Physician extenders—nurse practitioners and physician assistants—have been part of the medical team since the mid-1960s. Today, training for both NPs and PAs is based on internal/general medicine diagnosis and treatment. This leaves a deficit in the academic preparation of any new NP or PA who wants to go into neurosurgery, let alone gain enough exposure in this area of medicine to be able to determine that it is of interest.
At the same time, there is a demand for physician extenders: Most neurosurgeons already employ them and more than half of neurosurgeons surveyed in 2005 said they need more. But the vast majority of neurosurgeons employing physician extenders must provide them with “on the job” training in neurosurgery. There clearly is a need for standard, competency-based training programs that better prepare physician extenders for neurosurgery and thus better serve the needs of our patients and supervising neurosurgeons.
Formal Training for Physician Extenders
Standardized training for PAs in primary care is well established. Every PA
currently practicing has undergone a national training curriculum and received
a degree, and most PA programs in the United States confer a master’s degree.
Unfortunately, most PA programs offer no surgical subspecialty rotations or
electives.
The NP route includes completing additional courses in family medicine and obtaining a master’s degree, which is the entry level degree for certification. Additional course work and testing to become an RN first assistant is required for billing and reimbursement of surgical services. As for PAs, there is a lack of neurosurgery-focused training that would allow a smooth transition into the job market.
There are approximately 500 PAs currently employed in neurosurgery, according to the 2008 American Academy of Physician Assistants survey. However, only one postgraduate training program in neurosurgery is listed on the Postgraduate Physician Assistant Program site. There are no other formal training programs in neurosurgery available to either PAs or NPs.
Further, accurate measurement of competency in trainees requires some type of standardized testing. But currently no formal examination platform exists for physician extenders in neurosurgery.
Neurosurgeons want their physician extenders to undergo advanced training that prepares them for the neurosurgery setting. A survey conducted in 2005, the AANS Physician Extender survey, examined the attitude of neurosurgeons relative to the training of physician extenders. More than three quarters of neurosurgeons felt it would be beneficial to establish formal training programs in neurosurgery for physician extenders. In response to the survey findings, the AANS considered long-range plans that included development of a physician extender curriculum for competency in neurosurgery, an advanced curriculum for continued education, and Web-based training modules.
The AANS since has provided training for physician extenders in practical clinics, plenary sessions, scientific sessions, and breakfast seminars at its annual meeting. Such sessions are informative and insightful but fall short in practicality for the physician extender who desires basic training in neurosurgery. There are online modules for AANS members through the Web site, but again, basic educational modules are not provided, and most of the education offerings through professional neurosurgery are too advanced for the early career physician extender.
Industry-supported seminars that are offered year-round can be a source of advanced training, but since they are supported by business entities, they are label-focused and potentially biased. Further, continuing medical education credit is not offered in conjunction with these programs.
Proposed Postgraduate Training Program
There is a need for development of a postgraduate training program in neurosurgery
for physician extenders that includes a competency-based curriculum with didactic
and practical sections based on the medical model. The program would be similar
to neurosurgery residency programs but limited both in training time and depth
of content. The direction of the training should parallel the responsibilities
placed on the majority of physician extenders presently working in neurosurgery,
and training would ensue under direct supervision of neurosurgeons who are
program faculty.
There are, however, barriers to development of such a program, including those raised by PA and NP professional organizations. These organizations have dismissed consideration of a formal subspecialty program in neurosurgery because it potentially could “box” a PA or NP into one specialty for the rest of their careers or shift funding from a large, centrally located professional organization to smaller, specialized organizations.
There should be a way to keep physician extenders from being “stuck” in a particular specialty yet still allow them to demonstrate competence in general medicine. The void in physician extender education demands a solution, and such a solution should withstand the rigors of the medical credentialing process set by not only neurosurgery but also by the PA and NP accreditation bodies.
My experience of more than 17 years in neurosurgery has shown me that on a practical level physician extenders have in common the strongest desire to work as a member of the neurosurgical team and provide the best patient care. While there are training opportunities for physician extenders available now, ultimately a structured, competency-based system will need to be fully developed, implemented, and then evaluated for viability and reliability. With such a system in place, physician extenders will be able to display the confidence, knowledge, and practical and technical skills that are needed to be productive, efficient partners on the neurosurgical team.
Joseph Hlavin, PA-C, is a member of the AANS Neurosurgeon Editorial Board. He practices in the neurosurgery division of the Texas Brain & Spine Institute, Bryan, Texas. The author reported no conflicts for disclosure.
For Further Information
- ARC-PA, www.arc-pa.org
- Craig KT: The PE potential. AANS Bulletin, 14(4):26-27, 2005, www.aansneurosurgeon.org, article ID 37390
- Crane SC: Perspectives on the physician assistant specialty credentialing debate. Mountains Beyond Mountains. JAAPA, 19(8):16, 18-19, 2006
- Postgraduate Physician Assistant Program, www.appap.org