Plans to enable non-doctors to become surgeons were announced yesterday

[toughlife]

HOw long before this idea comes to the US and midlevels begin to encroach on surgeons' turf?

http://www.timesonline.co.uk/articl...1540507,00.html



Nurses, physiotherapists and operating theatre assistants will all have the opportunity to train to perform minor surgery.

The government launched a consultation on setting up a training programme for surgical care practitioners.

Practitioners have been in place since 1989 - but the aim of the new programme is to encourage more staff to take on the role.

Under supervision of a surgeon, the practitioners would perform minor surgery and run out-patient clinics for care before and after operations, under the proposals.

The department of health said this would boost medical training as many of these routine tasks are performed by junior doctors.

Hugh Phillips, president of the Royal College of Surgeons, said it welcomed surgical care practitioners as members of the extended surgical team.

He said: "The College has enshrined in the curriculum framework for surgical care practitioners, the standards it will expect of those qualifying to practice in this role, and will continue to influence their development. The College would wish to approve those institutions that would offer programmes of education and training".

Health minister Lord Warner said: "The NHS is working hard to give patients faster access to care. By developing the roles of healthcare staff we are able to offer patients skilled practitioners who are able to carry out simple surgical procedures - freeing up doctors to deal with more difficult cases."

But the British Medical Association said it was puzzled as to how the scheme would work - and warned it could place "significant demands" on the time of consultants.

Simon Eccles, chairman of the BMA’s Junior Doctors’ Committee, said patients had a right to know if their operation was not being performed by a doctor.

He said: "We welcome well-thought out measures to expand the clinical team, expand capacity to perform operations, and for nurses to extend their skills into areas such as minor surgery.

"But we are concerned over how these proposals would be implemented. Doctors in training must get as much experience as possible to hone their skills, as they train to be the surgeons of tomorrow."

http://www.staffnurse.com/nursing-n...geons-1142.html

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Members don't see this ad.

 

[cyanocobalamin]

I've already watched APRNs and PAs do almost entire procedures in ortho, ob/gyn surgery, and surgery. So what's new? Every field has midlevels gaining more and more abilities: CRNAs in anesthesia, APRNs in medicine, family medicine, and peds...

HOw long before this idea comes to the US and midlevels begin to encroach on surgeons' turf?

http://www.timesonline.co.uk/articl...1540507,00.html



Nurses, physiotherapists and operating theatre assistants will all have the opportunity to train to perform minor surgery.

The government launched a consultation on setting up a training programme for surgical care practitioners.

Practitioners have been in place since 1989 - but the aim of the new programme is to encourage more staff to take on the role.

Under supervision of a surgeon, the practitioners would perform minor surgery and run out-patient clinics for care before and after operations, under the proposals.

The department of health said this would boost medical training as many of these routine tasks are performed by junior doctors.

Hugh Phillips, president of the Royal College of Surgeons, said it welcomed surgical care practitioners as members of the extended surgical team.

He said: "The College has enshrined in the curriculum framework for surgical care practitioners, the standards it will expect of those qualifying to practice in this role, and will continue to influence their development. The College would wish to approve those institutions that would offer programmes of education and training".

Health minister Lord Warner said: "The NHS is working hard to give patients faster access to care. By developing the roles of healthcare staff we are able to offer patients skilled practitioners who are able to carry out simple surgical procedures - freeing up doctors to deal with more difficult cases."

But the British Medical Association said it was puzzled as to how the scheme would work - and warned it could place "significant demands" on the time of consultants.

Simon Eccles, chairman of the BMA’s Junior Doctors’ Committee, said patients had a right to know if their operation was not being performed by a doctor.

He said: "We welcome well-thought out measures to expand the clinical team, expand capacity to perform operations, and for nurses to extend their skills into areas such as minor surgery.

"But we are concerned over how these proposals would be implemented. Doctors in training must get as much experience as possible to hone their skills, as they train to be the surgeons of tomorrow."

http://www.staffnurse.com/nursing-n...geons-1142.html

 

[Ross434]

Who cares about Britain.. is their healthcare system the same as the US? no.

 

[mddo2b]

HOw long before this idea comes to the US and midlevels begin to encroach on surgeons' turf?

http://www.timesonline.co.uk/articl...1540507,00.html



Nurses, physiotherapists and operating theatre assistants will all have the opportunity to train to perform minor surgery.

The government launched a consultation on setting up a training programme for surgical care practitioners.

Practitioners have been in place since 1989 - but the aim of the new programme is to encourage more staff to take on the role.

Under supervision of a surgeon, the practitioners would perform minor surgery and run out-patient clinics for care before and after operations, under the proposals.

The department of health said this would boost medical training as many of these routine tasks are performed by junior doctors.

Hugh Phillips, president of the Royal College of Surgeons, said it welcomed surgical care practitioners as members of the extended surgical team.

He said: "The College has enshrined in the curriculum framework for surgical care practitioners, the standards it will expect of those qualifying to practice in this role, and will continue to influence their development. The College would wish to approve those institutions that would offer programmes of education and training".

Health minister Lord Warner said: "The NHS is working hard to give patients faster access to care. By developing the roles of healthcare staff we are able to offer patients skilled practitioners who are able to carry out simple surgical procedures - freeing up doctors to deal with more difficult cases."

But the British Medical Association said it was puzzled as to how the scheme would work - and warned it could place "significant demands" on the time of consultants.

Simon Eccles, chairman of the BMA’s Junior Doctors’ Committee, said patients had a right to know if their operation was not being performed by a doctor.

He said: "We welcome well-thought out measures to expand the clinical team, expand capacity to perform operations, and for nurses to extend their skills into areas such as minor surgery.

"But we are concerned over how these proposals would be implemented. Doctors in training must get as much experience as possible to hone their skills, as they train to be the surgeons of tomorrow."

http://www.staffnurse.com/nursing-n...geons-1142.html

This is a topic that pisses me off....every field in medicine has given an increasing role of care to midlevel practioners. The problem is that now they want licences to practice on their own. The thing i cant undrstatnd is why the puplic is not in an uproar. When i tell my family about cases that i have preformed, they all say the same thing, :if i were to go for surgery there is no way i would let a resident do the case, i am paying for the attending and thats wheat i want. Yet they have no problem going to the OBGYN or internest and being seen by a non-physician...WHY? There is a reason that we go through the torture of med school and residency, because that is how long it takes to learn the material. When r docs going to wake up and put these mid level practioners in place. All i can sayis that when a PA at my institution starts to get too big for their britches, i remind them that PA stands for Physician ASSISTANT (or as i prefer, PA stands for Please Ask, because u r NOT A DOCTOR

 

[Tenesma]

it is just a matter of time before this becomes true in this country --- heck i have seen a cardiac PA open a chest, go on bypass, harvest the veins, prep the veins, come off bypass, place chest tubes and close the chest (sometimes without the surgeon in the room!!! - at a community heart hospital)...

just look at the strength of midwives in OB, NPs in ER/FP and CRNAs in Anesthesia... while this will help the surgeons lifestyle - it will end up causing the same headaches.

 

[kendall]

what???????

a PA doing and ortho case? a PA doing a bypass case? i have NEVER EVER EVER EVER even heard of such. wow. that is really fu%#'d up. i can't imagine any surgeon signing off on an open procedure done by a PA. again, wow.

k

 

[Blade28]

it is just a matter of time before this becomes true in this country --- heck i have seen a cardiac PA open a chest, go on bypass, harvest the veins, prep the veins, come off bypass, place chest tubes and close the chest (sometimes without the surgeon in the room!!! - at a community heart hospital)...

WOW. And all the CT surgeon did was the proximals and distals? The PA did everything else? That's a scary thought...

 

[Tenesma]

at that hospital the CT surgeon would see the patient in the morning in the CICU to confirm go-ahead for the case... then we would see him again to review the vein grafts, do the distals (the proximals were done w/ the PA), assist w/ hemostasis and then leave to talk to the family. This was for routine straight-forwards CABGs. total time in the OR approx 45-55 mins. Totally different situation for redos, valves, IABP, etc...

 

[fourthyear]

Doesn't seem quite fair - a resident is rarely allowed this much autonomy these days, even at the cheif level to do such a huge portion of a case without the attending even in the room.

And what do you think the patients would say if they knew the surgeon wasn't even doing most of the operation?

I know some patients might not like the idea of residents, especially interns, operating on them...but at least the "real" surgeon has to stand over their shoulder watching them and will take over if the resident is in danger of really messing something up. And at least the patients are generally aware upfront that they are at a teaching hospital and that having residents operate on them is part of the deal - I really doubt they are aware that such a huge portion of the surgery is being done by a PA or NP.

I mean, I might be okay with PA's and NP's doing minor office procedures at the level a family practicioner or ER doc might - but major cardiac surgery should be done by a fully trained surgeon.

Come on, I'm sure we could train airline mechanics to fly a plane and they could do a great job - but everyone demands a fully trained and liscenced pilot - b/c even a routine flight/surgery can get complicated and you want someone as highly trained as possible to handle these complications. The general public would never get on a plane that was knowingly piloted by a non-pilot and I don't think they want to have major surgery done by a non-surgeon!

 

[cyanocobalamin]

Doesn't seem quite fair - a resident is rarely allowed this much autonomy these days, even at the cheif level to do such a huge portion of a case without the attending even in the room.

And what do you think the patients would say if they knew the surgeon wasn't even doing most of the operation?

I know some patients might not like the idea of residents, especially interns, operating on them...but at least the "real" surgeon has to stand over their shoulder watching them and will take over if the resident is in danger of really messing something up. And at least the patients are generally aware upfront that they are at a teaching hospital and that having residents operate on them is part of the deal - I really doubt they are aware that such a huge portion of the surgery is being done by a PA or NP.

I mean, I might be okay with PA's and NP's doing minor office procedures at the level a family practicioner or ER doc might - but major cardiac surgery should be done by a fully trained surgeon.

Come on, I'm sure we could train airline mechanics to fly a plane and they could do a great job - but everyone demands a fully trained and liscenced pilot - b/c even a routine flight/surgery can get complicated and you want someone as highly trained as possible to handle these complications. The general public would never get on a plane that was knowingly piloted by a non-pilot and I don't think they want to have major surgery done by a non-surgeon!

In the cases I've seen with "substantial" to complete PA/APRN involvement the attending was always there.

 

[Dupree]

--- heck i have seen a cardiac PA open a chest, go on bypass, harvest the veins, prep the veins, come off bypass, place chest tubes and close the chest (sometimes without the surgeon in the room!!! - at a community heart hospital)...

I call B.S.
Especially the part about going on and coming off bypass.

 

[SteadyEddy]

Actually...I've seen some of the same at one of the community hospitals we train at. I too am not sure though about the bypass part. Maybe a little bit of a stretch

I call B.S.
Especially the part about going on and coming off bypass.

 

[Tenesma]

a bit of a stretch about bypass????

1) going on bypass: cannulate the aorta, then cannulate the IVC - then turn on bypass machine after heparinization....

2) coming off bypass: slowly wean off the bypass machine after warming up the patient - maybe overdrive pace the heart as well, and if everything looks good with some tone support, decannulate and reverse heparinization...

it doesn't take a CT surgeon to do this for a "healthy" CABG, especially since at most community hospitals (where speed/efficiency are more important than ego-stroking) the cardiac anesthesiologist coordinates coming off pump...

the only reason to have the CT surgeon when coming off pump is 1) if the pump run has been long and there may be a need for IABP 2) a bunch of jump grafts that are shoddy to begin with 3) a cruddy aorta with concern of dissection with decannulation, etc....

so should the CT surgeon be there for patients that are out of the ordinary? absolutely.... but in a community hospital setting doing 1st time CABGs on pts who are otherwise not compromised, the surgeons are able to do 3-4 cases per day (and make TONS of money) by delegating the minor components of the surgery to surgical assistants who have done tons of these cases....

the only reason why i brought this up as an example, was to show that it is just a matter of time where PAs and NPs will be perform minor surgeries - maybe even independently.... and this will pose huge problems for the surgical community (from a reimbursement point of view as well as a litigation issue)...

my 2 cents

 

[cyanocobalamin]

I call B.S.
Especially the part about going on and coming off bypass.

I've seen a PA harvest the saphenous vein for CABG at a hospital I've rotated through.

 

[jimdoc]

But Tenesma is right on.....I personally witnessed a very advanced fellow complete an entire case with a PA as the attending was in the next OR with a LVAD going bad.....For a typical CABG, at my hospital it was routing for the attending to come in only for the distal anastamosis and for coming off of pump.........
Heart surgery is very technical, and good technicians do very well in it whether they have been to med school or not.....

 

[CTS-PA]

"Heart surgery is very technical, and good technicians do very well in it whether they have been to med school or not....."

This is true to some extent; though it is very technical, nothing in CT-Surgery is simple. To get the point where a PA is doing all the stuff Tenesma wrote about you have to exceptionally good at what you do and very experienced. Most PAs work with the Surgeon with a reasonble degree of lattitude based on their training, experience, working relationship and the PAs abilities.

Just realize one thing, these Surgeons have spent countless years of post graduate training to get where they are, and they would not compromise their reputation or their patient's life by leaving an incompetent person to care for their patient.

To learn more about PAs in Cardiovascular and Thoracic Surgery check out Association of PAs in Cardiovascular Surgery and read the endorsement statements from the Society of Thoracic Surgeons and the American Association of Thoracic Surgeons or you can PM me.

"PA stands for Please Ask, because u r NOT A DOCTOR" by mddo2b
...Why are you so angry dude?

 

[Dupree]

We need to get back to the good old days when surgeons ran the show and operated on patients themselves without outsourcing the work to a proxy.

 

[CTS-PA]

"....the good old days"....Dupree

"...Dr. Robert H. Goetz performed what appears to be the first clearly documented coronary artery bypass operation in a human, which was successful. The surgery took place at Van Etten Hospital in New York City on May 2, 1960..." History of Cardiac Surgery - L. Stephenson MD

"In 1973 two Physician Assistants were first employed by the division of Cardiothoracic Surgery of the Emory University School of Medicine..." The Surgical PA as a Member of the Cardiothoracic Surgical Team in the Academic Medical Center - W. Williams MD.

As stated above, a mere 13 years after the advent of 'Modern' Bypass Graft Surgery, PAs were working in this field. The truth of the matter is PAs have been around since the good old days, you should ask some of the Old School Surgeons.

 

[Winged Scapula]

Actually...I've seen some of the same at one of the community hospitals we train at. I too am not sure though about the bypass part. Maybe a little bit of a stretch

I've seen it too. Matter of fact, caused a bit of contention amongst the surgery residents who were "allowed" to do very little while the PAs were doing most of the case with the fellow or attending.

 

[iliketocut]

The problem I see with giving PA's and other non-MD's more autonomy in the OR is that we are in a way devaluing what surgeons do. As residents, we spent four years in med school, will spend 5-7 years in surgical training and then go on to fellowship (possibly). To allow someone with significantly less education do the same things is insulting. My program is a large, urban teaching hospital and our chairman absolutely refuses to allow PA's in the OR. They handle the floors while the residents are in the OR, do discharge paperwork, etc. My understanding is that their title is "physician ASSISTANT, " not physician, surgeon, etc. I am not trying to put anyone down, this is simply a fact. I guess other programs feel differently than we do.

 

[Tenesma]

iliketocut - while i can understand your gut instinct, i don't think anybody plans to use PAs, NPs etc to be equivalent to surgeons. However, they will be used as surgeon-extenders, performing tasks that surgeons feel can be done safely within a set of algorithms/protocols (and in many circumstances already are).... the issue is the devolution/evolution of those uses...

as far as "handling the floors" - at first there was great opposition to letting PAs/NPs run the floors, and the 80 hour work week has really increased their numbers on the floors. As somebody who has worked with PAs, NPs (quite a few who have been around for >10 years), I often had to clean up their messes (ie: they overlooked issues, over-treated other things, or just misinterpreted data) on a regular basis -

I believe we should be very careful in how we use our physician extenders, continue providing the supervision they need, and be attentive to their lobbying/political goals of increased independence (for ego/financial reasons on their part)....

 

[iliketocut]

I absolutely agree. I think it is up to physicians to determine the appropriate use of physician extenders and to understand the limits of NP's and PA's. It sounds like, from reading some of these posts, that certain places allow non-physicians to have more autonomy than others. Although our surgery department stricly limits the use of non-physician extenders, our emergency department and trauma bay are more liberal. In these venues, I have seen NP's and PA's take more liberties than they should, often making critical mistakes because they overestimate their abilities/knowledge. I have also seen residents approach them (in a bengin, professional way) to question them and they immediately become hostile and defensive. The attending, caught in a tricky situation, usually ends up telling the resident to "ignore it" and never really addressing the situation. This is not good for patients.

 

[MacGyver]

Why do I always have to straighten you guys out around here?

PAs and NPs ARE NOT EQUAL THREATS. NPS ARE MUCH, MUCH MORE THREATENING THAN PAS ARE.

The reason is because the PA scope of practice, by state law, is regulated by the state medical board, which is controlled by doctors. PAs cant get an increased scope of practice unless the state medical board authorizes it.

Now, contrast that situation to NPs, in which state NURSING boards control the scope of practice. I guarantee you if NPs start to encroach in the surgical theatre, its only a matter of time before the state NURSING BOARDS write new scope into their regulations allowing NPs to expand. Doctors would have NO SAY over this, since state law dictates that only the state nursing board has authority to determine scope of practice.

Surgeons whoring their profession out to PAs is unethical and slimy. Whats even worse is surgeons allowing NPs to infiltrate the field under the veil of "supervision." What the surgeons fail to realize is that at the drop of a hat, the state nursing boards have full authority to REMOVE SUPERVISION as a requirement. If enough NPs start working in surgery with sham supervision (i.e. doc is in another operating suite) they will have all the ammo they need to do just that.

As with gas and opthos and IM and FP and every other medical field, the reason these "outsiders" ever got involved was because a few greedy ass doctors decided they wanted to make $$$$ by "supervising" these people. Over time, these ****** realized they could make even MORE $$$ by setting up sham supervision rules.

Why just supervise one PA/NP when you can supervise 5 of htem simultaneously while you are in another hospital doing a totally different procedure? Meanwhile, the PA and NPs are taking notes about their "supervision." Eventually they run off to the state legislatures and nursing boards, claiming that their scope should be increased because they are already doing these procedures as DE FACTO solo practioners because of the sham supervision rules set up by the greedy doctors.

And where are those greedy doctors when the scope of practice regs are changed and midlevels now have full autonomy? They are retired, living the good life with the millions they made by "supervising" these outsiders. They could care less about what the future of the profession is, or how these outsiders have totally tainted the field. You want to stop the influx of these outsiders? Tell your greedy ass attendings to stop whoring out the profession so they can retire to a private island in the Bahamas.

 

[iliketocut]

Also, there was an article in Time or Newsweek recently and the title was "Who Needs Doctors?" and it went on to talk about NP's and PA's and how valuable they are and how some patients prefer to see them over doctors (in the primary care setting). The other problem is that the public is not educated regarding what a PA is and what an NP is and how their skills and knowledge compare to that of doctors. I think the common theme in this thread is that doctors need to step up and be more responsible about the use of non-physician extenders. Despite what McGyver said, doctors are in ultimate control of what goes on, particularly in the operating room. To test that, let's have no surgeons show up on an operative day at a busy hospital. The surgeries cannot and will not start regardless of how many PA's and NP's are around.

 

[cyanocobalamin]

Why do I always have to straighten you guys out around here?

PAs and NPs ARE NOT EQUAL THREATS. NPS ARE MUCH, MUCH MORE THREATENING THAN PAS ARE.

The reason is because the PA scope of practice, by state law, is regulated by the state medical board, which is controlled by doctors. PAs cant get an increased scope of practice unless the state medical board authorizes it.

Now, contrast that situation to NPs, in which state NURSING boards control the scope of practice. I guarantee you if NPs start to encroach in the surgical theatre, its only a matter of time before the state NURSING BOARDS write new scope into their regulations allowing NPs to expand. Doctors would have NO SAY over this, since state law dictates that only the state nursing board has authority to determine scope of practice.

Surgeons whoring their profession out to PAs is unethical and slimy. Whats even worse is surgeons allowing NPs to infiltrate the field under the veil of "supervision." What the surgeons fail to realize is that at the drop of a hat, the state nursing boards have full authority to REMOVE SUPERVISION as a requirement. If enough NPs start working in surgery with sham supervision (i.e. doc is in another operating suite) they will have all the ammo they need to do just that.

As with gas and opthos and IM and FP and every other medical field, the reason these "outsiders" ever got involved was because a few greedy ass doctors decided they wanted to make $$$$ by "supervising" these people. Over time, these ****** realized they could make even MORE $$$ by setting up sham supervision rules.

Why just supervise one PA/NP when you can supervise 5 of htem simultaneously while you are in another hospital doing a totally different procedure? Meanwhile, the PA and NPs are taking notes about their "supervision." Eventually they run off to the state legislatures and nursing boards, claiming that their scope should be increased because they are already doing these procedures as DE FACTO solo practioners because of the sham supervision rules set up by the greedy doctors.

And where are those greedy doctors when the scope of practice regs are changed and midlevels now have full autonomy? They are retired, living the good life with the millions they made by "supervising" these outsiders. They could care less about what the future of the profession is, or how these outsiders have totally tainted the field. You want to stop the influx of these outsiders? Tell your greedy ass attendings to stop whoring out the profession so they can retire to a private island in the Bahamas.

In the end it all comes down to evidence. Whatever the evidence shows as safe and efficacious will be allowed, and whatever is most cost effective will be adopted by insurance companies. The public may "care" but there's really only so much they can do. In the end, it seems like most issues of the day will run based on money flows and medical-legal issues.

The trend will only advance, so adopting and making the best of the situation seems wise.

 

[Denial]

I had the same issue with the PAs in my program! THis cretin would delegate me the consults and then leg into the OR even if it meant holdin the retrator.It took me a swollen month to discern this pattern. She would soak up all the gravy and I would be dictating H and P and consults!
After that month I told her squarely! Dude ! I am going to the OR if when there is a case on my service. IF I have a CONSULT I would scrub and you would consult. After this candor I was scrubbing a whole lot. I was ready to bring my program director into this if things dirty etc.

 

[iliketocut]

I just don't understand why in ANY situation the PA would go to the OR over the resident. It does not make sense. Didn't the attendings ask where the resident was? And why is she delegating to you? Please explain...

 

[Tenesma]

there are a few reasons why a PA would go to the OR over the resident -

1) the surgeon is in a rush and wants to work with somebody they have worked with for several years....
2) some of the patients on the floor may be too complicated for a mid-level, and therefore they need the attention of the resident instead of the PA
3) at some programs PAs are very powerful (especially if the surgeon has hired them privately, long work-association, etc...)

 

[iliketocut]

You know what, that's a shame. Surgical residents are in training to learn to be surgeons. PA's are not. Any program that has attendings who would prefer to have a PA in the OR than the residents they selected to train is a weak program.

And Tenesma, if you are a surgical resident and are defending this, that is also a little strange...

 

[Tenesma]

1) In NO WAY am i defending this - I find it very sad - but a true development that we as physicians have to be more conscious of. As residents all of us would be dismayed at this behavior - However as attendings outside the serious academic environment, don't be surprised that attending-colleagues will choose their PAs over residents if money and speed are their primary motivator --- and this is a problem for resident education.

- i am just providing food for thought on the reality of community programs or certain academic environments...

pS: i am an anesthesia attending

 

[Denial]

You know what, that's a shame. Surgical residents are in training to learn to be surgeons. PA's are not. Any program that has attendings who would prefer to have a PA in the OR than the residents they selected to train is a weak program.

And Tenesma, if you are a surgical resident and are defending this, that is also a little strange...

Hey the PAs sneak into to the OR saying that the intern is in the middle of a consult that she started and will scrub as soon as she is done.
THis I nipped it in the bud. THis would only happen to NEW interns! NOT THE RESIDENTS( PGY-2 etc).
The things get stickier when there are PA students training! Then they go to the OR to watch and crowd the table . THen when I get to close it is up to me to let them staple etc. Then you just feel bad.

 

[iliketocut]

Tenesma-don't take this the wrong way, but why are you posting on this thread as an attending? Don't you have other things to do, seriously?

 

[Pir8DeacDoc]

he's probably a little more open to midlevels in the workplace as an anesthesia guy.

 

[Tenesma]

iliketocut...

i broke my leg and am stuck at home w/ a laptop and can't move very far - so this is my entertainment/brain distraction... trust me, there are many other things i'd like to do!

the reason i posted is that the midlevel issue is a big one - it has brought the anesthesia profession to its knees and I am hoping you guys can avoid the same pitfalls...

 

[iliketocut]

Gotcha. Sorry about the leg. I'm sure you guys are feeling the burn with CRNA's and everything, I don't think it will ever get to the point where PA's are completely substituting for surgeons. Patients would never go for it. And in academic institutions, it IS NOT an accepted practice to have PA's go into the OR before residents. I think my chairman would quit before that ever happened.

 

[Visioncam]

Optometrists have started to do surgery in Oklahoma. It is expected that they will do more surgery in the near future because of change in regulations. MD's have no role in regulating or protecting patient safety in terms of optometrists getting state authority to do surgery.

Other specialties can shrug their shoulders but inaction will eventually hurt the entire medical profession and the public.

It would not be shocking to see non-MD psychologists practice psychiatry, CRNA do the work of anesthesiologists, optometrists (none of whom go to medical school) do the work of ophthalmologists (MD/eye surgeons), and nurse surgeons do lap cholecystectomies/breast biopsy/inguinal herniorrhaphies. Some of this has already started.

 

[iliketocut]

Please name the hospitals this is happening in. This is all news to me. I've never heard of a nurse/surgeon and I don't think one exists.

 

[adamdowannabe]

Although my name says DO wannabe,

I applied to. and got accepted to both PA and Osteopathic med school,

I decided to go with a PA program, (for many reasons)

You guys scream and yell about how PA's don't have the training, yada yada yada, and how on earth can a PA be allowed to perform some of the surgical tecniques you are hearing that they are delegated, but yet you never seem to take to brain, that PA's spent 3 didactic semesters to your 4...... and 3 rotation semesters to your four...... (skipping the hadcore specialties of medicine....and spending time on the generals) then, PA's get to work, or do a surgical residency YES, a SURGICAL RESIDENCY.... about 15 schools have ortho and general sugical residencies, Identical to a PGY1 surgical year, the same 80 hour weeks, ER call at least once a week...the whole scut monkey experience, then they WORK, and are required more CME then physicians, and a board re-certification every 6 years, PA's don't stop learning after school......

Are you guys seriously saying a PA who has been working in surgery for 5,6,7..... 10 years in CVT, hasn't picked up the hands to perform surgery?

Heck, a ROBOT does better surgery then a human surgeon, it's dexterity and PRACTICE,

you should all briefly read about the "shouldice Hospital" hernia factory, it's a bunch of MD's (none of them surgeons) who trained to just repair hernias, they have the shortest average surgery time, 45 mins, and ~1% recurrance rate, simply put they are the best.....because all they do is hernias,

I would rather take a CVT PA who ONLY DOES the same saphenous harvesting day in and day out, then a surgical resident that is running through specialties............

The resident's previous experience, although intense, does not make them any better at "doing surgery" then a PA with the same experience, just because the PA spent less time reading books on the specifics of embryology, and all the other info you learn, spit back on the USMLE, then never have to recall again.

Also, PA's were designed to fill a physician shortage, rapidly educated and trained in only the really important aspects of medicine (the everyday stuff) and the PA student typically has 5-10 years of previous health care experience.... (where the medical student before medical school hasn't even seen or typically touched on Human A&P) The experinces allows the future PA, to be able to apply the information effectively at didactic phase, creating a more effective usefull mental storage of the info!

(and you can flame me all you want, I took all the same pre-meds you did, took the same MCAT you did, got into medical school just as you did....) I am not some sad med school reject!

 

[adamdowannabe]

I totally agree, what makes an excellent surgeon, is someone who knows what needs to happen, when, and how..... and that takes a true undertanding of the material, the years of experience the surgical residency offers......

Here is where one of the reasons I opted for a career as a PA instead of dedicating my life to becoming a surgeon..... in the current state of managed care, I have been told (by physician friends and physician family) everyone answers to someone, and everyone collaberates. A doctor who thinks he knows everything, and doesn't themself get a second opinion on a tough case, is a scary thing........ just as a PA is trained to know their limits, and only do what they are capable of......a good doctor shouldn't assume they know it all.... and now it seems that the ultimate say, the one EVERYONE answers to, is some business man at an insurance company, who's bonus is the main agenda, not the best suited healthcare for the sick.

Even in the cases of the decision making, computers are more effective and more accurate when you plug in all the signs/symptoms, then a human going on gut feeling, but we all seem to like the idea that Doctors are something special and their gut feeling holds some power, unfortunately, computers are still better (sad I know....)

Not to bash medicine, because I have longed to practive medicine since I was a young person, but medicine as a career.....being a doctor, is like being a monkey, you get taught to look at all the facts and fit the best decision from the options.

Based on research, individuals with very high IQ, and problem solving potentials do not become physicians, they persue PhD and research careers, medicine isn't changed by practicing MD's and DO's, its changed by PhD's, (the physiologist, Biochemist, bio-engineers) we as future doctors (and PA) pretty much do what we are told, until we know to do on our own, not that we have really made the decision, but, a surgeon has seen something 10,000 times, and done it 5 thousand times, and is good at it, and knows what needs to happen and does it, and the individuals that take on the new and the unfamiliar, are the "BEST of BEST" they sit down and plan with each other, they ask everyone and their mom for an opinion. Superman surgeon doesnt' come sweeping in with all the answers.

 

[Tenesma]

adam.... you live in a fantasy world - but i understand that you actually need to believe everything you wrote just to justify your career choice!!

 

[mddo2b]

I have heard all these arguments before, and all i can say is enough...There is a reason that residencies are as long as they are...because that is how long it takes to learn the techniques needed to not only perform the surgery, but also how to handle the UNEXPECTED. This is the biggest argument against the SHOLDICE institute. Even though complications are rare in somethin like a hernia repair, i have seen them. What happens when you mistakenly nic a major vessel, or perf the bowel...what do they do...call the surgeon. I am so tired of wanna be docs, learning to perform a proceedure, and then when they get a complication they go running for help. Enough!
As far as the embryology example, again, another example of ignorance...embryology teaches us to understand the variations we see everyday in surgery. So yes i learned embryo, and it was on the boards and yest i use it often in the OR. When will you guys get it....PA stands for physcian ASSISTANT...so do your job and assist, and leave the medicine to the doctors.

 

[Denial]

I totally agree, what makes an excellent surgeon, is someone who knows what needs to happen, when, and how..... and that takes a true undertanding of the material, the years of experience the surgical residency offers......

Here is where one of the reasons I opted for a career as a PA instead of dedicating my life to becoming a surgeon..... in the current state of managed care, I have been told (by physician friends and physician family) everyone answers to someone, and everyone collaberates. A doctor who thinks he knows everything, and doesn't themself get a second opinion on a tough case, is a scary thing........ just as a PA is trained to know their limits, and only do what they are capable of......a good doctor shouldn't assume they know it all.... and now it seems that the ultimate say, the one EVERYONE answers to, is some business man at an insurance company, who's bonus is the main agenda, not the best suited healthcare for the sick.

Even in the cases of the decision making, computers are more effective and more accurate when you plug in all the signs/symptoms, then a human going on gut feeling, but we all seem to like the idea that Doctors are something special and their gut feeling holds some power, unfortunately, computers are still better (sad I know....)

Not to bash medicine, because I have longed to practive medicine since I was a young person, but medicine as a career.....being a doctor, is like being a monkey, you get taught to look at all the facts and fit the best decision from the options.

Based on research, individuals with very high IQ, and problem solving potentials do not become physicians, they persue PhD and research careers, medicine isn't changed by practicing MD's and DO's, its changed by PhD's, (the physiologist, Biochemist, bio-engineers) we as future doctors (and PA) pretty much do what we are told, until we know to do on our own, not that we have really made the decision, but, a surgeon has seen something 10,000 times, and done it 5 thousand times, and is good at it, and knows what needs to happen and does it, and the individuals that take on the new and the unfamiliar, are the "BEST of BEST" they sit down and plan with each other, they ask everyone and their mom for an opinion. Superman surgeon doesnt' come sweeping in with all the answers.

ok then dont page a SURGEON when you perf a bowel or hemmorhage a vessle which should never have been touched in the first place. Do it all yourself. And when you are at it ...take the ABSITE also. The truth is that every patient is different and by treatimg them as some item which needs to be repaired in Indutrial sizes is a FATAL mistake. There is this PA i kno who performed a tube thoracostomy ( chest-tube) only he installed the 32 french in the suprapleurally in the arm! under the pectoralis. It was presented to us in the M and M. It is ok to do thi sbut then be prepared to address the situation and dont seize uncontrollably and page surgery!
Another example is a PA who inserted a chest-tube to evacuate a large hemothorax and evacuated like more then 2000cc at once leaving the patient in acute reperfusion/reinflation injusry. If only he went to med school and perused what reinflation injury entails! Learn to read Chest xrays and discern the pulmonary edema which was iatrogenic to start with.

 

[Denial]

I totally agree, what makes an excellent surgeon, is someone who knows what needs to happen, when, and how..... and that takes a true undertanding of the material, the years of experience the surgical residency offers......

Here is where one of the reasons I opted for a career as a PA instead of dedicating my life to becoming a surgeon..... in the current state of managed care, I have been told (by physician friends and physician family) everyone answers to someone, and everyone collaberates. A doctor who thinks he knows everything, and doesn't themself get a second opinion on a tough case, is a scary thing........ just as a PA is trained to know their limits, and only do what they are capable of......a good doctor shouldn't assume they know it all.... and now it seems that the ultimate say, the one EVERYONE answers to, is some business man at an insurance company, who's bonus is the main agenda, not the best suited healthcare for the sick.

Even in the cases of the decision making, computers are more effective and more accurate when you plug in all the signs/symptoms, then a human going on gut feeling, but we all seem to like the idea that Doctors are something special and their gut feeling holds some power, unfortunately, computers are still better (sad I know....)

Not to bash medicine, because I have longed to practive medicine since I was a young person, but medicine as a career.....being a doctor, is like being a monkey, you get taught to look at all the facts and fit the best decision from the options.

Based on research, individuals with very high IQ, and problem solving potentials do not become physicians, they persue PhD and research careers, medicine isn't changed by practicing MD's and DO's, its changed by PhD's, (the physiologist, Biochemist, bio-engineers) we as future doctors (and PA) pretty much do what we are told, until we know to do on our own, not that we have really made the decision, but, a surgeon has seen something 10,000 times, and done it 5 thousand times, and is good at it, and knows what needs to happen and does it, and the individuals that take on the new and the unfamiliar, are the "BEST of BEST" they sit down and plan with each other, they ask everyone and their mom for an opinion. Superman surgeon doesnt' come sweeping in with all the answers.

HOw ******ed no one should think they know everything. TRUE! when you hemorrhage the femoral veins while cardiac cathing ,PAGE A VASCULAR SURGEON!!!! NOT A PA . When you perf a uterus while HYSTEROSCOPY page a GENERAL SURGEON to establish the integrity of the bowel not the PA!!!! Yes everyone should know their limits but a PA should not only be educated to know their LIMITS

 

[Leukocyte]

Edited.

 

[devildoc2]

bump:

Can I get an update on this issue? Is this legit? ARe there really PAs and NPs doing most of the surgery while the attending is on another case?

 

[AlloImmune]

...Based on research, individuals with very high IQ, and problem solving potentials do not become physicians, they persue PhD and research careers, medicine isn't changed by practicing MD's and DO's, its changed by PhD's, (the physiologist, Biochemist, bio-engineers) we as future doctors (and PA) pretty much do what we are told, until we know to do on our own, not that we have really made the decision, but, a surgeon has seen something 10,000 times, and done it 5 thousand times, and is good at it, and knows what needs to happen and does it, and the individuals that take on the new and the unfamiliar, are the "BEST of BEST" they sit down and plan with each other, they ask everyone and their mom for an opinion. Superman surgeon doesnt' come sweeping in with all the answers.

Forgive me if I ask you to cite this "research" that you are referring to. Medicine and especially surgery is and always has been changed by physicians. Surgeons throughout history have not only been gifted technicians, but also the scientists who have made such advances as open heart surgery and organ transplantation.

It is the physicians, who are on the front lines of medical treatment, that must interprate and even direct basic, translational, and clinical medical research. The biochemist may understand the minutia of the chemical reactions and can read about coagulation cascades. The physiologists can create complex animal and in vitro models to mimic what is occuring in humans. However, they have never been in an OR with a patient actively bleeding out. The physician, who is there holding pressure on the wound, is the one who must think, "what else can be done...there must be a better way." It is the physicians who are best able to apply the tools of knowledge provided to us by basic research to correct the problems human disease.

Not every case fits into the neat protocols and criteria defined by the literature. Physicians are trained not only to follow a protocol, but we to strive to understand and to question everything that is occuring. In fact, physicans are responsible for developing these protocols. Much of our training is spent learning to think and to interpret what is occuring in our patients. Especially at academic institutions, the research training of physicians is becoming increasingly important. The addition of 1-3 years of research training into many surgical residencies certainly attests to this fact. You should also note that some surgeons pursue PhDs during medical school or residency, and many MDs (and DOs) very successfully pursue research of their own accord.

 

[boston]

Even in the cases of the decision making, computers are more effective and more accurate when you plug in all the signs/symptoms, then a human going on gut feeling, but we all seem to like the idea that Doctors are something special and their gut feeling holds some power, unfortunately, computers are still better (sad I know....)

Not to bash medicine, because I have longed to practive medicine since I was a young person, but medicine as a career.....being a doctor, is like being a monkey, you get taught to look at all the facts and fit the best decision from the options.

Ok, I know this guy posted over a year ago and probably isn't posting on this forum anymore -- but still, reading this is like listening to somebody drag their nails across a chalk board.

That description was how I saw doctors -- in junior high. Patients aren't just a conglomerate of signs and symptoms leading to a diagnosis. Otherwise, you'd have computer expert systems instead of doctors.

And just because you diagnose somebody with high grade carotid stenosis or rectal cancer, that doesn't equate with reflexively giving them an operation. You're treating a human being, not a disease entity. Granted, a technician can perform the surgery, but it takes judgment to weigh the patient's performance status, life expectancy, quality of life, and the patient's own wishes. A computer won't be able to do that for a long, long time.

 

[Bitsy3221]

Alright, I have to weigh in on this issue.

First off, I WAS a physician assistant in an academic surgical setting before I went to medical school, so I know first hand what a PA education and what an MD education entails. Yes, I chose to go back to medical school because I wanted to be the surgeon on the "big" cases, so that obviously tells you a lot about where I stand on this issue.

Having said that, I will tell you that as a PA I actually knew quite a bit. So much of what a surgeon (or surgical resident, for that matter) does on a regular basis and the knowledge they call upon day after day was NOT learned in medical school, it was learned on the job through years of clinical training. PA school, despite what many of you seem to believe, is NOT easy or a "general overview" of medicine. I worked much harder in PA school than I ever did in medical school. I often used the same textbooks and was required to learn the same amount of material in many classes. In addition, PA school actually did a slightly superior job educating students on the practical aspect of patient care--H&P, interpreting radiologic studies, labs, EKGs, etc. than medical school. (And yes, I did externships and worked with med students from other schools--this is not just a reflection on my school) And I did all the same rotations as the third year med students, took the same mini-boards at the end of the rotations and passed my boards--pretty comparable (though not quite as many questions) as the USMLE Step 2.

When I started working as a PA, I encountered some resistance from residents, but I worked hard and learned a ton and the residents rapidly became very glad to have us. After a couple of years, I was able to function fairly independently, and despite what you may think I (along with pretty much every other PA/NP I know) was very aware of my personal limits--usually more aware than the junior residents who would think they could handle a situation that rapidly got out of control. (As our Chairman says: who is the most dangerous person in the hospital? The third year surgical resident--their ego has grown much faster than their skills!)

When you are all new interns/residents start I urge you not to stomp all over the PAs/NPs with your big-bad-new-doctor shoes. Those providers know the system, likely know more clinical medicine and have taken care of more surgical patients than you and will go drain that peri-rectal abscess for you or change that central line or put in that chest tube--"surgical skills" that are not overwhelmingly difficult--when you have a million other things you have to get done. Will you eventually surpass them in knowledge and surgical skill? Probably, but that is no reason to start throwing statements like "PA stands for 'please ask'" around.

Let me know if in a few years you wouldn't be willing to let a qualified PA or NP get out of bed at 1:30 am to drain a peri-rectal abscess after you have already done 100's of them. Do you really think your surgical education will be compromised if you don't get to do all those straigtforward cases? Doubtful. Trust me--there are enough cases to go around.

 

[Surgeon24]

Hi,

Surgery should be done by a surgeon.

 

[Dunce]

I totally agree, what makes an excellent surgeon, is someone who knows what needs to happen, when, and how..... and that takes a true undertanding of the material, the years of experience the surgical residency offers......

Here is where one of the reasons I opted for a career as a PA instead of dedicating my life to becoming a surgeon..... in the current state of managed care, I have been told (by physician friends and physician family) everyone answers to someone, and everyone collaberates. A doctor who thinks he knows everything, and doesn't themself get a second opinion on a tough case, is a scary thing........ just as a PA is trained to know their limits, and only do what they are capable of......a good doctor shouldn't assume they know it all.... and now it seems that the ultimate say, the one EVERYONE answers to, is some business man at an insurance company, who's bonus is the main agenda, not the best suited healthcare for the sick.

Even in the cases of the decision making, computers are more effective and more accurate when you plug in all the signs/symptoms, then a human going on gut feeling, but we all seem to like the idea that Doctors are something special and their gut feeling holds some power, unfortunately, computers are still better (sad I know....)

Not to bash medicine, because I have longed to practive medicine since I was a young person, but medicine as a career.....being a doctor, is like being a monkey, you get taught to look at all the facts and fit the best decision from the options.

Based on research, individuals with very high IQ, and problem solving potentials do not become physicians, they persue PhD and research careers, medicine isn't changed by practicing MD's and DO's, its changed by PhD's, (the physiologist, Biochemist, bio-engineers) we as future doctors (and PA) pretty much do what we are told, until we know to do on our own, not that we have really made the decision, but, a surgeon has seen something 10,000 times, and done it 5 thousand times, and is good at it, and knows what needs to happen and does it, and the individuals that take on the new and the unfamiliar, are the "BEST of BEST" they sit down and plan with each other, they ask everyone and their mom for an opinion. Superman surgeon doesnt' come sweeping in with all the answers.

The monkey quote was classic !!!!

And by the way, I can confidently guarantee you that my IQ is higher than that of the vast majority of those super hero researchers you speak of . . . and I chose to go into medicine.
Medicine is a highly intellectual field that is far from simple or routine.