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Ann Thorac Surg 2006;81:195-200
© 2006 The Society of Thoracic Surgeons
Joseph B. Whitehead Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Accepted for publication July 11, 2005.
* Address correspondence to Dr Miller, Section of Thoracic Surgery, Crawford Long Hospital, 550 Peachtree St NE, Suite 7700, Medical Office Tower, Atlanta, GA 30308 (Email: jmille6331{at}aol.com).
Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.
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Abstract |
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 Top Abstract IntroductionMaterial and Methods and...CommentThe Society of Thoracic...DiscussionAcknowledgmentsReferences |
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METHODS: A retrospective review of the utilization of CTS PAs was performed at a university center from 1973 to 2003.
RESULTS: The number of PAs has increased from 2 (1973) to 23 (2003), corresponding to the increased clinical service demands with a constant resident number for the past decade. Physician assistant employment has expanded from one hospital to five hospitals in our university system where CTS is performed. The CTS service has expanded from 400 total cases per year (1973) to 4,000 cases (2002). We have had a 50% retention rate with duration of employment from 6 months to 28 years (11 PAs with service more than than 15 years). The PA role has changed little, with duties varying from history and physical examination, conduit harvesting, insertion of invasive catheters and chest tubes, surgical first assisting, closure of the chest, and optional primary intensive care unit night-time in-house call. Salary currently ranges from $55,000 to $100,000 depending on length of service and overall merit. Job satisfaction for PAs employed longer than 12 months has remained high.
CONCLUSIONS: The addition of PAs to our CTS university service has allowed us to resolve many problems of work assignment and coverage and enabled us to establish effective and efficient surgical teams without increasing the number of categorical CTS residents.
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Introduction |
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Since 1973, two newly trained physician assistants from the Duke University PA program were employed by the division of cardiothoracic surgery at one academic teaching hospital [2–5]. Our experience now covers 30 years with a total of 23 physician assistants in five hospitals.
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Material and Methods and Results |
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The second phase in our utilization of PAs began in 1974, when a new cardiovascular surgical service was established at Crawford Long Hospital (CLH) of Emory University (Tables 1 and 2). Because there were no cardiothoracic residents at CLH in 1974, the PAs along with the staff surgeon performed all aspects of preoperative, intraoperative, and postoperative management. The PAs took in-house first call on days when cardiac cases were performed (overtime pay was provided for those PAs performing in-house night call). Eventually, the PAs shared in-house call responsibilities with the cardiothoracic resident. As the number of residents has increased at CLH, the PAs no longer take in-house call. However, with the restrictions imposed by the Accreditation Council for Graduate Medical Education (ACGME) on resident work hours, PAs now have a voluntary option for in-house first call for supplemental pay.
The third hospital in our system to utilized PAs was the Egleston Hospital of the Children Healthcare of Atlanta (Tables 1 and 2). In addition to the rotating cardiac surgery resident, a dedicated pediatric cardiothoracic 1-year fellow has been added to the Egleston Hospital cardiac program since the mid-1980's. The PAs have functioned to a large extent as in our community hospital (CLH). In the role of the cardiothoracic resident, the PA alternates taking in-house first call with the two other cardiothoracic residents.
Adult cardiac surgery was initiated at the Veteran's Administration Hospital in Atlanta in 1987 (Tables 1 and 2). Before the initiation of the cardiac program, thoracic surgery was performed there with the assistance of one PA. With the increase in cardiac surgery volume, a total of two PAs and one cardiothoracic resident currently remain on this service. Adult cardiac surgery was initiated at Grady Memorial Hospital in 1973. One cardiothoracic resident and one PA remain on this service. The roles for the PA at the Veteran's Administration Hospital and Grady Memorial Hospital are as listed in Table 2.
Physician assistant job satisfaction has remained relatively high in our academic cardiothoracic surgical program. Eleven PAs (47.8%) have remained within our division of cardiothoracic surgery for more than 15 years. A confidential survey of all 23 PAs within our division revealed that 10 PAs (43.4%) noted that their job satisfaction was excellent, and 13 (56.5%) noted that their job satisfaction was good.
Physicians Assistant Compensation
In the early 1970s, the salaries for cardiothoracic surgical PAs at Emory University ranged from $15,000 to $25,000 per year, depending upon the length of service and overall merit. It now ranges from $55,000 to $100,000 (mean, $84,000) in 2003, and is determined by the compensation committees of the individual hospital system. In 2003, consensus data from the American Academy of Physician Assistants reveals a mean salary of all PAs in the United States at $76,039 [6], and data from the Association of Physician Assistants in Cardiovascular Surgery [7] reveals that the average yearly salary for all cardiothoracic PAs at approximately $90,000. Salary compensation for cardiothoracic surgery PAs at EUH and CLH and one half of the PAs at Egleston Hospital is from our section funds of the division of cardiothoracic surgery as generated by the income by the 16 members of our section. The PAs at the Veteran's Administration Hospital, Grady Memorial Hospital, and one half of the PAs at Egleston Hospital are compensated by the individual hospitals.
Impact of PAs on the Cardiothoracic Residency
Although the number of cardiothoracic surgery training programs and residency slots available for appointment year from 1993 to 2003 has remained relatively constant at between 89 and 95 programs and 132 to 146 positions, the number of residency slots not filled has risen from a low in 1998 of 5 positions to 21 unfilled positions in 2003. Moreover, the number of applicants from United States medical schools has decreased from 161 in 1993 to 107 in 2003 [8]. These changes parallel trends showing a 30% decrease in the number of medical students applying to general surgery over the past 9 years. A multitude of interesting issues have resulted in a decline in general surgery and hence applications to cardiothoracic surgical programs. These factors include presumed evidence of a limited job market for residents completing cardiothoracic training. In a recent web-based survey by the Thoracic Surgery Residents Association, Salazar and colleagues [9] noted that approximately 20% of finishing fellows were unable to find jobs in 2003. Moreover, 87% of these residents believed that the number of trainees should be decreased to allow for improved job opportunities and compensation.
Furthermore, the ACGME has mandated standards addressing resident duty hours starting July 2003 [1]. As the current study evaluated the role of the PA until June 2003, we did not assess the impact of PAs on resident work. Further studies evaluating the impact of nonphysician providers on resident work hour regulations are warranted. In our practice, the interdigitation of the cardiothoracic surgery resident staff with PAs has not been a problem. The PA has been able to relieve the residents of many time-consuming routine duties so that more of their time can be devoted to operating room and other more educational tasks. Furthermore, each resident is able to participate to a greater extent in the operating room than would be possible if many more residents and fellows were required and utilized for the nonoperative aspects of patient care. Residents must continue, however, to participate in preoperative and postoperative care to assure their understanding of the associated pathophysiology.
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Comment |
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Function of the PA on Our Service
There is a multifactorial role for cardiothoracic surgical PAs at an academic institution (Table 2). They play a vital role in (1) education of patients, families, nurses, PA students, and general surgery and cardiothoracic residents in training; (2) administrative functions of the planning of admissions, scheduling of operations and special procedures, arranging and presenting information to patient-care conferences, and maintaining records required for quality assurance, long-term patient evaluation, and clinical research; (3) communication between staff surgeons, cardiologists, and other consulting specialists; and (4) surgical assistant during the performance of surgical procedures.
Although the role of a cardiac surgical PA may differ from academic to private environments, most work 40 to 60 hours each week. They provide expertise in the preoperative, intraoperative, and postoperative care of the surgical patient. Cardiothoracic PAs frequently assume the primary care aspects of the hospitalized patient and should be proficient in the management of hypertension, diabetes, and chronic obstructive pulmonary disease.
The relationship between PAs and the nursing staff has not been problematic. Because PAs do not infringe on the traditional territory of nursing services, they have developed a good working relationship with the nurses. The PAs availability during day hours when surgery residents and staff are commonly in the operating rooms allows for more efficient and thorough patient care. Furthermore, that provides a continuity of care that rotating cardiac residents are unable to provide. Overall, it is inevitable that the PA will play an intermediary role, serving as the "middle-person" between the staff surgeon and nurses, patients, families, and other physicians.
Over the past 30 years, the role of our PAs at Emory University has expanded and their utilization in the operating room has greatly increased. The cardiothoracic PA has a significant amount of autonomy in the operating room and performs the critical task of harvesting the greater saphenous veins or radial arteries (utilizing open or endoscopic techniques) for use as a bypass conduit as an essential component of almost every coronary bypass procedure. After preparation of the bypass conduit, the PA either first or second assists during the remainder of the case, including tasks of providing cardiac retraction, closure of the incisions in the lower extremity, assist in cannulation and decannulation, and closure of the chest. They function primarily as surgical first assistants, especially at CLH, where there remains a discrepancy in the number of cases performed and number of cardiothoracic residents available. The PA is the ideal first assistant in these settings, as they are trained specifically to meet the needs of the staff surgeon and are knowledgeable of the surgeon's idiosyncrasies. As expected, the exact role of the PA is determined by their clinical experience and the discretion of the attending cardiothoracic surgeon.
The usefulness of the PAs in each of our hospital situations cannot be overestimated. The PA has enabled us to expand our services without jeopardizing patient care. In the operating room, they have functioned in the roles of first and second assistants and have allowed us to increase our surgical volume without increasing the number of residents and fellows. With long-term job commitment, the PAs' own technical skills have become very refined, and they are superb assistants to staff surgeons and surgical residents. The PAs provide not only a foundation for overall patient management within our cardiothoracic services, but also bridge a gap between the nurses, cardiothoracic resident, and the staff surgeon.
The Future: Physician Assistant Residencies and Changing Roles
Challenges and unanswered questions facing the implementation of a new nonphysician healthcare provider to our cardiothoracic surgery practice in 1973 included PA job stability, usefulness in a complex surgical subspecialty, compatibility with cardiothoracic residents and nurses, long-term job satisfaction, and PA ability to improve the efficiency and care of our cardiovascular surgical service. After 30 years of experience, there remains no doubt that PAs can adequately perform the tasks at hand.
With the concordant restrictions in resident work hours and potential hiring of more costly nonphysician clinicians at hand, the more pressing question now has become can the surgeons or the institution afford to replace residents with PAs. One solution would be to further develop PA surgical residencies. The creation of surgery PA residency programs has been previously described and has been shown to allow approved surgical resident physician programs to review manpower needs [10, 11]. Standards, accreditation, and allocation of economic resources for such programs are scarcely available.
Overall, our cardiothoracic PAs are vital and an effective professional members of our team. On the basis of our experience to date, we think that the addition of PAs to our surgical service has allowed us to resolve many of the problems of work assignment and coverage and has enabled us to establish effective and efficient cardiovascular and thoracic surgical teams in the various hospitals of our university system.
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The Society of Thoracic Surgeons Policy Action Center |
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TopAbstractIntroductionMaterial and Methods and...CommentThe Society of Thoracic...DiscussionAcknowledgmentsReferences |
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Discussion |
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DR THOURANI: Thank you for that question, Mark. Obviously Dr Guyton, being the chief of the entire division, has the overall management of the cardiothoracic PAs. As you may recall, there are chiefs at each of our five affiliated hospitals: Emory Hospital, Crawford Long Hospital, the VA, Grady Memorial Hospital, and Egleston Hospital of the Children's Healthcare of Atlanta. The cardiothoracic surgeon who is the chief of that hospital is specifically involved with the day-to-day activities of the cardiothoracic PAs in that hospital. For example, Dr Joseph Craver at Emory Hospital, is in charge, per se, for the day-to-day practices of the PAs at Emory Hospital. We do have one person, Keith Causey, PA-C, who is in charge of all the PAs employed by our division and is really the go-between from Dr Guyton to the rest of the system as needed. Furthermore, each respective hospital has a chief PA who reports either to Mr. Causey, Dr Guyton, or the chief of cardiothoracic surgery at their hospital.
The PAs who we have at the VA and at Grady are funded by those institutions, and so they don't fall within the auspices of the role that Mr Causey holds, and they are directly under the chief of cardiothoracic surgery of that hospital.
DR GEORGE R. DAICOFF (St. Petersburg, FL): We have used PAs in our private practice for more than 25 years, and I agree with everything you have said except one thing. We do not allow the PAs to give informed consent, that is, to talk about the diagnosis, risks and benefits of the operation. I think that is still the responsibility of the surgeon.
DR THOURANI: That is an excellent point, and I whole-heartedly agree with you. If it was perceived that the surgeon has relinquished his role as a communicator with the patient or family, then I apologize for that misnomer. Obviously all of the residents and attending surgeons talk extensively with the patients regarding the benefits and risks associated with surgery. However, our PAs sometimes in the middle of the day or in the office do obtain consents.
DR ROBERT B. LEE (Jackson, MS): I had the pleasure of discussing this a bit with Dr Thourani before his presentation, which was quite excellent, but one of the things that I thought was most important that he brought out was the economics of utilizing PAs in an academic situation where the hours are now limited, and that is also going to apply to private practice. With the reimbursement for all of us going down, the PA salaries have slowly gone up and not yet plateaued, and if you look at a mean of $80,000, that is coming close to 30%, maybe 20%, a little bit less, of some cardiothoracic surgeons' total income. Have you taken an institutional approach to look at the limiting of PA salaries or how you are going to compensate them in the future with your health care dollars decreasing?
DR THOURANI: Doctor Lee, those are excellent comments. That is, I think, one of the problems that is coming forth with the implementation of reduced resident work hours. This is quite important as there is a trend for new and possibly expanding roles for cardiothoracic surgical PAs. To counteract the increase in compensation for PAs, some institutions have started to investigate a PA residency system. This allows for lower pay of a fully accredited PA for that predetermined residency time period. As far as I am aware, our institution has not implemented this system. Perhaps Dr Guyton or Dr Miller would care to comment.
DR JOSEPH I. MILLER (Atlanta, GA): Let me clarify that for you. That is not a fair question to put to him. The PA salaries at Emory University have declined by 17% to 20% over the last 5 years. They were cut automatically because we couldn't afford to let them continue to rise. They have been totally plateaued for the last 3 and a half years. There is a max regardless of time that they don't go above.
We employ both the group at the University Hospital and at Crawford Long out of our own sectional funds that the staff surgeons generate. At the Childrens Hospital they pay for three and we pay for three, but the others are that. But the PA salaries now have plateaued, and they have not continued to rise.
The salaries that you see there, Bob, and I realize what you are saying about how much a cardiothoracic surgeon makes, but also, by the same token, we are doing almost 5,000 cases per year among 16 people and trying to maintain services and work hours. So we have plateaued the salaries and they are down 17%, and that has been true, and now they are maxed out.
DE HUGH M. VAN GELDER (St. Petersburg, FL): The PAs out in the community have opened their own businesses, and in fact, because of that, they are not under contract by HMOs. In certain instances, they can make more money on a case than we do as the surgeon without any liability, and by allowing that to continue to happen, we just kind of ruin the entire system for ourselves, and we can't allow that to continue to happen. We are the guys who went out there in the training, we are the guys who do the operation, we are the ones who the patients are being sent to, and for people to make more money off of a case than we do is ridiculous in today's society.
In our corporation, we have our own PAs, but there are physicians in the community who do not have their own PAs because they are not large enough to be able to handle the cost of what it is to run a PA, and so they look for first assistants. These corporations are there to first assist, but like I said, they do not have contracts with the insurance companies and therefore they can make more money per case than we do.
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Acknowledgments |
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TopAbstractIntroductionMaterial and Methods and...CommentThe Society of Thoracic...DiscussionAcknowledgmentsReferences |
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References |
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TopAbstractIntroductionMaterial and Methods and...CommentThe Society of Thoracic...DiscussionAcknowledgmentsReferences |
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