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Before you start on your surgery journey, you meet many members of the surgery team including the nurses, students, residents, surgical fellows, anesthesia doctors, etc. Most people assume that it will be their surgeon who will be involved with ALL aspects of their surgical care. This is not always the case!
So Who will be Performing Your Procedure?
Depending on the setting where you have surgery (surgery center, teaching vs community hospital, surgical clinic), your surgery may be supervised by your surgeon, but the scalpel could be held and operated by assistant surgeons, medical/surgical students, residents, fellows, physician assistants, or nurse practitioners. In fact, some “simpler” procedures may be done by these medical providers without primary surgeon’s oversight, if they fall within their legal scope of practice.
Everyone expects that their surgeon will be in the operating room during surgical procedure. You usually meet this person much ahead of the surgical procedure during the pre-operative clinic appointment.
During your last clinic appointment, the surgeon or assisting staff will ask you to review the consent form which should list details of the procedure including benefits, risks, and potential complications. It is usually a fairly lengthy legal document that is meant to give you a summary of what the surgery and rehab is going to be like. This is the time to ask any additional questions and ask for clarifications. Once this document is signed, the surgeon will alert the operating room to plan your surgery.
In addition to explaining your procedure, the consent may list the names or job titles of other individuals that may be in the operating room and assisting/performing your surgery. So who are these individuals?
Assistant Surgeon
This could be a person who is as knowledgeable or more knowledgeable with your procedure than your primary surgeon. This person is usually a surgeon in the same field and with the same level of or increased level of training and familiarity with the procedure. This is particularly helpful if you are undergoing a revisional procedure and the assisting surgeon has done many of these types of surgical case. There are other benefits as well. An assistant surgeon may advise on finer details of surgical procedure and may recommend specific improved approaches and techniques. Surgery time may be shorter and outcome may be improved with the use of knowledgeable assistant.
Medical/Surgical/PA/NP Student
These are health care professionals in training to become doctors, surgeons, nurse practitioners or physician assistants. They are not allowed to work on patients without supervision of a fully qualified/certified doctor also known as “attending” doctor. If you are having your surgical procedure in an Teaching or University affiliated hospital, you are very likely to be assisted by these students. They are usually very friendly and eager to answer your questions about the surgical preparation, instrumentation used, and expected post operative protocol….if they are well prepared. Unfortunately, they are ones of the least experienced members of the surgical team and tend to have big picture understanding of what is involved. They help the main surgeons with logistics of the surgery and receive didactic and clinical training in return.
Residents and Fellows
Residents are doctors who graduated from medical or podiatry school and have license to practice under supervision of another fully licensed doctor. Residents often work at University based teaching hospitals. They are significantly more knowledgeable and skilled than students but are still considered to be in training. Residencies for sub-specialties have different durations and can be from 3 years (surgical podiatrist) to 7 years (neurosurgery). Explore linked list here for nice summary of residency durations. The main surgeon should be in the operating room from the point of skin cut (incision) to the point of patient being rolled out into the recovery room. This however is not always so and residents may be left relatively unsupervised in the operating room based on main surgeons discretion and level of trust in residents training. Residents in their last year of training should be very comfortable with performing surgical procedures as they are about to become “attendings” themselves.
A wise supervising surgeon, however, will be there during the whole duration of surgery and you, as a patient should request this! What distinguishes a very experienced residents from an attending doctor is depth of knowledge that can only be acquired by experience. In surgery, complications arise!
Successful outcome, therefore, will depend on knowing not only on how to do the procedure but also on changing the course and quickly addressing complications. Difficult situations (bleeding, hardware breaking, instrumentation not fitting or working, changes in patient’s medical stability and comfort, poorly controlled pain, and many other issues) may arise at any time during surgical procedure and can happen unexpectedly. This is why it is essential that supervising surgeon is present and available through the whole surgical procedure.
Fellows are known as “super-residents”. They are usually fully credentialed doctors who can operate to full extend of their license and training. However, they choose to undergo additional training to get new skills or to deepen their comfort with already existing skills. In the world of podiatry, fellows are choosing to have additional training in the reconstructive surgery/trauma, sports medicine, pediatrics, research and limb salvage and preservation. These fellowships may or may not be accredited. The main purpose of undergoing fellowship is to obtain an immersive, fast paced sub-specialty training experience. If there is a fellow surgeon assigned to do your surgery, you can bet that this individual will be doing the majority of the surgical procedure. If you are uncomfortable with this, you should definitely discuss this with your main surgeon.
Training is an essential part of the process to become a fully fledges surgeon. If students, residents and fellows are not allowed training avenue, eventually we will run out of doctors. Thus, it is important to keep balance between need for training and safety in patient care. Having surgery at a teaching hospital has its benefits as these centers usually have access to the latest medical equipment and research. Thus, if your surgery is for a rare condition, university hospital could be best place to have surgery. Surgeons that work with trainees tend to be at the forefront of latest technology and data within their field. This is because students, residents and fellows tend to read latest research and very inquisitive. This forces surgeons to be on “their toes” as they must stay up to date and constantly be aware of new skills and knowledge within their field. Having multiple individuals involved in the surgical case can help avoid errors as these individuals are reviewing the same information in the medical chart. This increases the chance that inconsistencies will be spotted and complications will be avoided.
Can you refuse the care by residents and students?
It is absolutely withing your right as a patient to be treated by the specialists and health care providers you are comfortable with. If you do not feel that your care will be optimal when trainees are involved, you should bring this up with your surgeon. This is done best during your pre-operative appointment but can also be done on the day of surgery. It is never too late and your wishes as a patient should be respected. It is the job of the surgeon and surgery team to give you comprehensive education as far as the process of surgery is concerned. You may not want to know all the “finer” details of the surgical procedure and may not be able to understand medical jargon. However, you should be able to have all your questions answered and all concerns addressed before going under anesthesia. This is part of the informed consent.
Physician Assistant/Nurse Practitioner
There is a difference between PA (physician assistant) and NP (nurse practitioner).
Physician assistant is a highly trained health care specialist who is considered to be a physician extender. Therefore, this individuals can do any medical/surgical task as assigned by the surgeon under surgeon’s direct or indirect supervision. The extent of involvement of the PA specialist depends on their training, comfort with performing specific assigned/selected tasks, and surgeon’s assignments. In general, the more complex the assignment, the greater degree of supervision required. Much of this depends on the surgeon/PA professional relationship, trust, and skill awareness.
Nurse practitioners are independent health care providers. They provide health care directly to patients without oversight of other health care professionals. They frequently work with other health care professionals as members of comprehensive medical/surgical teams. Nurse practitioners are able to perform any surgical procedure to the full extent of their training. Nurse Journal describes the difference in medical and surgical practice between doctors and nurse practitioners.
Who else is involved in your surgical care?
Anesthesia doctor or CRNA
Anesthesia doctor or Certified Registered Nurse Anesthesiologist (CRNA) will usually meet with you in the pre-operative area and will discuss how to make you most comfortable during the surgical procedure. In addition to Intra-venous sedation, monitored anesthesia care, and general Anesthesia, you may be offered a regional anesthetic block. In the world of podiatric surgery, regional blocks and other blocks are frequently used. These may include various pain reducing nerve blocks like spinal block, epidural block, and blocks to lower limbs like popliteal and ankle blocks.
CRNAs are nurses with advanced training similar to a fellowship who are licensed to administer anesthesia under the supervision of the Anesthesiology doctor.
Operating room nurse and Circulating nurse
Operating room nurse works closely with the surgeon during the operation. This person may be wearing sterile attire and may assist the surgeon with retraction of tissue, intra operative logistics and instrumentation handling. Alternatively, Surgical Technicians are certified specialists who specialize in preparation and set up of surgical instruments and supplies in the surgical room environment.
Circulating nurse is present in the Operating room and works to record the details of the procedure. This person is not dressed in sterile attire, because they do not work within direct surgical sterile field. They are available for trouble shooting devices and equipment and are important in surgical field set up. Having circulating nurse in the room allows sterile members of the surgical team to continue with the case when additional equipment and set up becomes necessary during the course of surgery. For example, if the surgeon drops an instrument and new sterile instrument is required, circulating nurse can obtain such an instrument. Another example is when the blood becomes necessary for transfusion, a circulating nurse can make a phone call to the blood bank to request it. This can be done without having the surgeon interrupt the procedure.
Medical Device Company Representative
This individual is never directly involved with the surgical care. Medical Representative brings the instrumentation required for surgery from the medical device company is educated and knowledgeable in implementation and trouble shooting of the medical equipment use. They act as a great resource for the surgery team when instruments are not working as intended or instrument design concerns arise.
Ultimately, it is your primary surgeon who is the “captain of the ship” when it comes to your surgical procedure. The responsibility for your successful surgical outcome is on your surgeon. Therefore, it is essential for you to be aware of all the members of the surgical team involved in your care! This is so you can communicate your fears, concerns, suggestions and desires to your surgeon to achieve best possible outcome!
Author bio:
My name is Dr. Marat Kazak. I have been working as a professional Podiatrist serving Northern California community since 2014. My extensive medical and surgical knowledge combined with an ongoing curiosity to learn about the latest trends define my success in the field of foot, ankle and leg medical and surgical care.
The goal of this website is to give you the tools to better care for yourself, to dispel medical myths, and to empower you with information to save time and money! If you are looking for an answer on foot and ankle pain, this is the place to find it. If you do not see your topic of interest covered, please send me a message and I will do my best to discuss it thoroughly in my next upcoming post.
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