Physician extenders and surgical training: Integration or separation?

The Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) hosts an annual Symposium at the ACS Clinical Congress, featuring a debate on controversial topics in health care and surgical practice. This year’s symposium will focus on Physician Extenders and Surgical Training: Integration or Separation? The symposium will take place Sunday, October 21, at the Boston Convention & Exhibition Center, MA.

Background on the issues

Modern surgical education is a constant battle of adhering to duty-hour restrictions, balancing work with educational requirements, and navigating the administrative burden of electronic health records, while continuing to gain sufficient operative experience. In response to these demands, many surgery departments have hired physician extenders (PEs) to offset the resident workload. Although gaining momentous attention this century, PEs have been surfacing in the health care field as early as the 1960s.1

PEs, though inclusive of varying degrees of providers, are usually classified as physician assistants (PAs) or nurse practitioners (NPs). NPs are registered nurses with months to years of additional training in medical and nursing care, whereas PAs come from various undergraduate backgrounds and pursue two years of dedicated training.2,3 Physicians at first only delegated educational and counseling tasks to extenders rather than diagnosis or decision-making responsibilities.4 In 1975, Victor Fuchs, PhD, renowned American health economist and Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy, Emeritus, Stanford University, CA, changed the climate by suggesting that PEs can perform an array of physician functions with guidance and supervision in an organized setting.

In 1978, Laws and colleagues surmised that PAs and NPs would play a major role in future surgical care delivery.5 Possible reasons for such an extrapolation stemmed from witnessing the impact of PEs on fostering productivity and maintaining quality while lowering health care expenditures.2 Furthermore, given the predicted decrease in surgical residency positions, PEs were conjectured to be the perfect substitute for resident physicians. By 1995, more than 60 percent of medical directors at teaching hospitals were reportedly using PEs to compensate for resident shortages and growing patient volume.6

More recently, Pezzi and associates linked the hiring of most of today’s PEs to the 2003 Accreditation Council for Graduate Medical Education (ACGME) restriction on resident duty hours. In fact, university programs have hired an average of four PEs per program since the ACGME’s mandate on resident duty hours.6 The Association of American Medical Colleges predicts that by 2025, the U.S. will experience a deficit of at least 125,000 physicians nationwide. The current PE workforce would compensate for only half of that shortage; thus, the additional development of PE programs seems inevitable and must be embraced.7 However, while more than five decades have elapsed since PEs were introduced, the roles of PAs and NPs still vary widely and a universally recognized job description for these practitioners has yet to be developed.

The extender dilemma

As a result of nebulous expectations and interprofessional dynamics, the question of where a PE fits into the surgical care team sometimes arises. While the culture of surgery has led to misperceiving residents as cheap labor, PEs should not just be viewed as replacements or substitutes for residents. Ideally, NPs or PAs should be viewed as colleagues with unique goals and objectives.6 However, when examining critical care experience, Kahn and colleagues found that 25 percent of 354 surgical resident survey respondents believe extenders detract from the overall training experience. The dissent is noted primarily from junior residents who are eager for procedural opportunities and may feel threatened by PEs as potential competition.7,8 Additionally, greater concerns have emerged that the presence of PEs on surgical teams may negatively affect resident education by reducing the time residents spend with patients.9,10

Clearly, defining a niche for PEs in surgery is problematic, yet even when roles are apparent, controversy exists. In a survey of surgical residents and PEs, despite both parties reporting that the PE role was well-defined, significant differences in perceptions about where PEs fell within the surgical hierarchy were noted. Most PEs perceived that they functioned at a senior resident level or higher, whereas most residents believed that PEs functioned at an intern level or lower.11

If PEs function at such a high level, one would assume they would be held to the same standards as residents. However, Clark and colleagues reveal in their survey of surgical trainees that many residents begrudge PEs because extenders are paid significantly more despite having much shorter, daytime work hours.12 Furthermore, many PEs feel that their exposure to medical liability is so minimal that they often do not purchase liability coverage, yet all residents must be insured. Surgeon, attorney, and politician T.R. McLean, MD, FACS, has even referred to them as “free riders” who are covered under the corporate policy of their respective physician.13

Much of the existing literature pertaining to this topic is survey-based, which may not provide an accurate representation of the benefits and barriers PEs bring to surgical education.

Two common schemas used for PE assimilation

Teaching institutions commonly use one of two schemas for PE assimilation: the parallel player and the integrated partner.

The parallel layer

Having PEs serve as parallel players, distinct from residents, offers several benefits. PEs often are part of a surgical team for an extended period of time and are familiar with the service-specific pathologies, approaches to care, and established provider preferences.14 Hence, they are well-equipped to care for patients. Robles and colleagues studied the impact on patient care of an NP who specifically worked with three surgeons at a single tertiary care institution. The results demonstrated a decrease in emergency department visits, an increase in discharge services arranged for postoperative patients, and an increase in follow-up phone calls made to patients. This NP was able to provide continuity of patient care and monitor clinical progress, thereby enhancing patient satisfaction and financial benefit.15 Residents were not affected by this PE’s labor as the NP was working in parallel—coexisting without interacting.

Another recent study by Matsushima and colleagues evaluated the impact of night shift surgical intensive care unit coverage by extenders. When compared with a parallel group of resident physicians, the PEs provided equivalent initial trauma resuscitation. Interestingly, the PEs transfused significantly less blood products and demonstrated greater than 50 percent reduction in hospital mortality compared with the resident team (6.2 percent versus 12.8 percent, p = .058).16 In the event that a patient needed a central venous catheter, arterial line, or tube thoracostomy, PEs also were found to be capable of performing such tasks. Sirleaf and colleagues compared the complication rates for these procedures between a resident team and a corresponding PE team and found a 2 percent complication rate in 555 patients for both groups.17 With equivalent patient outcomes, there should be no qualms about separate but equally capable teams of PEs and resident surgeons—or should there?

Clinical guidelines are great resources for structuring health care delivery, and PEs heavily rely on them. Extenders, though competent, still are less formally educated than physicians, and the level of knowledge and clinical acumen acquired in a PE’s relatively brief schooling is insufficient to help when a patient deviates from the norm. The notion that PEs can provide synonymous and near-error-free care using clinical guidelines alone is unrealistic.13

Traditionally, surgical teams have been rooted in hierarchy, and the integration rather than juxtaposition of a PE risks violating the “chain of command.”10 A recent survey of faculty from 13 U.S. general surgery residency programs regarding their experiences with PEs confirmed that integrated PEs disrupted the residency ladder.10 Furthermore, in a national survey of approximately 1,200 surgical trainees, many residents reported that nurses contacted PEs preferentially for patient-care issues.7 The biased communication between PEs and registered nurses may lead to occupational schisms, provider confusion, and poor patient care. In fact, some residents believe that the incorporation, rather than paralleling, of an NP to a surgical service increases the number of sign-outs and potential communication breakdowns, and they fault NPs for compromising patient safety.18 However, a framework in which PEs manage their own distinct service and do not integrate with residents would rectify this situation. This assumption holds true to some extent. Residents may feel that PEs are held to a different standard. Perhaps because of intrinsic flexibility in career paths, when PEs have an adverse experience or lose interest, they can seek an alternative position in any field of medicine.8 Residents do not have that luxury. They can be treated unfavorably, yet are still expected to deliver steadfast, excellent patient care. Differences in expectations with regard to division of labor, responsibility, and accountability can create friction within the team, particularly at the junior and mid-level resident level.

Nevertheless, not only can a model of individual teams for residents and PEs optimize direct communication among PEs and registered nurses, it also can decrease competition for operations. PE roles have expanded to assisting in the operating room  (OR) either alongside residents or as first assistant. At one institution where PEs assisted residents with case coverage, 63 percent of 50 residents reported no detrimental impact on operative experience because of the presence of a PE.9 The remaining 34 percent of residents thought they were less likely to perform key portions of the case because of PEs acting as junior residents. Fortunately, in a setting where PEs act only as parallel players, it is unlikely that a PE and junior resident would ever operate together, thus eliminating such intraoperative competition.

When PEs serve as parallel players, residents are still challenged to learn the professional and clinical pearls that they may miss when managed by integrated PEs. Examples include difficult counseling conversations with patients and families and subtle presentations of common postoperative complications.9 This observation is essential because it has previously been reported that faculty and residents perceive that PEs simplify resident involvement in patient care and minimize trainee responsibility.9,10 This reduction in resident involvement occurs in the opposing integrated schema, which allows residents to escape the clinical care for patients. Some faculty feel that by freeing up time for the resident to be in the OR, the integrated model will produce surgeons who are too detached from pre- and postoperative patient care. Merely allowing residents the opportunity to perform a procedure and inadvertently depriving them of the decision-making process is a disservice to surgical education. Therefore, the parallel model of service for extenders actually promotes independent resident thought and fosters physician-patient relationships.

The integrated partner

PEs have already been integrated into private practice and surgical departments throughout the U.S., but now there is support for directly integrating these professionals into the surgical training environment. Proponents argue that it is imperative to assimilate PEs into academic departments, side-by-side with surgical residents. Advantages of this approach are practical, like sharing administrative burden and generating an increased ability for didactic and operative experiences.6 Proponents also note the need for residents to understand the role of PEs before completing their training, which can only be accomplished by working together. Furthermore, having residents work with PEs on patient care teams can provide unexpected benefits from diversity of thought, training, and experience.

Integrating PEs in academic surgery training programs prepares surgical residents for employment environments where extenders are increasingly present. The ACGME emphasizes this fact and states that “the goal of a surgical residency program is to prepare the resident (1) to perform the role of a surgeon at the advanced level expected of a board-certified specialist, and (2) to direct interprofessional and multispecialty teams necessary for the care of surgical patients.”19 In short, a resident must work collaboratively with PEs so that they can be adequately prepared to direct the entire team.

The American social scientist Scott E. Page, Leonid Hurwicz Collegiate Professor of Complex Systems, Political Science, and Economics, University of Michigan, Ann Arbor, writes about the “diversity bonus” that occurs when teams comprise multiple members with differences in demographic background, training, and opinions.20 PEs by definition have undergone different training than surgeons and may have experiences that can augment the physician perspective. Integrating PEs into the same teams as surgical residents enhances the group dynamic, with all team members and patients reaping the benefits of diversity of thought and practice.20 Teams composed of both PEs and physicians also contribute more effectively to patient care than if either worked separately (that is, in parallel). This notion holds true for surgical residents, who also may benefit from the knowledge, institutional memory, and practical guidance offered by more veteran PEs. Although patient care may be enhanced by PE integration in limited retrospective studies or surveys, the patient perspective is often overlooked, which questions the ethics of integrating physician extenders into resident teams.

One study from the U.K. highlights the confusion regarding job titles of various health care professionals. A total of 190 otolaryngology patients were questioned about the role of a surgical care practitioner (that is, surgical NP or PA); 48 percent thought these providers were physicians.21 Although many patients were amenable to a PE performing suture removal and wound care, 98 percent wanted a surgeon to remove a neck lump. Furthermore, 94 percent of respondents wanted to be informed when a surgeon was not providing the surgical care, which reinforces the principle that patients have a right to know the qualifications of their health care professionals.21

Using titles like doctor of nursing practice or doctor of philosophy in nursing implies that the holder of such a title is a qualified physician, capable of independent, high-quality care. This misrepresentation can be viewed as negligent and is a source of liability claims against physicians for their corresponding nonphysician providers.3 Proponents of surgeon-performed operations argue that training nonphysician technicians to perform even one type of operation, regardless of the degree of difficulty, should be discouraged. As world-renowned hernia surgeon A.N. Kingsnorth, MB, BS, FACS, said, “Operative surgery is not just a question of performing a list of technical maneuvers. It requires the continuous conscious and subconscious deployment of decision making and judgement.”21

Despite the ethical implications, another important contribution of PEs to surgical teams has been to expedite the discharge process and decrease hospital length of stay and costs.22,23 These positive outcomes occur most likely because PEs have prolonged continuity on specific services and can better facilitate complex discharge planning. Consequently, they are an essential resource for junior residents learning to navigate the logistics of the hospital infrastructure.23 Of note, even though a PE’s presence on the same service may allow residents to spend less time overall with patient paperwork, opportunities for patient counseling and meaningful interaction remain. A lower number of administrative burdens also equates to increased resident satisfaction and stress-free periods, which protect against physician burnout.22,24

When functioning as integrated partners on the surgical team, PEs can similarly assist with patient care duties in the trauma resuscitation bay or the OR. In the surgical intensive care unit, the presence of integrated PEs yields higher compliance to critical care guidelines and quality metrics, such as improved venous thromboembolism prophylaxis, stress ulcer prophylaxis, and anemia management.25 Additionally, when residents are unavailable during educational conferences, PEs are accessible to complete tasks normally carried out by residents. Recent work by Schwed and colleagues found that general surgery resident attrition was lower at institutions that offered educational time, specifically, fully protected educational time.26 Therefore, integrating PEs seems to benefit all parties.

Traditionally, obtaining adequate operative experience for junior residents has been challenging because of the time demands associated with patient care. Kreutzer and colleagues highlight that the volume of work for residents has evolved without accompanying system changes to support education or duty-hour compliance.27 Surgical trainees now are expected to comply with an 80-hour workweek and complete increased work and documentation and coordinate care more than ever. Although subjective data would suggest improved resident sleep hygiene and less fatigue with new work-hour changes, some surgeons and residents believe the restrictions have had a negative impact on operative experience and technical skills.28 Interns are absent from the OR repeatedly, and several admit to performing administrative work from home to appear compliant with duty hours.27 However, if charged with equal responsibilities as residents, with PEs integrated into the resident team, administrative tasks of answering pages, entering orders, and scribing notes can be distributed among multiple team members, which allows junior residents more time to operate.6 For example, in a single institution study evaluating resident impressions of the impact of PEs on surgical training, 90 percent of residents reported leaving the OR less frequently to manage patients.9 While a team of parallel PEs caring for patients may decrease the overall patient census for the corresponding resident team, it would not alleviate the day-to-day administrative tasks required of residents, which hinder operating.

Tailoring the approach

Integrating PEs on resident surgical services exposes residents to differing health care professionals but may lead to competition and communication breakdowns. Conversely, by separating PEs from residents, residents learn logistics of the trade, but attending surgeons may elect to solely function with the PEs. The end result would eliminate resident involvement with such attendings, leading to a diminished operative experience. Therefore, the benefits of incorporating PEs with resident education must not be offset by potential disadvantages. The strategies to circumvent the issues of having a PE on a surgical service are manifold.7,10,11 It is first vital that program directors ensure that residents still have a range of operative and educational experiences. For PEs to benefit surgical residents, PEs must represent a complement, not a competitor.

Defining roles is necessary to reap the benefits of PE participation. PEs should not disturb resident autonomy nor team dynamics by competing for procedures or making decisions independent from team discussion.10 Pre-service orientation meetings to clarify roles and expectations have been suggested to assuage this issue.7 One collaborative model shows the intricate web of communication and respective responsibilities of residents and nonphysician providers (NPPs), or PEs (see Figure 1). High-level issues are communicated to an NPP by an attending or chief resident, but NPPs only communicate with the chief resident to prevent disjointed plans. NPPs, as well as chief residents, both discuss patient care with lower-level residents. As shown, NPPs are a common thread that preserves team cohesion and prevent redundancy.29

Russell and colleagues describe their 20-year experience of incorporating PAs into a surgical education program. They reveal that the success of a program is grounded in six key issues: (1) need for institutional, not just departmental, commitment; (2) importance of hospital-specific historical circumstances; (3) emphasis on partnership instead of competition among residents and PEs; (4) value of an educational component for all providers; (5) need to build a cohesive program, not simply intermittent individual substitutes; and (6) importance of leadership among PEs for liaison and advocacy purposes.30

Figure 1. A collaborative model for physicians and PEs

Figure 1. A collaborative model for physicians and PEs

Conclusion

As more regulations and restrictions are imposed on surgical training, residents and program directors must adapt to sustain the production of well-prepared surgeons. PEs not only can mitigate this dilemma, but also offer increased efficiency, productivity, and consistency. Introducing them into the surgical pyramid is problematic, but models like the parallel player and integrated partner have availed. Determining which approach to choose depends largely on the attitudes of junior residents and PEs, availability of departmental funds, and institutional acceptance of PEs in an already precarious health care atmosphere. Nonetheless, for any system to function well, surgical residents and PEs should be regarded as complementary academic positions, not interchangeable labor.


References

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