PA PROFILE • BY TRACY WATSON, CCPA

I am a Physician Assistant who is currently working in Neurosurgery which specializes in adult neuro-trauma, neuro-oncology and degenerative disorders. I graduated from the McMaster University Physician Assistant Program in 2013 and have been working in Neurosurgery for the past four years. Prior to my enrollment in the PA program, I completed an undergraduate degree at McMaster University in Psychology, Neurosciences and Behaviour. I enjoy managing inpatient, outpatient and perioperative responsibilities for patients with cranial or spine pathology.

I did my undergraduate degree in neurosciences and always felt strongly towards neuroanatomy and pathology. It is a fascinating field where thorough histories and physical examinations are necessary to localize and lateralize lesions. I completed clerkship rotations in Pediatric Neurosurgery at McMaster University and Adult Neurosurgery at Hamilton General Hospital, where I had a fantastic experience with neurosurgical conditions and operative procedures. I like the versatility of attending clinics, assisting in the OR and conducting inpatient management. There is a lot of opportunity for advanced procedural skills, autonomous decision-making and dealing with acute medical management.

My schedule includes shift-work, thus hours can vary. Outpatient clinics are typically 8:30-5pm, evening call shifts are typically 4pm-12am, and weekend call shifts may be 8am-5pm or 8am-8pm. The schedule is very flexible depending on which staff are on service and where the gaps are in the call-schedule.

In theory I work 37.5 hours per week, though this is often higher in practice. Specific shift lengths vary depending if it is an “on-call shift” (8-12 hours) versus an outpatient clinic shift (8 hours).

My roles include working in both inpatient and outpatient settings. Outpatient clinics are either new consultations, follow-ups or post-operative assessments. Procedures are occasionally done in the clinic (ie, lumbar punctures).

Tracy inserting an external ventricular drain

The number of patients I see a day depends on the clinic I am working in. In outpatient clinics, the PA will typically see between 8-10 patients per day (though the surgeon’s roster will be between 20-25 patients). Inpatient management can consist of up to 25-30 inpatients.

I see a mix of new consults and follow-ups. In the outpatient clinic, it is a mixture of new neurosurgical consultations, follow-ups for non-operative patients (ie, screening for benign tumours, unruptured aneurysms, degenerative spines, fractures) and post-surgical follow-ups.

I do call – typically during evenings and weekends when there is limited residency coverage.

I am in the Operating Room. PAs can function in all clinical domains for surgical patients (inpatient, outpatient, OR) which promotes continuity of care. This is especially appreciated in centers without a dedicated residency program. The PA functions as a first-assist under direct supervision and our intra-operative scope increases as competency is obtained.

I review investigations daily on every patient.  Inpatients are categorically more medically complex or acute and will therefore have investigations ordered on an “as-needed basis” depending on clinical status. As such, bloodwork, ultrasound and imaging are frequently ordered and reviewed on a routine basis. Outpatients, however, are typically followed with either clinical reassessment or serial imaging (CT, MRI, X-ray) depending on the medical condition in question.

I currently work in an academic centre, however there is not a dedicated neurosurgery residency program. We do have “off-service” residents (ie, general surgery neurology, orthopedics, emergency medicine) and medical students who rotate through the neurosurgery service as part of their academic requirement. We do have nurse practitioners who help implement inpatient management and discharge planning.

There was a steep learning curve for neurosurgery, as it is a subspecialty with a unique patient population. I would say that it took a good 6 months to familiarize with the basics (physical exam, neurosurgical conditions, procedures, follow-ups) and 12 months to become competent at independent inpatient management and neurosurgical decision-making. That being said, there is always opportunity for continuous learning as skills are obtained (procedures, neuroimaging, acute medical emergencies, OR assisting, diagnosis formulation). Certainly there was a lot of one-on-one supervision with physicians in the beginning. Overtime the direct supervision transitions to more remote supervision as a level of trust is established based on the PAs competency, skill set and decision making ability.

There is a mixture of both direct and indirect (remote) supervision depending on the clinical task at hand. Outpatient clinics are often run in tandem with a Neurosurgeon, whereby PAs will formally conduct the consultation (history, physical exam, image review & diagnoses), though the surgeon will finalize the management plan. However some clinics are run by remote supervision (telephone handover with the neurosurgeon) if face-to-face contact is not feasible. Intraoperative assisting is always direct supervision as you are functioning as first assist alongside the surgeon. Inpatient management or “on-call” duties are remote (indirect) supervision, though surgeons are always accessible by phone as needed. This allows the PA to make independent medical decisions on behalf of their supervising physicians as delegated through medical directives, thereby allowing neurosurgeon to allocate their time to other cases.

Know your neuroanatomy and master your neurologic assessment (for both brain and spine) as this will allow you to lateralize and localize the lesion. Know pearls for post-operative care as well as common neurosurgical conditions. Practice your suturing skills and become familiar with reading CTs and MRIs. Work hard, read reference books and enhance your knowledge base.

• “Handbook of Neurosurgery” by Greenburg (this is very comprehensive and best reserved for people interested in pursuing neurosurgery as a career)
• “Neurosurgery for Basic Surgical Trainees” by W.A.Leibenberg & R.D. Johnson helpful
• “High-Yield Neuroanatomy” by Lippincott, Willians & Wilkins
• “Internal Medicine Residency Training Program Resident Survival Guide” (“the red book”). This is always helpful for inpatient management for overall medical management
• “Toronto Notes” (neurosurgery section)

Identify the needs of your service. Are there deficiencies in managing outpatient clinics (long wait-times)? Inadequate on-call coverage (neurosurgeons taking first call or relying on off-service residents)? Inadequate inpatient management (disposition planning, access to acute medical management or advanced procedural skills)? This will determine where the PA will be most beneficial.

Teach your PA. Given the subspecialized patient population and neurosurgical procedures, there should be a grace period of intensive teaching and observation. Clinics and inpatient rounding are gentle starts for exposure to neurosurgical conditions. As competence develops, the PA will be able to function more independently (performing consultations, admissions, inpatient management, procedures). Intraoperative assistance will take time and exposure. It will be worth it in the end to have an advanced health provider who is able to function across all domains of the neurosurgery spectrum with a versatile and specialized scope-of-practice.

Advocate for the PA role. It is a new role to Canada and there is a lot of skepticism and confusion surrounding politics and regulation. Be familiar with the concept Medical Directives and Direct Orders. As a Supervising Physician, you alone, are responsible for determining the PAs competency and content of the Medical Directives. Ask other centers about existing Medical Directives and professional mandates to help streamline the process of integrating the role at your center. Educate others and promote awareness.