Which surgical disciplines have midlevels that are closest to being "fully operational?"

[Brahnold Bloodaxe]

Get it...Fully operational? Ok I'll stop now.

Seriously though. Let's say you're a "healthcare leader" who has just stumbled upon an innovative, cutting edge idea that's never been implemented before*: cutting costs to raise profits by leveraging mid-level providers in place of higher paid physicians. If you had your eyes set on the surgical fields, you'd obviously want to start with those specialties that already heavily utilize midlevels in the OR as first assists, since it's easier to take someone who already has x/100 of a given skillset and top them off than to train people from scratch.

My question is which specialties not only make extensive use of midlevels in the OR, but also use them for relatively "value added" stuff and not just retracting and closing. And in contrast, which specialties make relatively little use of them? My uneducated guess would be that anything with large, open operative fields where big structures are moved around during surgeries would give midlevel first assists the most opportunities to learn the tricks of the trade. On the other hand, small fine surgeries and especially laparoscopic stuff is probably relatively midlevel free.

So, basically:
Ortho and general surg are most susceptible?
Urology and ENT are least susceptible?

Am I close here or completely off the mark?

*sarcasm, obviously.

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[ThoracicGuy]

 

[evilbooyaa]

Don't see PA's doing any of the real surgery bits in either Gen Surg or Ortho (although my exposure to that was minimal). PA's are first assists to be the second set of hands. In time they may be able to predict the attendings movements on a case, but I can't imagine that anybody is really letting them do the dissection on a lap chole

Even the most involved ones in like cardiac surgery are doing vein harvests solo. I'd expect something like Gyn doing EUAs, D&Cs, maybe some cervical coning/LEEP, and maybe Uro with diagnostic cysto, and maybe, just maybe, ureteral stents (although I doubt that). Certain IR procedures like thora/paracentesis could be farmed out. Don't see anything in vascular surgery, maybe vein stripping? but that's cosmetic generally so gonna be run by doctors.

But maybe the surgeons here have some other ideas.

 

[mimelim]

Get it...Fully operational? Ok I'll stop now.

Seriously though. Let's say you're a "healthcare leader" who has just stumbled upon an innovative, cutting edge idea that's never been implemented before*: cutting costs to raise profits by leveraging mid-level providers in place of higher paid physicians. If you had your eyes set on the surgical fields, you'd obviously want to start with those specialties that already heavily utilize midlevels in the OR as first assists, since it's easier to take someone who already has x/100 of a given skillset and top them off than to train people from scratch.

My question is which specialties not only make extensive use of midlevels in the OR, but also use them for relatively "value added" stuff and not just retracting and closing. And in contrast, which specialties make relatively little use of them? My uneducated guess would be that anything with large, open operative fields where big structures are moved around during surgeries would give midlevel first assists the most opportunities to learn the tricks of the trade. On the other hand, small fine surgeries and especially laparoscopic stuff is probably relatively midlevel free.

So, basically:
Ortho and general surg are most susceptible?
Urology and ENT are least susceptible?

Am I close here or completely off the mark?

*sarcasm, obviously.

I think that you are completely off the mark. Not that you are asking the wrong questions, but rather that you don't have much experience in the field and don't have any foundation in how to get from not being able to perform a surgery to being able to. This is obviously a reflection of where you are at in your training, so a few thoughts from someone a little down the line from you.

Technical proficiency is one of the easiest components of training a surgeon. So much so that we don't test people on it. We test on clinical competence via a written and an oral exam so that people are safe, but we don't test whether or not someone can physically do the surgeries. Thus, I don't think looking at things from a technical standpoint is helpful. Most people who have been around surgery long enough have seen experienced PAs that could probably from a purely technical perspective perform certain procedures on their own. Sure, they would need some more training than what they have, but most of surgery is not technically beyond most people and certainly not beyond people that have been doing a lot in the OR for decades.

By far the harder component is well, everything else. Who to operate on, more importantly, who not to operate on. Which procedure to perform. When to perform it. Etc. Those are the things that take years to develop and honestly, you start learning in medical school and refine gradually throughout residency. Are they universally beyond the abilities of non-MDs? No. Anyone that tells you otherwise is delusional. But, it is far harder to quantify what is necessary (many, myself included, would argue that surgical training is inefficient and often excessive) and then provide that necessary training when it comes to non-OR technical aspects of care. In many ways, this is one of the larger problems that vascular surgeons have with non-vascular surgeons doing endovascular cases. From a technical perspective, hard to see fault in other people doing procedures similar to what they are already doing. But, you see simple, "rookie" mistakes often enough that are born not from technical incompetence, but from short cutting 5 years of training.

To me the obvious vulnerable areas are things that are easy to diagnose (and doesn't often get disputed) and things where the operations are the same the vast majority of the time. ie where you can boil things down to simply being a technician rather than a clinician. Areas in vascular surgery would be venous insufficiency work and catheter work (not endo work, but placement of catheters/ports). While both certainly have their nuances, I could imagine those ending up 'out-sourced'.

 

[Psai]

I think what you meant was interventional radiology cases. You know, the guys that invented endovascular technique.

 

[Brahnold Bloodaxe]

I think that you are completely off the mark. Not that you are asking the wrong questions, but rather that you don't have much experience in the field and don't have any foundation in how to get from not being able to perform a surgery to being able to. This is obviously a reflection of where you are at in your training, so a few thoughts from someone a little down the line from you.

Technical proficiency is one of the easiest components of training a surgeon. So much so that we don't test people on it. We test on clinical competence via a written and an oral exam so that people are safe, but we don't test whether or not someone can physically do the surgeries. Thus, I don't think looking at things from a technical standpoint is helpful. Most people who have been around surgery long enough have seen experienced PAs that could probably from a purely technical perspective perform certain procedures on their own. Sure, they would need some more training than what they have, but most of surgery is not technically beyond most people and certainly not beyond people that have been doing a lot in the OR for decades.

By far the harder component is well, everything else. Who to operate on, more importantly, who not to operate on. Which procedure to perform. When to perform it. Etc. Those are the things that take years to develop and honestly, you start learning in medical school and refine gradually throughout residency. Are they universally beyond the abilities of non-MDs? No. Anyone that tells you otherwise is delusional. But, it is far harder to quantify what is necessary (many, myself included, would argue that surgical training is inefficient and often excessive) and then provide that necessary training when it comes to non-OR technical aspects of care. In many ways, this is one of the larger problems that vascular surgeons have with non-vascular surgeons doing endovascular cases. From a technical perspective, hard to see fault in other people doing procedures similar to what they are already doing. But, you see simple, "rookie" mistakes often enough that are born not from technical incompetence, but from short cutting 5 years of training.

To me the obvious vulnerable areas are things that are easy to diagnose (and doesn't often get disputed) and things where the operations are the same the vast majority of the time. ie where you can boil things down to simply being a technician rather than a clinician. Areas in vascular surgery would be venous insufficiency work and catheter work (not endo work, but placement of catheters/ports). While both certainly have their nuances, I could imagine those ending up 'out-sourced'.

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Since it's determining when to cut and what kind of operation to perform that's the limiting factor, if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo, since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating.

 

[mimelim]

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Since it's determining when to cut and what kind of operation to perform that's the limiting factor, if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo, since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating.

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. So people with infinite more experience on the topic tell you this, but you "remain skeptical" based on what exactly? What knowledge or experience makes you "skeptical". To be honest, it sounds like Donald Trump vs. the intelligence community on the topic of Russia. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Do you know how physicians are paid? Do you have even the vaguest of notions of the multitude of practice setups and the interfaces between hospitals and physicians? Since it's determining when to cut and what kind of operation to perform that's the limiting factor, Based on what can you make this kind of gross simplification? This is not a biochemical reaction that has a rate limiting step. While I am a large proponent that technical aspects of surgery are only a small part of the job of being a surgeon, it is far from a nothing. After all, conservatively, I will have spent over 20,000 hours in the hospital during my residency and will have spent over 5,000 of those hours in the operating room, there is clearly a technical aspect that is at play. if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. You do know that you can't legally do this right? This isn't something that is up to the hospital. Further, why would surgeons work there when they could work in any number of other practice models? I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go. Do you know what a professional fee is? Do you know what OR privileges are? Do you know anything about professional licensure and it's limitations state by state on how hospitals function? Here is a hint, professional fees are just a drop in the bucket compared to the facility fees. Trying to change this model is way against hospital interests. Trying to chase after professional fees is laughable.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Or you literally know nothing about this topic and assume based on vague notions and wishful thinking. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo The part keeping PAs and others out of the operating room is incredibly complicated and multifaceted. There are many huge barriers that would need need to be overcome on the federal level, the state level, as well as on a professional level. You don't know anything about any of that. , since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating. Really? You've illustrated this? Never mind the complete lack of any knowledge on the topic and the inaccurate claims, you seriously think that in 157 words you can explain a new way of practicing medicine.

How we practice medicine in the United States can be improved in many ways. We are inefficient in both our training and clinical practice. There are radical changes to our system that I would personally make. Sometimes they are upsetting to physicians and future physicians (see many different threads on SDN) because I have little loyalty to the profession compared to loyalty to pragmatism and the overall well-being of the healthcare system as a whole. I am far from an expert on this topic. I would strongly recommend you learning some healthcare economics or maybe simply learning the most basic aspects of how our healthcare system works before trying to propose changes. Also, while you certainly have every right to be skeptical of things and have your own opinions on things, if you want to be taken seriously, you should have more backing than, "I'm skeptical because it doesn't fit my argument."

 

[mcworbust]

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. So people with infinite more experience on the topic tell you this, but you "remain skeptical" based on what exactly? What knowledge or experience makes you "skeptical". To be honest, it sounds like Donald Trump vs. the intelligence community on the topic of Russia. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Do you know how physicians are paid? Do you have even the vaguest of notions of the multitude of practice setups and the interfaces between hospitals and physicians? Since it's determining when to cut and what kind of operation to perform that's the limiting factor, Based on what can you make this kind of gross simplification? This is not a biochemical reaction that has a rate limiting step. While I am a large proponent that technical aspects of surgery are only a small part of the job of being a surgeon, it is far from a nothing. After all, conservatively, I will have spent over 20,000 hours in the hospital during my residency and will have spent over 5,000 of those hours in the operating room, there is clearly a technical aspect that is at play. if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. You do know that you can't legally do this right? This isn't something that is up to the hospital. Further, why would surgeons work there when they could work in any number of other practice models? I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go. Do you know what a professional fee is? Do you know what OR privileges are? Do you know anything about professional licensure and it's limitations state by state on how hospitals function? Here is a hint, professional fees are just a drop in the bucket compared to the facility fees. Trying to change this model is way against hospital interests. Trying to chase after professional fees is laughable.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Or you literally know nothing about this topic and assume based on vague notions and wishful thinking. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo The part keeping PAs and others out of the operating room is incredibly complicated and multifaceted. There are many huge barriers that would need need to be overcome on the federal level, the state level, as well as on a professional level. You don't know anything about any of that. , since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating. Really? You've illustrated this? Never mind the complete lack of any knowledge on the topic and the inaccurate claims, you seriously think that in 157 words you can explain a new way of practicing medicine.

How we practice medicine in the United States can be improved in many ways. We are inefficient in both our training and clinical practice. There are radical changes to our system that I would personally make. Sometimes they are upsetting to physicians and future physicians (see many different threads on SDN) because I have little loyalty to the profession compared to loyalty to pragmatism and the overall well-being of the healthcare system as a whole. I am far from an expert on this topic. I would strongly recommend you learning some healthcare economics or maybe simply learning the most basic aspects of how our healthcare system works before trying to propose changes. Also, while you certainly have every right to be skeptical of things and have your own opinions on things, if you want to be taken seriously, you should have more backing than, "I'm skeptical because it doesn't fit my argument."

Woah

 

[VincentAdultman]

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. So people with infinite more experience on the topic tell you this, but you "remain skeptical" based on what exactly? What knowledge or experience makes you "skeptical". To be honest, it sounds like Donald Trump vs. the intelligence community on the topic of Russia. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Do you know how physicians are paid? Do you have even the vaguest of notions of the multitude of practice setups and the interfaces between hospitals and physicians? Since it's determining when to cut and what kind of operation to perform that's the limiting factor, Based on what can you make this kind of gross simplification? This is not a biochemical reaction that has a rate limiting step. While I am a large proponent that technical aspects of surgery are only a small part of the job of being a surgeon, it is far from a nothing. After all, conservatively, I will have spent over 20,000 hours in the hospital during my residency and will have spent over 5,000 of those hours in the operating room, there is clearly a technical aspect that is at play. if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. You do know that you can't legally do this right? This isn't something that is up to the hospital. Further, why would surgeons work there when they could work in any number of other practice models? I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go. Do you know what a professional fee is? Do you know what OR privileges are? Do you know anything about professional licensure and it's limitations state by state on how hospitals function? Here is a hint, professional fees are just a drop in the bucket compared to the facility fees. Trying to change this model is way against hospital interests. Trying to chase after professional fees is laughable.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Or you literally know nothing about this topic and assume based on vague notions and wishful thinking. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo The part keeping PAs and others out of the operating room is incredibly complicated and multifaceted. There are many huge barriers that would need need to be overcome on the federal level, the state level, as well as on a professional level. You don't know anything about any of that. , since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating. Really? You've illustrated this? Never mind the complete lack of any knowledge on the topic and the inaccurate claims, you seriously think that in 157 words you can explain a new way of practicing medicine.

How we practice medicine in the United States can be improved in many ways. We are inefficient in both our training and clinical practice. There are radical changes to our system that I would personally make. Sometimes they are upsetting to physicians and future physicians (see many different threads on SDN) because I have little loyalty to the profession compared to loyalty to pragmatism and the overall well-being of the healthcare system as a whole. I am far from an expert on this topic. I would strongly recommend you learning some healthcare economics or maybe simply learning the most basic aspects of how our healthcare system works before trying to propose changes. Also, while you certainly have every right to be skeptical of things and have your own opinions on things, if you want to be taken seriously, you should have more backing than, "I'm skeptical because it doesn't fit my argument."

A simple "lol" would've sufficed.

 

[akwho]

Nobody roasts people like an angry vascular surgeon.

 

[Brahnold Bloodaxe]

Yes, I've heard of this notion that "it's not operating that's hard, it's knowing when to operate" many times before and remain skeptical of its veracity. So people with infinite more experience on the topic tell you this, but you "remain skeptical" based on what exactly? What knowledge or experience makes you "skeptical". To be honest, it sounds like Donald Trump vs. the intelligence community on the topic of Russia. If it's actually the truth, boy those hospitals sure are stupid to have their highly paid surgeons wasting the hospital's money cutting away in the OR. Do you know how physicians are paid? Do you have even the vaguest of notions of the multitude of practice setups and the interfaces between hospitals and physicians? Since it's determining when to cut and what kind of operation to perform that's the limiting factor, Based on what can you make this kind of gross simplification? This is not a biochemical reaction that has a rate limiting step. While I am a large proponent that technical aspects of surgery are only a small part of the job of being a surgeon, it is far from a nothing. After all, conservatively, I will have spent over 20,000 hours in the hospital during my residency and will have spent over 5,000 of those hours in the operating room, there is clearly a technical aspect that is at play. if I'm a hospital administrator I'm going to try my best to move to a model where I have one or two surgeons seeing patients in clinic and on the floors and sending those who need surgery to ORs manned by cheap midlevels. You do know that you can't legally do this right? This isn't something that is up to the hospital. Further, why would surgeons work there when they could work in any number of other practice models? I could pay those midlevels a straight <200k salary and pocket the balance of the professional fee instead of giving OR privileges/employing 40+ surgeons and letting them collect the professional fee. Just pay those handful of surgeons to triage and let the rest go. Do you know what a professional fee is? Do you know what OR privileges are? Do you know anything about professional licensure and it's limitations state by state on how hospitals function? Here is a hint, professional fees are just a drop in the bucket compared to the facility fees. Trying to change this model is way against hospital interests. Trying to chase after professional fees is laughable.

Since we're not as of yet moving towards such a model, I would presume that the operating bit is actually the critical path. Or you literally know nothing about this topic and assume based on vague notions and wishful thinking. Note that critical path doesn't mean it's necessarily the harder part of surgery, but that it's the part that's keeping midlevels out of doing surgery solo The part keeping PAs and others out of the operating room is incredibly complicated and multifaceted. There are many huge barriers that would need need to be overcome on the federal level, the state level, as well as on a professional level. You don't know anything about any of that. , since as I've illustrated above you could easily have MD surgeons do the decision making part and delegate operating to midlevels if those midlevels were actually capable of operating. Really? You've illustrated this? Never mind the complete lack of any knowledge on the topic and the inaccurate claims, you seriously think that in 157 words you can explain a new way of practicing medicine.

How we practice medicine in the United States can be improved in many ways. We are inefficient in both our training and clinical practice. There are radical changes to our system that I would personally make. Sometimes they are upsetting to physicians and future physicians (see many different threads on SDN) because I have little loyalty to the profession compared to loyalty to pragmatism and the overall well-being of the healthcare system as a whole. I am far from an expert on this topic. I would strongly recommend you learning some healthcare economics or maybe simply learning the most basic aspects of how our healthcare system works before trying to propose changes. Also, while you certainly have every right to be skeptical of things and have your own opinions on things, if you want to be taken seriously, you should have more backing than, "I'm skeptical because it doesn't fit my argument."

What's with the bold, blood red type? The content itself aptly conveys hostility and aggression, the graphical aids are overkill in my opinion.

Anyway. I'm not sure why you're getting your panties in a bunch. I simply acknowledged that something you wrote in your first post is indeed commonly accepted wisdom in the surgical profession, and offered up a reason why I remain skeptical that this thing is the primary barrier standing between midlevels and independence in the OR. I never claimed to be convinced technical skills are more important than decision making skills. I only said that if decision making is indeed the limiting factor to delivering surgical care, you could easily circumvent that obstacle by continuing to have surgeons make the decisions on when and how to operate, and then having midlevels perform the actual surgery once the decision has been made.

This logic seems pretty sound to me, and you haven't really said anything in your riposte to refute it. The rest of my post was merely there to illustrate why it would be financially beneficial for hospitals to adapt such a model if indeed it was possible. I'm well aware that the facility fee is a multiple of the professional fee. That doesn't mean the hospital wouldn't take it if it was available. In general, humans aren't in the business of leaving money on the table.

But whatever. I don't want to get into a pissing match about this. The point of this thread was to ask a simple question: which surgical fields make the most extensive use of midlevels and have midlevels with the highest technical competence relative to the surgeon.

 

[VincentAdultman]

This logic seems pretty sound to me,

Believe it or not most surgeons are surgeons because hey enjoy operating. So yeah good luck finding surgeons to go along with that.

But yeah otherwise "pretty sound." lol

 

[LucidSplash]

This logic seems pretty sound to me, and you haven't really said anything in your riposte to refute it.

if you really believe that, you didn’t actually read his post and you don’t realize how little you understand about the financials of medicine. The short version is: most surgeons aren’t employed by the hospital. They bring their business to the hospital and the hospital benefits. Surgeons contribute more financially to the bottom line of the hospital than just about any other specialty, especially at the community level. Hiring mid-levels to “do surgery” would kill a hospitals use by surgeons pretty fast.

The point of this thread was to ask a simple question: which surgical fields make the most extensive use of midlevels and have midlevels with the highest technical competence relative to the surgeon.

Answer: none.

 

[TypeADissection]

Hey guys. Don't wanna violate HIPAA or anything, but I've found Branhold Bloodaxe. He's in our burn unit right now. Calculated at 40% TBSA. I don't know if he's gonna make it.