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Physicians Assistants in Cardiothoracic Surgery: A

30-Year Experience in a University Center
Vinod H. Thourani, MD, and Joseph I. Miller, Jr, MD
Joseph B. Whitehead Department of Surgery, Section of General Thoracic Surgery, Emory University School of Medicine,
Atlanta, Georgia

Background. The purpose of this study was to evaluate PAs with service more than than 15 years). The PA role
our 30 years of experience with the use of physician has changed little, with duties varying from history and
assistants (PAs) on a cardiothoracic surgery (CTS) physical examination, conduit harvesting, insertion of
service. invasive catheters and chest tubes, surgical first assisting,
Methods. A retrospective review of the utilization of closure of the chest, and optional primary intensive care
CTS PAs was performed at a university center from 1973 unit night-time in-house call. Salary currently ranges
to 2003. from $55,000 to $100,000 depending on length of service
Results. The number of PAs has increased from 2 (1973) and overall merit. Job satisfaction for PAs employed
to 23 (2003), corresponding to the increased clinical longer than 12 months has remained high.
service demands with a constant resident number for the Conclusions. The addition of PAs to our CTS univer-
past decade. Physician assistant employment has ex- sity service has allowed us to resolve many problems of
panded from one hospital to five hospitals in our univer- work assignment and coverage and enabled us to estab-
sity system where CTS is performed. The CTS service has lish effective and efficient surgical teams without increas-
expanded from 400 total cases per year (1973) to 4,000 ing the number of categorical CTS residents.
cases (2002). We have had a 50% retention rate with (Ann Thorac Surg 2006;81:195200)
duration of employment from 6 months to 28 years (11 2006 by The Society of Thoracic Surgeons

S ince the development of programs conceptualized to

specifically educate a physician assistant (PA) as a
new health professional was implemented at Duke Uni-
five hospitals and more than 3,000 adult and pediatric
cardiac cases and approximately 700 thoracic cases in
2002. Table 1 shows the current distribution of residents,
versity in 1965, the role for cardiothoracic surgical PAs cases, and PAs at Emory University Medical Center
has increased substantially. After the changes in the during three periods (1973 to 1982, 1983 to 1992, and 1993
regulations of resident housestaff duty hours in 2003 [1], to 2003). The role of the PA within each of our hospital
there has been resurgence in the need and demand of varies; the predominant duties are listed in Table 2.
PAs and other nonphysician healthcare extenders. The At Emory University Hospital (EUH), the number of
field of cardiothoracic surgery has historically utilized nonphysicians has increased from two PAs in 1973 to five
PAs for preoperative, intraoperative, and postoperative PAs, two nurse practitioners, and two surgical assistants
care. to accommodate the increase in CTS cases. A maximum
Since 1973, two newly trained physician assistants from of nine PAs were utilized at EUH during the early and
the Duke University PA program were employed by the mid 1980s. Although PAs are on second call by beeper for
division of cardiothoracic surgery at one academic teach- operations at night, the PAs at EUH do not take in-house
ing hospital [25]. Our experience now covers 30 years call. Furthermore, the PAs at Emory University Hospital
with a total of 23 physician assistants in five hospitals. do not participate in the management of patients in the
intensive care unit.
The second phase in our utilization of PAs began in
Material and Methods and Results
1974, when a new cardiovascular surgical service was
Our initial experience began in 1973, with the hiring of established at Crawford Long Hospital (CLH) of Emory
two PAs in a single hospital with a case volume of 400 University (Tables 1 and 2). Because there were no
cases per year and a thoracic surgical volume of 250 cases cardiothoracic residents at CLH in 1974, the PAs along
per year. Over the ensuing 30 years, we have expanded to with the staff surgeon performed all aspects of preoper-
ative, intraoperative, and postoperative management.
Accepted for publication July 11, 2005. The PAs took in-house first call on days when cardiac
Presented at the Fiftieth Annual Meeting of the Southern Thoracic cases were performed (overtime pay was provided for
Surgical Association, Bonita Springs, FL, Nov 1315, 2003. those PAs performing in-house night call). Eventually,
Address correspondence to Dr Miller, Section of Thoracic Surgery,
the PAs shared in-house call responsibilities with the
Crawford Long Hospital, 550 Peachtree St NE, Suite 7700, Medical Office cardiothoracic resident. As the number of residents has
Tower, Atlanta, GA 30308; e-mail: increased at CLH, the PAs no longer take in-house call.

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00

Published by Elsevier Inc doi:10.1016/j.athoracsur.2005.07.031


Table 1. Trends in Hospital Cardiac Surgery Volume Among Hospitals of Emory Healthcare
No. of Hospital No. of Cardiac No. of CTS
Beds No. of PAs Cases Fellows

Crawford Long Hospital 500 beds

1973 to 1982 1 to 3 120 to 330 1
1983 to 1992 4 to 6 450 to 630 1
1993 to 2003 6 to 9 630 to 1270 2 to 3
Emory University Hospital 600 beds
1973 to 1982 1 to 5 300 to 1800 2 to 3
1983 to 1992 6 to 9 1100 to 1700 3 to 4
1993 to 2003 4 to 5 750 to 1150 3 to 4
Egleston Hospital 225 beds
1973 to 1982 1 to 3 50 to 190 1
1983 to 1992 3 to 5 150 to 380 1 to 2
1993 to 2003 5 to 6 400 to 550 1 to 2
Veterans Administration Hospital 250 beds
1973 to 1982 1 0 1
1983 to 1992 1 60 to 130 1
1993 to 2003 2 100 to 150 1
Grady Memorial Hospital 800 beds
1973 to 1982 1 70 to 85 1
1983 to 1992 1 80 to 130 1
1993 to 2003 1 90 to 150 1

CTS cardiothoracic surgery; PAs Physicians Assistants.

However, with the restrictions imposed by the Accredi- tion was excellent, and 13 (56.5%) noted that their job
tation Council for Graduate Medical Education satisfaction was good.
(ACGME) on resident work hours, PAs now have a
voluntary option for in-house first call for supplemental Physicians Assistant Compensation
pay. In the early 1970s, the salaries for cardiothoracic surgical
The third hospital in our system to utilized PAs was the PAs at Emory University ranged from $15,000 to $25,000
Egleston Hospital of the Children Healthcare of Atlanta per year, depending upon the length of service and
(Tables 1 and 2). In addition to the rotating cardiac overall merit. It now ranges from $55,000 to $100,000
surgery resident, a dedicated pediatric cardiothoracic (mean, $84,000) in 2003, and is determined by the com-
1-year fellow has been added to the Egleston Hospital pensation committees of the individual hospital system.
cardiac program since the mid-1980s. The PAs have In 2003, consensus data from the American Academy of
functioned to a large extent as in our community hospital Physician Assistants reveals a mean salary of all PAs in
(CLH). In the role of the cardiothoracic resident, the PA the United States at $76,039 [6], and data from the
alternates taking in-house first call with the two other Association of Physician Assistants in Cardiovascular
cardiothoracic residents. Surgery [7] reveals that the average yearly salary for all
Adult cardiac surgery was initiated at the Veterans cardiothoracic PAs at approximately $90,000. Salary com-
Administration Hospital in Atlanta in 1987 (Tables 1 and pensation for cardiothoracic surgery PAs at EUH and
2). Before the initiation of the cardiac program, thoracic CLH and one half of the PAs at Egleston Hospital is from
surgery was performed there with the assistance of one our section funds of the division of cardiothoracic sur-
PA. With the increase in cardiac surgery volume, a total gery as generated by the income by the 16 members of
of two PAs and one cardiothoracic resident currently our section. The PAs at the Veterans Administration
remain on this service. Adult cardiac surgery was initi- Hospital, Grady Memorial Hospital, and one half of the
ated at Grady Memorial Hospital in 1973. One cardiotho- PAs at Egleston Hospital are compensated by the indi-
racic resident and one PA remain on this service. The vidual hospitals.
roles for the PA at the Veterans Administration Hospital
and Grady Memorial Hospital are as listed in Table 2. Impact of PAs on the Cardiothoracic Residency
Physician assistant job satisfaction has remained rela- Although the number of cardiothoracic surgery training
tively high in our academic cardiothoracic surgical pro- programs and residency slots available for appointment
gram. Eleven PAs (47.8%) have remained within our year from 1993 to 2003 has remained relatively constant at
division of cardiothoracic surgery for more than 15 years. between 89 and 95 programs and 132 to 146 positions, the
A confidential survey of all 23 PAs within our division number of residency slots not filled has risen from a low
revealed that 10 PAs (43.4%) noted that their job satisfac- in 1998 of 5 positions to 21 unfilled positions in 2003.


Table 2. Duties of the Physician Assistant on a Cardiothoracic Service

1. Preoperative workup
a. Obtain information and record admission history on standard preprinted form.
b. Perform and record admission physical examination on standard preprinted form.
c. Write routine admission orders on standard preprinted form.
d. Explain the details and risks of operative procedures and may obtain the signature of the patient or legal guardian on the
operation permit.
2. Intraoperative assistance
a. Serve as a first or second assistant in the operating room.
b. Harvest saphenous vein and radial artery conduits using both endoscopic and open techniques.
c. Depending on skill level: open or close median sternotomy, or both; decannulation of ascending aortic and right atrial
cannulae; open or close thoracotomy incision, or both.
3. Perioperative care
a. Perform minor procedures such as suture removal, dressing changes, wound debridement, chest tube insertion, thoracentesis,
urinary bladder catheterization, arterial and venous punctures for laboratory blood work, placement and removal of intra-
aortic balloon pumps, initiation of temporary cardiac pacemaking.
b. Be available to the hospital staff as a resource person.
c. Provide continuity of care for the patient and the patients family.
d. Assess the need for written patient educational material and collaborate with others in this development.
e. Facilitate the development of interdisciplinary cooperation and rapport in providing comprehensive patient care.
f. Monitor progression of the patients diet.
g. Monitor progression of the patients level of activity.
h. Establish intravenous and oral fluid limits.
i. Perform routine laboratory work, chest voentigenograms, and electrocardiograms.
j. Change blood replacement as needed.
k. Discontinue central venous pressure, swan-ganz, or arterial catheters and temporary pacing wires. Remove appropriate
monitoring devices when no longer indicated.
l. Write transfer orders when patient no longer needs intensive care.
m. Guide respiratory support and the process of weaning.
4. Discharge care
a. Dictate appropriate narrative summary at the time of patient discharge.
b. Arrange follow-up plan, including time and place of appointment with appropriate physician.
c. Communicate with referring physicians and other medical personnel at the request of or with approval of the sponsoring
5. Research
a. Participate in clinical research under the supervision of the responsible cardiothoracic surgeon.

Moreover, the number of applicants from United States sician providers on resident work hour regulations are
medical schools has decreased from 161 in 1993 to 107 in warranted. In our practice, the interdigitation of the
2003 [8]. These changes parallel trends showing a 30% cardiothoracic surgery resident staff with PAs has not
decrease in the number of medical students applying to been a problem. The PA has been able to relieve the
general surgery over the past 9 years. A multitude of residents of many time-consuming routine duties so that
interesting issues have resulted in a decline in general more of their time can be devoted to operating room and
surgery and hence applications to cardiothoracic surgical other more educational tasks. Furthermore, each resident
programs. These factors include presumed evidence of a is able to participate to a greater extent in the operating
limited job market for residents completing cardiotho- room than would be possible if many more residents and
racic training. In a recent web-based survey by the fellows were required and utilized for the nonoperative
Thoracic Surgery Residents Association, Salazar and col- aspects of patient care. Residents must continue, how-
leagues [9] noted that approximately 20% of finishing ever, to participate in preoperative and postoperative
fellows were unable to find jobs in 2003. Moreover, 87% care to assure their understanding of the associated
of these residents believed that the number of trainees pathophysiology.
should be decreased to allow for improved job opportu-
nities and compensation.
Furthermore, the ACGME has mandated standards
addressing resident duty hours starting July 2003 [1]. As The discipline of cardiothoracic surgery uniquely pro-
the current study evaluated the role of the PA until June vides limitless challenges for a cardiothoracic surgical
2003, we did not assess the impact of PAs on resident physician assistant. Numerous variables of patient age
work. Further studies evaluating the impact of nonphy- (newborn, adult, or the elderly), diagnosis (congenital or


acquired cardiac, pulmonary, or esophageal disease), and cannulation and decannulation, and closure of the chest.
degrees of severity of illness (elective or emergent coro- They function primarily as surgical first assistants,
nary or valvular heart disease, simple or complex con- especially at CLH, where there remains a discrepancy
genital heart defects, benign or malignant pulmonary in the number of cases performed and number of
and esophageal diseases) allow the PA a wide array of cardiothoracic residents available. The PA is the ideal
work opportunities and skills. These highly technical and first assistant in these settings, as they are trained
demanding skills are mastered only through years of specifically to meet the needs of the staff surgeon and
experience, and as the specialty of cardiothoracic surgery are knowledgeable of the surgeons idiosyncrasies. As
continues to evolve, the flexible and adaptable nature of expected, the exact role of the PA is determined by
the surgical PA will be an essential element for every their clinical experience and the discretion of the
successful practice. attending cardiothoracic surgeon.
The usefulness of the PAs in each of our hospital
Function of the PA on Our Service
situations cannot be overestimated. The PA has enabled
There is a multifactorial role for cardiothoracic surgical
us to expand our services without jeopardizing patient
PAs at an academic institution (Table 2). They play a vital
care. In the operating room, they have functioned in the
role in (1) education of patients, families, nurses, PA
roles of first and second assistants and have allowed us to
students, and general surgery and cardiothoracic resi-
increase our surgical volume without increasing the
dents in training; (2) administrative functions of the
planning of admissions, scheduling of operations and number of residents and fellows. With long-term job
special procedures, arranging and presenting informa- commitment, the PAs own technical skills have become
tion to patient-care conferences, and maintaining records very refined, and they are superb assistants to staff
required for quality assurance, long-term patient evalu- surgeons and surgical residents. The PAs provide not
ation, and clinical research; (3) communication between only a foundation for overall patient management within
staff surgeons, cardiologists, and other consulting spe- our cardiothoracic services, but also bridge a gap be-
cialists; and (4) surgical assistant during the performance tween the nurses, cardiothoracic resident, and the staff
of surgical procedures. surgeon.
Although the role of a cardiac surgical PA may differ
from academic to private environments, most work 40 The Future: Physician Assistant Residencies and
to 60 hours each week. They provide expertise in the Changing Roles
preoperative, intraoperative, and postoperative care of Challenges and unanswered questions facing the imple-
the surgical patient. Cardiothoracic PAs frequently mentation of a new nonphysician healthcare provider to
assume the primary care aspects of the hospitalized our cardiothoracic surgery practice in 1973 included PA
patient and should be proficient in the management of job stability, usefulness in a complex surgical subspe-
hypertension, diabetes, and chronic obstructive pul- cialty, compatibility with cardiothoracic residents and
monary disease. nurses, long-term job satisfaction, and PA ability to
The relationship between PAs and the nursing staff improve the efficiency and care of our cardiovascular
has not been problematic. Because PAs do not infringe surgical service. After 30 years of experience, there re-
on the traditional territory of nursing services, they mains no doubt that PAs can adequately perform the
have developed a good working relationship with the tasks at hand.
nurses. The PAs availability during day hours when With the concordant restrictions in resident work
surgery residents and staff are commonly in the oper- hours and potential hiring of more costly nonphysician
ating rooms allows for more efficient and thorough clinicians at hand, the more pressing question now has
patient care. Furthermore, that provides a continuity of
become can the surgeons or the institution afford to
care that rotating cardiac residents are unable to pro-
replace residents with PAs. One solution would be to
vide. Overall, it is inevitable that the PA will play an
further develop PA surgical residencies. The creation of
intermediary role, serving as the middle-person be-
surgery PA residency programs has been previously
tween the staff surgeon and nurses, patients, families,
described and has been shown to allow approved surgi-
and other physicians.
Over the past 30 years, the role of our PAs at Emory cal resident physician programs to review manpower
University has expanded and their utilization in the needs [10, 11]. Standards, accreditation, and allocation of
operating room has greatly increased. The cardiothoracic economic resources for such programs are scarcely
PA has a significant amount of autonomy in the operating available.
room and performs the critical task of harvesting the Overall, our cardiothoracic PAs are vital and an effec-
greater saphenous veins or radial arteries (utilizing open tive professional members of our team. On the basis of
or endoscopic techniques) for use as a bypass conduit as our experience to date, we think that the addition of PAs
an essential component of almost every coronary bypass to our surgical service has allowed us to resolve many of
procedure. After preparation of the bypass conduit, the the problems of work assignment and coverage and has
PA either first or second assists during the remainder of enabled us to establish effective and efficient cardiovas-
the case, including tasks of providing cardiac retraction, cular and thoracic surgical teams in the various hospitals
closure of the incisions in the lower extremity, assist in of our university system.


5. Williams WH, Kopchak J, Yearby LG, Hatcher CR Jr. The

The authors appreciate the superb and endless efforts by the surgical physician assistant as a member of the cardiothorcic
previous and the following physician assistants currently em-
surgical team in the academic medical center. In: Carter RD,
ployed in the care of adult and pediatric cardiothoracic patients
Perry HB, eds. Alternatives in health care delivery: emerging
in hospitals affiliated with Emory University School of Medicine:
Aimee Abide, Barry Anderson, Sharon Ashe, Dianne Bailey, roles for physician assistants. St. Louis, Missouri: Warren H.
Beth Bain, Randy Bundschu, Keith Causey, Gene Coughlin, Green, 1984:201-9.
Masoud Daneshnia, Damon Denzin, Samantha Ellington, James 6. American Academy of Physician Assistants Census Report
Farmer, Mandy Green, Larry Hogan, Michael Kandrach, Jan 2003. Available at:
Koehler, Jodi Lackey, Philip Miller, Jenny Nakaoka, Rene Nazar, intro.html#highlight. Accessed October 13, 2003.
Wayne Olsen, David Seidel, and Kim Wettlaufer. 7. APACVS salary and benefits survey. Available at: http:// Accessed October 11,
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1. Accreditation Council for Graduate Medical Education.
Common program requirements for duty hours. Available 9. Salazar JD, Lee R, Wheatley GH, Doty JR. Are there enough
at: Accessed October 5, 2003. jobs in cardiothoracic surgery? The thoracic surgery resi-
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Surg 1974;68:750 6. 10. Heinrich JJ, Fichandler BC, Beinfield M, Frazier W, Krizek TJ,
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DR MARK FELGER (Austin, TX): I will have you know, I DR THOURANI: That is an excellent point, and I whole-
enjoyed your talk. I have a couple of questions. We have several heartedly agree with you. If it was perceived that the surgeon
PAs in our private practice, which is a little bit different than has relinquished his role as a communicator with the patient or
what you have laid out here, but I was wondering who is family, then I apologize for that misnomer. Obviously all of the
responsible and how do you clinically manage your PAs, be- residents and attending surgeons talk extensively with the
cause we are having a hard time trying to keep our PAs satisfied patients regarding the benefits and risks associated with sur-
and having one central person that they are responsible to. gery. However, our PAs sometimes in the middle of the day or in
the office do obtain consents.
DR THOURANI: Thank you for that question, Mark. Obviously
Dr Guyton, being the chief of the entire division, has the overall
DR ROBERT B. LEE (Jackson, MS): I had the pleasure of
management of the cardiothoracic PAs. As you may recall, there
discussing this a bit with Dr Thourani before his presentation,
are chiefs at each of our five affiliated hospitals: Emory Hospital,
which was quite excellent, but one of the things that I thought
Crawford Long Hospital, the VA, Grady Memorial Hospital, and
was most important that he brought out was the economics of
Egleston Hospital of the Childrens Healthcare of Atlanta. The
utilizing PAs in an academic situation where the hours are now
cardiothoracic surgeon who is the chief of that hospital is
limited, and that is also going to apply to private practice. With
specifically involved with the day-to-day activities of the cardio-
the reimbursement for all of us going down, the PA salaries have
thoracic PAs in that hospital. For example, Dr Joseph Craver at
slowly gone up and not yet plateaued, and if you look at a mean
Emory Hospital, is in charge, per se, for the day-to-day practices
of $80,000, that is coming close to 30%, maybe 20%, a little bit
of the PAs at Emory Hospital. We do have one person, Keith
less, of some cardiothoracic surgeons total income. Have you
Causey, PA-C, who is in charge of all the PAs employed by our
taken an institutional approach to look at the limiting of PA
division and is really the go-between from Dr Guyton to the rest
salaries or how you are going to compensate them in the future
of the system as needed. Furthermore, each respective hospital
with your health care dollars decreasing?
has a chief PA who reports either to Mr. Causey, Dr Guyton, or
the chief of cardiothoracic surgery at their hospital.
The PAs who we have at the VA and at Grady are funded by DR THOURANI: Doctor Lee, those are excellent comments.
those institutions, and so they dont fall within the auspices of That is, I think, one of the problems that is coming forth with the
the role that Mr Causey holds, and they are directly under the implementation of reduced resident work hours. This is quite
chief of cardiothoracic surgery of that hospital. important as there is a trend for new and possibly expanding
roles for cardiothoracic surgical PAs. To counteract the increase
DR GEORGE R. DAICOFF (St. Petersburg, FL): We have used in compensation for PAs, some institutions have started to
PAs in our private practice for more than 25 years, and I agree investigate a PA residency system. This allows for lower pay of
with everything you have said except one thing. We do not allow a fully accredited PA for that predetermined residency time
the PAs to give informed consent, that is, to talk about the period. As far as I am aware, our institution has not imple-
diagnosis, risks and benefits of the operation. I think that is still mented this system. Perhaps Dr Guyton or Dr Miller would care
the responsibility of the surgeon. to comment.


DR JOSEPH I. MILLER (Atlanta, GA): Let me clarify that for DE HUGH M. VAN GELDER (St. Petersburg, FL): The PAs out
you. That is not a fair question to put to him. The PA salaries at in the community have opened their own businesses, and in
Emory University have declined by 17% to 20% over the last 5 fact, because of that, they are not under contract by HMOs. In
years. They were cut automatically because we couldnt afford to certain instances, they can make more money on a case than
let them continue to rise. They have been totally plateaued for we do as the surgeon without any liability, and by allowing
the last 3 and a half years. There is a max regardless of time that that to continue to happen, we just kind of ruin the entire
they dont go above. system for ourselves, and we cant allow that to continue to
We employ both the group at the University Hospital and at happen. We are the guys who went out there in the training,
we are the guys who do the operation, we are the ones who
Crawford Long out of our own sectional funds that the staff
the patients are being sent to, and for people to make more
surgeons generate. At the Childrens Hospital they pay for three
money off of a case than we do is ridiculous in todays society.
and we pay for three, but the others are that. But the PA salaries
In our corporation, we have our own PAs, but there are
now have plateaued, and they have not continued to rise.
physicians in the community who do not have their own PAs
The salaries that you see there, Bob, and I realize what you are because they are not large enough to be able to handle the
saying about how much a cardiothoracic surgeon makes, but cost of what it is to run a PA, and so they look for first
also, by the same token, we are doing almost 5,000 cases per year assistants. These corporations are there to first assist, but like
among 16 people and trying to maintain services and work I said, they do not have contracts with the insurance compa-
hours. So we have plateaued the salaries and they are down nies and therefore they can make more money per case than
17%, and that has been true, and now they are maxed out. we do.

The Society of Thoracic Surgeons Policy Action Center

The Society of Thoracic Surgeons (STS) is pleased to E-mail senators and representatives about upcoming
announce a new member benefitthe STS Policy Ac- medical liability reform legislation
tion Center, a website that allows STS members to Track congressional campaigns in ones districtand
participate in change in Washington, DC. This easy, become involved
interactive, hassle-free site allows members to: Research the proposed policies that help or hurt
ones practice
Personally contact legislators with ones input on Take action on behalf of cardiothoracic surgery
key issues relevant to cardiothoracic surgery
Write and send an editorial opinion to ones local media This website is now available at

2006 by The Society of Thoracic Surgeons Ann Thorac Surg 2006;81:200 0003-4975/06/$32.00
Published by Elsevier Inc