Lisa Kerr, PA-C

	A surgical first assistant plays an integral role in the surgical team. Physicians have several options for how to fill and use the position. An option that should be considered is utilizing a physician assistant (PA) as a first assistant. As a PA myself, I feel it is important that physicians are aware of this option and understand its benefits.

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	There are many options for a surgical first assist, including an another physician, a fellow or resident physician, a PA, surgical assistant-certified (SA-C), and registered nurse first assistant (RNFA).

	Why should you consider using a PA as your first assist? Here are some reasons:

		PAs first assisting at surgery are usually reimbursed at 85-100% of the first-assist fee paid to a physician acting as the first assistant (which is generally 16% of the primary surgeon fee).

		PAs bill for their services at the full physician fee schedule. They should use their national provider identifier number and the “AS” surgical assistant billing modifier. The Medicare carrier or Private payer will implement the appropriate discount. For more information, see the 

Medicare Claims Processing Manual, Chapter 12, Section 110.3

		Using a PA as a first assist will free up a physician to schedule more surgeries or see more clinic patients, thereby generating more revenue and decreasing patient wait times.

		PAs who first assist are better familiarized with the perioperative and intraoperative care of patients, allowing them to provide more comprehensive patient education and care in the preoperative and postoperative setting.

		Many PAs desire a multifaceted working environment. Encouraging professional development and growth by perfecting a new skill can boost morale and job satisfaction. Varying the PA’s schedule with clinic, procedures, inpatient work, and OR time can be very rewarding. Job satisfaction will help with employee recruiting and retention leading to less turnover.

 for reimbursement for first assisting in any procedure where a physician would receive such reimbursement (American Association of Physician Assistants)(CMS)

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 , which assigns all surgeries with CPT codes a ranking of whether or not they require a physician as a first assistant: 1 - almost always, 2 - almost never, or 3 - some of the time. There is also an excerpt called “Surgical Assistants” from the American College of Surgeons Statements on Principles regarding the qualifications of surgical assistants, including non-physician providers.

	In teaching hospitals, Medicare restricts coverage of PAs for first assisting at surgery. There are no restrictions for other services PAs provide. If a teaching hospital has an approved and accredited surgical training program related to the surgery being performed and has a qualified resident available to perform the service, no reimbursement is made for a PA first assisting.

	If the primary surgeon has a policy of never allowing residents to act as assistants, or in trauma cases, or if the surgeon believes that the resident is not the best individual to perform the service, Medicare will reimburse for a PA first assistant. In these cases, claims should be accompanied by an explanation that the first assist was medically necessary and that no qualified resident was available to first assist at that time. Medicare requires the following attestation in the operative report:

“I understand that section 1842(b)(7)(D) of the Social Security Act generally prohibits Medicare physician fee schedule payment for the services of assistants at surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services for which payment is claimed were medically necessary and that no qualified resident was available to perform the services. I further understand that these services are subject to post-payment review by the Medicare carrier.”

	For more information regarding PAs assisting in Teaching Settings, see the 

Medicare Claims Processing Manual Chapter 12, Section 100.1.7

	How do PAs get trained in first assisting? There are three ways:

		Many PAs are exposed to surgery during PA school as PA programs require surgical rotations. This may include observation and hands-on experience. If hiring a new graduate, ask to review any procedure logs they may have kept as a student.

		There are postgraduate PA training programs in various surgical subspecialties including urology that integrate first assist training into their curriculum.

		The majority of PAs receive on-the-job training by their supervising physician(s) and by experienced PAs already employed by the practice. There is no mandated or standardized approach for on-the-job training as it varies from practice to practice and must comply with hospital credentialing policies.

	I completed training at the UT Southwestern Urology PA Postgraduate Fellowship program, which included procedural and operative training. By the completion of my yearlong training, I felt comfortable to first assist on the majority of robot-assisted laparoscopic surgeries applicable to urology, including prostatectomy, cystectomy, partial nephrectomy, pyeloplasty, and sacrocolpopexy. My training progressed from observation to MD/PA-supervised assisting (typically I and another qualified PA double scrubbed at the bedside) and then independent first assisting.

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	The first 3 months of the program, I mostly observed and did some assisting with another PA present and scrubbed. This would take place anywhere from one to three times weekly. As my knowledge and ability increased, my supervising PA took less of an active role.

	After getting to the point where the supervising PA no longer had to scrub but was present just to observe, I then transitioned to first assisting without another PA. As I was in a dedicated training program, this process was about 6 months to independent first assisting. However, I do not think the training process always needs to be that lengthy. If training a new graduate or PA without surgical assisting experience, consider additional online training courses and conferences to supplement on-the-job training. For example, Intuitive Surgical, via its 

, offers free training modules, full-length surgery videos, and information on upcoming conferences.

	You may also consider reducing clinic and inpatient responsibilities during the training period to maximize OR exposure.

	Participating in the OR as a first assist has greatly enriched my career and job satisfaction as well as my understanding of urologic surgery and my ability to counsel patients.

	Physicians, I hope after reading this you will consider adding a PA to your surgical team.

	PAs, I hope you will consider discussing the possibility of first assisting with your physician team.

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Articles

UT blogger Lisa Kerr, PA-C, makes her case for using physician assistants to first assist on surgical procedures.

Why you should consider a PA to first assist in surgery

	Physician assistants are rapidly increasing in number, making their presence in all fields of medicine more common. With an estimated 101,977 licensed PAs reported by the 2014 National Commission on Certification of Physician Assistants census, PAs have grown by 36.4% in the past 5 years. Of those, 1.4 % were practicing in urology at the time of the survey.

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	However, the need for urology providers is expected to increase considering the aging population of practicing urologists. According to the AUA 2014 census, nearly 23% of practicing urologists are 65 years of age or older. As they retire, PAs will be called upon to help fill the provider deficit.

	An additional strain on academic medical centers is resident work hour restrictions. Academic medical centers will often integrate PAs to help offset these limitations and to augment the learning opportunities for the residents. PAs are commonly responsible for both inpatient and outpatient care. As outpatient providers, we can evaluate both new and returning patients, order and interpret laboratory data and diagnostic imaging, provide patient education, and perform outpatient procedures such as cystoscopy, transrectal ultrasound prostate biopsy, and insertion of testosterone pellets (Testopel).

Next: "Some institutions are now utilizing PAs as dedicated first assists on robotic procedures."

	As inpatient providers, we can see emergency department and inpatient consultations, perform preoperative and postoperative rounds, admit or discharge patients, and perform procedures such as difficult Foley placement, priapism irrigation, abscess incision and drainage, and bladder irrigation. Intraoperatively, we can first assist on open, laparoscopic, or robotic procedures. Some institutions are now utilizing PAs as dedicated first assists on robotic procedures.

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	I began my career as a PA working in an internal medicine subspecialty, but always knew I would find my way into urology eventually. A year and a half later, I accepted my first urology position. I could not have been more excited to start my dream career.

	That excitement rapidly turned to frustration as I quickly realized I had joined a practice that did not know how to integrate a PA appropriately. I pleaded with my supervising physicians to institute a structured orientation to ensure I was properly trained prior to seeing a full clinic schedule and performing inpatient rounds independently. There was significant confusion about my role in the practice. Some physicians viewed me as a perpetual intern who would carry out all the mundane tasks with absolutely no hope for career advancement or professional growth and development. Others thought my role was to see all walk-in patients and spend the remainder of my time assisting with nurse visits and answering phone calls.

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	In addition, no one could agree on the appropriateness of a PA performing procedures in the office or inpatient setting. Unsurprisingly, there was significant contention among the physicians and myself regarding my role in the practice.

Next: "My second urology position was remarkably different from the first in every way."

	My second urology position was remarkably different from the first in every way. I was welcomed into a large academic practice with PAs who were well established. The mentorship program of experienced PAs and physicians ensured that I was adequately trained. Clear clinical, surgical, and educational goals were in place and clearly outlined. Regular evaluations ensured that I was progressing. Autonomy gradually increased as I progressively met my educational goals.

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	The role of the PAs in the practice was fluid and adaptable. Over the years, the PAs accepted more responsibilities and learned new skills. They were encouraged to pursue patient subsets that interested them. Finally, all my urology dreams had come true. Within a year, I was independently performing outpatient procedures, first assisting in robotic surgeries, and managing inpatient and outpatient duties with confidence.

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	My first urology experience left me wondering what the role of a PA in urology should be. Five years later, I still frequently contemplate this question. Perhaps some of the confusion surrounding the role of a urology PA stems from lack of prior experience and understanding of the possible ways PAs can be integrated into a urologist’s practice.

Next: Using the AUA Consensus Statement on Advanced Practice Providers

AUA Consensus Statement on Advanced Practice Providers

 for guidance. The consensus statement outlines how PAs (and other advanced practice providers) are educated and proposes a mentorship program with varying levels of physician supervision and defined skill levels to which to aspire. The goal is to cultivate a PA who can adeptly manage complex patients and formulate appropriate treatment plans with remote physician supervision.

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	The consensus statement also provides information on key issues such as physician-PA supervision regulations, Medicare/Medicaid regulations, and integration of PAs into practice. I truly hope all practicing urologists become familiar with the consensus statement and refer to it prior to adding a PA to their practice. Just as importantly, PAs need to utilize the guidelines in the consensus statement when discussing their practice goals with their supervising physicians.

	Ultimately, the role of the urology PA should be to meet the needs of their practice and patient population while fulfilling their own career goals. Urology PAs should become familiar with current literature, such as the AUA Consensus Statement on Advanced Practice Providers, to advocate for themselves and achieve their desired role. A continuing open discussion with their supervising physicians is essential to ensure the PA-MD relationship is maintained and evolving in a way that makes sense.

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In her first blog post for Urology Times, Lisa Kerr, PA-C, shares two very different employment experiences that taught her about the urology PA’s role in today’s practice.