Patients who require subspecialty surgical care may be referred to the surgeon by a primary care provider (PCP), a medical specialist, or another surgeon. Physician assistants (PAs) now work in nearly all surgical subspecialties. The need for PAs in the subspecialties continues to grow as resident work hours decrease, fewer surgical residency spots are available, and patient demand for these services increases. According to the American Academy of Physician Assistants, approximately 25% of all PAs work in one of the surgical subspecialties listed in Box 33.1 .
Colon rectal surgery
Head, ear, nose, and neck surgery
Plastic and reconstructive
Surgical intensive care
This chapter focuses on how surgical subspecialties, other than general surgery and orthopedic surgery, approach the patient and how students can get the most out of a surgical subspecialty rotation.
Approach to the patient
After the surgeon accepts a referral, the introductory consultation establishes the appropriateness of the referral and the potential surgical intervention. Although the approach to the patient being seen is specific to the surgical subspecialty, the basis for all surgical decision making is a thorough history and focused physical examination. Review the patient’s past medical history, surgical history, any complications with past anesthesia, surgical recovery history, current medications, and allergies to medications or latex. After these data are collected, the specialist can choose the diagnostic studies needed to determine the type of surgery, the specific surgical approach, other specialists that should be involved, and the adjuvant treatment necessary to achieve the best outcome.
Primary care–surgical specialist relationship
If a patient is deemed a candidate for subspecialty surgery, it is common that the surgeon will request that the patient’s PCP perform a risk stratification evaluation. The surgeon is seeking advice from the PCP regarding what the risks to the patient are if the patient has the recommended anesthesia and surgery. When risk factors are identified, the PCP can provide interventions to help reduce the overall anesthesia and surgical risk.
As mentioned in the chapter on Medical Subspecialties (see Chapter 32 ), providing the best care for the patient depends on the ability of the PCP and the surgical specialist to collaborate. Surgeons may admit patients to their services and seek assistance from the PCP or a hospitalist to manage the patient’s medical problems. Alternatively, surgical subspecialists can serve as consultants for patients admitted to the PCP or hospitalist service. Both teams then round on the patient with their respective focus. As hospital systems become progressively more compartmentalized, effective communication among the teams is essential. The PA should strive to ensure that each team understands who has responsibility for each aspect of the patient’s care.
A typical day in surgical subspecialties
Depending on the model of the surgical subspecialty, PAs will typically divide their time among the clinic, hospital wards, intensive care units (ICUs), operating rooms (ORs), and outpatient surgical facilities. In other models, PAs work solely as the first assistant in the OR or on the hospital floor. When choosing a subspecialty surgery rotation, ensure you fully understand the preceptor’s model of the practice so that the experience fits your expectations. It is also in your best interest to inquire about the involvement of other student learners and residents on the service because their presence may impact your learning experience.
PAs are often the first practitioner seen in a surgical subspecialty clinic, and similar to the PAs in the medical subspecialties, these PAs have a great deal of responsibility. PAs perform a thorough history and physical examination, develop differential diagnoses, and determine the most salient diagnostic tests and interventions that the patient might need. All of this information is relayed to the surgeon, and the surgeon, the PA, and the patient work together to choose the best approach to the patient’s problem.
By performing the first evaluation, the PA can establish a trusting relationship with the patient from the start. This relationship will be the basis for continuity of care. When the patient sees the PA work closely with the surgeon to develop the plan, the patient’s trust in the PA is augmented. After all, the patient has sought out the surgeon for relief from his or her unique and often complex ailment. The subspecialty PA must know every detail about the patient that the attending surgeon will need, including test results, patient preferences, and who else will be consulting on the patient. Surgical PAs must perform these duties while conducting themselves in a professional and caring manner.
Often a PA is the comforting face to a patient on hospital rounds or during frequent clinic visits. Many times the surgeon’s time is best served starting an operation, and the PA ties up any loose ends for the service. The PA and the surgeon work together to most efficiently accomplish the tasks needed to provide optimal patient care for all of their patients.
Expectations of physician assistant students on surgical subspecialty rotations
For most students, a surgical subspecialty rotation is an elective; however, this is not the time to coast. Instead, integrate your internal medicine, general surgery, and critical care knowledge to get the best experience from your surgical elective. You will have the opportunity to work with physicians and PAs who have deep knowledge and skill sets unique to their fields. Use the rotation to refine your knowledge of this specialty area and always ask yourself, “How can I apply this expertise to my everyday practice, even if I don’t ultimately work in a surgical setting?”
As a PA student, you will be expected to evaluate new patients by performing complete histories and physical examinations on your patients. You will then concisely present your findings, differential diagnoses, proposed laboratory or radiologic testing, and potential surgical interventions to the team. You will be expected to round on the hospitalized patients before the attending physician or chief resident arrives on the ward in the morning. You will then present your findings to the team. You may be asked to write daily progress notes and perform oral presentations as well. You most likely will accompany the attending physician, the resident, or the intern to the OR and may be asked to assist with the procedure as an observer, second assistant, or first assistant. In this setting, it is essential that you have reviewed the surgical procedure before the surgery so you can answer all of the questions the surgeon will inevitably ask. You may also be asked to assist in composing the postoperative orders as a student exercise when the resident or attending physician writes the orders. The surgeon who performed the procedure will typically write the operative note. You will work each day with the surgical team, which consists of the surgeon, anesthesiologist, nurse anesthetist, PAs, scrub nurse (or technician), circulating nurse, perioperative nurse, postoperative recovery room nurse, surgical ward nurse, and, in some instances, clinical pharmacist. It is your job to assist the team in providing safe patient care, understanding your student role, and remaining helpful to the overall team. ( Fig. 33.1 )
Essential clinical information in surgical subspecialties
As has been emphasized throughout this book, a thorough history and physical examination are expected in all specialties. The more experience you gain during a given surgical rotation, the more you will know about which specific laboratory studies, medications, and tasks you are expected to perform. Consider how you would investigate symptoms and presentations in a concise and thorough manner. Keep in mind that patients may not use medical terms when describing their complaints or symptoms. Asking the same question in a different manner or asking patients what they mean by a certain term can help clarify what a patient is experiencing.
Whether documenting or providing an oral presentation on the hospital ward or ICU, get into the habit of presenting the following items:
Postoperative day number
Antibiotic day number
Overnight events (with insights from the patient’s nurses)
Trajectory of the patient: same, better, or worse
Rated pain; type of pain medication provided and quantity used
Pertinent system-based review of systems (always includes attention to nausea, vomiting, bowel movement, flatus, urination, oral intake, diet status, mobility status, chest pain, dyspnea, and extremity swelling or pain)
Pertinent physical examination (including wound appearance)
Results of any testing performed in the last 24 hours
Input and output
System-based assessment and plan
Cardiovascular and thoracic surgery
Specific questions regarding cardiac, pulmonary, and vascular symptomatology should be emphasized during the patient history. Even if the cardiologist or PCP has sent you some of this history, best practices are to ask again. Every cardiothoracic and vascular history should begin with age, gender, and onset of symptoms. This should be followed by the PPQRST questions: provocative, palliative, quality, radiation, severity, and timing of the symptoms. Box 33.2 lists some common cardiothoracic and vascular symptoms and presentations you should become familiar with during this rotation.
Shortness of breath
Rapid heart rate
Pale or blue lips or extremities
Anxiety or feelings of impending doom
Cold extremities, numbness, or tingling
Weight loss or gain
Tearing back pain
Family members can be helpful when patients cannot remember if they have been diagnosed with a prior myocardial infarction, abdominal aortic aneurysm, or chronic obstructive pulmonary disease. They can also let you know if the patient has had any diagnostic testing and where it was performed.
A typical daily routine of a cardiovascular and thoracic surgery PA includes completing ward and ICU rounds and first assisting in the OR. Common ward procedures include insertion of central venous catheters (CVCs) and Swan-Ganz catheters, inserting and removing chest tubes, removing pacing wires, and maintaining postoperative sternal and leg wound complications. Common operations include coronary artery bypass grafting, valve procedures, and aneurysm repairs in which PAs serve as the first assistant; endoscopic leg vein harvesting is usually performed autonomously by a PA.
PAs entering this rotation should have an understanding of cardiovascular risk factors, heart anatomy and physiology, electrocardiogram interpretation, shock, Swan-Ganz readings (including cardiac output), systemic vascular resistance, cardiac index, end-diastolic volume index, and central venous oxygen concentration. Additionally, students should review therapeutics, such as vasopressors and inotropes, and have a clear understanding of current ACLS guidelines and interventions.
A clinical rotation in neurosurgery focuses on cerebrovascular diseases, such as ischemic and hemorrhagic stroke; central nervous system malignancies; and malformations of the brain, spinal cord, and spine. Every neurosurgical patient history should begin with age, gender, time of symptom onset and handedness (to determine brain dominance for language); drug history, including use of nonsteroidal anti-inflammatory drugs, anticoagulants, and aspirin, and last dose; detailed pain medication history; family history (particularly of cancer); and social history, including place of work and exposures to toxins and radiation. The onset of specific neurologic or neurovascular symptoms should be ascertained, followed by the PPQRST questions. If a patient cannot answer questions because of dementia, delirium, aneurysm, stroke, or cognitive decline, question family members and friends. Box 33.3 lists common neurosurgical symptoms and presentations that will be helpful for you to review before starting the rotation.