Working as a PA in Otolaryngology
Currently I work in Otolaryngology, Head and Neck Surgery. This was formerly known as “ENT” (Ears, Neck and Throat) but surgeons are staying away from that term. The field is quite subspecialized. Previously I was in a cardiac surgery for one year, 3 months in Geriatrics which was a little stint just to get my toes wet into primary care. Prior to that, General Surgery with a focus on colorectal and surgical oncology.
I am Monday to Friday, 7:30 to 3:30 PM. I always arrive 45 minutes early, this is key as it has allowed me to work on outside projects. I will work on my podcast, read journal articles or work on research and just give myself 45 minutes to start my day. Then I have an awesome teaching for 1 hour from 7:30 to 8:30 AM. I am very fortunate to have that. The residents or staff will give lectures in Otolaryngology.
8:30 to 9:30 AM we run the list and disperse, that is when the patient care starts for myself.
9:30 to noon – We try to get the residents to the operating room and/or clinic as soon as possible. The procedural care on the ward can include tracheostomy changes, decannulations, pulling any percutaneous drains, writing orders, following labs, replacing electrolytes, etc.
We “put out fires” as they come. We have fresh tracheostomies on the ward so there are always things that can go wrong, which includes persistent desaturations that require readmission to the ICU. Dealing with acute issues as they arise. I try to get clinic myself, sometimes two times per week, otherwise the ward is quite demanding.
The resident team that I am on only has three residents on at a time, and we have two hospitals that they operate in. I often find myself alone on the ward; it is my role to manage the 20-30 patients depending on how many we have. If there is time, I get to clinic. If there is time I will help the on-call resident as there are a lot of issues during the day that they have to deal with, including nose bleeds, tracheostomies, or acute airways.
I actually serve as the first contact point for the attending surgeon who takes all the consults from the Emergency Department and outpatient settings. Our catchment area in Edmonton is huge, so we take consults from NWT, Yukon, British Columbia. Anything west of Winnipeg comes to us, and anything East of Winnipeg comes to Toronto. From my understanding those are the two primary centres for OHNS in Canada (although I am uncertain about how Winnipeg handles OHNS).
The surgeon will contact me with any Emergency consults that come. I have to recognize how urgent it is and find the junior resident that is on-call that day, and clarify if I can get started on that consult while we’re waiting for them to come through STARS (which is similar to ORNGE helicopter transport).
At the end of the day I run through the list again. Otherwise I send a handover blurb over secure email. I am very fortunate because once my 8 hours are done I get to go home.
Similarly, if you picture a medical student model learning with the residents, I am very happy to go and start the consult, pre-admit people. I am not directly involved in call, but because I am the continuity it is easier for the surgeon to contact me, and I disperse out the consult. This is opposed the surgeon having to be on top of the call schedule which changes all the time with the residents.
Priority for OR time does go to the residents. I want to get residents to the OR to enhance their operating ability. I did have more OR time in Toronto, however, it is more procedural on the ward. Between the Respiratory Therapists and myself, I will volunteer to do the tracheotomy changes so I can keep up with my skills.
I occasionally do get the opportunity to operate if there are multiple rooms or the residents are spread out.
In OHNS is quite a large division
- Facial Plastics
- General ENT
- Head and Neck
- Paediatric OHNS
I am allotted to head and neck, so this is the Oncology side of things. The most common thing is any malignancy between nasal/oral cavities to skull base, down to the larynx and hypopharyngeal area.
For instance, laryngeal cancer, oropharyngeal cancer, and tongue cancer. Acutely on call, we will see patients with epiglottitis and neck abscesses.
Poorly healing neck incision post-laryngectomy.
We do see unusual penetrating traumas that are rare, but when it happens it’s interesting. For example, “I fell onto the knife and now it is in my neck”.
Neck Necrotizing Fasciitis, which involves debridements which I’ve seen several times.
Leeching an auricular hematoma
Another case was severe, profound sepsis from pharyngitis, which is scary requiring intubation and surgery just from a pharyngitis. As benign as some of the conditions our primary care colleagues see, we see the more extreme ends of the spectrum of common, benign conditions like pharyngitis in OHNS.
I don’t do Paediatrics. I got to do two weeks with each subdivision in OHNS which was a great introduction to the role. During the day they have a Paediatric day call resident.
Our chief residents change every 3 months. In a given year I will have four different leadership opportunities where that individual is my go-to person. The intimate residency program makes it easier to accommodate to what their preferences are. Whereas if you have a larger program, I know one of my colleagues is in Urology, which is a big program. That can be challenging with a lot of resident turnover.
Most of my resident team and two attendings.
In OHNS we have a smaller service. The staff that I work are four male staff, we get along fantastically. I’m so fortunate to be in a prestigious academic centre. The criteria to work at this hospital, they have to be considerable leaders themselves. Their resumes and CVs are so impressive. So I am working with fantastic, lovely people, and I am super lucky.
It does absolutely get challenging. Some are more hands on while others are hands off. I know them well enough, for this decision I can make it on my own and review it after the fact, or do I need to talk to them first before making a decision. It’s understanding as your role as a PA. I don’t want to step on toes, you need to know how to navigate yourself through making a decision.
As early on in our career, I do not mind working in teams. I manage the ward in lower-level decision making, but for the acute things, that has to go through the the chief resident. Early on in our career, being on the academic centre on a resident team you would not find in a community position. I’m so grateful for the rounds that I get to attend. I have the privilege and opportunity for caring for a broad range of patients including palliative care and active patients.
I like being on a resident team. They are studying for their exams and it encourages me to study. If you are in a one-on-one community practice, the onus might more be on yourself to take initiative. But when I am in this environment of quizzing each other, pimping each other, PGY5 are so stressed studying for their exams in 2 weeks. I see how hard these individuals work and to better themselves in this specialty, and I get inspired by that.