Alifiya, General Surgery PA

Alifiya is a McMaster PA graduate from the Class of 2014. Prior to this she completed a Bachelors of Science with a major in Biochemistry and a minor in Psychology at McMaster University. She works at Mount Sinai Hospital in Toronto in the General Surgery service alongside another PA. Alifiya is involved in research, teaching, PA advocacy and medical writing.

Choosing to pursue PA

In the fourth year of my undergraduate degree I was looking at different career options, and I knew that I had always been interested in working in health care. I looked at several health care professions including physiotherapy, occupational therapy and medicine. I came across the PA program when I learned one of my friends was in the PA program at McMaster. I learned what the role entailed and that the PA profession had a lot of potential. At the time I was also looking at applying to medical school, however considering the years of schooling, work life balance and career flexibility I opted to apply for the PA program. I applied in my fourth year and was accepted for the following September. After I completed the PA program, I was hired by Mount Sinai Hospital in General Surgery. I have been practicing there for 3 years and I love my job!

Working in General Surgery

Why I enjoy General Surgery

I am really drawn to acute care, and in general surgery a patient presents with an issue and you can easily provide a solution to fix the problem. The specialty is also very hands on, and I get exposure to the operating room as well. With my specific role, what I really like is that each day is flexible and different depending on where they need me to be – for instance one day I may be in clinic, each day I do inpatient ward management, assisting in the OR – its never a monotonous schedule. I enjoy being a liaison of the team and the level of interprofessional collaboration we provide for our patients.

How I obtained my job

I obtained my job through Health Force Ontario’s Career Start Program. I graduated in 2014, so the funding paid for half my salary for one year. After the one year contract was completed, I was offered a permanent position for my role. This is partially funded by the hospital and partially funded by the Surgery department.

How I was trained for my PA Position in Surgery

Week 1 of Employment –

• Shadowing a PA – When I first started as a new PA grad, I shadowed a PA that was already working on the surgery service for one week duration. During this observership I observed how she functioned within the team, I got to know the resources around the hospital and allied health.

• Shadowing Allied Health & Complementary Services – I shadowed the nutritionist, pain services, and other providers/services that our surgery patients see post-operatively. Spending time with these services familiarized me with their role. This also included shadowing the wound care nurses to learn about stomas and management of surgical wounds.

• Reading around cases – I read a lot around cases, especially considering Mount Sinai’s Surgery service is very subspecialized – in addition to seeing your normal bread and butter surgery cases (e.g. appendicitis, gallstones, etc.) we are the only centre in Ontario that treats peritoneal malignancies, for example.

• General Surgery Skills Lab – There are suture materials available, and I usually attend when I wish to brush up on my suturing skills

Week 2 of Employment –

This is where I was assigned to a surgery team, and was treated very similar to a junior resident who was first starting their rotation on a service. In this dynamic, the senior resident delegates tasks on the team. As I acquired more expertise over time, I started to function more autonomously.

Medical Directives

• Working with Medical Directives – Our medical directives were recently approved. I have to write an “inpatient service” test before the medical directives are implemented and used. The medical directives will allow us to write orders, investigations, and medications with exception of narcotics and controlled substances.

• Working without Medical Directives – Prior to having medical directives implemented, we were allowed to input orders, however this required a co-signature from a physician (whether a resident, fellow or staff physician). This was challenging as this required ensuring a physician was around.

Common Conditions/Surgeries on our Service

• While on General Surgery Team:

  • We do not have an Acute Care Surgery team, therefore we do see common Acute Surgery conditions, including referrals for Cholecystectomies, Appendectomies, Bowel Obstructions, Hernia Repairs etc. as referred through the Emergency to the admitting team when the staff surgeon is on call

• Colorectal Surgery:

  • Surgery for Crohn’s and Ulcerative Colitis patients (examples of procedures: ileocolic resections, ileal pouch anal anastomosis, total colectomy, stoma creation/reversal)

  • Surgery for colon and rectal cancer patients ( examples of procedures: hemicolectomy, sigmoid colectomy, abdominoperineal resection, low anterior resection, stoma creation/reversal)

• Surgical Oncology:

  • Peritoneal Malignancies (HIPEC, diagnostic laparoscopy)

  • Breast Cancers (lumpectomy, mastectomy, axillary node dissections)

  • Colon Cancers

Examples of Procedures I perform

• Placement of a foley inside a stoma to relieve an obstruction

• Rectal tube insertion

• Wound infection management (i.e. opening up the wound, draining the pus, packing it)

• In the OR: retraction, performing subcuticular sutures, JP drain insertions, perineal incision closures

• Staple removal

• Removal of percutaneous drains (PIG tail catheters)

Interesting Procedures I am Involved In

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to treat peritoneal malignancy, which is specialized at Mount Sinai.

We do a reductive surgery first where visible disease is removed, and what is left is microscopic disease. Next heated chemotherapy is absorbed into the abdomen for 90 minutes and the belly is shaken, the chemotherapy is drained. This procedure lasts 10-15 hours.

I may be involved in the surgery by assisting in the OR and look after them post-operatively. These patients are complex since they underwent a prolonged surgery AND chemotherapy. Postoperative course includes ICU admission for cardiorespiratory monitoring, fluid management and pain control. Once transferred to the surgical floor they need to monitored closely with NG tube decompression until return of bowel function, BID lytes, liver function tests, etc

Working with other Health Care Professionals

Structure of the Surgery Team

The General Surgery service is comprised of 10 staff surgeons which includes colorectal surgeons and surgical oncologists. We have four surgery teams, comprising of residents, staff surgeons and myself, the PA.

The team includes:

1. 2-3 Staff Surgeons

2. Fellow

3. Senior Resident

4. Junior Residents

5. Physician Assistant

I rotate between the colorectal and surgical oncology teams every six months.

PA/MD Supervision

PA/MD Supervision – The PA, residents and staff physician (if present) see inpatients simultaneously during inpatient rounds. During clinic the staff physician sees and reviews every patient the PA sees, especially for new consults. Every case is reviewed, but the supervising physician may not necessarily enter the room. For new consults, once the PA has performed the assessment, reviewed the case with the physician, the PA and MD enter the room together to finish the patient encounter. However, in other instances for example, routine 1 year follow-ups that require a mammogram, the physician reviews the case but the staff physician may or may not choose to come in and have the PA finish off the patient encounter. This is similar the supervision residents have with their staff physicians. In the operating room, I am always supervised by either the staff surgeon or resident physician.

How I work with RNs

How I work with RNs – I speak with the charge nurses and nurses on the floor every morning, where we communicate patient plans for the day. For example, if Patient XYZ’s plan would be to have clear fluids and start ambulating – I would communicate those plans to the charge nurse after morning rounds, who in turn will communicate the orders to the nurse caring for Patient XYZ. After rounds the resident or PA puts the care orders in, co-signed by the physician / or by medical directives. Throughout the day, nurses have ongoing communication with the PA where they page with inpatient questions or issues. I deal with most inpatient issues independently as usually the rest of the team is scrubbed into the OR, however, in certain cases I also go down to relay the issues to the team in the OR and feedback the plans to the nurses . Furthermore, the patients on our service sometimes have complex disposition issues and several discharge barriers. The charge nurse is excellent at anticipating PSW needs, mobility concerns, etc. and will communicate with the PA to work together and develop a discharge plan. At our hospital, the nurses and PAs have established a great relationship and system to ensure optimal patient care and safety.

How I work with Nurse Practitioners

There are no NPs on our surgery service, however there are Nurse Practitioners on the Acute Pain Service. These NPs manage post-operative pain through PCA or epidural. The NPs are similar to PAs in that they are the constant face of care (where residents / team members keep changing due to the length of resident rotations being 2-3 months).   We know each other and discuss cases as appropriate to facilitate care.

My Schedule

My hours are 6:30 AM to 2:30 PM Monday to Friday. I work in many settings, including inpatient/ward management, clinic, in the OR, scopes. I carry the team’s pager during the day and address any concerns inpatient issues.

Mondays:

• Inpatient Rounding – I start each day at 6:30 AM where I join inpatient rounds. We ensure we see all our patients before 8 am. Once we finish rounding I give handover to the nurses, where I update the charge nurses on the floor about the plans for each patient as discussed in rounds. This helps us maintain continuity of care through various health care disciplines. Between 8:00 AM to 9:00 PM I take care of any emergent inpatient issues that may have developed over the weekend.There are two important components after inpatient rounds, this includes (1) putting orders in, then (2) communication: with charge nurses and allied health re: patient plan, referrals to inpatient consulting services, and getting prescriptions and homecare referrals ready for patients being discharged. The PA and junior resident usually tackle these tasks together, typically the junior resident puts the orders in and then I take care of the communication.

• Surgery Clinic –

  • At 9 am this is when clinic starts. Here I see post-op follow-ups, new consults from the community, and referrals from the Emergency department. We found the most efficient use of the Physician Assistant is to see new patients. These assessments would include a comprehensive history, physical examination, review of imaging, and putting together a provisional assessment/ diagnosis and plan. I then review with the staff surgeon and together we go into come up with the plan. Should the patient require surgery, I will take care of the surgical consent and paperwork involved with booking the surgery. This frees up the physician to attend to more complex cases. I’m an equal member of the surgery team, working alongside the staff physicians, fellows, senior resident, and junior residents. We split our responsibilities equally, for instance, if there is too much work on the inpatient ward that day, one of us will stay back on inpatient while the other continues in clinic. In this instance, I am able to fill the gaps where I am required.

  • During clinic, I am also holding the team pager, and simultaneously answering the pager for any inpatient issues.

• Multidisciplinary Rounds – At 1:00 PM on Mondays we have multidisciplinary rounds. I am the representative for our surgery team, so I attend the rounds and meet with allied health, including physiotherapy, occupational therapy, social work, nutritionists and charge nurse. During these rounds we go through the patient list and discuss their disposition in detail, and any acute issues that need to be addressed. This takes much longer than our morning rounds.

• Handover – At 2:00 PM at the end of my day I handover to the senior resident. I run through the patient list with them and discuss what’s pending and what’s happened to patients during my shift. No new tasks are assigned to me after 2 pm.

• Tuesdays

  • Inpatient Rounds start again at 6:30 AM

  • Palliative Care Rounds – We have surgical patients who are admitted in palliative care. During these rounds we meet with the Palliative team and go through each patient and discuss patient care. This helps us coordinate care between services.

  • Operating Room – Tuesdays are typically OR day for the PA, since junior residents have academic half days on Tuesdays. We usually have two rooms running for General Surgery, and I get called in to the OR where I scrub in. As first or second assist, I primarily retract, perform wound closure, and drain insertions. I ensure I liaise with my surgery team between surgical cases.Since Junior Residents have academic half days, they have usually missed the inpatient rounds on Tuesday mornings, they meet with me once they return to hospital and I run through the patient list with them. The residents then scrub into to the rest of the surgery cases.

  • Handover takes place at 2:00 PM.

• Wednesdays – Wednesdays tend to be more relaxed. I start the day off again with inpatient rounds, followed by work on Quality Improvement (QI) projects and resident orientation. During this time I continue to manage the ward and answer my pager for inpatient issues.

• Thursdays – are similar to Tuesdays

• Fridays – I start the day again with inpatient rounding, following this we attend Quality of care rounds as a team between 7:30-8:30 AM. Then, I will either work in the clinic or assist in the operating room. I go where I am needed most, for instance, if I had a busy clinic I’ll work in the clinic. If they need an extra hand in the OR, I will scrub in. 2 pm is handover.

I also do Family Meetings – I take an active part in family meetings of surgery patients especially since I spend most of my time in the ward between 6:30 am to 2:00 PM, and I’ve built relationship and rapport with the patient and am able to speak to how the patient is doing and the plan from that perspective.

I do not formally do call – as ER consults (or consults from other wards) are taken care of by the junior residents. There are occasions that I help out with call consults, for example, if the junior resident received multiple consults at once I will go see a few of those consults to ensure that the consults are seen in a timely manner. There are times I will assess patients in the ER, however the surgery team has not yet decided whether the patient will be admitted or followed up on an outpatient basis so this is usually a pending decision.

Quality Improvement Projects

• Project 1 – Post-discharge follow up App

  • This is a stepwise project that began in 2016 with a telephone study assessing the needs of post-op patients after discharge. This was followed by development of a mobile app for post-discharge monitoring of patients undergoing colorectal surgery. I am currently leading a randomized control trial (RCT) based on the discharge app we developed. This is an everyday project which involves reviewing results of when patients input information into the app. I use Wednesdays to do charting and fill out the spreadsheet which tracks readmission rates and callbacks, etc.

Alifiya with her research partner Saira,after winning 1st place at the Annual CAPA/CPAEA Poster Session for their research poster.

Project 2 – Resident Education

• I regularly update the General Surgery Resident Handbook which orients new junior residents to the General Surgery service

• Junior Resident Orientation – Junior residents rely heavily on me to orient them to the Surgery Service

• Resident Feedback about clinical rotation to improve education

• Project 3 – Developing and advocating the use of CCAC templates

  • Post-op colorectal surgery patients usually have complex home care needs requiring stoma care, drain and wound care.

  • Home care arrangements can get complex and time consuming . Therefore, the PAs and nurses worked together to develop customized templates – so all you need to do is select the care that you need (e.g. percutaneous drain care), and the care details populate the referral and it gets sent. I ensure that the residents on my team are informed and know how to use these templates.

  • Since developing the standardized template for home care orders, this has saved a lot of time from writing out all of the orders, and decreased the number of “Request for Information “ (RFIs) from CCAC.

• Project 4 – Monthly Interprofessional Event Group Lunch and Learns

  • Led by the VP of Medical Education and an internist at Mount Sinai Hospital, the Interprofessional Event Group holds monthly meetings with several health care providers – physiotherapists, Physician Assistants, and more for students who are affiliated with Mount Sinai hospital to learn about the role of different health care providers in the hospital.

  • This is akin to a “lunch and learn” with students, I find this is a great opportunity for me to get involved with PA advocacy, and participate in role awareness.

• Project 5 – Annual Value-Stream Mapping Event

  • PAs are invited to streamline processes. This two day event involves physicians and allied health who review the whole process from patient pre-admission to patient discharge. We then examine where the breakdowns in communication and delivery of care occur.

  • Since PAs provide a lot of continuity of care, we are able to effectively contribute ideas for Quality Improvement.

Alifiya presenting her research on development of a mobile app to follow patients after discharge.

Benefits of Adding a PA

I was lucky that the PA role had already been initiated prior to me starting. Had I started at a hospital or service that was PA naive, I would have had to engage in more PA role awareness and education.

Continuity of Care – Residents rotate every 2 months or so depending on what level of residency they are in. Having a PA, one constant person, on the surgery team that knows the patients helps during the transition of new team members when residents rotate. I also have established relationships with the interdisciplinary team.

Research – I have an active role in research and  quality improvement and my staff physicians really appreciate it. I work on the randomized control trial, monitoring results everyday.  Having a PA/ dedicated member of the team to take on a leadership role in these types of QI projects is valuable.

Patient safety – I am constant member of the team,  there are things that a new team member may not know but I  can alert them to it.  This way I am able to  help fill the gaps in patient communication and assist in decision making.

Reduced Resident Workload – General surgery residents are overworked and are often on-call or post-call, and must juggle academic half days. There are also now restrictions on how many hours residents work. This creates gaps in care, and having a PA on the team who is there consistently on the ward able to share resident  workload leads to a higher satisfaction with their rotation.

Reduced staff workload – When a PA is helping with a surgeon in clinic, we are able to help the physicians see patients faster in  clinic. This frees the staff surgeon to see more complex cases. With increasing experience, knowledge and skills, the surgeons often rely on me to address complex disposition issues, because they know I am acquainted with that process and coach other members of the team (residents). The staff surgeons are also not as worried about the resident orientation as I am available to assist in this area.

Resources for General Surgery

• Toronto Notes (now USMLE)

• Best Practices in General Surgery (BPIGS) – Free resource offered through University of Toronto. These were developed to standardize evidence based practice in the divisions of general surgery. To date the following guidelines have been implemented*:

  • Surgical Site Infection

  • Pre-operative Mechanical Bowel Preparation

  • DVT Prophylaxis

• Antimicrobial Stewardship Program (ASP) – which uses a collaborative and evidence- based approach to improve the quality of antimicrobial use by getting patients the right antibiotics when they need them.

Tips for New Grads

I encourage new PA graduates to choose a specialty that you know you are going to enjoy, if possible.

Don’t be afraid to ask questions, and advocate for yourself. Part of being a PA is on us to establish our role and educate around what PAs do to staff, colleagues, patients and families. Don’t be afraid to put yourself out there!

Create a Professional Activity Report – this is a great way to keep track of your professional activities. This is like a professional portfolio or dossier where you keep the most updated version of your resume, but you also file conferences you attended, posters you presented, courses or CE you’ve completed, mentors/mentees, copies of past reference letters, advocacy initiatives you were involved, committees you joined and projects you’ve taken on. It’s helps you build a CV, but also is nice to easily track and simultaneously track what you’ve done over your career.

Future Goals

My future in this PA role – I will continue to be a crucial member of the general surgery team and  as I acquire more expertise I will obtain more autonomy.  With the recent implementation of  medical directives, my clinical role will evolve to include more responsibilities, thereby freeing up even more time for the residents on the team.   We are involved step wise projects in QI, I see my role in research and QI progressing. I am now actively involved with the Medical Education department;  and as a result of being invited to speak at interprofessional events, I’ve gotten to know a lot of physicians /allied health in other specialties. It’s always nice to advocate my role and educate other professions  and students about PAs. I’m hoping to acquire similar additional opportunities within the hospital. We are getting PA clerkship students in January which is new for me which involves PA teaching.

Professional Goals – When I just started, I was just getting used to my clinical role; now that I’m 3 years in I’m much more comfortable to take on PA advocacy initiatives and participate in PA led research.  I’m interested in writing and editing, hence I have signed up to be  a JAAPA peer reviewer and am working on manuscripts for journal submission.  I am also looking into furthering my education and I am considering obtaining  a Masters in Public Health in the near future.