Surgeons Discover New Instrument, the Physician Assistant

SURGICAL PHYSICIAN ASSISTANTS EMPLOYED BY HOSPITAL

The physician assistants are moving out of primary care medicine and into the OR. The best instrument a surgeon has the surgical physician assistant.

You are listening to ReachMD, The Channel for Medical Professionals. Welcome to the Clinician’s Roundtable. I am Lisa D’Andrea, your host and with me today is Bob Blumm. Bob has been a practicing surgical physician assistant for 38 years and is the current president of the Association of Plastic Surgery Physician Assistant. Bob received the first AAPA Paragon Award for the Physician/PA Team and he is a recipient of the John W. Kirklin Award for excellence in surgery. Bob served as an administrator, clinician, and a role model for the entire PA profession. Today, we are discussing surgical physician assistants employed by hospital.

MS. LISA D'ANDREA:

Hi Bob, welcome to ReachMD.

MR. BOB BLUMM:

Thank you very much, pleasure to be with you.

MS. LISA D'ANDREA:

Bob, what is the difference between a PA and a surgical PA?

MR. BOB BLUMM:

The difference between the generic PA and the surgical PA is that the surgical PA has additional education or training specific to the specialty in which they are going. However, in general, one is never to forget that all physician assistants regardless of their specialty rating are primary care physician assistants.

MS. LISA D'ANDREA:

And what are the possibilities of a surgical PA employed by a hospital?

MR. BOB BLUMM:

The responsibilities are manifold in the fact that they may be utilized within the hospital situation, in a clinic situation, in the preadmission testing portion of the hospital so that the same people who will be in surgery and following the patients on the floors who have done the preoperative examinations. They give some preoperative instructions and make sure that there is a total understanding. They make sure that all of the consultations have been acquired or if they feel that someone needs to be seen by a cardiologist or a pulmonologist that they will indicate that and they will initiate that from their place in the preadmission process. They are also involved intraoperatively. We try to utilize the same physician assistants that do the preoperative work in the operating room. So, they have either preexisting surgical training or have gone to a surgical residency program and have learnt on the job, but they are in the operating room serving as the first assistant in surgery. The first assistant in surgery is the assistant surgeon and they are qualified depending on the specialty area to be doing something as simple as hernia repairs to as complex as cardiothoracic surgery. After that, they go to the recovery room, they will go to PACU and write postoperative orders, examine the patient, reexamine the patient, and then follow them on the surgical floors. They will be responsible to the physician and to the nursing team to respond to any potential problems, any complications, or any questions relating to the surgery itself. If the patient is in need of going to a critical care unit such as a SICU, it is the physician assistant, who will also be a part of that particular scenario and will undergo the specialty area of critical care medicine. Surgical PAs receive training in all of these areas as a component of their didactic in the clinical training, but the remainder of that knowledge is usually received from a residency program or on-the-job training.

MS. LISA D'ANDREA:

Do hospitals require surgical PAs to complete a surgical residency prior to employment?

MR. BOB BLUMM:

No, they don’t and I am very grateful that they don’t because when you look at the number of surgical training programs out there, they are not enough at the present moment to ever meet the demand that exist today. In the surgical residency programs at the present moment, we have exactly 12 of them and these residency programs may take as few as 2 or 3 residents or as many as <_____> will take 12 or 15, but that’s the maximum. So, we take approximately 50 years to get the right number out there. So, this is an ideal situation because of the knowledge of critical care medicine that these people receive, but there are very few that have indeed taken that residency program.

MS. LISA D'ANDREA:

Let's talk about credentialing. Do PAs need to be credentialed in the same process as a physician?

MR. BOB BLUMM:

Absolutely, in every manner they are looking at their background. They are looking at their education, they are listening very carefully to the responses such as if you are in an operation at 2 o‘clock in the morning and your surgeon happens to have a heart attack, what would you do? And that's one of the frequent questions and they don’t want to hear to answer that you would complete the entire operation. They want to hear that you will put a lap pad and make sure bleeding is stopped and that you are waiting for another physician to come in.

MS. LISA D'ANDREA:

What about professional liability insurance? Does a surgical PA in a hospital setting need their own insurance?

MR. BOB BLUMM:

The surgical PA in a hospital setting is already covered by the hospital in terms of their malpractice insurance, but it is of the utmost importance, I think and many of my colleagues who have been around for a while think to get their own professional liability insurance. When it comes down to the litigation of person they have and I have been practicing for 38 years and haven’t not had one, but that is only a little bit of luck I think along with some skill, but should this happen when you have a personal liability insurance, you will know that there will be an attorney and a group that will be working 100% for you rather than for the hospital or the physician.

MS. LISA D'ANDREA:

If you are just joining us, you are listening to the Clinician’s Roundtable on ReachMD, The Channel for Medical Professionals. I am Lisa D’Andrea and I am speaking with Bob Blumm, president of the Association of Plastic Surgery Physician Assistant. We are discussing surgical physician assistants employed by hospitals.

Bob, since restricting surgical resident work hours, have surgical PAs met the responsibility imposed upon them from the healthcare system in regard to the mandatory 80-hour workweek for residents?

MR. BOB BLUMM:

Yes, they have. In my last year or two as chairman of the Surgical Congress of the AAPA, I was at every American College of surgeon’s meeting and there are specific group dealing with non-physician providers in the college of surgeons and this became a great concern of this because the 80-hour workweek would require that surgeons could not be taken care of some of the problems on the floors or could not be in the operating room at all times and so the physician assistant was considered the next most qualified person to do that job and that’s how we have been utilized. We have been filling in, in the operating rooms more so than we did before, in the critical care units, on the floors and it has helped tremendously to alleviate the problem relating to residents being overworked. The other group of people that had been doing this in particular in cardiothoracic surgery would be nurse practitioners, who have the same scope of practice as physician assistants.

MS. LISA D'ANDREA:

Let's talk about billing. Are medical services provided by a surgical PA reimbursable at the supervising physician rate and can a hospital bill for a first-assist services provided by a PA?

MR. BOB BLUMM:

It all depends on how things are set up. You can have bundle billing where all of the fees relating to a procedure are universally paid to the surgeon and the hospital will get their share, but that does not happen with every insurance company. Medicare is more than happy to pay 85% of the physician’s fee to the PA or to the company that has in fact hired the PA. Many individual insurers will pay 13.5% and if a person is out of network that fee can be increased well beyond that, but there is reimbursement and there is a separate reimbursement in most cases.

MS. LISA D'ANDREA:

Can surgical PAs function in more than one specialty at the same time?

MR. BOB BLUMM:

Yes they can. I have started 3 separate businesses in my carrier where I joined with other physician assistants. We would have 7, 8, 9, or 10 in a group. We would cover 4 or 5 hospitals and we would do call, weekend call. We started out doing weekend call Friday through Monday morning and in that particular role, we were able to cover everything from General Surgery to Orthopedics to Thoracic, Vascular Surgery or whatever. When we are credentialed in a hospital, we are credentialed according to our knowledge in surgery and if we ask for privileges and can provide information that shows that we have had experience in that particular area, then our request for privileges will be granted by the chairman of that subspecialty department and then will be countersigned and finally approved by the chairman of the department of surgery. So, in fact, we can do 7 different specialties simultaneously.

MS. LISA D'ANDREA:

Are PAs members of the American College of Surgeon?

MR. BOB BLUMM:

Yes I have in the past been a liaison to the American College of Surgeons for the AAPA for 5 years and in my last year, I was able to convince the leadership of the College of Surgeons that it would be to their best interest to allow what they called at that point non-physician providers to have an affiliate membership in the College of Surgeons. So, at the present moment, there is an affiliate membership that it does not cost us much in the way of money. It allows us to have same access to the American College of Surgeon's site and allows us to attend the American College of Surgeon’s conference yearly free.

MS. LISA D'ANDREA:

When a hospital is considering hiring a new PA graduate, what should the expectations of the hospital and the surgeon consist of?

MR. BOB BLUMM:

I think that's a very good question. One of those things that I do is I am an adjunct instructor for surgery and Emergency Medicine for Hospital of University and so we produce 30 or 40 PAs every year. If a hospital is going to hire a new graduate, they need to be aware that all graduates and no different than anyone else is. They all have a basic knowledge or basic fount of knowledge based on the PA program. They assume the responsibility to enhance that knowledge through their own in-hospital continuing medical education and by doing mini-mentoring situations within specialty areas so that the PA learns to develop an increased knowledge of that specialty area. I have had some of my PAs graduate and go into a cardiothoracic program, do flag shifts of 12 hours, work 48 hours a week, and start with a salary of 90,000 dollars. So, it really is very important that they get that education and the hospitals are more than willing to teach them.

MS. LISA D'ANDREA:

How does the hospital benefit by hiring a surgical PA?

MR. BOB BLUMM:

The hospital benefits in that the general surgeon as well as other specialty areas are severely overworked. They need to know that the person, who is assisting in the operating room, has the ability also, when they are not operating, to go downstairs to the flaws and to reexamine the patient to prevent problems from happening. We want to learn not only how to respond to emergency events, but how to prevent them from happening and that's the safety that that has been placed into the hospital scenario by hiring their own surgical PAs. They will follow them. They know them preoperatively because they have examined them preoperatively. They have developed a relationship with them and they will be the same individuals who can discharge them so that the surgeon does not have to come into the hospital and give them the prescriptions and the information necessary for followup in the private office practice.

MS. LISA D'ANDREA:

And where can we give more information about surgical PAs?

MR. BOB BLUMM:

The greatest fount of information will come from the AAPA website and then you can go to the aaspa.org, which is the American Association of Surgical Physician Assistants and that is the major group responsible for most of the information relating to all PAs and then there are many references. I was the author of an article in the bulletin of the American College of Surgeons on surgical physician assistants help solve contemporary problems, that came out in June of 2003 and when you go to the specialty area such as the College of Surgeons, you might find articles like this, which will teach a Surgery Department how to incorporate PAs into the hospital.

MS. LISA D'ANDREA:

Thank you Bob for coming on the show.

MR. BOB BLUMM:

Thank you.

MS. LISA D'ANDREA:

I am Lisa D’Andrea and you have been listening to the Clinician’s Roundtable on ReachMD, The Channel for Medical Professionals. Please visit our website at reachmd.com, which features our entire library through on-demand podcasts and thanks for listening.

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