Dee, Acute Care Surgery PA
Dee Naidu, CCPA is a PA practicing in Acute Care Surgery at Sunnybrook Health Sciences Centre. She is a graduate of the McMaster PA program, class of 2013. She has completed a Masters of Public Health.
While in her second year of undergrad, Dee shadowed her Uncle, an Anesthesiologist in Detroit. It was during this time that she had her first encounter with a Physician Assistant. The PA was brilliant, working alonside the Neurosurgering, see consultations in the trauma bay and doing procedures in the operating room. PAs were growing in Canada, and that is how she discovered the PA program at McMaster.
Working in General Surgery
What is General Surgery?
General Surgery is a surgical specialty involving organs within the abdominal cavity – this includes the stomach, small bowel, colon, liver, pancreas, gallbladder, and appendix. We will even operate on the gastric valvula and on hernias that are in the thoracic cavity.
Subspecialties in surgery include trauma / surgical critical care, laparoscopic surgery, colorectal surgery, breast surgery, vascular surgery, endocrine surgery, transplant surgery, surgical oncology, cardiothoracic surgery and Paediatric Surgery – all areas in which PAs can work.
What drew me to General Surgery
Acute care general surgery is very exciting, with a lot of variety.
Every day is different, and you can never quite predict what will walk in through the door.
Surgery is also a very hands-on specialty and satisfying. Patients are sick – in pain and discomfort, but they come to hospital, are admitted to our service and their presenting ailments have immediate, effective solutions.
For example, a patient comes in sick with appendicitis, we take out their appendix and we cure them, they feel better and then they get to go home. Another aspect of General Surgery I enjoy is the number of procedures I get to perform in this specialty.
And unlike emergency medicine, I have the opportunity to build a little bit more of a longitudinal relationship with patients in General Surgery. They are admitted to the acute care surgery service for a few days (sometimes longer), I see them every day and follow their progress, then I see them a month later in our outpatient clinic and I am able to see how our care made an impact on their lives.
What Training for General Surgery Entails
PAs are trained as generalists during PA school. As part of McMaster’s PA Program 2nd year PA clinical year, we have six weeks in General Surgery rotation that is mandatory with a two week selective in a surgical subspecialty. My training for General Surgery actually began when I was in clerkship, and I completed my rotation at Sunnybrook. I came in at 6 am daily to round on patients.
Once I was hired on the General Surgery service, orientation took place over a period of two weeks. I spent time in different areas of the hospitals and with different professions – this included wound care, stoma care nurse, and the acute pain service. In addition I also spent time in Surgery Clinic, following and working with Surgery residents, as well as receiving feedback. I also completed an EMR orientation, and a scrubbing session.
In Ontario, PAs in large institutions often require medical directives to function to their potential. If medical directive are not yet developed or in place, PAs require a co-signature from the supervising physician for any orders (prescriptions, investigations, orders and discharges).
When I first started working in the General Surgery service, I did not yet have medical directives in place. Using existing templates, I developed my own medical directives to reflect my scope, Now, I no longer require the supervising physician to co-sign on my orders.
In the Acute Care General Surgery Service where I work, there are many different General Surgeons who rotate through. Therefore each week I work with a different surgeon, and each surgeon may have differing expectations. I started to feel very confident in my role as a PA after 1.5 years of working, especially after medical directives had been implemented and I had the opportunity to rotate with each of the different Surgeons several times.
Common Conditions seen in General Surgery
Appendicitis
Colorectal Cancer / Surgical Oncology Presentations
Gallstone Disease (Cholelithiasis, Cholecystitis, Choledocholithiasis, Cholangitis, Gallstone Pancreatitis)
Hernias (all types: umbilical, ventral, inguinal, femoral)
Bowel Obstructions (large and small of various etiologies)
Bowel ischemia
Wound infections
Foreign Body
Perforated Colon Cancers
An example of a rare condition I see is gallstone ileus.
My Practice Setting
I work in a large academic centre filled with residents, medical students and PA students. We do not have Nurse Practitioners on our service, but there are NPs in various other areas of the hospital (e.g. Acute Pain Service).
Physician Assistants can function in all aspects of General Surgery – including inpatient/ward management, outpatient surgery clinic, operating room first assist, general surgery consultations, call, admitting and discharging patients, ordering and interpreting investigations, performing diagnostic and therapeutic procedures, and more!
A typical week in the Life of a PA in Acute Care Surgery
Monday –
Inpatient / Ward Management/Consultations
Tuesday –
Inpatient / Ward Management/Consultations;
Outpatient Clinic
Wednesday –
Admin Day to focus on work as PA Professional Lead
Morbidity and Mortality Rounds
Thursday –
Operating Room, first assist Thursday morning (if needed);
Interprofessional Rounds
Inpatient / Ward Management
Consultations
Friday –
Inpatient / Ward Management
Consultations
My Hours
Daily Hours –
My hours each day start at 7:30 AM and end at 5:30 PM five days per week.
If I am rounding on patients, I come in at 6 am instead.
Shifts – There is no shift work.
Call – I do not do call regularly – only if required. In the 4 years I have worked here, I have only come in a handful of times to do call on the weekend. If this occurs, I will take days off in lieu of the time I did during call.
Typical Inpatient / Ward Management and Consultation Day
6 am – Rounds, we’ll go and see patients without the staff surgeon, assess their status and then develop preliminary plans
7:30 am we meet with staff surgeon we will discuss each patient with the staff surgeon including if there were were any events overnight (e.g. fever overnight, vomiting) and discuss if we need to investigate things further, And what else is needed to manage them pre-operatively and post-operatively.
After rounds, I will spend the rest of the day: waiting for consults, seeing consults in the emergency, or on the ward, following up on blood work, imaging and investigations, going to family meetings, completing home care or rehab forms and discharging patients.
What I do in Outpatient General Surgery Clinic
I work alongside the staff surgeon during the Outpatient General Surgery Clinic.
During this clinic, we typically see post-operative patients that were admitted to hospital, had surgery performed, and are now seeing us for follow-up. Here we assess the patient, ensure there are no post-surgical complications, ongoing wound infections or new complaints.
We do sometimes manage patients on a chronic basis if there are issues with wound healing or ongoing pain.
General Surgery Consults
I also perform General Surgery consults for the Emergency Department and for patients admitted to other services. Often we get consult requests regarding thickening of bowel not yet diagnosed (NYD), abdominal pain NYD, appendicitis, gallstone disease (ex. cholelithiasis, cholecystitis), bowel obstructions, upper or lower GI bleeds, and non reducible hernias to name a few examples.
PAs & Team-Based Care
What PA/MD Supervision Entails in General Surgery
There are two types of PA supervision: Direct and indirect.
Direct supervision involves the physician being physically present to see the patient alongside the PA.
Indirect supervision involves the Physician Assistant seeing the patient independently, with the physician being available by phone or on site.
The supervision I have as a PA on my service is generally indirect supervision, but there is also direct supervision:
In General Surgery Consults – There are times that I am performing General Surgery Consults, and carrying the pager. When the pager beeps and I receive a request to do a Consult, I will go down and see the patient. I call the supervising physician and review the patient who will agree or modify my plan. I will then initiate orders based on the plan. The physician will then see the patient when doing their own rounds or later when they are taking the patient down to the OR.
In Outpatient Surgery Clinics – I work with the General Surgeon and supervision is direct. Here I will see and assess the patient, review the patient verbally with the surgeon, and then she will come in and speak with the patient briefly. However, there are times when the surgeon may be called into the Operating Room during the Outpatient Clinics, and I will see the patients independently. This then becomes indirect supervision. I see patients, and am operating autonomously within the medical directives set out, while the surgeon is still on site and available for review.
Describing the PA Role and How I work with Surgery Residents
In a teaching hospital, like the one I work at, I often work with a variety of learners and members of the interprofessional team. This includes Senior Residents, Junior Residents, Clinical Clerks (3rd/4th year medical students, or 2nd year PA students) and med/PA students who are observers.
The interprofessional team can comprise of nurses, physiotherapists, occupational therapists, social workers and dietitians. When trying to describe the Physician Assistant role to other health care professionals, I often explain that I am very similar to a “junior resident – with less operating time”. I work alongside the senior and junior residents, and clinical tasks are divided between the residents and the PA.
There are a few differences between me (as an experienced PA) and the residents:
Junior residents rotate on the service 1-2 months at a time, as a PA I am there full time and permanent, and have built relationships with nursing staff and staff physicians of different departments. For instance, I’ll be less hesitant to get on the phone with the Interventional Radiologist when there is a specific question or a request, like inserting an urgent cholecystostomy tube for management of cholecystitis.
Residents typically prioritize time gaining surgical experience in the OR, as a PA I do occasionally assist in the OR if required, however I typically spend more time in surgical clinic, seeing consults in the emergency department and on the ward, managing patients pre- and post-op and liaising with the interprofessional team to provide quality, patient-centred care.
Note: In large academic teaching centres, surgical first assists typically include fellows, residents, and other medical learners. In community hospitals without residents to rely on as surgical first assists, hospitals typically rely on surgical nurses, or physicians in the community (i.e. family physicians) to assist in the OR if required – there is certainly a role for PAs to step in as surgical first assists)
I also do teaching and orientation with junior residents and medical students/PA students. We review conditions with the gallbladder, small bowel obstructions, hernias, colon cancer, diverticulitis and more.
How I work with other Health Care Professionals
I work with nursing staff on the General Surgery Floor and in the ER when consulting, and we work collaboratively in a collegial relationship. Often I find it is easier for nursing staff to speak with the full time, permanent PA than a resident they may have met earlier that week. As a PA for the General Surgery service, I am the continuity of care, a familiar face, and I tend to be more accessible to the nursing staff than the residents or the staff surgeons.
Some questions I do answer for nursing staff include: “There wasn’t an order written for diet? Can we take patients off NPO status? Are they allowed to start? Do you know when surgery will take place? The patient’s family is here, can you talk to them and answer their questions? Can you give them an update? Can you write an application for rehab, CCAC?”
There are other times when I am the only person available on the floor (residents or staff are at teaching rounds or in the OR), and a patient, for example, becomes tachycardic and hypotensive. I am available to immediately respond with regards to making decisions about calling the rapid response team, giving resuscitation and medications in that acute setting.
Hiring a Physician Assistant in Surgery
How my General Surgery PA Position is Funded
My job was initially funded through the Health Force Ontario Career Start program. The funding at the time was for 50% of my salary for a 2 year contract. After the 2 year contract was completed, I was kept on as permanent and now, 50% of my salary is funded through the hospital, and the other 50% is funded through the Division of General Surgery.
Through this funding model, I am an employee of the hospital and I get benefits and other advantages. It is dual reporting model, where I report to a group of Surgeons with regards to my clinical responsibilities and a Patient Care Manager with regards to any other human resources related issues.
How a General Surgeon can Hire a Physician Assistant in Ontario
There are two avenues that a General Surgeon can look into working with a PA in hospital. PAs can be hired as private employees (out of the surgeon’s pocket, with Career Start Grant funding) with a special hospital agreement or having the PA hired as a hospital employee. Funding can come from a few sources:
LHIN
Department of Surgery or Division
Hospital Budget
Allied Health Budget (if a family health team, or community health centre)
Or hired privately by a single General Surgeon or General Surgery group
I am funded 50% by the Division of General Surgery and 50% by the hospital.
For Physicians looking to work with a PA, but would like to explore the option I urge them to consider taking on a 2nd year PA student (clinical clerk, who is similar/identical in role to a 3rd/4th year medical student/clinical clerk) to see how they could envision a PA fitting into their practice.
The Benefits of Adding a Physician Assistant to a General Surgery Service
Some of the benefits of adding a Physician Assistant to a General Surgery Service include:
Better continuity of care
Better relationships within the interprofessional teams (nursing, PT/OT, pharmacy, etc.) – care for patients is more collaborative
Improved quality of life / less physician workload – this is primarily because you have a PA on staff who essentially functions like a physician, but under supervision. Staff PAs do not leave after 1-2 months (like a resident) would and knows the organization and resources within the hospital. With an extra clinician who can tackle the same workload you do, you are decreasing physician workload while increasing access to a provider.
A resource for learning for all medical learners – the residents do learn from me, especially when it comes to helping navigate resources in the hospital and tips on expectations of different staff Surgeons.
Excelling in General Surgery as a PA Student
Tips for Medical Learners to Excel in General Surgery
When I take on a medical learner, the characteristics of PA clerks who excel on their rotation include:
Being very keen and enthusiastic about learning
Taking a lot of initiative to learn, and to help
Being observant of what happens throughout the day and taking note of what is important to know
The best students read around cases (always be reading!)
Get to know your environment – Orient yourself to the services and some of the locations of the different departments
Get to know your charge nurse, physiotherapist and other interprofessional team members on the floor, they can be valuable resources during your short 4-6 week rotation. Take the time to introduce yourself and build relationships.
Try not to miss learning opportunities, keep in mind you are there for 4-6 weeks, and the schedule can be gruelling (6 am to 6pm, with 1 in seven days call). When PA students do a rotation with me, call is not required. However I encourage our PA clerks to do call, as a lot can happen overnight and you may miss out on potential learning experiences. On overnight call, you may be the only learner there you’ll be first to see the consult or right in the middle of trauma.
Another tip I would have for 2nd year PA students is to advocate for yourself – especially in big academic centers that also have medical students, residents, and fellows – you might not have all the opportunities to do all the procedures and scrub into surgery.
When I have PA learners on with me, I will advocate for the PA student and ask on behalf of the student if they can get in on a special procedure, or observe during a special case. However for PA students that may not have a “liaison” to help them do that, it’s important to step up and speak out to ask for those learning opportunities when they present themselves.
Another tip is to always be practicing Professional advocacy – especially if you go into a learning setting where there are no PAs. Do education around role awareness and get good at describing what PAs do. When I have medical students that do rotations with us, I will take a moment to explain what my role is, how long I’ve been there, my education, and how I am integrated into the Surgery service as a PA.
Tips on Work-Life Balance During a General Surgery Rotation
For 2nd year PA students who are completing their General Surgery rotation, work-life balance can be challenging when you may have 12 hour days. Maintaining work-life balance is a lot about efficiency and occasionally making sacrifices to leisure time. When I was a student on my surgery rotation, I was living with my parents in Mississauga. After I completed my work day, I would read around cases at the hospital until traffic died down before driving home from Sunnybrook.
Resources for General Surgery
Whenever we have students coming on, I send them a package of resources which includes specific articles around topics that I feel are pertinent to General Surgery.
Advancing my PA Career
What is the PA Professional Lead Role?
When I listed my schedule earlier on in the blog post, you’ll notice that I included Wednesday – Admin Day. I recently took on the role as Professional Lead for Physician Assistants at our hospital. My roles and projects have included developing a process for hiring and integrating PAs in different departments in the hospital to make it as seamless as possible. I have developed PA medical directives for the hospital, participated in education around PA role awareness, and troubleshooting. I run PA council meetings where PAs from different departments in the hospital get together and discuss what’s going well, and challenges in their day to day practice.
I advocate for the PA role in the hospital (e.g. continuing medical education days, role awareness meetings with other healthcare professionals). I also put together a PA retreat for the PAs of the hospital to team as a way to build strategic thinking that they can bring to the workplace.
The hospital’s trauma service recently decided to include military PAs who are part of the special operations unit. These military PAs now come into the hospital for 1 week rotations every month before being deployed. This is an incredible learning opportunity for the military PAs, and I was involved in the development of medical directives and education for staff of the trauma unit, ICU and ER department.
Deciding to Pursue My Master’s of Public Health
Deciding to Pursue an Master’s in Public Health (MPH) – In addition to starting my PA role several years ago in General Surgery, I also decided to pursue a Master’s in Public Health. I wanted to learn more about how patients connect with services in their community once they leave hospital (e.g. CCAC). For instance, if you discharge a patient who is homeless – how would the patient have access to CCAC? The hospital I work at is located in a fairly affluent area, however there are still socioeconomic disparities that I noticed. This inspired me to help bridge the gap between patients and the communities they are going back to when discharged from hospital.
What is an MPH – In a Master’s of Public Health, you learn about the determinants of health, program planning (designing health intervention programs), health promotion, prevention, program evaluation, and important patient metrics related to my work as a PA (e.g. that factors that affect whether patients get discharged before 11 am on a unit). The MPH gives you a background of statistics and epidemiology which is valuable in a clinical setting and pursuing research.
What do you do after acquiring an MPH? Graduates of the program take on leadership roles in public health and tackle complex public health issues (e.g. access to care for Ontario’s aging population). Organizations that you can work in include community outreach programs, government and policy making, working for the Ministry of Health and Long Term Care. You can coordinate different programs and be the liaison with the community and the patient.
Pursuing an MPH and having a clinical background – You do not have to be a health care provider to pursue a Master’s in Public Health. However, having clinical experience allows you to approach complex public health issues from a different perspective. For example, when we evaluated programs in my course I had a different perspective that I brought to the table. For example, in a recent course, we discussed the success of Naloxone kits and I was able to provide insights on opioid overdose symptoms.
Completing an MPH while working full time as a PA – I am completing my Master’s of Public Health through the University of Waterloo. There is a 2 year full time option, and 4 year part time/online option which I am completing now. The curriculum also includes placements working with a local public health unit, provincial and federal government agency or non-governmental organization. I am currently completing my placement with the Office of Injury Prevention at Sunnybrook.
