MLMIC Opens Door for PA
First-Assisting in Bariatric Surgery

For many years, Medical Liability Mutual Insurance Company (MLMIC), the major medical malpractice carrier in New York , has not permitted surgeons covered by them to use physician assistants as first-assistants for bariatric surgery. The explanation provided focused on the high-risk nature of bariatric surgery, and their desire to reduce risk to the patient, the surgeon, and ultimately to their company. MLMIC was approached throughout this period requesting a change to their policy, as many PAs routinely provide quality surgical care to high-risk patients.

However, this year in “MLMIC’s  Bariatric Surgery Survey Priority Recommendations, January 2008”, there is now the opportunity for PAs to be considered as first-assistants in surgery.  In the “Professional Team” section , is the following: “Priority Recommendation: First Assist in bariatric surgery should be performed only by surgeons certified by the American Board of Surgery, or its equivalent, who are credentialed to perform general surgery, or a fellow who is currently training in the field of bariatric surgery.

Upon written application from a facility, MLMIC's Physician Underwriting Committee will consider a proposal to permit the performance of first surgical assist by a mid-level provider, such as a physician assistant. Items which will be considered in the Committee's review will include training, experience, and credentials of the proposed mid-level provider, along with a detailed description of the role that midlevel provider will perform in the care of the bariatric patient.”

When I spoke with a MLMIC representative, I found that there was enough input from physicians and PAs around the state regarding this issue that they decided to change their policy. MLMIC decided that the team approach to care is as important as who assists, and that could include appropriately trained, experienced, and supervised PAs. Needless to say, this is very positive news to those who have or may assist in bariatric surgery, and a tribute to all who have worked on this issue through the years.

This new policy applies only to physicians who utilize MLMIC as their malpractice carrier, so if your physician uses another company, this does not apply to you. If you expect to assist a MLMIC-covered physician, the MLMIC representative recommended that a letter be sent by the physician and the hospital in which the cases will be performed to the MLMIC's Physician Underwriting Committee on behalf of each PA requesting approval for each PA to first-assist in bariatric surgery. The letter should specifically outline what qualifies the PA to be a first-assistant in bariatric surgery, including the PA’s training, experience, and credentials. The level of supervision must be detailed, especially if the PA is to assist the surgeon in non-OR work such as with the care of the patient post-operatively. The representative was very clear that supervision must be close, and that the PA cannot supplant the physician in the care of the patient. An example given by the representative which would not be approved was one in which the PA was asked to see a post-op patient who later returned to the emergency department instead of the physician. Because of MLMIC’s past practice, many of us have not had the opportunity to assist on bariatric surgery. My suggestion would be to include in the letter how you expect to learn, i.e. how many cases prior to being cleared by your physician and institution to be the first-assistant. The letter should be addressed to:

Robert A. Menotti, M.D., President
Medical Liability Mutual Insurance Company
Two Park Avenue
New York , N.Y. 10016
ATTN: Physician Underwriting Committee 

Their next meeting is in early April, so be sure to submit your letters well in advance. Please let us know what response you receive, and if there are any barriers you encounter. If you want a copy of the MLMIC document, please contact me.

John Hallowell, RPA-C, MBA
Vice-President, NYSSPA
Jhallo53@aol.com
2/15/08