. I certainly felt substantially more prepared than the PA students I encountered on rotations, and there were higher expectations for us.

I don't have anything against PAs (I've found them much better colleagues than NPs on average), but there's this perception that you're a dick unless you smile and nod when they make comments about how they're equally trained.

 

[JackADeli]

I am going to respond to both these replies seperately. They both clearly show lack of understanding.

...was on a service for a month ...the PAs would go in to close the chest, harvest veins etc. without letting me know. My chief kind of rolled with it and only towards the end of the month did he have them page me. ...residents can't really tell PAs/NPs employeed by the hospital what to do...

The PAs thought was that if they could be proficient in these skills at an academic center they then could land a nice private practice job. I get that, no real problem.

...Even if it does involve re-inventing the wheel on a monthly basis.
...that influence should be utilized to preserve the selective and rigorous nature of the field.

First, you are correct, only a month! The PAs/NPs have contracts and set job expectations/descriptions. Their job security depends on them doing just that. In most institutions, midlevels stay until the case is done. Your chief (?resident) has nothing to do but roll with it. If speaking of a resident, he does not have management authority over the midlevels and does not write their paychecks.

I don't know what conversations you have had with the PAs to know their thoughts. However, the vast majority of PAs MUST do their jobs skillfully and efficient just to keep their current job. It does not require thoughts of future/potential other jobs to motivate them. They are in their end-point career. They are mastering their trade. Their jobs depend on it.

Surgeon influence is used to "preserve the selective and rigorous nature of the field". thus the PAs/NPs jobs depend upon excellence. Further, the surgeons practice depends on excellence. So, surgeons can NOT re-invent the wheel every month for every newbee to get some ~fun. The surgeons patients would not be too happy running around with poor chest closures and wound complications because an inexperienced team is started every month.

This is scary that the primary surgeon on a case can't/won't pick who opens and closes. IMO, the PAs/NPs/SAs whoever should only assist in cases when there is no junior doctor available to do so. When would the juniors learn the basics of positioning the patient, prepping the correct field, layout of surgical instruments, etc.-all of which should be known well before they learn to cut and close!..

They do choose. You have an interesting opinion. I can tell you, as a board certified surgeon, I never spent much time learning about "layout of surgical instruments". I put my hand out and if a good/experienced surgical team is there, the correct instrument is placed into my hand. I don't rumage or review the instrument table/s. Juniors can learn about positioning, prepping, and draping before the start of the case. It doesn't need to be at chest closure, or vein harvest.

... however most of the ones who have the power are complacent as they have escaped this take-over and so are not doing anything to protect their legacy for future generations. ...patient's body ...should be an earned privilege of the best and the brightest who are willing to undergo the rigors of training, and not just anyone who wants the glory without paying their just dues in the form of blood, sweat, tears, and long hours!

...we need to raise back the boundaries between doctors and allied health care professionals. As an analogy, if we all had always worried about the impact on environment our over-consumptive wasteful life would have, we wouldn't have to worry about global warming, and celebrate "earth day" today!

...to end this coup ...for all doctors across USA to unite as one regardless of specialty and refuse to employ any NP/PA/others who want to practice outside the scope of their training or with minimal supervision. ...it will ...maintain the sanctity of our profession....

This is just too much drivel. Frankly, at the very least it is insulting to the numerous allied healthcare/midlevel providers that work very hard and earned their positions.... worse, it just sounds like hot air intended to bate and provoke illogical forum flame wars. Whatever the intent.... these postings show very little understanding of real world medicine and its practice.👎

If you are using experience from your UK training.... it sounds like your UK CT division lacks in efficiency and workload distribution. That may explain a great deal of the UK health system. One can learn to be a practicing surgeon or you can waste alot of time practicing to be a midlevel or scrub nurse. There is not enough time in current training paradigms for you to do everybodies' job.

 

[Chemdocx]

" The surgeons patients would not be too happy running around with poor chest closures and wound complications because an inexperienced team is started every month."

its an academic center, a surgical residency, I as a surgical resident feel I should get first dibs on closing a chest if I didn't know how to do it. An attending/fellow/senior resident is there to supervise. I assume you know this from your training.

 

[Eta Carinae]

That may work in academics but what are those of us in private practice supposed to do? I don't have residents unless there is someone rotating with me as an elective. So I am forced to hire a surgical assist.

However, in academic medical centers I TOTALLY agree. If you are using a PA/RNFA in the OR, then residents should not be rotating on your service. This was a major problem we had with CT during residency - eventually they pulled us off the service because the CT surgeons refused to give up their PAs and NPs.

I agree that surgeons need not be so complacent. We were complacent when:

- work hour reform was talked about; it was forced on us because we refused to participate
- 90 day global period; it was forced on us because we refused in force to discuss the issues surrounding this
- encroachment of midlevels; it will be forced on us and you will see nurses doing surgical "residencies" because we refused to think it could happen to us or were greedy and failed to support our brothers in other fields. As you know, if you refuse to help me, when it comes your turn, you may not expect any help. We should be supporting our FM colleagues, our anesthesia brothers, etc. because who will help us when we need it?

and sisters

👍

 

[Eta Carinae]

I am going to respond to both these replies seperately. They both clearly show lack of understanding.
First, you are correct, only a month! The PAs/NPs have contracts and set job expectations/descriptions. Their job security depends on them doing just that. In most institutions, midlevels stay until the case is done. Your chief (?resident) has nothing to do but roll with it. If speaking of a resident, he does not have management authority over the midlevels and does not write their paychecks.

I don't know what conversations you have had with the PAs to know their thoughts. However, the vast majority of PAs MUST do their jobs skillfully and efficient just to keep their current job. It does not require thoughts of future/potential other jobs to motivate them. They are in their end-point career. They are mastering their trade. Their jobs depend on it.

Surgeon influence is used to "preserve the selective and rigorous nature of the field". thus the PAs/NPs jobs depend upon excellence. Further, the surgeons practice depends on excellence. So, surgeons can NOT re-invent the wheel every month for every newbee to get some ~fun. The surgeons patients would not be too happy running around with poor chest closures and wound complications because an inexperienced team is started every month.


They do choose. You have an interesting opinion. I can tell you, as a board certified surgeon, I never spent much time learning about "layout of surgical instruments". I put my hand out and if a good/experienced surgical team is there, the correct instrument is placed into my hand. I don't rumage or review the instrument table/s. Juniors can learn about positioning, prepping, and draping before the start of the case. It doesn't need to be at chest closure, or vein harvest.This is just too much drivel. Frankly, at the very least it is insulting to the numerous allied healthcare/midlevel providers that work very hard and earned their positions.... worse, it just sounds like hot air intended to bate and provoke illogical forum flame wars. Whatever the intent.... these postings show very little understanding of real world medicine and its practice.👎

If you are using experience from your UK training.... it sounds like your UK CT division lacks in efficiency and workload distribution. That may explain a great deal of the UK health system. One can learn to be a practicing surgeon or you can waste alot of time practicing to be a midlevel or scrub nurse. There is not enough time in current training paradigms for you to do everybodies' job .

Wherein is the training then?

 

[JelloBrain]

I am going to respond to both these replies seperately. They both clearly show lack of understanding.

They do choose. You have an interesting opinion. I can tell you, as a board certified surgeon, I never spent much time learning about "layout of surgical instruments". I put my hand out and if a good/experienced surgical team is there, the correct instrument is placed into my hand. I don't rummage or review the instrument table/s. Juniors can learn about positioning, prepping, and draping before the start of the case. It doesn't need to be at chest closure, or vein harvest.
This is just too much drivel. Frankly, at the very least it is insulting to the numerous allied healthcare/midlevel providers that work very hard and earned their positions.... worse, it just sounds like hot air intended to bate and provoke illogical forum flame wars. Whatever the intent.... these postings show very little understanding of real world medicine and its practice.👎

If you are using experience from your UK training.... it sounds like your UK CT division lacks in efficiency and workload distribution. That may explain a great deal of the UK health system. One can learn to be a practicing surgeon or you can waste a lot of time practicing to be a midlevel or scrub nurse. There is not enough time in current training paradigms for you to do everybodies' job.

I have no intention or desire to start any kind of flame wars, so if I come across as such, I apologize. I was trained in a variety of specialties in UK-they changed the system only after I moved to USA. I only mentioned CT surgery as that was the only one where SAs were used. In every specialty in every hospital, the junior trainee is (was) always the first in and last out on a case-from the time you position and prep patients to opening, learning the procedure, closing and finally escorting them to recovery or ICU, etc. I am just surprised that it is not similar in USA, and that there are a variety of mid-levels involved in lieu of interns/residents.

As for setting up instruments, etc. , I probably learnt all that in my own time I guess, so maybe it's an exception rather than the norm. It did come in very handy when I had to head a large animal project in USA where I had to buy appropriate neurosurgical instruments to set up a full neurosurgical OR, make my own sterile surgical packs, and teach the correct techniques of laying instruments out to my techs for judicious use of hand movements. Unfortunately I had no one to look to for advice. Same for establishing full anesthesia for extended periods of up to 22-24 hours at a stretch, followed by recovery, except I had an anesthesiologist who took me through the basics of animal anesthesia.

I feel that we should learn at least the basics of the jobs that our mid-levels/scrub nurses do-you never know when you might need that knowledge. I can confidently say that I can happily set up my own large animal lab and train people to work in it once I get funded. No knowledge is ever wasted. 🙂

Anyway, back to the topic on hand. I guess I shall not express what I think (hope) are appropriate solutions to this issue and go and bury my head in the sand too.

 

[JackADeli]

Wherein is the training then?

I am not advocating No training for residents. The point is that advocating this coup d'etat against midlevels is ludicrous. More importantly, the question is what is the learning intent of a given rotation and where do you achieve that learning? I think, given the ABS removal of any real cardiac requirements from GSurgery residency, your place on a cardiac service is not to harvest vein or close the chest. I would further add, all the most recent publications on cardiac graft patency has shown a marked detriment to grafts if harvested by someone with little to no experience. PAs that "shuck vein" are trained over time. Unlike a physician, their focus is mostly on a very small number of tasks that they master over time. I don't begrudge them their six procedure careers. A one month rotation... not the place for you to harvest. I wouldn't want my heart vessel patency dependent on who reinvented the wheel that month.

One month oversight and observation can only help so much and lost graft is a significant complication/issue. If you want to be "trained" in harvesting vascular grafts, I suggest advanced training after you complete the foundation training (i.e. vascular/CV/etc... training). I can tell you that through my entire GSurgery residency I harvested very, very little vein... definately not cardiac vein. I did assist in some peripheral vascular vein harvest. I do think there is some value in learning how to open and close the chest.

...I only mentioned CT surgery as that was the only one where SAs were used...

As for setting up instruments, etc. , I probably learnt all that in my own time I guess, so maybe it's an exception rather than the norm. It did come in very handy when I ... had to buy appropriate ...instruments to set up...

I just obtain a copy of the procedure card when I graduated and review the list with my highering hospital.

Long and short of it, IMHO, we (surgeons) are in surgery cause we love to operate. In our training/residency, we must be efficient to obtain the appropriate training and experience. Often, one of the biggest deficits is the cognitive pre/post care component (i.e. non-operative). I don't see a need for residents to spend 4-6 hours craning their head over to watch a coronary and/or hold an iced heart. The old school paradigm that that is "paying your dues" to earn the right to cut the sternum is, IMHO, wrong and wasted valuable time.

 

[Amgen1]

I am not advocating No training for residents. The point is that advocating this coup d'etat against midlevels is ludicrous. More importantly, the question is what is the learning intent of a given rotation and where do you achieve that learning? I think, given the ABS removal of any real cardiac requirements from GSurgery residency, your place on a cardiac service is not to harvest vein or close the chest. I would further add, all the most recent publications on cardiac graft patency has shown a marked detriment to grafts if harvested by someone with little to no experience. PAs that "shuck vein" are trained over time. Unlike a physician, their focus is mostly on a very small number of tasks that they master over time. I don't begrudge them their six procedure careers. A one month rotation... not the place for you to harvest. I wouldn't want my heart vessel patency dependent on who reinvented the wheel that month.

One month oversight and observation can only help so much and lost graft is a significant complication/issue. If you want to be "trained" in harvesting vascular grafts, I suggest advanced training after you complete the foundation training (i.e. vascular/CV/etc... training). I can tell you that through my entire GSurgery residency I harvested very, very little vein... definately not cardiac vein. I did assist in some peripheral vascular vein harvest. I do think there is some value in learning how to open and close the chest.

I'm going to call crap on this mindset.

The reason any resident is on that service should be two fold:
1) Learn the management of cardiac patients. As components of the management of these pts may help in management of other critically ill pts
2) Learn components of cardiac surgery that they may take away and add to their general surgery skill set

I would venture to say that the exact reason that resident is on the service is to learn to harvest vein and close chest. Not because that person will ever do a cabg as a general surgeon, but a general surgeon may certainly need to do a sternotomy during a trauma or harvest vein for a rsvgb else where in the body.

The reason general surgeons still do subspecialty rotations is to learn these small components

If the resident is not there to learn any of these things then they should not be on the service. they don't need to learn how to do discharge summaries

As to the argument that the CV surgeon does not want to reinvent the wheel every month. If they don't want to do that, then they should get out of academics. That is their job

In terms of vein graft patency. The resident should be doing that under direct supervision of the staff surgeon. If done under supervision of the staff surgeon, there should be no difference in patency from month to month

This type of attitude infuriates me. Is it easier to have a PA that they trained for the past 3 years harvest the vein while they check emails, sure. But then they should not be at an academic center and they should have no residents on the service

 

[JackADeli]

I'm going to call crap on this mindset.

...I would venture to say that the exact reason that resident is on the service is to learn to harvest vein and close chest...

You can call crap on it all you want. The facts are that at numerous residencies... GSurgery residents do NOT rotate on cardiac services. This based on the ABS positions on what a GSurgery resident should learn.

...I would venture to say that the exact reason that resident is on the service is to learn to harvest vein and close chest...

Let me venture to say that the "exact reason" a GSurgery resident is on the cardiac service should be spelled out by the cardiac division and PD of GSurgery residency. In that aspect, you might ask what is the reason.... not just assume it is to do x, y, z. As I mentioned earlier, I do think performing sternotomies and closing sternotomies is a worthwhile experience/training. But.... it is ultimately up to the PD with the specialty rotations to determine what the actual/"exact" learning objectives are. A resident should not simply assume. You should ask and get a straight answer as to what you are expected to get out of each rotation. Harvesting cardiac vein is likely NOT why you are on the service.... again ask your cardiac & PD attendings so you do not have unmet expectations. Maybe you should be doing vein harvesting on vascular service which is to my understanding still a required GSurgery rotation.

...As to the argument that the CV surgeon does not want to reinvent the wheel every month. If they don't want to do that, then they should get out of academics. That is their job

In terms of vein graft patency. The resident should be doing that under direct supervision of the staff surgeon. If done under supervision of the staff surgeon, there should be no difference in patency from month to month...

They might be in academics to train advanced residents/fellows. While we all like to believe the entire hospital revolves around GSurgery residency, it does NOT. An academic surgeons "job" again will vary according to the guidelines/expectations set by your residency PD and the specific subspecialty service. I appreciate the sense of entitlement and expectations one can formulate in their head during residency. However, you should go beyond that and actually ask the questions.

...In terms of vein graft patency. The resident should be doing that under direct supervision of the staff surgeon. If done under supervision of the staff surgeon, there should be no difference in patency from month to month...

Your argument is based on assumptions NOT demonstrated in the literature. Suggests you have no business doing the operation because you have failed to do the critical reading. Vein harvesting... "shucking vein", may seem like the most simple component of the operation. But, it is often the most important component to patient outcomes. You are not going to succeed in making someone good and proficient in this task in just one month. And, yes, you need to be at the very least good at it or it is all a game at the patients expense. If your residency has only a one month cardiac surgery exposure/experience, you are not their to get vein. If your PD expects you to get vein with only a one month rotation, he/she has made a significant error in judgement. It takes months of numerous vein harvest under supervision to be able to do it right with appropriate patency. To sacrifice all your patients over a 4 wk period in the hope that the resident at the end of the month might be able to harvest a single good vein and then leave.... to start over again with the next newbee is ludicrous.

 

[SLUser11]

Vein harvesting... "shucking vein", may seem like the most simple component of the operation.

Side question: What do you think about the recent literature that says open vein harvest results in patency rates superior to endovein?

It seems like once people become fascile with the endovein, the trauma to the vessel would be similar, and the lower patency rates are due to inexperienced practitioners...but I'm not sure because I'm one of the people that steer clear of CV surgery for the most part.

I wonder if old-school CV surgeons will use this study to justify not learning the endovein harvest technique....

 

[JackADeli]

Side question: What do you think about the recent literature that says open vein harvest results in patency rates superior to endovein?

It seems like once people become fascile with the endovein, the trauma to the vessel would be similar, and the lower patency rates are due to inexperienced practitioners...but I'm not sure because I'm one of the people that steer clear of CV surgery for the most part...

I think the problem is two-fold...maybe three-fold.
1. There is a learning curve. Most patients expect endovein... so again, don't see residents being trained in a month to do what attending surgeons do not.
2. Speed is an issue. Folks want rapid turn-over and quick vein grafts.
3. I am always appalled/amazed at how much graft contact and traction is placed on the vein during harvest.... worse endovein then open. However, endovein seems to violate the old rules of "no touch" harvest. That scope and system slides up and down the vein/s over 100 times during harvest and bovies really close. Other final point, the back table final prep.... Often over distended, stretched, etc....

All of these issues are why someone doing a 1 month rotation should not be expecting to be harvesting cardiac vein. A leg bypass you might have additional graft options.... not so in the heart.

I know endovein is popular and the whole leg scar and/or wound issues are real. But, as an observer (I'm not a heart surgeon), I am concerned a good number of bad grafts are sutured in evryday!

...I wonder if old-school CV surgeons will use this study to justify not learning the endovein harvest technique....

I don't know many attending Cardiac surgeons that do vein graft harvest open (IMHO, almost universally a PA job). I don't know ANY Cardiac surgeons that do endovein harvest (IMHO, ~universally a PA job).

 

[JackADeli]

Not to say it is impossible or has never happened.... but, I have never known of any GSurgery resident doing the endovein harvest for a heart case. I know I never did as a GSurgery resident.

 

[SLUser11]

I don't know many attending Cardiac surgeons that do vein graft harvest open (almost universally a PA job). I don't know ANY Cardiac surgeons that do endovein harvest (~universally a PA job).

Surely you are aware that things are done differently in different places. I think there are many places where CV surgeons operate independent of a PA.

I've been in several practice environments, and I've seen everyone from the attending to the PA to the resident to even the student harvest vein. As for endovein, while at Nebraska, I saw a couple staff doing it themselves. Some attendings in Wichita do it themselves as well.

Still, I agree with you that sometimes the vein gets beat up pretty bad with endovein harvest.

 

[JackADeli]

Surely you are aware that things are done differently in different places. I think there are many places where CV surgeons operate independent of a PA...

As I said....

...I don't know many attending Cardiac surgeons that do vein graft harvest open (IMHO, almost universally a PA job). I don't know ANY Cardiac surgeons that do endovein harvest (IMHO, ~universally a PA job).

Not to say it is impossible or has never happened.... but, I have never known of any GSurgery resident doing the endovein harvest for a heart case. I know I never did as a GSurgery resident.

...Still, I agree with you that sometimes the vein gets beat up pretty bad with endovein harvest.

With one's own observation And with more recent publications.... IMHO, you would have to really question the ethics of having a student or even a GSurgery resident doing the endovein. Brings me back to my earlier statement:

...I know endovein is popular and the whole leg scar and/or wound issues are real. But, as an observer (I'm not a heart surgeon), I am concerned a good number of bad grafts are sutured in evryday!...

 

[SLUser11]

As I said....
With one's own observation And with more recent publications.... IMHO, you would have to really question the ethics of having a student or even a GSurgery resident doing the endovein. Brings me back to my earlier statement:

I'm not sure how quoting yourself added much there, but I think we're generally in agreement.

The problem with surgical ethics is that it's easy to create both hypothetical and real situations that hit close to home. We think it's unethical for a general surgery resident to do endovein, but we're okay with the resident doing an appendectomy for the first time despite his inexperience and lack of expertise. Pretty soon, we are questioning whether the whole concept of residency is unethical, since all patients are on some level "practice" for a less-experienced surgeon.

Unfortunately, it's sort of a slippery slope. I'm not sure where I stand on this issue, as I frequently walk students and junior residents through procedures that I can do better myself, while I'm just as often walked through procedures by my staff that they can do better themselves....

I'm not sure where to draw the line. However, I definitely don't find saphenous vein harvest to be the most technically challenging procedure a general surgery resident does, so why is that one specifically off limits? Because there's a study out?