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| Looking at the past and the future of Surgical PAs and NPs |
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by Bob Blumm, MA, PA-C, DFAAPA - August 30, 2011
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From 1999 to 2004, I served as the Liaison to the American College of Surgeons representing the AAPA. Part of my job was to attend all general meetings of the College and particularly to be present at the Allied Health meetings as this is where APCs were discussed and decisions were born. This particular year of which I am writing was a positive forward move as some of the most important people in the College spoke to the issues of assistants at surgery. I am presently discarding all of my writings and paperwork of the last 20 years at my wife’s bequest but I am hanging on to a few so that I can do what I am attempting at this moment which is to bring the current APCs to an understanding of our past history and the projections for the future.
On Oct 13, 1999 at 0830, a diverse group of practitioners and administrators descended upon the Mascone center in San Francisco to listen to four speakers who were the assembled first assistants from every group that has this honor. This group consists of surgeons, residents, PAs, NPs, CSAs, CSTCFAs, RNFAs, and Perfusionists, which at that time made up the bulk of assistants at surgery. They were handed a statement or Issue Brief: “The Surgical Physician Assistant---A Summary.” In addition to this brief, they received an article from the Journal of Trauma, Injury, Infection and Critical Care entitled: ”Use of physician assistants (generic) as surgery, Trauma House staff at an American College of Surgeons verified Level ll Trauma Center.”
Dr. Fabri of Florida, then Chair of this committee, opened the meeting with a 10-minute talk followed by Dr. Ralph Doerr, who spoke for 35 minutes. Dr. Doerr spoke from his past experience as a Physician Assistant who had now been a surgeon for 25 years but was thoroughly conversant with the subject from a contemporary viewpoint at that time. Although some of his slides were outdated, and even far more a decade later, he spoke from the position of one of our strongest allies. The last two speakers spoke on the Role of the Nurse Practitioner in a surgical practice and the last on “Changing role of the CST in the future.” What would have been a lively discussion period was curtailed by the Chairman for discussion the following year by this same assembled group and additional new people from all surgical professions.
Dr Fabri made the following statement: ”The total number of NP and PA graduates exceed that of MD graduates.”
Thought: what does the AMA and the ACS think of this? Is this a problem for physicians? Do they perceive us to be a threat? How will they deal with this statistic? Dr Fabri added, ”(at that time) 49 states accept the PA/NP model, have verified their job description and has authorized their reimbursement for services rendered.” Thought: Is this considered competition? Is this considered a rationale for hiring APCs? Are they calculating the deficit to MDs medical reimbursement if both of these groups were independent?
Dr. Fabri went on to say, “When MDs are employed in the backdrop of global fees, it allows mid level providers to perform preoperative exams, causes less confusion for family and friends, there is greater documentation, more significant findings, more detail and more communication.” Thought: Now that’s an epitaph! Dr. Fabri continued, ”In a surgical practice it would be usual and customary for a PA (and more recently additionally a NP) to perform and report on all aspects of the pre-operative workup. The PA would give the informed consent (now the duty of only the surgeon) as well, would do pre-operative teaching. PAs (and now NPs) would perform the Discharge Directions; do moderation in the form of “rounds.” They would write the prescriptions for patients at discharge and during subsequent visits, orchestrate the post-operative care in both the hospital and the office.”
Thought: MDs and DOs must give their own informed consent. If PAs and NPs engaged in the informed consent it would be the grounds for greater litigations for these clinicians. From Dr. Fabri’s statements, some MDs can be led to believe that they can almost abandon their patients. We need to educate PAs/NPs on this matter as we are the secondary caregivers and the surgeon remains “Captain of the ship.”
Dr. Fabri: “Surgery is teamwork. There is a greater affinity to practice as a team in surgery than there is in primary care. The College must look at new and exciting ways to promote the team. ”Thought: Great for PAs and NPs but I consider the Primary Care providers to be an important part of that matrix of the surgical team as they have a role in understanding and communicating their health history and treatment and can encourage the patient by being knowledgeable about the procedures. This needs to be covered in our conferences such as those of the AFPPA and the AANP and AAPA.
Dr. Fabri: “Both PAs and NPs are listed as having substantial involvement in the First Assistant Role” Over this past decade, this has proven itself to be true, and Fabri was almost a prophet as his futuristic thinking relates to what has happened up to 2011 and the inclusion of more PAs and NPs into the surgical workplace. More than 2% of NPs are now in surgery, and their numbers will increase precipitously, and 27% of PAs are in this specialty.
Dr Doerr than stated, “Issues to PAs relate to cost, competition, accuracy quality and medico legal. All studies suggest that PA employment improved access, efficiency and care. The added benefit is that surgeons can perform more surgery.” Thought: What’s to say? That’s great! He then spoke of the future but the numbers of PAs and NPs were inaccurate as they were out of date and are even more out of date in 2011 where there are 240,000 NPs and PAs .He projected that there would be 65,000 PAs in 2006 and that was correct. He projects that MD candidates will decrease. He has noticed that NPs are increasing every year and almost double the PA number and lastly he said that there would be lower compensation for MLPs.
The PEW Paper suggested in that year that PAs should be considered as incorporated into the medical staff of an institution. This is now a reality in 2011. Present conditions (1999) will be modified as the current system undergoes an overhaul—it has! MDs are seeing Privilege Changes as suggested by the Regulatory Board of hospitals and HMOs. These institutions mandate verifiable training, education and competence based upon a clinical practice over a two-year period. Those Boards will determine the appropriate Scope of Practice, define competency standards and perform practice audits. Dr. Doerr believes that this will carry over to the PA/NP professions and that they too will have mandated competency exams to maintain or add to their current privileges.
Summary: Dr. Cosgrove, then chief of Cardiovascular surgery at the Cleveland Clinic and I spent fifteen minutes in private conversation about PAs, who I was representing at this meeting. He has an international reputation and is proud that in 1999 he had 55 PAs on his team. I asked his opinion of their value and he stated that, “Neither the hospital or he personally could do without them.” Members of the APACVS and Dana Gray told me that NPs are lumped into this figure also which is interpreted as to their combined value. In closing both then (1999) and today (2011) it is suggested that NPs and PAs continue to develop a better relationship and strive to work in a cooperative collegial manner. We are well on that road as we go to each other’s conferences, share committee work and in general realize that our efforts to work as teammates will enhance patient care in the United States.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 150 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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