Surgeon's assistant

Surgeons at Work

Surgeon's Assistants also known as Surgical Assistants are highly skilled, credentialed surgical health professionals who work under the direction of licensed surgeons performing surgical procedures.^[1][2] Surgeon's Assistants, defined by the American College of Surgeons, are qualified practitioners during surgery who are licensed practitioners with sufficient training to conduct a delegated portion of a procedure without the need for more experienced supervision and who are approved by the hospital for these operative or patient care responsibilities.^[3]

In the United States the Surgeon's Assistants,^[1] role is also performed by: surgical resident trainee, assistant surgeon,^[4] surgical physician assistant,^[5] or registered nurse first assistant.^[6] In the US, the National Uniform Claims Committee has a taxonomy classification for surgical assistants^[7] and Centers for Medicare & Medicaid Services (CMS) issues an National Provider Identification (NPI) for Surgical Assistants practicing in the US.^[8][9] Surgical resident trainees will evolve from surgeon's assistants to operating surgeons as their training progresses during the course of their surgical residency programs.^[10]

During a surgical procedure a surgical assistant functions in the role of a second physician in the operating room.^[11] The surgeon assistant's role is carried out by surgical practitioners who are: doctors of medicine, nurses specialized in perioperative nursing who have completed registered nurse first assistant programs, surgical resident trainees, surgical physician assistants and surgeon assistants who are certified, licensed or registered. Surgeon assistants are trained in surgery and undergo rigorous credentialing to practice in that role. The healthcare professionals practicing as surgeon assistants varies internationally and each country has legal requirements for the scope of practice for the surgeon assistants. Surgical assistance is the practicing specialty of surgeon assistants in clinical roles in the United States. In large complicated surgical cases there can be two surgeon assistants during the surgical procedure, one acting as a first surgeon assistant and the other as a second surgeon assistant.^[12]

Professional framework

The origins can be traced back to the nineteenth and twentieth centuries. In the navy, a surgeon's mate, who was renamed assistant surgeon in 1805, was historically the individual providing surgical assistant duties during the nineteenth century. In the US, in the 1920s, the role of surgical assistant is popularized by Sister Mary Joseph, a pioneer in the field. In the twentieth century the origins of the surgical assistant role in the United States can be traced back to the specialized surgical teams assembled by Michael E. DeBakey during World War II. In the US, having a second doctor as an assistant surgeon has been a requirement for all major procedures for decades. Today the role of the assistant surgeon is carried out by surgeon's assistants.^[13] In hospitals without surgical residents, the role of assistant surgeon is performed by properly credentialed licensed providers.^[14]

Surgical assistants, assistant surgeons and assistants-at-surgery, who serve as members of the surgical team, perform tasks under the direction of surgeons and aid them in conducting surgery. The scope of practice of these tasks may include making initial incisions ("opening"), exposing the surgical site ("retracting"), stemming blood flow ("hemostasis"), surgically removing veins and arteries to be used as bypass grafts ("harvesting"), reconnecting tissue ("suturing"), and completing the operation and reconnecting external tissue ("closing"). Some of these tasks, like retraction, are relatively simple, while others, such as harvesting, are more complex. An assistant-at-surgery may perform one or more simple or complex tasks during an operation. Members of a wide range of health professions serve as assistants-at-surgery, including physicians, residents in training for licensure or board certification in a physician specialty, several different kinds of nurses, and members of several other health professions. For purposes of this report, international medical graduates do not include individuals who are in U.S. residency programs or who are physicians licensed in the United States, but may include some who are certified as surgical assistants. International medical graduates are physicians who have graduated from a medical school outside the United States, Puerto Rico, or Canada. In the United States since 1994, the American College of Surgeons, with other surgical specialty organizations, has conducted studies to determine which surgical procedures require physicians as assistants-at-surgery. These studies classify surgical procedures as "almost always," "sometimes," or "almost never" requiring an assistant-at-surgery. The 2002 study classifies approximately 5,000 surgical procedures, about 1,750 of which are designated as "almost always" requiring a physician to serve as an assistant-at-surgery.^[15]

The Royal Australasian College of Surgeons states that the specific role of a surgical assistant may be primarily: to act as a facilitator, to act as a facilitator and co-worker, and to act as a facilitator and a consultant to the surgeon.^[16] In Australia, like in many countries, the Surgeon's Assistant role is carried out by a Doctor of Medicine or a professional like a Perioperative Nurse Surgical Assistant.^[17] The Royal College of Surgeons in England has created a curriculum framework for the education and training of Surgical Care Practitioners who are health professionals performing minor surgeries and assisting in major surgeries in England.^[18][19] In Ontario, Canada there are physicians whose focused practice is full-time surgical assisting, providing surgical care in the operating rooms.^[20]

Qualifications

In the United States the American Medical Association,^[21] American College of Surgeons^[22] and The American Congress of Obstetricians and Gynecologists^[23] have policy statements on the role and qualifications of surgeon assistants.

The American College of Surgeons states that it may be necessary to utilize nonphysicians as surgeon assistants. Surgeon's Assistants (SAs) or Physician's Assistants (PAs) with additional surgical training should meet national standards and be credentialed by the appropriate local authority. These individuals are not authorized to operate independently.^[22] The American Medical Association states that in some circumstances, it is necessary to utilize appropriately trained and credentialed unlicensed physicians and non-physicians to serve as surgeon assistants to qualified surgeons.^[21] The American Congress of Obstetricians and Gynecologists states that competent surgeon assistants should be available for all major obstetric and gynecologic operations. It states that in many cases, the complexity of the surgery or the patient's condition will require the assistance of one or more physicians to provide safe, quality care.^[23]

Employment

Surgeon assistants job descriptions in the US are role-specific during the surgical procedure.^[24] Hospitals employ residents, international medical graduates, and all the types of nonphysician health professionals whose role is of a surgeon assistant. Hospital employees likely serve as assistants-at-surgery for a majority of the procedures for which the ACS says an assistant is "almost always" necessary.^[25] Assistant surgeon policy is established by individual insurance providers and are based on CMS guidelines.^[4] Most surgical procedures in the US are performed in hospitals without surgical residency programs and the surgical procedures are performed by surgeons with surgeon assistants.^[13] In the US, payment for a surgeon assistant's services in the role of assistant surgeon are determined by the Current Procedural Terminology (CPT) Codes and Descriptors produced by the American Medical Association.^[26]

Surgeon assistants can be employed by hospitals or surgical centers; however, a growing number are employed by Surgical Assistant Provider companies, physician groups, private SFA practices, medical travel agencies, or are self-employed. According to the National Surgical Assistant Association (NSAA), the average annual salary for the non-physician surgical first assistant in 2005 ranged from $50,000 (entry level) to $150,000 annually for full-time practitioners, with top wages reaching $200,000 yearly. The American Medical Association lists the average as $75,000 yearly.^[27][28]

Education

In the United States, physicians (both US graduates in surgical residency programs and international medical graduates), surgeons, physician assistants, registered nurse first assistants, and surgical assistants^[29] may all be credentialed to practice as surgeon assistants. International medical graduates in the US that are licensed, registered or certified as surgeon's assistants are credentialed with a scope of practice of surgical assistance. International medical graduates must hold a Medical Doctor Degree listed in the World Directory of Medical Schools,^[30] have surgical training and hold a nationally recognized surgical assistant certificate, registration or licensure as surgeon assistant. Physician assistants who have graduated can specialize in surgery by completing a PA surgical residency program^[31] to specialize as surgical physician assistants.^[32] Registered Nurses who have undergone nursing credentials and certifications can fill the role of surgeon's assistant and usually have completed the registered nurse first assistant program and are certified as RNFAs.^[33] Surgical assistants with an associate degree can complete a CAAHEP program to sit for a nationally recognized surgical assistant examination. The Commission on Accreditation of Allied Health Education Programs (CAAHEP) has established and published guidelines for surgical assistants who want to be certified by completing a certified educational program. Programs which meet these criteria are able to be reviewed and obtain accreditation through CAAHEP. Currently, there are several schools in the United States which offer CAAHEP accredited surgical first assistant training programs. Additional programs are approved by the National Commission for the Certification of Surgical Assistants (NCCSA) and the American Board of Surgical Assistants (ABSA). NCCSA recognizes all Surgical Assistant Programs accredited by CAAHEP and ABHES that have completed the NCCSA Program Approval Process. These programs typically last between 12 and 24 months and lead to a Certificate of Completion or Associate of Science degree.^[34] There is one Master level educational program for surgical assistants at East Virginia Medical School.^[35]

In the United States, regulation of a surgeon assistant is done through licensure, certification, or registration. Each of these regulations have different levels of educational and professional experience requirements.

In the United States and internationally, surgeons also work as surgeon assistants in addition to their surgical practices. In the United States surgeon assistants are credentialed as surgical physicians assistant's, registered nurse first assistants, nurse practitioners, licensed assistant surgeons, licensed surgical assistants and certified or registered surgical assistants. In the United States, surgical assistants can be certified nationally by the American Board of Surgical Assistants (ABSAs), the National Board of Surgical Technology and Surgical Assisting (NBSTSA), and the National Commission for the Certification of Surgical Assistants (NCCSA). Registered Nurse First Assistants (RNFAs) can be certified as well^[36] and are referred to as CRNFAs. Some states, such as Kentucky, Texas, Colorado, Illinois, and Washington DC have additional state registration and licensure requirements. When deciding which professional certification, registration or licensure to pursue, the surgical assistant practitioner should consider local legislation, facility policy, and regional practice as some credentials are preferred over others in different parts of the United States. Additionally, local laws and hospital policies may favor or require a specific credential to practice as a surgical assistant.

In the United States there are two states that license surgical assistants: District of Columbia and Texas. The board of medicine of DC regulates surgical assistants in that city. In Texas the Texas Medical Board regulates licensure for surgical assistants.^[37] The Texas Medical Board grants licensure to become a licensed surgical assistant (LSA) once the following requirements have been met:

• Minimum education of an associate degree from a 2 or 4-year institution or greater:
• One of the four educational pathways below:

1. Graduation from a CAAHEP accredited Surgical Assisting educational program^[38]
2. Registered Nurse First Assisting program^[33]
3. Surgical Physician Assistant Program^[31][39]
4. Full Medical School (and receipt of a Physician's Degree).

• Worked 2000 hours within the last 3 years as a Surgical Assistant.
• Taken and passed one of the three national certifying exams.
• Have a current national Board Certification.
• Have never been convicted of a felony or crime of moral turpitude.
• 100% honest and forthcoming on the application.

The surgeon assistant is a critical member of the surgical team in the majority of surgical procedures performed. Patients undergoing surgery should be aware of the surgeon and surgeon assistant who will be performing their surgical procedure. Surgeon assistants work as surgical practitioners in surgical procedures which are team-based, role-specific and outcomes driven encounters.

The surgical team works in the operating room and the team members are made up of surgeon, surgeon assistants (SAs), anesthesia provider, circulator nurse and surgical technologist. The surgeon and surgeon assistants are the team members performing surgery on the patient.^[40]

References