Editor
It was with great interest that I read Mr. Hlavin’s article on postgraduate neurosurgical training for physician extenders [physician assistants and nurse practitioners] in the most recent AANS Neurosurgeon (Vol. 18, No. 1). I believe that I can speak about this subject, at least with regard to physician assistants, from the perspective of 29 years’ experience as a clinical PA, administrator and academician, including service as a PA program director for 10 years prior to taking my first neurosurgical job in 2007.
Mr. Hlavin treads on a dangerous path for the future of the entire PA profession. He is certainly not without supporters in the specialty ranks of the profession, but I disagree with his premise that PAs are ill-prepared for practice in a neurosurgical specialty. Since the beginning of our profession, PAs have been educated in the general medical model, allowing for broad exposure which can lead to a job in almost any medical specialty. The flexibility to move between specialties without the time and expense of additional formal training is the beauty of our profession and is based on a strong primary care foundation. The ability to perform an excellent history and physical examination and develop a differential diagnosis is foundational for all medical specialists. All other tasks build on this cornerstone, which is the strongest element of any PA’s education.
Since graduating from PA school in 1980, I have worked clinically in cardiovascular surgery, primary care, diabetes care, emergency medicine and neurosurgery in addition to time spent as a hospital administrator and academician. I have been successful in all of these endeavors by keeping focused on the fact that every day is a learning process. I have been in neurosurgery for two years and learn something new every day. A formal training program might have sped up the learning curve but would have been totally impractical at any stage of my career. Ultimately, neither I nor my supervising physicians believe it would have made any material difference because my practice style should reflect that of my supervising physician, not that of a postgraduate training program.
PAs are “dependent” practitioners. This is foundational to the success of our profession. We should always have the expertise of our supervising physicians upon which to depend if and when gaps in our education exist. Yes, there will be a steep learning curve for any new neurosurgical PA. Yet, nearly every physician I encounter would prefer that this education take place on the job, where the PA will be trained to practice in the style of the supervising physician. Formal postgraduate education is unnecessary and potentially detrimental to the future of our profession. Less-formal education such as seminars and short courses in conjunction with meetings of the AANS and other organizations seems much more practical.
“Competency-based” is a phrase which is often bantered around the academic world, but who really determines competency? Everyone in medicine knows someone who completed all the training and passed all the exams, but is ultimately incompetent. Neither an educational program nor a standardized test is an adequate reflection of competence. In the case of PAs, competence is best determined at the level of the individual practice by the supervising physician. Adding formalized training programs and examinations will provide a revenue stream to the academic institutions and credentialing bureaucracy but, in my opinion, will do little to protect the public from “incompetent” providers.
—Richard Nenstiel, PA-C, MBA, Mobile, Ala.
The author reported no conflicts for disclosure.
The author responds:
I thank Mr. Nenstiel for his excellent letter concerning my recent article on postgraduate neurosurgical training for physician extenders. He makes several insightful points based on years of professional experience that included several years as a physician assistant working in a wide range of medical areas. In contrast, I sampled several areas of medicine in the military and developed a strong affinity for neurosurgery during PA school; I was fortunate to be trained in a surgically focused program, of which there are few.
His letter reflects a concern among many in our profession: the fear of being locked into a particular area of medicine, or worse, of being marginalized by insurance and credentialing forces. These concerns are most viable and are a resilient topic at our professional meetings.
While PAs with years of experience would be unlikely to consider the type of training program I described, a new graduate is a different matter. The program is really designed for those PAs who have a strong desire to gain advanced learning and experience. It is not intended to set graduates on one course for the rest of their careers. Although Mr. Nenstiel makes a good point regarding the basic knowledge currently imparted to PAs, basic knowledge is inadequate for handling neurosurgical patients efficiently. In my estimation, it takes seven to 10 years in private practice neurosurgery to manage very complex patients with any confidence.
According to a 2005 AANS survey, neurosurgeons support formal training for new physician extenders who have a desire to work in neurosurgery, although the length of such training and who should pay for it are areas for further development.
I appreciate Mr. Nenstiel’s insight and look forward to working with him to further our profession.
—Joseph Hlavin, PA-C, Bryan, Texas
The author reported no conflicts for disclosure.
For Further Information
- Craig, KT: The PE potential. AANS Bulletin 14(4):26-27, 2005,
https://www.aansneurosurgeon.org, article ID 37390
- Hlavin, J: Is your PE optimally trained for the job? AANS Neurosurgeon
18(1):42-43, 2009, https://www.aansneurosurgeon.org, article ID 61446