Recycling the retired surgeon: Surgical assisting—A Canadian’s perspective

Most surgeons never receive any training on how to set up an office and run a practice—private or full-time academic. It’s enough of an intellectual and physical challenge to absorb general surgical training, let alone the surgical specialization that often follows. Therefore, it is not surprising that most, if not all, surgeons have no idea how to plan for their retirement or even what to do when that magic time arrives. One solution is to become a surgical assistant. This article provides some perspective on becoming a surgical assistant and an historical review of surgical assisting in North America, particularly from a Canadian’s perspective.

Retirement

Many surgeons start to think about retirement as they approach the 60-year mark. In a 2000 longitudinal analysis of the U.S. pediatric surgeon workforce, the average age of graduating trainees going into practice was 34, and the average practicing lifetime of pediatric surgeons was 30 to 32 years, making the typical retirement age approximately 65.1,2 In a personal communication during the annual meeting of the Specialty Committee of Pediatric Surgery (of the Royal College of Physicians and Surgeons of Canada) in September 2010, it was revealed that an estimated 5 percent of pediatric surgeons presently in active practice in Canada and the U.S. are in their 60s.

Statistics Canada reported, “Retirees (over the age of 55) have more health problems than people their age who don’t stop working altogether.”3 This 2009 report showed that approximately 24 percent of Canadians who were fully retired from the workforce said their health was in poor or fair condition and influenced their decision to retire, compared with 11 percent of those who were only semi-retired, and 5 percent of those (ages 55 to 64) who had returned to work after their initial retirement.3 In these latter two groups, financial considerations drove 40 percent of these retirees to continue working. Eleven percent claimed that retirement separated them from the social support that their workplace and co-workers provided.3

Few of our advisors prepare us for the beginning of a surgical practice, and even fewer prepare us for its end, and so it’s perhaps no surprise that some surgeons can’t really decide when it is time to retire. If we could, it would always be nice to retire on our own terms—when we want to and how we want to. Mike Hargrove expressed this philosophy nicely when he resigned as manager of the Seattle Mariners in early July 2007:

  1. Leave on Your Terms, Not Your Bosses’. …Hanging on until someone else decides you should go, while gratifying to the passive, results more often than not in more traumatic departures…bittersweet with the accent on the bitter.
  2. Leave on a High Note. More often than not, you’re remembered for whatever big event or set of events happened just before you left office…. So more than just leaving at a time of your own choosing, try to leave on a highlight, a new accomplishment, something positive you will always be remembered for.
  3.  Leave If You Know You Can’t Get Better Every Day/Week. …In a competitive world, you’re not doing your workgroup, your organization or yourself much of a favor by going through the motions….4

Once the decision to retire is made, retirees need to figure out what they will do with all of their spare time. For people who are used to working 100 hours per week, “sitting around” is not likely to be a viable option. As a common aphorism advises, the most important thing is to be useful.

A personal experience

For me, the solution was surgical assisting. I began surgical assisting in a large, community general hospital in July 2005. Lakeridge Health Oshawa (LHO) is 100 years old and is now the largest part of a four-hospital complex with 637 beds. Oshawa is located 50 km east of Toronto, ON, with a population of 150,000. LHO is one of the busiest acute care community hospitals in Ontario, with a catchment area of 500,000 people. In May 2007, the R.S. McLaughlin Durham Regional Cancer Centre, a $106 million cancer treatment facility, was added to the hospital. The hospital has 16 operating rooms (ORs), of which 10 function daily. The entire surgical staff totals 47, and the only surgical specialties not covered include cardiac, neurosurgery, pediatric surgery, and vascular.

Currently, 14 surgical assistants (SAs) are on staff at LHO: eight retired surgeons (from five specialties) and six retired family physicians/anesthesiologists. All 14 SAs scrub in on daily elective operative lists, and nine take emergency call from 4:00 pm to 7:00 am, and 24-hour weekend and holiday call. SA service is supplied 24/7. Since 2006, LHO has had a teaching association with the department of surgery, faculty of medicine, Queen’s University in Kingston, ON (located 250 km east of Oshawa), which sends a few house officers to rotate through the division of general surgery at LHO. These medical students/residents do not sleep at LHO when they are on call, and do not scrub in on every general surgical case, so their presence is inconsistent and therefore doesn’t always affect the operative help provided by the SA. In some cases, the SA participates in the intraoperative teaching, but only to a minor degree. There are also emergency and family practice residents who occasionally help on obstetrics/gynecology and orthopaedics.

Surgical assisting

The majority of surgeons have spent most of their lives in the OR, largely assisting residents and fellows as they learn the finer points of being a good, gentle surgeon. In that respect, surgical assisting is almost a continuation of our surgical experience, expertise, and lifetime work.

At LHO, the staff surgeons call the SA of their choice to arrange daytime elective surgical assisting, and SAs may sign up for four to six emergency call days per month. Some SAs choose to only work a few days a week. The only requirement is that the SAs as a group must provide 24/7 emergency call coverage, and that has never been a problem. (Staying in the hospital overnight when on call is optional.) One of the benefits of living in a small town is that everything is nearby; driving time from our house to the hospital is typically a five-minute commute.

Community surgeons have always had some sort of assistance in performing their operations, if only on a purely informal basis. They may do the small operations on their own, but may seek assistance from a colleague, a family physician, or an OR nurse to do the larger and more complex procedures. Surgical assisting has been around for as long as surgical procedures in the OR.

Some individuals have raised concerns about the quality of SA surgical training and experience. It cannot be assumed that the family physician, surgical resident, or registered nurse first assistant (RNFA) has the experience and/or ability to help the staff surgeon if something suddenly goes wrong during the operation, or to even complete the operation if something should happen to the surgeon. Most family physicians and nurses do not receive any special surgical training to act as SAs other than on-the-job experience. Moreover, both the Ontario Medical Association and Ontario College of Family Physicians acknowledge that most physician assistants lack the ability to complete an operation should something happen during the operation and/or to the staff surgeon.5 More often than not, in such emergency situations, the staff surgeon or the SA is able to call for help, especially if it’s during a daytime elective case. However, help may not be immediately available during an emergency procedure, especially if it should occur at night, on a weekend, or on a holiday. In some rare instances, the SA could possibly complete the procedure, or at least help control the intraoperative emergency. In most cases, however, the SA would be unable to complete the operation, unless the SA is a surgeon. Certainly, a family physician, junior surgical resident, or RNFA would be ill-prepared to handle such a situation; hence the need for the retired surgeon as an SA. Presently, the Section of SA of the Ontario Medical Association is exploring the possibility of establishing requirements to be an SA.

The medicolegal responsibility of an SA seems to be a common-sense one, according to the Canadian Medical Protective Association (CMPA). SAs are expected to speak up and/or surgically intervene when they believe that something serious or life-threatening is occurring during an operation. I have rarely seen this occur in my five years as an SA. On the other hand, sometimes I have been asked my opinion on certain aspects of an operation, and very occasionally, I have offered a suggestion that I thought might benefit the operative procedure. On both of the former occasions, my opinion seemed to be well-received. Apart from my intraoperative time and responsibility, I have no other patient or surgical obligations, which makes the role of surgical assisting more fun than work. Moreover, because I am still reading, writing, and reviewing pediatric surgical papers, I can do this work between cases without shirking my patient-care obligations.

The only expenses that LHO SAs incur are the annual CMPA malpractice fee, medical college practice fees, and the annual fee for the medical staff association; the latter is part of the hospital appointment of the SA to the courtesy staff.

History of surgical assisting

Surgical assisting as a distinct profession has evolved in North America in several definitive ways. First, there is the physician assistant (PA), who provides a broad range of health care services, including assisting in surgery. The PA came into existence in the mid-1960s due to the shortage and uneven geographic distribution of primary care physicians in the U.S. Eugene A. Stead, MD, of Duke University Medical Center, Durham, NC, assembled the first class of PAs in 1965, composed of former U.S. Navy hospital corpsmen and U.S. Army combat medics who had received considerable medical training during their military service and gained valuable experience during the Vietnam War.6 According to the American Academy of Physician Assistants (AAPA), as of January 2008, an estimated 68,000 PAs were working, with 24 percent employed in hospitals.7 Because of several recent developments—one of which is restrictions on resident work hours—the U.S. Department of Labor’s Bureau of Labor Statistics anticipates the “employment of PA to grow 27 percent by 2016, much faster than the average for all occupations.”8

There is very little literature on the use of PAs within the Canadian health care system. Sigurdson, using data from two hospitals in Halifax, NS, demonstrated that the use of PAs could significantly increase surgical productivity.9,10 According to the Manitoba Pharmaceutical Association Newsletter and Canadian Association of Physician Assistants, the PA concept is being explored by this association. Canadian military PAs are gaining legislative changes, allowing them to work in the civilian world after retirement from military service. These education programs (which are 24 month-long sessions) are now offered at the Universities of Manitoba, Western Ontario (London), McMaster (Hamilton), and Toronto.11

In 1979, a group of SAs banded together to form the Virginia Association of Surgical Assistants and set up a job description and standards for practice in the U.S. The Eastern Virginia Medical School then became the home for the SA program in the U.S., and with the help of the department of surgery at Sentara Norfolk General Hospital, Norfolk, VA, they developed a certification exam. This group also conducted a survey across the U.S. to determine how many individuals were actually working as SAs. The researchers were amazed to find out how many unofficial SAs there were who were unrecognized and untrained for the job. Reaching out across the U.S., the association’s membership grew and eventually the Virginia Association of Surgical Assistants became the National Surgical Assistant Association (NSAA) in 1983, with a professional code for its members.8,12 In the U.S., the Certified Surgical Assistant (CSA) designation is now available to qualified applicants including medical graduates, allied health professionals, medical doctors, doctors of osteopathy, and foreign medical graduates. As of December 2008, the NSAA must approve all SA education programs in the U.S. before graduates may sit for the CSA certification examination.

In July 2005, there was no formally recognized SA organization in Canada. When I started my surgical assisting, LHO had 12 SAs for elective daytime surgical lists, but only three regularly took emergency call (nights, weekends, and holidays). That left some elective and many emergency operations without an assistant of any kind. In such instances, a doctor colleague (surgical or otherwise) who happened to be in the hospital at the time was asked to help with the operation; otherwise, it was left to the OR nurse to lend a hand. When I looked at the SA emergency call schedule and realized that only Mondays, Wednesdays, and Fridays were covered in a consistent fashion, I put my name down to cover Tuesdays, Thursdays, and one weekend day. With that move, there was virtually 24/7 coverage.

As a result of what, at the time, was an inconsistent call schedule situation (which was likely happening for years at other community hospitals in Ontario as well), the College of Nurses of Ontario (CNO) wrote to the Ontario Medical Association (OMA) on May 26, 1997, “…requesting information regarding the role of the surgical first assistant and requesting a meeting with the OMA to discuss this matter.”5 On October 29, 1997, the OMA met with the CNO to discuss the role of the surgical first assistant, and the College of Family Practice was also invited by the CNO to attend this meeting. At the meeting, it was established that “Nurses in Ontario are, in fact, carrying out the role of surgical first assistant in many instances and do so without the sanction of their college.”5 It was further noted at that time by the OMA that “…to date the CNO position is that the role of surgical first assistant is beyond the scope of nursing.”5 The recommendations from that meeting were as follows:

  • The surgeon must have the authority to determine who will be the surgical first assistant.
  • The patient’s family physician should be the surgical first assistant in most circumstances.
  • If the surgical first assistant is someone other than a physician, appropriate certification to ensure the proper skill set and knowledge must be provided.
  • Funding for the nonphysician surgical assistant must be determined (the Ontario Health Insurance Plan [OHIP] is not to be the source of that funding).
  • The issue of liability is a critical one and it must be determined that there is demonstrated adequate coverage for nonphysician surgical assistants.5

Today’s SA

In May 2006, Ontario’s Ministry of Health and Long-Term Care (MOHLTC) attempted to fill the shortage of health care professionals by creating four new roles in areas of need, one of which is “surgical first assist.” In 2007, MOHLTC began funding 50 percent of RNFA positions in order to decrease wait times for orthopaedic surgery. The RNFA is an interest group of the Peri-Operative Registered Nurses Association of Ontario. They report:

As more individuals learn about the benefits of the position (SA) either through direct experience or published reports, interest in the role increases. This, coupled with the reality of physician shortages, is bringing the RNFA role to the forefront in numerous hospitals across the country. Nonetheless, funding the position is one of the largest challenges that hospitals and RNFAs face in converting a recognized need into the reality of a paid RNFA position. The RNFA has, however, had success in situations where physician/resident assistants are not available, or where there is a shortage of available qualified assistants. The RNFA position is not intended as a replacement for all physician/resident assistants.13

In fact, four years later, in 2010, Chris Jamieson, MD, professor of surgery at Dalhousie University, Halifax, NS, and president of the Canadian Association of General Surgeons, said the degree to which surgeons and general practitioners/family physicians (GPs/FPs) interact directly depends on the size of the community.14 However, Robert Algie, MD, president of Ontario College of Family Physicians (who practices in the small northern Ontario community of Fort Frances), concurs with this observation, and is of the opinion that GPs/FPs working in more rural areas maintain close relations with their surgical colleagues. However, Dr. Algie goes on to say that having GPs/FPs assist in the OR may not be the most effective use of their time, and in his community, nurse practitioners have taken on this role very effectively.14 The statements and observations made by Dr. Jamieson and Dr. Algie strengthen the argument that there is a demonstrated need for SAs.

In Canada, most surgical programs and hospitals do not pay directly for their SAs. Traditionally, SAs have been family physicians who bill their provincial health care plan for their services. Some provincial health departments (including British Columbia’s) calculate precisely how much public money is paid out for SA.13,15 Most provinces, however, do not track this information. Family physicians and surgical residents are not hospital employees, and hospitals do not have funds designated for SAs; therefore RNFAs are in a tenuous situation. (Surgical residents also assist in the OR as part of their residency training, almost always in teaching hospitals.)

In July 2005, the only remuneration for SAs at the LHO was a fee for each operation, as listed in the Ontario Schedule of Fees, based on both the type of procedure (elective or emergency) and the length of time spent in the OR. In September 2005, the LHO administration asked the SA section for its “mandate, goals and objectives.” On October 13, 2005, the SA section met and formulated the following:

  • Establish and maintain a status and dialogue with the hospital and between members of the section with respect to availability, on-call coverage, compensation, and other items of interest
  • Provide a source of medical and surgical experience in the OR
  • Clarify the role of continuing medical development
  • Make a membership list available to members and surgeons/offices
  • Explore the relationship with other sites

The MOHLTC of Ontario sent a letter to the chief executive officer of the LHC stating that the Hospital On-Call Coverage (HOCC) Enhanced Program became effective on October 1, 2005, and that no hospital was to add to this stipend. In November 2005, the OMA held the first meeting of the probationary section of OR assistants to discuss rules and regulations, central registry, HOCC stipend, and so on. The HOCC funding for SAs was approved for LHO in May 2006 at $480 per on-call day (in addition to anything that is billed by the SA), retroactive to October 2005. The first annual meeting of the OMA Probationary Section of Operating Room Assistants was also held, and its name was changed to “Surgical Assistants”; business (in the full sense of the word) of the section was under way, including progression to full section status.

SAs earn half as much money, work one-quarter the time, and have none of the legal responsibilities of practicing surgeons. Nothing is compulsory. SAs are the world’s best kept secret for the retired surgeon (at least until now).


References

  1. O’Neill JA Jr, Gautam S, Geiger JG, Ein SH, Holder TM, Bloss RS, Krummel TM. A longitudinal analysis of the pediatric surgeon workforce. Ann Surg. 2000;232(3):442-453.
  2. Moore FD, Boyden CM, Sabiston D, Warren R, Peterson OL, Zeppa R, Heer D, Murthy N. The production, attrition, and biologic lifetime of surgeons in relation to population in the United States. Ann Surg. 1972;176(4):457-468.
  3. Dinner M. Retirees aren’t livin’ the dream. Toronto Sun. February 1, 2011;26.
  4. Angus J. “After the bottom of the 9th: Mike Hargrove models managerial exit with class.” Management by Baseball (blog). July 2, 2007. Available at: http://cmdr-scott.blogspot.com/2007/07/after-bottom-of-9th-mike-hargrove.html. Accessed February 22, 2012.
  5. Ontario Medical Association. Statement on Surgical First Assistants. October 2007. Available at: https://www.oma.org/Resources/Documents/2007SurgicalFirstAssistant.pdf. Accessed February 20, 2012.
  6. Physician Assistant History Center. Eugene A. Stead, Jr., MD. Available at: http://www.pahx.org/stead-jr-eugene. Accessed February 1, 2012.
  7. American Academy of Physician Assistants. Physician Assistants Census Report. Alexandria, VA: 2008.
  8. U.S. Department of Labor. Bureau of Labor Statistics. Physician Assistants, 2006.
  9. Sigurdson L. Meeting challenges in the delivery of surgical care: A financial analysis of the role of physician assistants. Halifax, NS: Saint Mary’s University; 2006. Available at: http://web.mac.com/lsigurdson/Leif_Sigurdson/Profile_files/Surgical%20Care%20Challenges.pdf.  Accessed December 7, 2009.
  10. Bohm ER, Dunbar M, Pitman D, Rhule C, Areneta J. Experience with physician assistants in a Canadian arthroplasty program. Can J Surg. 2010:53 (2):103-108.
  11. Physician assistant. Available at: http://en.wikipedia.org/wiki/Physician_assistant. Accessed March 9, 2012.
  12. National Surgical Assistant Association. Available at: http://www.nsaa.net/about.php. Accessed February 3, 2012.
  13. Groetzsch G. Show me the $$$?!: Factors to consider when looking to finance a RNFA position. Can Oper Room Nurs J. 2004; 22(4):23-24, 38.
  14.   Canadian Medical Association. Relations at the knife-edge: Surgical care. MD Lounge. 2010. Available at: http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/MDLounge/2010/mdloungemar23-eng.pdf. Accessed February 3, 2012.
  15. RNFA interest group. Financing the RNFA role. Available at: http://rnfa-ontario.ca/financing.html. Accessed February 16, 2012.

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