PAs going cardiac cath

[MacGyver]

I've heard there are some areas which allow PAs to do cardiac caths fully unsupervised.

Anybody have any experience with this? Should only a full blown cardiologist be allowed to do it?

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[smackdaddy]

where?

 

[neutropeniaboy]

I highly doubt it.

But, to be honest, I've done aortograms and lower extremity runoffs before (supervised, of course). And I can count those cases on 2 fingers. They're not difficult. I suppose any well-trained monkey could thread a wire around the arch and inject a pre-filled syringe and tell the radiology tech to shoot the pictures.

 

[eddieberetta]

Originally posted by neutropeniaboy
But, to be honest, I've done aortograms and lower extremity runoffs before (supervised, of course). And I can count those cases on 2 fingers.

Does that mean you've done 2 cases?

Originally posted by neutropeniaboy
I suppose any well-trained monkey could thread a wire around the arch and inject a pre-filled syringe and tell the radiology tech to shoot the pictures.

I guess that applies to a lot of things. I suppose you would agree that any well-trained monkey could do tubes and tonsils?

 

[neutropeniaboy]

Originally posted by eddieberetta
Does that mean you've done 2 cases?


I guess that applies to a lot of things. I suppose you would agree that any well-trained monkey could do tubes and tonsils?

Yes...two cases. My point is that they're not difficult. And, no, tonsillectomies and PET placements aren't difficult either.

 

[task]

I think an aortogram is a slightly different beast than coronary angiography. Using guidewires and catheters to engage the L and R coronary systems takes more expertise and practice than simply shooting dye into the aorta itself.

Having said that, I do believe that most procedures (diagnostic cath, routine diagnostic endoscopy, many surgical procedures) could be taught to non-physician providers. Here in Texas, there are PAs doing flex sigs and diagnostic colonoscopies (supervised) -- but this has grown from the fact that the current supply of GI docs can't keep up with SCREENING demand. But anything more complex than routine screening or anything requiring a procedure (e.g. polypectomy or bx) is deferred till an MD is holding the scope.

What distinguishes non-physician providers from MDs, as I think most people would agree on, is the use of judgement and experience before performing any of these procedures and in there interpretation and clinical use.

For example, take something as seemingly benign as diagnostic cardiac cath. The usual consent for cath includes risk of "death, MI, stroke" and sequelae from dislodging plaque in the aorta. I've taken care of pt. who suffered CVAs presumably from dislodged plaque that has embolized.

So who should get cath'd and who shouldn't? Well, that's for a cardiologist to decide, because of the training and experience one has with these cases.

As with any procedural specialty, it's not the ability to perform the procedure that becomes important, but determining what procedure is appropriate and whether or not a procedure needs to be done, and to intelligently and appropriately apply the results of a procedure to clinical mgmt/outcome.

Cardiologists are quite aggressive and have a strong lobby in health care centers precisely because what they deal with involves the most prevalent disease process(es) in this country and therefore brings in mucho $$$$. There is no chance they would relinquish such a central diagnostic procedure to PAs or NPs.

Also, have you looked at a coronary angiogram. They are not easy to interpret without looking at LOTS, and interpretation is a dynamic and real-time process in that you have to change angles and catheter position to optimize shots. Plus, you usually correlate anatomy with EKG findings, non-invasive imaging, and clinical picture.

This ability to integrate all forms of available clinical data is what distinguishes us as physicians from PAs or NPs, and therefore, in my opinion, would keep procedures like this and others solely in the hands of MDs.

 

[MacGyver]

Originally posted by task
Here in Texas, there are PAs doing flex sigs and diagnostic colonoscopies (supervised) -- but this has grown from the fact that the current supply of GI docs can't keep up with SCREENING demand. But anything more complex than routine screening or anything requiring a procedure (e.g. polypectomy or bx) is deferred till an MD is holding the scope.

You say that now, but all it takes is a few years of doing supervised procedures and then the PA lobby will fight to have these procedures done UNSUPERVISED. They will point to years of experience where supposedly no bad incidents happened. MDs will stand quietly by and do nothing. Meanwhile, the PAs scope will widen year by year. Eventually they will be able to do these procedures unsupervised.

What distinguishes non-physician providers from MDs, as I think most people would agree on, is the use of judgement and experience before performing any of these procedures and in there interpretation and clinical use.

I tend to agree, but that makes no difference to the general public or the state legislatures who control scope of practice. At any rate, if you give PAs wider scope to do more procedures, eventualy they become de facto competitors against MDs (i.e. places will hire PAs instead of MDs; they wont totally replace MDs but instead of hirign 5 MDs they might hire 2 MDs and 3 PAs).

So who should get cath'd and who shouldn't? Well, that's for a cardiologist to decide, because of the training and experience one has with these cases.

True, but PAs are still competiting with MDs direclty even if its only the procedures they are doing and not the decision making. I can hire 1 MD to make the decisions and 5 PAs to do all the procedures. In previous decades I was not allowed to do this and thus would have to hire 4 MDs to cover the workload. This represents a loss of career opps for MDs at the hands of PAs. Will they totally replace all MDs? No, but PA use will mean that less MDs are hired.

There is no chance they would relinquish such a central diagnostic procedure to PAs or NPs.

I would not be so sure on this. It wont happen overnight, but over the course of years. PA/NP will gradually have their scopes in cardiology widened. One new procedure here, one new one there. Little by little they will encroach more and more on cards people.

This ability to integrate all forms of available clinical data is what distinguishes us as physicians from PAs or NPs, and therefore, in my opinion, would keep procedures like this and others solely in the hands of MDs.

I agree with you in principle, but the fact of the matter is that MDs as a whole have done a VERY POOR job of keeping the PA/NP scope narrow. Every year they get more concessions to have a wider practice scope.

 

[PACtoDOC]

God Bless Macgyver, he sure is panhandling the forums trying to find someone who will agree with him. He needs to realize that PA's have pretty much max'd out in their capabilities. You must be stupid to think that state legislatures make any decisions regarding PA practice rights without the blessing of the physician organizations. SO what are your credentials to make all these loud predictions? Here is a prediction; You are one day going to find someone that agrees with your philosophy, and then you will be saddened to see you were only looking at a mirage! Get a shorter quote by the way. Its longer than most of your thoughts.

MJM, PA-C, Med Student

 

[MacGyver]

Originally posted by PACtoDOC
You must be stupid to think that state legislatures make any decisions regarding PA practice rights without the blessing of the physician organizations.

this is total bull****. State legislatures certainly will listen to what physicians groups have to say, but in no way is their decision dependent on what the doctors groups position is.

Most of the time, there is a pissant MD response to new legislative bills regarding PAs. MDs are far too passive regarding this issue, and as a result, PA scope has been consistently widened over the past 5 years.

By the way, there are still plenty of procedures in specialty areas that PAs can expand their practice too, so in no way are they "maxed out"

 

[PACtoDOC]

Oh, I am sorry MacGyver. I had no idea you were also a legislative expert as well as a non-provider PA expert. I guess my role as a consultant to the state legislature for some PA issues was not enough to formulate a response to your personal knowledge base. If you think that physician groups sit back and take a passive role in PA scope of practice, you are again wrong. Physician groups sit back when the increase in practice rights benefits them as well. Don't forget who makes all the money off PA's...the docs you smart guy!! But I have personally seen times when physician groups literally jump out of their passive stupor to suppress even the thought of certain ideas. I saw it when insurance companies were considering putting PA's in their provider book as a PCP a patient could choose. This never made it into the capital building. You are arrogant if you think that PA lobbyists stand a chance ever against big medicine lobby. PA groups don't have the budget to lobby to this degree anyway, and know where to draw the line. PA's only make headway in the legislative arena when it is backed by physician groups. I challenge you to show me a substantial example to the contrary. There has never been a major piece of PA legislation passed that had overwhelming opposition from physicians. And don't quote me some bill that passed where 4 physicians were against it. Show me something substantial. And we are all still waiting to hear what your credentials are that give you the wherewithal to make such predictions Mac. People like you give the PA profession the reputation of wanting to become independent practitioners away from docs. That would spell then end to the PA profession. Look what happened to the NP's. Even though there are 4 times as many NPs as PA's, and they in theory have more practice rights, physicians universally despise them more and pay them less because of it. The PA approach has always been to practice team medicine under the supervision of a physician. That is why PA's make more money, get to eat in the physician's dining room, and routinely are treated as equals among physicians. Once people like you push for PA's to become replacements for physicians in any setting, the docs will take their gloves off, and trust me, they have a harder punch than any legislative body second only to the trial lawyers. Be careful what you predict and wish for. Be happy with a 6 figure salary, playing doctor, and getting nearly the same rewards. Try and change that and life can only get worse for PA's.

 

[FMLizard]

You forget the most powerful lobby of all...corporate America, i.e. managed care. Unless every MD and DO in this country were to flat out strike in protest, non-physician providers will continue to gain scope and prevalence. It is simple economics. Many of these organizations are driven by a bottom line, and couldn't care less about experience, quality of care, or even basic knowledge. If NPs and PAs can do it for less, they will continue to encroach on the docs for as long as someone has a financial interest in medicine.

 

[deleted6669]

fyi- pa's do cardiac caths at duke medical center after completing a fellowship with interventional cardiologists.their outcome numbers are comprable to residents doing the same procedures. there are probably other places this is done but the duke experience is the one most often quoted.

 

[smackdaddy]

yes there are many places where pa's participate in cath.
but the OP said fully unsupervised.
i can't believe that duke claims they are ready to perform unsupervised cardiac catheterization.

 

[deleted6669]

FROM THE DUKE MEDICAL CENTER WEBSITE:THIS WAS A RECENT STUDY CONCERNING SUPERVISED CATHS-

ORLANDO, Fla. -- A study by Duke University Medical Center researchers has shown that
physician assistants, with proper training can successfully perform cardiac catheterizations.

"Under the careful supervision of experienced attending cardiologists, trained physician
assistants can perform diagnostic cardiac catheterization, including coronary angiography, with
procedural times and complication rates similar to those of cardiology fellows. This is the first
large study that demonstrates that this is a safe practice," said Dr. Richard Krasuski, a Duke
cardiology fellow who led the study which was presented Wednesday at the 50th Annual
Scientific Session of the American College of Cardiology.

Physician assistants (PAs), who originated at Duke in the 1960s, work with physicians to provide
diagnostic and therapeutic patient care in virtually all medical specialties and settings. Cardiac
catheterization involves threading a thin catheter through a patient's arteries until it reaches the
heart. X-ray dye is then injected to determine if the arteries are blocked.

"With cardiac catheterizations increasing more than 300 percent during the last 10 years,
physician assistants have begun performing more of these procedures under the supervision of
cardiologists. However, there was insufficient evidence before this to support whether this was a
safe practice," Krasuski said.

The Duke study compared 929 diagnostic cardiac catheterizations performed by PAs with
supervision by a cardiologist to 4,521 catheterizations performed by cardiology fellows.
Cardiology fellows are physicians receiving three to four years of advanced training in cardiology
after completing an internal medicine residency. The procedures were performed at Duke
between July 1998, when PAs were first given approval by the institution to perform the
procedure, and April
2000. The patients in the two groups were of similar demographics.

The study showed that the incidence of major complications, such as myocardial infarction (heart
attack), stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema
requiring mechanical ventilation and vascular complications requiring surgical intervention, were
nearly identical in both groups. For PAs, the complication rate was
0.54 percent as compared to a
0.58 percent complication rate for cardiology fellows.

Additionally, the cases performed by the PAs were done more quickly (
70.2 minutes versus
72.6 minutes by the cardiology fellows), and used less fluoroscopic time (
10.2 minutes as compared to
12.2 minutes). Krasuski noted that the time and fluoroscopic differences were most likely due to
the fact that the patients treated by the fellows were slightly sicker.

"We are not saying that PAs should replace doctors in performing cardiac catheterizations or
should be stand-alone operators. What this study shows is that this is a skill that can be learned
and successfully performed by PAs, thus permitting cardiologists to become more efficient in the
cath lab while maintaining excellent patient care," Krasuski said.

Krasuski added that with the involvement of PAs, cardiologists are freed up to interpret data
generated by the catheterization, plan the patient's follow-up care and even consult with
referring physicians while the case is still going on.

PAs must receive approximately one year of specialized training to properly perform the
procedure. Additionally, they must have advanced life support training, remain up-to-date on the
latest techniques and information on catheterization and be approved by cath lab directors and
faculty to perform catheterizations. Furthermore, cardiologists must be present in the
catheterization suite supervising the PAs and be ready to take over the case should
complications arise.

Joining Krasuski in the study were Dr. John Warner, Dr. Andrew Wang, Dr. J. Kevin Harrison,
John Bolles, Erica Moloney, Carole Ross, Dr. Thomas Bashore and Dr. Michael Sketch Jr.








































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[smackdaddy]

the way i read that article is supervised. are you seeing something i am not?

 

[deleted6669]

I agree. my only point was that pa's are doing them. at duke they are supervised. elsewhere they might not be....

 

[eddieberetta]

Originally posted by emedpa
I agree. my only point was that pa's are doing them. at duke they are supervised. elsewhere they might not be....

Lucky patients!