FM + Surg?

[Guest CaesarCornelius]

Is there a surgical fellowship available after family medicine? Perhaps something along the lines of minor procedures?

 

Just curious

 

CC

[Guest physiology]

I think surgical assists are definitely possible. In smaller rural, hospitals, the family doctors are probably well-trained in doing caesarians.

 

However, I'm not sure if family doctors assist in tertiary care teaching hospitals like VGH in Vancouver. There are already enough residents and medical students fighting to get a piece of the pie already. In the smaller suburban hospitals, they definitely do play an active role in the OR doing surgical assists.

[Guest endingsoon]

Yeah you can do surgical assist even at larger community based hospitals in the Toronto area, although you would not be able to at a larger teaching facility.

 

Nice way to augment that income, they make a pretty penny for essentially doing the work of a medical student.

[Guest UWOMED2005]

As far as I know, there is NO 3rd year CCFP program that will give you surgical experience, at least to be the primary surgeon on any procedure.

 

But as previously stated, CCFP grads without any further training will often do 1st assist for smaller centre surgeons. They don't need any further training for this. Not to mention, many family docs will do lumps & bumps, biopsies, vasectomies and other minor procedures - without a specific 3rd year.

 

If you wanted to make yourself more competitive for this kind of work, I've heard an argument that the 3rd year anaesthesia year is suitable for such purposes as it gives you lots of OR training.

 

In fact, I've met at least one 3rd year anaesthesia grad who does nothing but anaesthesia and first assists. Another one does nothing but anaesthesia and emerg shifts.

 

Doing CCFP training does not necessarily mean doing family medicine.

[Guest macMDstudent]

Isn't there some post grad training FP grads can do in OB that allows them to do C-sections, D+C's, and abortions?

[Guest therealcrackers]

C-sections are usually done by an OB except in the most extreme circumstances... in a large centre the OBs will do them, and in smaller centres or rural settings the general surgeons are usually trained in doing them. The 3rd year OB program, as far as I know, trains people to do deliveries and D&Cs (for incomplete/inevitable spontaneous abortions), and how to treat the relatively common complications of those.

Someone with more knowledge can correct me...

[Guest EB]

Hi macMDstudent,

 

I'm on my rural rotation now, and in a community of 6400 that is 1 1/2 hrs from Edmonton, GPs with further training in Surg/OB to elective & emergency C-sections routinely... D & C's are also routinely done. Routine vaginal deliveries are also done in the community, with the recommendation that primips go to Edmonton.

 

Abortion training is easily done by GPs, and generally is not offered through the extra year of OB (I can only think of 2 or 3 universities that offer it).... This training can be done with out a dedicated 3rd year in OB, and you can perform terminations up to 14 weeks in any rural or urban centre across Canada. If there is a Med Students for Choice group at your school they should be able to give you info on OB & abortion training through Fam Med... If there isn't and you have more questions, feel free to drop me a line...

 

 

EB

[Guest UWOMED2005]

I was somewhat surprised to learn that in South Africa GPs are trained and expected to do C-sections, particularly in rural hospitals.

 

In a big city like Jo'burg or Capetown where there are a multitude of Obstetricians around, they will do all of the C-sections. But if you're in a rural area GPs have to do the majority of C-sections. Their system cannot afford transferring that many patients to tert care centres.

 

And a C-section is a fairly basic procedure. The two main skills you need if things go wrong is to know how to control bleeding, and if it comes to that you need to know how to do the hysterectomy to stop the bleeding.

 

The docs in South Africa actually offered to teach me how to do C-sections to the point I could do them independently. As that is not a skill I could particularly use in Canada, I declined the offer to spend more time in the OPD and casualty (essentially the emerg department.)

 

My understanding is that one of the key skills taught to 2 + 1 Obs/gyn people is C-sections. I haven't worked with enough of those docs to confirm that.

 

I have also, however, heard rumours that in some of the communities in remote Northern Ontario there are South African trained docs who will step in and do C-sections* if required. In that sort of a situation (transfer to a gen surg or obs/gyn taking 5 hours or more) sometimes it is impossible to transfer emergency C-sections to a facility with docs with more recognized C-section credentials.

 

*There were also references to these docs doing emergency procedures such as fasciotomies and amputations for sepsis

[Guest macMDstudent]

In the not to distant past, GP's did their own appendectomies and tonsillectomies as well. I was sitting down with a FP who moved into an office from a recently retired GP who was in practice for almost 50 years. He found in a room a few boxes of old "charts" that were just recipe cards with basic info on it about patients, including a record of care. He showed me one that said something like " pt. presents with with RLQ pain, fever, told to report to pre-op, will do appendectomy this evening." The next day there was entry, "I performed routine appendectomy yesterday, pt. recuperating nicely this morning." This was from the 1950's! They only did 1 year interning back then too!

[Guest UWOMED2005]

That's right - I'd forgotten about that. I met a couple of (older) GPs in Renfrew that could remember doing appendectomies, emergency laparatomies and minor orthopedic surgery procedures in the not too distant past.

[Guest adlinner]

I know a bunch of fm guys from Northern Ontario and out west, in isolated communities, who do their own hernias, appendectomies, c-sections, anal surgery, tubals, vasectomies, hand plastics, etc. The OR time is available in their communities. UBC and Alberta are the places that still do the third year programs (check the CFPC site).

 

Yours

Daren

[Bittersweet]

In about 5 years, FP assisting in the OR will be obsolete. Advanced practice RN's (RNFA) are now being partially funded by the government all across the country.

 

The role was implemented for 1) cost savings 2) to free up FM for their office / clinic. They are employed at larger city hospitals, teaching hospitals and community hospitals. At some hospitals, the RNFA's assess the patient's pre-operatively, assist in the OR (including suturing), and follow the patients post-operatively (under the direction of the surgeon).

 

Some FP welcome the role (ie. their office hours are inconvienced by unpredictable OR slates - ie. cases running late, being bumped), however some are completely opposed to it. Obviously it is a very politically delicate issue, as most advanced practice roles are (midwives, nurse practitioners and RNFA's).

[ploughboy]

In about 5 years, FP assisting in the OR will be obsolete. Advanced practice RN's (RNFA) are now being partially funded by the government all across the country.

 

The role was implemented for 1) cost savings 2) to free up FM for their office / clinic. They are employed at larger city hospitals, teaching hospitals and community hospitals. At some hospitals, the RNFA's assess the patient's pre-operatively, assist in the OR (including suturing), and follow the patients post-operatively (under the direction of the surgeon).

 

Some FP welcome the role (ie. their office hours are inconvienced by unpredictable OR slates - ie. cases running late, being bumped), however some are completely opposed to it. Obviously it is a very politically delicate issue, as most advanced practice roles are (midwives, nurse practitioners and RNFA's).

 

Is this a common thing? As far as I'm aware, there's only one programme in Ontario offering RNFA training (Mac, IIRC), and there's a significant time committment on the nurse's part to get her/his RNFA designation. Maybe there are regional differences?

 

In the hospitals I'm working in now there are a couple of RNFAs, but most of the first assists are retired family docs with time on their hands. I can't see that changing drastically within 5 years (there's only so much time you can spend playing golf!). It may change in a longer time-frame, but as you mentioned it raises the question: in the face of a nursing shortage, why are we taking nurses away from their primary role?

[Bittersweet]

Yes I am sure about the implementation of the RNFA role - I have been one for 5 years now. Currently waitlisted at Mac though.

 

There are a few RNFA programs in Canada actually. The original one is in Vancouver, and there is a french one in Quebec.

 

To be honest, the nursing shortage doesn't really have anything to do with it. Nurses who want to become midwives, nurse practitioners or RNFA's are leaving the 'general nursing field' for their own professional development. These nurses have years of experience in their field, and are looking to expand their clinical skills, increase their autonomy and responsibility. Many are bored, and looking for a more challenging and interesting advancement in their specialty.

Yes it is a major time committment, but isn't any educational program?

 

RNFA's are nurses that have 5-10 years OR experience (depending on the program requirements), a BScN, additional english courses, Surgical Certification and the RNFA course. Most have their MScN.

The government sees the role as a cost saving incentive (ie. RNFA's are paid 1/4 of what the FP bills for the same case).

 

I am in Toronto right now, and 8 hospitals are already utilizing them (for cardiac vein harvesting, vascular, plastics, private clinics, etc). Every province is utilizing them, however Calgary has the most RNFA's, and has been using them for years.

Some surgical assists are also retired surgeons - which obviously is great for the surgeon.

 

The government is supporting the role, and encouraging hospitals to use them by partially funding their salaries.

I suppose the controversy is similar to other healthcare roles (ie. midwives / obs.gyney, nurse practitioners / FP, and RN's / RPN's).

Roles and responsibility overlapping - which can be confusing and frustrating.

[ploughboy]

Yes I am sure about the implementation of the RNFA role - I have been one for 5 years now. Currently waitlisted at Mac though.

 

Cool. Good luck with the waitlist. I still disagree with your "in about 5 years" statement however.

 

 

RNFA's are nurses that have 5-10 years OR experience (depending on the program requirements), a BScN, additional english courses, Surgical Certification and the RNFA course. Most have their MScN.

The government sees the role as a cost saving incentive (ie. RNFA's are paid 1/4 of what the FP bills for the same case).

 

You really ought to talk to your union about that 25 cents on the dollar rate, because it sounds like you're selling yourselves short. Of course, that would lessen RNFA's competitive advantage in any "turf wars" with docs.

 

On the other hand and just to play devil's advocate, in my limited experience it seems like the pre-reqs for a surgical assist are: two arms, steady hands, a strong back, thick skin and able to take direction well. Mind-reading ability desirable, but not absolutely required. Ability to suture: optional. Do we need family docs, or even RNFAs, for that role? Think of all the money we'd save if we used RPNs as first assists.

 

 

Some surgical assists are also retired surgeons - which obviously is great for the surgeon.

Until they start arguing in the middle of a case! But yes, watching a surgeon operating with another surgeon as assist is pretty impressive.

 

I suppose the controversy is similar to other healthcare roles (ie. midwives / obs.gyney, nurse practitioners / FP, and RN's / RPN's).

Roles and responsibility overlapping - which can be confusing and frustrating.

 

Agreed. It's going to be interesting to see what the health-care system looks like in 10-15 years.

 

Good luck,

 

pb

[coastalslacker]

This is a good idea. When I was in Ghana 2 summers ago the local surgeon had trained a couple people with grade 3 or 4 educations to be his surgical assists. It is not rocket science, you don't need to be an MD, or even an RN.

 

You learn the anatomy, you learn the procedure, and you do what you're told. Once you've done something a few times you know what's coming next and have things ready.