What Are the Best Ways to Actually Help a Surgical PA?
Sarah Hermsdorf is a Surgical PA, specializing in neurosurgery, which encompasses surgical intervention in the brain and spine. Sarah discusses the details of her practice from the surgical suite, to hospital rounds, and in the clinic pre and post-surgery. She tells why she values good company representation in the OR, and what the best reps do to provide value to her, the physician and the patient. Additionally she shares why she loves her profession, the challenges, why patient education is so important, and what a typical surgery entails.
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Episode Transcript
This transcript was generated using an automated transcription service and is minimally edited. Please forgive the mistakes contained within it.
Patrick Kothe 00:31
Welcome. Physician's assistant, or PA has been a recognized profession since the mid 1960s, and there are currently over 140,000 PAs in the US. They practice in a variety of specialties. 19% are in family medicine or general practice, 19% in surgical subspecialties, 13% in emergency medicine, and 10% in internal medicine. They're an extremely valuable member of the patient care team and their responsibilities have really evolved over the years. Today we're going to hear from Sarah Hermsdorf, a PA, in Madison, Wisconsin, whose practice is in neuro and spine surgery. Sarah shares some great insights into her training, why she chose the profession, what she does, how she works closely with physicians and the surgical team, patient education, and how the profession has really changed. She also has some great comments on the importance of a good sales rep, and what the good ones do so well. Everyone in industry needs to listen to this, as she clearly tells why our products are more than just the hardware. Here's my conversation with Sarah. Sarah, can you explain what a physician assistant is?
Sarah Hermsdorf, PA-C 01:58
So physician assistant is a medical provider that works with the physician, you have direct supervision from a physician, either clinic or you know, surgeon, we kind of work right hand left hand we work together, there's a lot of trust there and my specific practice, I see all of my own patients. And then if there's ever a question or concern, I get the physician involved.
Patrick Kothe 02:27
So can we talk a little bit about your your practice, tell me tell me about about what you do.
Sarah Hermsdorf, PA-C 02:32
So I work in surgery, and that's very unique, you have more and more physician assistants going into surgery. So it's a very team based approach in the operating room and with the patients both before and after. It's unique, a lot of people think of physician assistants and nurse practitioners synonymously. And we have started to function in in that way. But physician assistants specifically have a surgical rotation in their training. So they have at least some exposure to know if, if that is an interest to them.
Patrick Kothe 03:10
So what type of surgery Are you involved in?
Sarah Hermsdorf, PA-C 03:13
Sure I do neurosurgery. So Brain and Spine I have, ironically jumped right into that as a new grad. I have been there for 18 years and I love it.
Patrick Kothe 03:25
What do you love about it?
Sarah Hermsdorf, PA-C 03:27
The challenge the patience. It's very very rewarding. Of course, there's you know, definitely some sad cases that pull your heartstrings but to to see the difference in somebody who comes into your office with severe pain and is just no quality of life and then to walk back in after surgery is is very rewarding.
Patrick Kothe 03:52
So you said Brain and Spine. So explain a little bit more about the types of patients that you see what what what type of brain surgery are you doing? What type of spine surgery How does the patient present what what what's going on with the patient.
Sarah Hermsdorf, PA-C 04:07
It's it's really across the board. We have an amazing team. Right now we have five surgeons, we just hired our six so we do all all brain everything from aneurysm subdials. brain tumors shunts to and then in the spine from just your straightforward decompression to really detailed multi level instrument infusions.
Patrick Kothe 04:35
So from the brain surgery standpoint, you know, you've got some pretty pretty heavy things that are going on there with tumors and things like that where you've got some emotional issues that patients are presenting with an in the in the spine area. It sounds like it's more of a more of a pain type of situation. Is that is that pretty well characterized? The majority Yes,
Sarah Hermsdorf, PA-C 04:59
I mean We do have spine tumors. We do have patients that you know come in with we now that we are Trauma Center, you know, big car accidents and in separate spinal cords. So you do have, you know, big, traumatic life altering injuries in the spine as well.
Patrick Kothe 05:19
So can you tell me about you where you're located and what what hospital you're operating out of?
Sarah Hermsdorf, PA-C 05:25
So I am up in Madison, Wisconsin out of SSM
Patrick Kothe 05:31
go badgers right. So SSM what is SSM?
Sarah Hermsdorf, PA-C 05:37
So SSM is Sisters of St. Mary's, the basis out of St. Louis.
Patrick Kothe 05:45
And it's it's a hospital group.
Sarah Hermsdorf, PA-C 05:47
Yep. So it is it's a private practice hospital hospital group. It's not part of the university setting up here. There's four hospitals in Madison. You have uw meriter va and SSM the two big neurosurgery. You know, primary hospitals are UW and SSM.
Patrick Kothe 06:11
What type of patients are you getting? Are you getting insurance patients? Are you getting just all different types of patients? How would you describe the demographics of the patients that come to you?
Sarah Hermsdorf, PA-C 06:22
So we actually get all types of patients especially because originally the St. Mary's Hospital, which was bought out by SSM is a Catholic hospital so we there's no discriminating and we have insurance. We have private pay, we have non insured, we have what we call badgercare. Up here, Medicare, Medicaid, everything.
Patrick Kothe 06:52
You work for SSM, do all of the physicians work for SSM as well.
Sarah Hermsdorf, PA-C 06:59
Every provider does, we used to have our own our own group called the dean Dean medical, you know, providers Dean health plan. We incorporated with SSM St. Mary's and Dean into SSM about two years ago.
Patrick Kothe 07:19
So all of the people in the office and all of the people within the hospital all work for SSM. So you're all on the same team, correct? That's not not as common as you, as you, as you may or may think.
Sarah Hermsdorf, PA-C 07:31
No, I know it. There was a big change for us two years ago.
07:35
Yeah,
Sarah Hermsdorf, PA-C 07:36
you know, it good and bad. You know, now we're all employees, whereas the MDS and the practice owns the company. So it has been some some major changes. So as a
Patrick Kothe 07:49
specialist, you have different insurance plans, that, that you're tied in with different groups that you're tied in with? How do you get your referrals? How do you get your get your patients?
Sarah Hermsdorf, PA-C 08:02
Great questions. So a lot of it is insurance based, some of it is location, you know, for the Medicare, Medicaid badgercare they can go anywhere, you have a you really build your referral source. So we have some very specific, you know, practices in more of the rural communities that we have great rapport with that, that send us patients in. So
Patrick Kothe 08:35
as a PA, do you get involved with rebuilding referrals? Or is that the physicians or how does that how does that work?
Sarah Hermsdorf, PA-C 08:43
You know, you absolutely do because I have my own patient, my own patient census on they they come in, they see me I have a great relationship with a lot of the outlying providers, they'll send me messages and emails. It's about a team based approach, but I definitely know names as you've been here, been here long enough and get to know people and and you know, with your outcomes, so we've, like I said 18 years is the average physician assistant changes jobs within the first five years and boy, I'm here to stay. Well, it isn't.
Patrick Kothe 09:27
So Sarah, the patient roster that you that you spoke of you have you have your own patients, how does that work? You've got some that are with you somewhere there with the physician. How do you decide where they go?
Sarah Hermsdorf, PA-C 09:42
So ultimately, because I'm supervised by the physician, any patient that is going to surgery does need to be seen evaluated? You know, the final decision is with the surgeon. I do see consults the you know The first time the patient comes into clinic, they will meet with probably almost 5050 meet with either one of the surgeons directly or meet with one of the APS. And we do a lot of trauma. So a patient who is non surgical or assumed to be from the get go, we'll come to one of the APS. So we have a really good triage system where every patient that's referred into our office, one of the APS looks at some of the history, what they're being sent for. And then the images, every patient needs to have some imaging via MRI or CT, that we get to review before they come in so that we know they're going to the right place. We don't want to waste a patient's time, if there's not something that we potentially feel we can surgically help with
Patrick Kothe 10:59
is the imaging in your office,
Sarah Hermsdorf, PA-C 11:01
it can be done anywhere now that you know, everything is done via telemetry, or I should say can at least be sent to us via telemetry. I mean, I've even seen images from Illinois and out of state.
Patrick Kothe 11:13
So when you're in the office, and you're seeing somebody as a pre surgery candidate, what does that exam look like?
Sarah Hermsdorf, PA-C 11:22
It's a lot of the general history when they come in, you really, really have to, you know, listen to the details. There's an examiner involved, by all means, but the majority of the majority of what you need to know from a patient, they'll they'll tell you if you listen to them and ask the right questions.
Patrick Kothe 11:41
Mm hmm. So you're asking the right questions, you've got the the images that you're looking at. So if you determine that it's probably a surgical candidate, do you bring the surgeon in at that point, you schedule a new appointment, what happens?
Sarah Hermsdorf, PA-C 11:57
So that is very much so physician preference, we work together and are in clinic at the same time, some of them will come in during that appointment and just, you know, spend five or 10 minutes with kind of the summary of what I've gone through with the patient, either agree, disagree, go forward with the plan, or others, a couple of our surgeons like to have their own appointment so that you know, they get to spend more time really getting to know the patient before a big surgery.
Patrick Kothe 12:35
So we'll get to surgery in a second. But let's kind of stay in the office. So So you've got we just described the pre surgery setting, then you've got the post surgery management of that patient back in the office once again, what is that like?
Sarah Hermsdorf, PA-C 12:53
Almost all 90 95% of all post op care is done by the APS we have for you when you say AP and I was just going to go into that. So AP is an umbrella term that they have given in the SSM system to advanced practitioners. So your APS are going to be your physician assistants, your nurse practitioners that also encompasses our crnas are nurse anesthetist. So in my neurosurgery department, we have four PhDs and two NPS that all function in the same AP or advanced practitioner role seeing patients in the clinic and doing surgery.
Patrick Kothe 13:38
So patient comes back and they're seen by an advanced practitioner, are they monitored for the effectiveness of the surgery, any infections, and rehab? What happens in those post surgery visits?
Sarah Hermsdorf, PA-C 13:55
Absolutely. So we usually do a two week and a six week depending on the surgery, adding in a three month and a one year appointment. So we really follow him out, you know far when they have instrumented fusions that you need to you know, watch the X ray for how the bone has healed. The two week is a pain pain and incision check six week you usually get your first set of X rays and really look and make sure alignment you know everything is holding. And then for a lot of the big tumor cases, anything that requires follow up MRI, that's your three month check.
Patrick Kothe 14:34
So inside the room, I imagine that obviously the patient is going to be in there, but often there's a spouse, there's a parent, there's a child of an elderly person, you may have several people in the room, how do you manage that?
Sarah Hermsdorf, PA-C 14:51
It's really about you so right now with COVID there's no one else in the room with very specific, you know, exception By all means, but I'll go to go to pre COVID. Yeah, there's, you know, when you get into really detailed spine surgery and a lot of our brain surgeries, I mean, it's nothing to have three or four family members in the room asking questions really wanting to be involved. I encourage it, I think it's great. I think it's very, very, very important. They say that a person takes away about 20% of the visit, because your mind is, you know, your mind is swirling, we give you a lot of information. It's a traumatic experience. So the more people their first support, and that can take in, what we're saying what we're explaining what they should expect, I think the better.
Patrick Kothe 15:47
that's a that's a really great point. And that 20% is, is can be generous, especially if you've got some emotional things going on, and maybe somebody who's compromised to begin with, what other things are you doing, knowing that it's 20%? What other things can you do to get that message really dialed in for that patient?
Sarah Hermsdorf, PA-C 16:10
Yeah, and a lot of all of the post op courses, education, I feel so very strongly about that. Because before surgery, you know, everybody's having anxiety over having surgery, the risk of surgery, they don't hear a lot of the follow up. expectation, or treatment, of course, I'll say. So to to just continue to repeat, and, and educate patients is very important, because I feel that people and patients, people do so much better and tolerate so much more with education and understanding if you know, this is, you know, you're in pain, but it's normal. And it's expected for the first six to eight weeks, even with a big spine surgery, they tolerate it so much better knowing it's a normal part of the course. Whereas if you don't communicate and educate patients, what's normal and what's not, is a lot harder to, to deal with on a day in and day out basis.
Patrick Kothe 17:18
The internet's a wonderful thing, but there's a lot of garbage information that's that's on there too. And things that maybe old are things that you don't particularly ascribe to. Well, how do you provide that information? And what resources do you use to make sure that they're getting the best and proper information?
Sarah Hermsdorf, PA-C 17:41
Yes, the questions that I that I get from Google searches is pretty amazing, some accurate and some way off base. I encourage people to ask questions and so that I can directly communicate, we also have pamphlets and paperwork that they that we give the patient from our office, as well as well be a program that they then you know, when they sign up for it get emails about, you know, what they should expect and leading up to surgery. So it's both pre and post.
Patrick Kothe 18:18
So we've just kind of described the, the pre care, the post care, let's get into before we get into surgery, how much of your time is spent in the office pre care post care how much is isn't surgery.
Sarah Hermsdorf, PA-C 18:33
We right now our schedules we run for for 10 hour days scheduled. So I have two days in clinic and two days in surgery a week with that fifth day being, you know, catch up and anything that happens throughout the week. So I do spend 50% of my time in clinic 50% of my time in surgery.
Patrick Kothe 18:53
Is that the same day every day or if you're getting emergency cases are you pulled into those?
Sarah Hermsdorf, PA-C 18:59
Yes. So we do you know 24 seven call. I'm usually on call one day a week and then every fifth weekend, on average. So in you know we we are a trauma center you can easily get pulled out of surgery when something comes in the ER, we have regularly scheduled clinics just for you know, continuity and for patient scheduling. So I am in clinic every Monday and Thursday and I am in surgery every Tuesday Wednesday.
Patrick Kothe 19:31
Okay. So you talked earlier about the left hand right hand. Yeah, different physicians. You've got five out of nose six surgeons that are in your in your clinic. But I imagine you're not working with all six because that left hand right hand needs to really work closely. Do you work with one or two specifically?
Sarah Hermsdorf, PA-C 19:54
I do we we are paired off primarily so on a day to day basis during the week I work with the same male surgeon. And he and I have been working together for 1717 of the almost 18 years it has, it has been amazing. We cross cover for vacations or you know, call the traumas. So I do work with all of them. But we have every department is different. Our orthopedic department just is basically day to day schedule where you're going to be clinic versus surgery, and you work with all the different surgeons, neurosurgery, because of the end, I'm not downplaying any other specialty, but because of the intensity, because we really, really feel that continuity of care for these patients who are going to be involved in our practice for, you know, up to a year in your spine fusions and for their whole life with their brain tumors, because you have to do surveillance after that the continuity is such an important part of neurosurgery that they they really have a team they have their surgeon, their AP team primarily. So yes, we do pair off.
Patrick Kothe 21:14
Okay. So your surgery days, you're going in into the hospital? And is there one particular surgical suite that that you go in? Are there several and how is the hospital set up?
Sarah Hermsdorf, PA-C 21:30
So we have 12 hours in the hospital. And neurosurgery has two to three rooms per day.
Patrick Kothe 21:40
Okay. And they're the same rooms every day,
Sarah Hermsdorf, PA-C 21:43
correct? Yes. Because what you need inside those rooms, you know, all of the details, the tables, the space is, is very, very specialty specific. So each room is designated to a specific practice.
Patrick Kothe 22:00
So can you explain the room, let's just take take one of those rooms and just explain what's in there, how it's different, how it's set up different specific for your surgeries.
Sarah Hermsdorf, PA-C 22:11
Sure. So the neurosurgery rooms are bigger rooms, because when you're doing a lot of these detailed, intricate, instrumented spine cases, you have a lot oh man up to a dozen pans of equipment. I mean, it's, it is it's intense. So we have at least you know, three tables of pans of equipment, you have, you know, the patient in the middle of the room, you have your nursing staff, your scrub tech that helps you and hands you the instruments, you have anesthesia in the room at the head of the table. So it's it is a it's it's a work of art.
Patrick Kothe 23:00
So let's let's talk a little bit about the people that are in there, you say anesthesiologists, you're in there, the surgeons in there, what other staff either is in there all the time or circulates through?
Sarah Hermsdorf, PA-C 23:12
Sure. So we always have one. If not two nurses, there is always a scrub tech in the room. Scrub tech is who sets up all of the instruments and then hands them to you while you're working. We have a nurse anesthetist so crna and then an anesthesiologist is So a crna is like my role in there. I work with the surgeon, the surgeon oversees the nurse anesthetist is in the room at all times. And then your anesthesiologist comes into the room and is responsible for three to four rooms overseeing you have when we're doing instrumented cases, when we're doing big tumor cases requiring a stealth machine, you're always going to have a rep in the room from you know the company of the instruments we're using.
Patrick Kothe 24:07
Okay, do you use robotic surgery? Do you have robots in there at the point?
Sarah Hermsdorf, PA-C 24:12
No, we don't we, we haven't gotten into that we do have microscopes. So there's big microscopes in the room. So I mean, the the actual, you know, incision and exposure is minimal.
Patrick Kothe 24:26
Okay, so setting up the room who sets up the room and how is the room setup? Let's say you're going to do a spine surgery.
Sarah Hermsdorf, PA-C 24:35
So we have a turnover turnover staff that cleans the rooms in between. Those are our Tech's there's usually four people in the room scrubbing the floors wiping all the surfaces down. Then we have the nurse and the tech in the room that are opening pans, counting instruments, you know, making sure everything that we would possibly need is available?
Patrick Kothe 25:03
And what about how long is setup?
Sarah Hermsdorf, PA-C 25:07
They like to quote you at 22 minutes, but you It all depends on the case and what pans need to be open, I'm going to say it's usually a good half an hour, maybe even 40 minutes, it depends on what they're taking down from the case before and what's, you know, coming in for the next one.
Patrick Kothe 25:23
Okay, and at what point will you walk into the room?
Sarah Hermsdorf, PA-C 25:27
I usually. So this brings to what I was actually going to talk about earlier. The reason I one of the reasons I love this job so much is we've talked about clinic, we've talked about surgery, we actually do a lot of work in the hospital itself, as well. So I show up every morning before seven o'clock and round on all of the patients in the hospital before then we either go to surgery at eight or go to clinic at nine. So in between surgeries, I am Waking the previous patient up writing all of the orders writing the OP note so that people you know, know what happened, what our blood loss was what fluids they got, as they're recovering in pa ICU, I usually then come in the room again, depending on turnover time, I'm either there right before the patient gets there, or we have a system on what's called a status board that has different colors by the patient name to tell the providers and and the staff, you know responsible for the room where this patient is. So the minute they turn green, that means the patient has entered the room. And that is the signal if I am not already in the room had there.
Patrick Kothe 26:44
So let's let's focus on one particular surgery. So spine surgery is a common procedure can and and you're using a lot of medical devices and you talk about the pans and we'll get into those in a couple minutes. But let's let's focus in on one type of surgery and the patient is there The room is set up what occurs and you pick the spine surgery and describe in detail what's going on.
Sarah Hermsdorf, PA-C 27:11
Okay. So I do, the surgeon I work with is 80% spine 20% brain and we're pretty pretty equal between cervical and lumbar neck and back, we'll let's just go with a big lumbar surgery a big instrument of lumbar surgery. So the patient comes in the room. And they are laying supine on the cart that they're brought in on anesthesia talks with them and then puts them to sleep. After they're asleep, it takes four of us around the table to then flip the patient prone because you're operating on their back, right and so you still have to have that you know, the to breathing for them in their mouth, you have to have access to their face, but yet, we need to be on their backs. So we flip them over onto a bar of bed that has more it's almost like a saddle so that we can get to their back, but there cannot be any pressure on their face, and there can't be any pressure on their belly. So the first 10 or 15 minutes after the patient is asleep is positioning because that is so very important in surgery. It's it's overlooked by a lot of people positioning and exposure can can really make or break the difficulty of of the case. So then once they are asleep and positioned, then we get an X ray to localize mark where we want to be going in again to make the incision as small as possible. As soon as we have our localizing X ray then we've prep. So that is you know, scrubbing with alcohol and then a surgical prep, getting the skin clean. You have to wait three minutes for that to dry for a maximum effect and that's when we scrub that's when we go out to the sinks and wash and then come back into the gown and gloves. We come in and the surgical tech is already there at the field scrubbed so they help us gown and glove and then we put all the drapes on. After that the first part of the surgery is well I should back up then you do a timeout timeouts have become so important because you know wrong patient wrong site surgery all of that it's it's real. It's very rare, but it's real. So you have multiple checkpoints and timeouts during this process. But the last one is before there is any incision and everyone in the room has to stop and listen participate, you know, goes over a patient name, date of birth, all of the risks of the surgery and the actual procedure itself. If there's any questions, and anyone in the room who has a question is obligated to speak up at that point, then we start the surgery. So first is the decompression, that's, you know, the whole reason the patient is in there is pressure on the nerves, arthritis, overgrowth of the joint. So we go and make an incision in the skin go down through the muscle and do the decompression take the pressure off, then if we're specifically talking about are instrumented cases, after you have all of the pressure off, the reason to instrument is instability, if their spine has motion, or or in order to get the adequate decompression, we had to remove too much of the joint that then would cause instability, we lock it into place with screws and rods in the back. So that's when our instrument reps come in, and the multiple pans that I was talking about come in because even though it's you know, it sounds like oh, you know, you put a couple of screws and a couple rods in, in this person's back the the work that it takes to get to that point preparing, you know, the the holes that you drill through is is really impressive and intense. So the pants all have different pants, different drills, you know, all different size screws from the width and the length. So that's where the the help and education from the rep from the company directly to the surgical team and specifically the scrub tech, the people who are amazing, amazing and make or break these cases are the scrub techs.
Patrick Kothe 32:04
So you're talking about the pans. Can you describe what is how big is the pan? What does it look like?
Sarah Hermsdorf, PA-C 32:10
There are different sizes, but the ones that have these instruments in a you know all of the the screwdrivers, the drills, the tamp the you know, Shavers, they are 1812 to 18 by 24. And they're metal? They're they're metal, they're heavy. Yeah.
Patrick Kothe 32:29
And do the reps bring these in? Are those are those stocked at the hospital? Do they get sterilized between every case?
Sarah Hermsdorf, PA-C 32:38
So the hospital stocks, a lot of the main instruments are the main instruments we use the company that they contract with. Now, again, we do have reps and other companies bring things in when there's, you know, something, we want to try a unique case that calls for a different type of instrument. So it's both they are sterilized in our central processing downstairs and brought up nothing can come directly into the hospital and be used.
Patrick Kothe 33:09
Okay, so there's a whole bunch of different pans with a lot of different things in there. Why has Why do they need to be different? Why is there no standardization? Why do you have that many pans that you need for an individual surgery?
Sarah Hermsdorf, PA-C 33:27
Sure. So this is probably a better question for scrub techs. However, I will do my best that a lot of the pans. The first two or three are general pans for the decompression, the things that we have in the hospital that we use for every spine case. So those come up automatically. Then some of the other pans It all depends on if you're going to put an inner body spacer between the body of the bones if you're going to put just screws and rods in the side. The the number of pans depends on the complexity of the case. Each pan maybe where you were kind of going with this is the pans that have the drivers and utensils that we put in and out of the spine are are sterilized but any implant any screw rod spacer, anything that we leave in the patient has a whole nother process that it has to go through have to be packaged separately.
Patrick Kothe 34:41
So sounds like you know you've got a screw rod. That something that gets left in the patient that is maybe a small percentage of the total number of devices that you're that you're using, or have available to you within these pans in it. In surgery,
Sarah Hermsdorf, PA-C 35:01
correct? Yes. So when when I say, you know, we put four screws in a patient, you know, and just fixate two levels together, or one disk space, those four screws come from a pan all by themselves, because at everybody's bone is different, different diameter of pedicle different depth. So every single screw is patient dependent after we prep the area. So the screws can in the pan, the options we have are everything from 35 millimeter to 7580 millimeter. And then and then we have everything from 4.5 to 8.5, you know, circumference diameter. So it really is, everything has to be in the pan available, because you can't sit and wait with this patient open if we don't have the right size.
Patrick Kothe 36:04
So going into the surgery, you may know approximately what you're what you're going to do as you're in a surgery or learning. So there's kind of the art and science of this thing. The art is, you know, opening opening up and saying, Okay, what do I have here? And I'm sure do you also have images that are up during a surgery? So you are referring back back to that you're looking at at the patient live? And then you're making some decisions on Okay, well, based on what I'm seeing with my eyes here, and what I'm seeing up on up on the the images, I'm going to now use this particular instrument or this particular screw or whatever.
36:44
Absolutely.
Patrick Kothe 36:46
So So at what point is that decision made? Is that you making that decision as at the surgeon making the decision? Who makes that decision,
Sarah Hermsdorf, PA-C 36:54
the surgeon, the surgeon makes the final decision, by all means we work together. So you know, a lot of the time we're bouncing ideas, questions, thoughts off of each other? It all comes down to experience because yes, I mean, you said it and in I'm going to go back to it. It is an art and a science. You learn all of this in textbooks and and you know with your education, but truly the art of experience and and you get a feel for it. I guess the best way I can describe this is the first couple years. You know, I was very hesitant and and you were trying to feel out how things worked. And now when we're putting these screws in when we're hammering tamping in, you can hear the difference in the bone when you're getting close. It's a field that just comes with experience.
Patrick Kothe 37:58
So, how much of this are you doing? And how much is the surgeon doing? How would you describe what your role is versus what the surgeons role is during the surgery itself?
Sarah Hermsdorf, PA-C 38:09
sure that I am the assistant and your your interaction or accountability in the surgery is directly related to the comfort level and camaraderie between you and the surgeon. My my role is exposure retraction, making sure that you know I am keeping the best visibility for the surgeon. And that's primarily the APS roll. As you work together longer and longer, we are doing more and more together. The ultimate decision is 100%. The surgeons though the man that I work with who he mean, he'll even tell patients This is my right hand and I said no your right hand is worth a lot of money. I'll be your left Don't be your non dominant hand. But he and I work together so closely that it's my job to make sure the nerve root is out of his way. It's my job to suction and make sure the blood is out of his way so he can see what he's doing. A lot of the time we're just working simultaneously without even talking because he knows what I'm going to do. I know what he's going to do. And it's it's it's like a play. It's awesome.
Patrick Kothe 39:32
So the surgeon that surgery that we've been talking about lumbar surgery, what do you said made an incision, well how long is that incision? How big is that incision
Sarah Hermsdorf, PA-C 39:41
depends on depends on the levels of fusion. If we're doing just a straightforward decompression inch. If you're fusing two levels or four screws into rods, you're probably looking at maybe two and a half inches. You know we've we've gone up to eight levels and that's, that's a good 12 inch incision. So it is
Patrick Kothe 40:05
so that the screws are described kind of the length could be an inch long.
40:13
Mm hmm.
Patrick Kothe 40:13
The rods, how long are the rods?
Sarah Hermsdorf, PA-C 40:16
So those are there, they're a lot longer than an inch, by the way. So I call I always laugh, the patients asked me, you know, can I see these and I said absolutely with your x rays. And they are just shocked by the size of these screws, I call them deck screws. I mean, you really think of them as deck screws, they're that big. rods, again, it depends on depends on the how many levels of fusion, but for one level, you know, probably, I don't know, three, three centimeters.
Patrick Kothe 40:48
So you've assessed, you've made your decisions, you've done your, your implant of the screws or rods, whatever that you've done in there. So now it's time to close backup is what happens at that point.
Sarah Hermsdorf, PA-C 41:03
Sure. So then we start closing the fascia or the you know, tight band of tissue above the muscle, that's our first layer. The second layer is the skin. Usually the surgeon is going to close the fascia together, I should say we close it together, he throws this throws the stitches, I tie him down 99.9% of the time, then he leaves I finished closing and then turning the patient back over and waking them up while he's gone. And it's talking to the patient's family, letting them know how everything went. So it's very much a team based approach.
Patrick Kothe 41:45
Okay, so let's go back into surgery for a second. Because you talked about about sales, representatives of company representatives being in there and bringing the equipment in there. Explain to me what a sales representatives role is in surgery.
Sarah Hermsdorf, PA-C 42:04
Yeah, so they are directly involved in the surgery, a lot of the times, you know, even though they're going to participate actively in only a smaller portion of the surgery, they're usually there the whole time. Again, watching watching the case, making sure that all of the education that they can help and provide is there.
Patrick Kothe 42:30
What specifically are they educating on what specifically what what is it portion of time where they're actively involved.
Sarah Hermsdorf, PA-C 42:38
So they are usually there as the scrub tech and the nurse are setting the instruments up before the patient is even in the room to make sure that all of the pans that they have instruments in are clean, correct? not missing anything. And then they will a lot of the times hang out with us in the room just because you know, it's it's we all talk it's a social environment, getting to know each other. There's a lot of trust in this as well. And then they will educate the scrub tech in what instruments you know what instruments we need, what they can have up on their stand. So there's back tables, where all of these instruments are in pans. And then the instruments that the scrub that we are going to primarily use that the scrub tech needs to have quicker access to they will they will if the scrub tech is not as comfortable in the case or I should say you know, doesn't do them every day with us, they will tell them those instruments need to be up on your mail stand. Those are the ones that are going to be used on a regular basis.
Patrick Kothe 43:56
So with COVID right now, there have been different technologies to have a telepresence within the O r so that the rep can be there remotely. Have you guys done any of that? What do you think of that concept?
Sarah Hermsdorf, PA-C 44:14
You know, we have not we have allowed and made sure that the reps that are going to be in in involved in this case are physically present. Why?
Patrick Kothe 44:29
Why is that so important to you?
Sarah Hermsdorf, PA-C 44:31
Right? Yeah, it is it is of utmost importance because if something happens if something breaks if something is missing in the middle of this case, well we are working time is of the essence. I mean it for every minute that patient is in surgery on the table under anesthesia. It is not only a large cost, but it's also a risk to the patient, the longer they're under anaesthetic. So we we have not done any, you know, telemedicine with our reps in surgery, they are functionally physically present. Because if it hits the fan, we all work together, you know, we can have the bit off of a screwdriver, sheer shear. So then instead of somebody being on a video saying, well, I can't see your pants from here, it should look like this, and then you want to look for this color handle, I mean, we have this person in the room, you know, pointing at what we need, right, then I think that makes a tremendous difference. And, you know, again, if this is a team based approach, everyone is important in their role, their education towards their instruments with the scrub tech, their experience, I mean, you know, they see stuff from all different hospitals, they can bring us information, you know, I mean, they're really, really good reps, they're really good reps are the ones who say, hey, I've seen this, what do you think? Do you want to try this? I mean, information that can be shared between facilities, and surgeons is amazing when they're open to it.
Patrick Kothe 46:21
So there's a lot of choices for different devices out there. And you just described how important the service or the the education or the presence is, as well. So when you are evaluating different technologies, how much do you put into the representation versus the product itself?
Sarah Hermsdorf, PA-C 46:47
Quite a bit, the instruments are all you know, good. And obviously, you know, approved, the hospital will a lot of the times choose between two different sets based on money, which I can understand a part of that, we will of course, do what we feel is the safest the best instrument with the longest longevity lifespan, I don't want to downplay at all that the the personal relationship with the rep is very important to I mean, I do know surgeons that use a company because they can count on the rep being there. being knowledgeable, helping the staff, I mean, if you have a really good rep, who knows his instruments, his or her I mean, but knows his instruments, and and can work with the tech in the room and take even five or 10 minutes off of the case, because they're prepared and ready. Hands down, they're going to be in the room, that is going to be our person.
Patrick Kothe 47:58
So it is complete knowledge of their particular product. And and also the surgery itself.
Sarah Hermsdorf, PA-C 48:07
Yes. Absolutely.
Patrick Kothe 48:09
Excellent. So how do you how do you hear about new products?
Sarah Hermsdorf, PA-C 48:15
A lot of the times the rep in the room after we're done with the case, because we do have you know, downtime when we're in the lounge, either, you know, getting something to eat between cases, doing our orders, doing other patient questions. They'll say, you know, hey, we've got this coming out, you know, this is what it looks like, this is the goal. This is why, you know, we we have tried this, you know, it usually is a modification of a previous device. I mean, there's not too much comes out when, you know, out of the blue. But they oftentimes that is the rep who's kind of talking with us between cases, at least that's the most common for me. I don't know, you know, with the surgeon themselves, if there's, you know, a lot more emails or other other lines of communication.
Patrick Kothe 49:09
Do you go to conventions, the different medical meetings? Do you hear about things from journals? You wouldn't?
Sarah Hermsdorf, PA-C 49:18
Really? Yeah, not not recently with COVID. But hey, that's all gone to the wayside? No, they they are, you know, they have standards and tables at the, you know, our conventions? Absolutely.
Patrick Kothe 49:33
Got it. So you described what a good representative really does. And it sounds like you've had some great representatives over the past 18 years. I imagine you've had some that have been not so great as well. Any common things that the reps who are not so great do or are things that kind of tick you off about about reps in general.
Sarah Hermsdorf, PA-C 49:58
So yeah, If it's it is attention to detail, it is paying attention. I totally understand that, you know, when we are doing a four or five hour instrumented case, when the first two hours of it is the decompression, it can get boring, because you're not, you know, actively part of that portion of the surgery, I totally understand that. I have turned around from the table, when we're, you know, taking X ray, getting pictures have to check the chart to you know, look at an image. I've turned around and seeing them, you know, on their phone and texting and, and, you know, playing on their laptop in in the O r? And I can tell you, that doesn't go very well, because I don't know if route is the right way to say it. But it's it's just if you if you physically aren't here with us, then you know, you shouldn't be in the room. Because if something bad happens, and you're not prepared for it or anticipating it, you know, you're going to be in the way
Patrick Kothe 51:10
really be present for everything, not just your portion.
Sarah Hermsdorf, PA-C 51:14
Yes, yes. Oh, great. That's also how you build the camaraderie and the the relationship with the surgical team. I mean, even when some of the best reps I know, I mean, they are spot on 100% during their portion of it. But they're they're getting to know people outside of that, you know, hey, how was your weekend? Oh, how was your daughter's basketball game? You know, just so that we all know a little bit about each other when you're in this space for hours and hours together.
Patrick Kothe 51:52
So we talked a little bit about learning new devices or learning about new devices. So two things. First of all, if you do see something that is of interest, and you said that there's a hospital Buying Criteria buying process and need to go through what is what does that look like if you say hey, there's a new product that I think could really benefit me and our patients, what happens?
Sarah Hermsdorf, PA-C 52:20
So I, me personally, I would talk, I talked to my surgeon team about it and say, you know, wow, this was at this conference, this was so cool. What do you think? I don't know, their exact, you know, direct line. I know it has to go through a bunch of different committees.
Patrick Kothe 52:42
So you bring it up to the surgeon and the surgeon fights the battle? Yes. Okay, great. So, once you have that product in, there's training, that that you need to go through as, as well. When when a surgeon is gonna embrace a new technology, does the team get trained on it? How does the training happen?
Sarah Hermsdorf, PA-C 53:07
that that is something that I think we could probably Well, I know we could do a lot better with, when, when the surgeon has a new product, oftentimes the rep and the surgeon will meet talk about it, and you know, do some training, I'm gonna say about 50% of the time the rest of the team is involved with that. So the biggest thing from a rep and education standpoint, that would be beneficial for the patient, the safety, you know, the efficiency of the surgery is to really meet with the assistant and the tech before and kind of talk through what the what the product is, what the procedure is how it's different than what we've done before. Because otherwise I you know, I have been in a surgery where we are using a new device in, in, in the back in the neck. And the surgeon is asking the rep, okay, how do I how deep do I go? Where Why do I want this angle? And I'm kind of standing there because this is this is like being in the room for me. So I don't I can't anticipate what the next step is because I'm learning the process at the table, I think to preemptively go through some of that would really be beneficial.
Patrick Kothe 54:43
So in an ideal world, what does that look like? Is that is that cadaver labs? Is that online training? What does that look like?
Sarah Hermsdorf, PA-C 54:52
I not online. I mean, I don't get as much out of online training because we're all hands on. I mean, you know, to see it as one thing to think Feel it is another. So I think it has to be hands on. I mean, of course, you'd prefer a cadaver lab, but those are darn hard to get your hands you know, get into an organized because, you know, it's just not efficient to do for like two people. A lot of the times it's the reps again before the surgery showing, having two sets of, of the instruments, one that's sterile waiting for the surgery, and then one that they're kind of showing me before the surgery,
Patrick Kothe 55:33
I think the message is pretty clear that it's not just training, the physician is training everyone that's involved with it beforehand, so that you're going to have a better outcome for the patient.
Sarah Hermsdorf, PA-C 55:42
Absolutely, absolutely. Now, that mean, now, surgeons used to work by themselves, you know, all the time. Now, I don't really know any surgeons that work by themselves, they have an assistant and they have a team. So more of a team based approach. I mean, they are 100%, the surgeon, you know, the responsible party, the decision maker, but for them to function, the most efficiently and safe safely. They you really do need the whole team involved.
Patrick Kothe 56:19
So you, you talked about how being a physician assistant has some great benefits and you really enjoy doing it. Every jobs got a little bit of a downside to it. Are there some frustrations that you have with being a PA? Yeah, I
Sarah Hermsdorf, PA-C 56:33
mean, I'm, I love my job, I absolutely wouldn't do anything different. The whole reason that I became a PA and it was actually one of the heart surgeons that I worked with as a nursing assistant. I have always wanted to do of all things heart surgery, I wanted to be a heart surgeon. And when I was going to school and and doing it was pre med at UW Madison. So I did my undergrad and my pa masters all at all right here in Madison. I'm a badger through and through. When I was going to school I he said what do you want to do? And I said, I want to be a heart surgeon. And he looked at me and said, Why? And I said cuz I've always loved medicine. I love surgery. Little history. I had heart surgery when I was young. So I've always been watched. So I was very, very aware of it. And it was it just I was totally captivated. So going back to this heart surgeon is he said do you want to have a family? And I said, Well, yes, of course I want to be a mom. And he was exaggerating a little bit. But he said I really you know if you want a work life balance, you should look into being a PA. He said I leave every morning I don't even know my kids favorite breakfast cereal. So it depends on how involved you want to be with your children and with your family. And that was like ice water to the face. I felt what? So I looked into PA school it I mean, I'm thrilled. I am so happy. I will never forget that conversation with him in the hallway at the hospital. Going back to this roundabout answer to your question, however, is originally it was well the PA is able to take care of patients in clinic, participate in surgery work in the hospital. I mean, we really are in all in my specific specialty in all three areas of medicine, you have your clinic, you have your surgery, you have your inpatient and you know intensive medical. Originally, we didn't take a lot of call, we weren't on the weekends. I mean, this is 18 years ago, when I started the responsibilities that we had at that point, were a fraction of the surgeons and that was the whole his whole, you know, reason for talking to me about this and having a family now, because of how far medicine has come how it's a really really team based approach. patient population is going up hospital census is going up the workload is intense. So now we take call 24 seven with the surgeon. I take all of the hospital phone calls through the night. I'm there every weekend rounding and doing surgeries. So the amount of responsibility and time that has been given to us in the last 10 years has drastically changed the role of the PA
59:55
in good and bad.
Patrick Kothe 59:57
Yeah, very interesting. Very interesting. So what what do you think that the general public doesn't know about being a PA?
Sarah Hermsdorf, PA-C 1:00:06
Hmm, great question.
1:00:08
Um,
Sarah Hermsdorf, PA-C 1:00:08
a lot. It's interesting a lot of the time you, you know, we wear white coats, and we walk around the hospital, and we're rounding and seeing you in the morning. And I mean, I have, like I said, my own patients in clinic, a lot of the time, they initially don't know the difference between, you know, the PA and the surgeon, and they are trying to call me doctor and I said, No, my name is Sarah, I can't call you, Sarah. So many patients will say to me, when they first meet me, how many more years do you have left? How many more years do you have left? When are you going to be a doctor? And I said, No, this is the end of my line. I am happy I have been doing this for you know, years. I'm a PA, I have my degree, I am happy to assist, I get to do what I love. But ultimately, I am not the end all responsible party. So I don't have that added stress to me.
Patrick Kothe 1:01:10
As you know, we are a podcast that's dedicated to people at work that are working within the medical device field, all different functional areas, all different types of medical devices. Is there anything that you'd like to say directly to the people who work within medical device?
Sarah Hermsdorf, PA-C 1:01:28
Yeah, I would have to say educate yourself. Learn your tools, communicate with the providers that you are encountering. I've met a lot of reps that aren't that don't speak up or really, you know, are quite bashful. I mean, I'm not saying go overboard and get in somebody's face, but the relationship that you bring to the table and the trust, after you've built that relationship is of utmost importance. Love your job, no, your know your tools, because you are part of the team. You're part of the team too. And it's important.
Patrick Kothe 1:02:11
I really enjoyed that conversation, a few of my takeaways that are specific to us in industry. First, the importance of training everyone, not just a physician, Sarah said patient care can be impacted. Make sure you don't overlook this important step. Second, the importance of reps as part of the patient care team. In this market, you're heard they're vital, but need to be properly trained in their product, as well as a total surgical procedure. Investing and rep training may be as important as investing in r&d. Let me say that again, investing in rep training may be as important as investing in r&d. Finally, the importance of being present. When you're in surgery, pay attention, not just when they're using your product. Your customers may not tell you, but they may be burning inside. Now for your action item, how our pa is being utilized in your specialty. I've got some links in the show notes that can help you with some general knowledge, but dig deeper and see how they fit in utilizing your technology or in the decision process for your technology. Sarah talked about the physician being the decision maker, but she also said she's the left hand so you can bet she has significant influence. Do you have pa or patient education programs that can help them do their jobs better. building better relationships with these important customers will help them you and the patients. Thank you for listening. Please spread the word and tell a friend or to to listen to the mastering medical device podcast. As interviews like today's can help you become a more effective medical device leader. Work hard. Be kind
