Physician assistants in cardiothoracic surgery

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Physician assistants (PAs) are well established in cardiothoracic surgery because they are a natural fit for complex teams. As key members of the cardiothoracic team, PAs' daily professional lives demand close coordination with surgeons in the surgical suite, ensuring proper pre- and postoperative care, coordinating the team effort, and being a resource to hospital staff, referring physicians, and the community. PAs in cardiovascular surgery are called upon to perform technical procedures requiring significant dexterity in a setting where every millimeter is critical and time matters. They must have the knowledge base and judgment to understand the complexity as well as the importance of a particular phone call from the ICU, general patient care area, or office during the day or in the middle of the night. The rewards of a cardiothoracic operation are saving and improving the quality of a patient's life. The risks accompanying the same operation are life-threatening. This dynamic combination of skill, knowledge, and judgment in a setting where excellence is required for a positive outcome is what draws special people into this complex field.

The surgeon's assistant program at the University of Alabama was established in 1967 and is credited with opening the door for PAs to practice in surgery. The driving force behind this was John W. Kirklin, MD, a legendary cardiothoracic surgeon instrumental in the development of cardiopulmonary bypass, and his wife, Margaret Kirklin, MD, who served as the program's first academic director.¹ John Kirklin thought that physicians were poorly distributed regionally, even in the absence of a physician shortage, and that PAs could be trained to manage many of the tasks traditionally performed by surgeons.¹ Emory University also published an account of its 30-year positive experience of using PAs in the cardiovascular departments.² This success was embraced across the cardiac world and in 1981 resulted in the development of the Association of Physician Assistants in Cardiovascular Surgery (APACVS), which seeks to provide education, networking, and advocacy for what was then a fledgling PA specialty.³

The demand for PAs in cardiovascular surgery has taken on a greater urgency for two additional reasons:

• Regulations in resident duty hours have created a demand for PAs to support surgical services.^4,5
• PAs in the cardiac specialty also have filled a staffing void left as a result of the difficulty in filling cardiothoracic residency positions in recent years.²

The idea has been to keep surgeons in the surgical suite and have PAs work with them there as well as manage the patients pre- and postoperatively. A survey of academic medical centers found that primary reasons for facilities hiring PAs were to manage patients because of resident duty hour limitations, improve access to care, and improve continuity of care.⁵ Other reasons included improving patient throughput and improving safety and quality of care.⁵ Internationally, PAs are beginning to be trained and used to care for cardiothoracic patients.⁶ Leaders from the APACVS recently presented and discussed a PA's role in American surgical teams at the European Association of Cardiothoracic Surgery meeting in Vienna, Austria. Today the National Commission on Certifying Physician Assistants (NCCPA) reports that 3,634 PAs identify themselves as practicing in the specialty, out of the 72,796 PAs who have completed professional profiles. NCCPA extrapolates that an estimated 4,744 PAs are in the specialty, out of 95,280 PAs certified by the organization (G. Thomas, personal communication, December 12, 2013). PAs in cardiothoracic surgery are employed by private practices, university hospitals, community hospitals, and by the federal government.⁷ They have proven to be safe and effective first assistants in cardiac surgery.⁸ PAs operate, serve as critical care intensivists, educate patients and staff, manage their services, and maintain databases that are used to better understand and improve the field.^2,7 They work long hours and can provide 24/7 in-house coverage or can be on call when they are away from the hospital.⁷

As members of surgical teams, PAs can have a positive effect on clinical quality and patient safety. A PA at Geisinger Medical Center in Danville, Pa., championed an effort to manage perioperative blood glucose that was associated with decreased complications and mortality.⁹ PAs in general surgery in Michigan successfully implemented a venous thromboembolism prevention program.¹⁰ A study in New York discovered that a PA home care program decreased hospital readmissions by 25% after cardiac surgery through evaluation, education, and medication adjustments.¹¹

PAs were central to the creation, development, and acceptance of endoscopic vessel harvesting that has been shown to be both safe and to decrease morbidity.¹² Their role as a part of the surgical team when using video-assisted thoracoscopic surgery techniques is integral to its success. PAs are involved with teaching the team-based approach to this minimally invasive technique to surgical teams throughout the country.

To meet the needs of the current healthcare environment, centers for PA education are growing and hopefully so is the interest of new graduates in the specialty of cardiac, thoracic, and vascular surgery. Educators need to recognize that most PA jobs are outside primary care. Leaders need to be innovative in ways to educate these new clinicians, inspire talented students to consider cardiothoracic surgery, and support them throughout their career.

Another challenge is to address the issue of a work and life balance. Although PAs are seen as a solution to limitations in resident hours as well as meeting the needs of community-based programs, they can find it difficult to be expected to work resident hours throughout their careers. Strategies to use PAs in a way that does not lead to burnout are vital.

In addition, PAs also still face laws that create barriers to PA practice. For example, California is often cited as a healthcare innovator but still prohibits PAs as first assistants to surgeons while a patient is on cardiopulmonary bypass, thus preventing patients from receiving the proven expertise and cost-effectiveness of PAs. PAs as first assistants has been proven safe in the medical literature and is the daily practice in ORs throughout the country.⁸ PAs need to continue to communicate their value both in clinical decision making and to facilities' financial health. A PA's value far outweighs the cost and needs to be continually communicated to the stakeholders in this process.

PAs in cardiovascular surgery engage in a high-profile, challenging specialty. They continue to meet the needs of patients, surgeons, and institutions. Career paths, educational opportunities, and legislative efforts need continued development to meet the demand.