Physician extenders: Integrated members of surgical teams

In the 1960s, the first physician assistants (PAs) class graduated from Duke University, Durham, NC. The concept of PAs was first established in response to the lack of primary care physicians and the need to expand health care coverage.1 The origin of this profession lends support to the idea that physician extenders (PEs) are integrated members of surgical teams. PEs are used in medical and surgical specialties across the U.S., and they perform many roles within each of those specialties.

Surgical residency involves learning the many aspects of patient care. The process of caring for patients includes, but is not limited to, evaluating patients pre- and postoperatively, placing appropriate orders to facilitate care, writing progress notes and discharge summaries, and assisting with operative procedures. These tasks are delegated to residents as well as PEs. Although both types of health care professionals perform these duties, residents also are responsible for achieving myriad educational objectives. In fact, PEs have become an integral part of surgical teams and help facilitate resident education in several respects.

Learning to care for critically ill patients is an important part of surgical education. Many surgical intensive care units (ICUs) employ PEs. A 2015 survey of 354 surgical residents showed that 48.4 percent of the respondents report that PEs have a positive impact on their ICU experience. Many residents report that advanced practitioner providers (APPs) not only decrease their workload, but also provide teaching and enhanced patient care.2 In these settings, residents perceive an educational benefit from having PEs in the hospital. APPs offer instruction in ICU protocols while assisting in patient care. Having PEs also allows for continuity of care. When residents transition off service after a month rotation, APPs remain in the same patient care area and continue following patients. PEs in this setting serve a dual purpose by providing continuity of care and resident education.

In 2009, a study was published showing that PEs are being hired for general surgery teaching services with the intention of helping enhance resident education.3 This study specifically mentions that PEs are most often used to perform histories and physicals, see consults, and assist in the operating room.3

One could argue that APPs are taking educational opportunities from residents by performing these tasks. The counter-argument is that the implementation of the 80-hour workweek has forced surgical residents to master the art of efficiency by completing a portion of these same service duties and attending educational conferences to meet Accreditation Council for Graduate Medical Education requirements for their residency programs.

Residents receive a large portion of their education through clinical practice and service; however, the educational benefits of conferences and lectures must not be overlooked. APPs play an important role on surgical teams when helping with resident workload and allowing them to attend designated activities. The benefit also is seen in enhanced patient care while residents are participating in these educational conferences. In addition to improved patient care observed by others, Stahlfeld and colleagues reported improved scores on the American Board of Surgery In-Training Examination for some residents with the addition of PEs.4 With the use of APPs, residents have more time to read and learn the surgical curriculum that is tested by the American Board of Surgery.

Surgical residents should embrace the concept of providing team-based care because it is vital to quality patient care. An environment that supports the use of PEs also is important for resident education. Buch and colleagues surveyed surgical residents and APPs at an academic medical center to evaluate the general experience between the two groups.5 The study’s results showed that residents and PEs at this facility have a collegial relationship. Both groups agree that PEs have a positive impact on resident educational experience through direct clinical teaching. The presence of PEs also provides the opportunity for residents to learn how to care for patients in a multidisciplinary fashion. Not all surgical teaching services have PEs, but there is a high probability that another service that frequently interacts with residents may have these providers. Thus, it is important that residents learn how to communicate and work with APPs from other specialties in order to provide high-quality patient care.

Surgical education involves the integration and balance of service-related duties with attending didactic conferences. The use of PEs is not only imperative for patient care, but residents have the opportunity to learn directly from these team members. As surgical education continues to evolve, residency programs that employ PEs will have an advantage that is reflected in the educational achievements of their future residents.


  1. American Academy of Physician Assistants. History of PA profession. Available at: Accessed April 15, 2018.
  2. Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents’ critical care experience. J Surg Res. 2015;199(1):7-12.
  3. Pezzi C, Leibrandt T, Suryadevara S, Heller JK, Hurley-Martonik D, Kukora JS. The present and future use of physician extenders in general surgery training programs: One response to the 80-hour work week. J Am Coll Surg. 2009;208(4):587-591.
  4. Stahlfeld KR, Robinson JM, Burton EC. What do physician extenders in a general surgery residency really do? J Surg Educ. 2008;65(5):354-358.
  5. Buch KE, Genovese MY, Conigliaro JL, et al. Non-physician practitioners’ overall enhancement to a surgical resident’s experience. J Surg Educ. 2008;65(1):50-53.

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