RAS-ACS Symposium essays: Residents describe the benefits and challenges of physician extenders in academic surgery

Every year, the Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) hosts a symposium at Clinical Congress. The focus of the symposium is a current and controversial topic in surgery that affects residents and surgical education. After much deliberation, the committee has chose Physician Extenders in Academic Surgery: Integrated Partner or Parallel Player? as this year’s theme.

The first physician assistants’ class graduated in the 1960s and was called to serve in a setting lacking primary care physicians with concurrent expanding health care coverage demands. A rapid evolution ensued, and today, physician extenders (PEs) are present in medical and surgical specialties across the U.S., performing many roles within each of those specialties. Different specialties are finding distinct ways of incorporating PEs, but challenges remain for successfully integrating these roles into surgery. The main focus of concern for residents is how best to use PEs without decreasing clinical exposure, learning opportunities, and, ultimately, the surgical education experience. Two main ways of including PEs in surgical education are as an integrated partner or a parallel player.

Integrated partner

With PEs serving as integrated partners, residents, attendings, and patients all benefit. Since the dawn of physician work hour limits, residents have increasingly been expected to perform administrative clinical tasks while maximizing time in the operating room (OR) and absorbing clinical knowledge. The role of PEs in assuming noneducational responsibilities enables residents to use their restricted time more effectively in a manner that preserves the quality of surgical education, allowing seniors to complete more operative cases and providing junior colleagues the opportunity to join them for critical learning opportunities.

It is well documented that PEs improve the efficiency and productivity of hospital-based residency programs. They decrease patients’ length of stay and resident workload, increase resident sleep time, and improve operating times without affecting patient morbidity or mortality. These roles may even result in cost savings. Beyond the educational opportunities for residents working in an integrated model, consistency in patient care is optimized, as PEs develop knowledge of individual attending preferences and are typically readily available in emergencies, unlike many scrubbed or post-call residents. It is beneficial for young physicians to understand PEs’ breadth of knowledge, what they’re capable of, and how they can best be used in a complex team environment. Ultimately, PEs are likely to become a permanent fixture in the surgical world. It is important to acquaint young physicians with PEs early in their training to better integrate them into the health care team.

Parallel player

The goal of a PE in the setting of a surgical residency should be to allow residents greater opportunity to pursue education, be it in the OR or in direct patient contact, by serving as a parallel player. There is an argument that the increasing reliance on PEs is entirely a monetary consideration—that is, they offer a cheaper way to perform the duties that a physician normally performs. Increasing red tape, administrative burden, and business modeling of medicine have led to PEs serving as “replacements for doctors.” There is an increasing practice of integrating PEs into the OR instead of having them serve as parallel players in taking care of floor patients. In the OR, the PE allows surgeons to bill more for the same case, be more efficient, and avoid the burden of teaching obligations. PEs, when not parallel players separate from residents, can also take away from the resident clinical experience outside of the OR. These missed learning opportunities could include anything from PEs performing bedside procedures or line access in the unit to making decisions about patient care.

Historically, teaching services have abided by a linear hierarchy, with attending physicians supported by a team comprised of the chief resident or fellow overseeing junior residents and interns. The introduction of midlevel providers modifies this structure, creating a system where a purely vertical hierarchy in knowledge and experience no longer exists, confusing roles and expectations. This hierarchal change has the potential to result in communication problems, as patient care information may be relayed to PEs, bypassing the resident, and potentially affecting patient care and patient safety. The role of PEs in health care is invaluable, but their role in residency may need to be limited.

The RAS-ACS Advocacy and Issues Committee sent out a call for essays on the topic of PEs in academic surgery, and it received numerous responses from surgical residents all across the country. The first-place winners were Reema Mallick, MD, an Associate Member who just completed a transition to practice fellowship at Geisinger Medical Center, Danville, PA, and Elizabeth Consky, DDS, MD, oral and maxillofacial surgery resident, postgraduate year-5, Emory University, Atlanta, GA. The resident essay contest winners were invited to present at the symposium at Clinical Congress 2018, along with moderator Kyla Terhune, MD, MBA, FACS, and panelists Anthony Kim, MD, MS, FACS; Brian Yorkgitis, DO, FACS; and Rita D’Aoust, PhD.

Following are the second-place entries on the topic.

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Jeffrey Hammoudeh
Jeffrey Hammoudeh

As an Academic Surgeon at a major teaching institution, we initially saw this potential disruption in the Hierarchy of Stability. We pivoted and adjusted our operative experience. The fellow, resident, intern and medical student have priority to scrub. If a case is uncovered then the PE scrubs. This allows us to: 1) Continue on the integral task of educating our trainees. 2) Respect the importance of our PE as they are tasked with holding the continuity of care that the service needs with the in/out rotation of trainee’s. They do a great job understanding the service, the preference of the… Read more »


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