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Musings: Blog of the JAAPA Editorial Board
Monday, November 17, 2014
Wanda C. Gonsalves, MD
 
A few weeks ago, at our class reunion, I celebrated 30 years since my medical school graduation from the University of Kentucky. I looked forward to seeing old friends, but especially to seeing the three women who, along with me, my classmates called “the Medicare Maidens” because we had turned 30 years old before our graduation. We had studied together for 4 years, helping to keep each other in school.
 
There were the usual questions: “What are you doing now?” “When do you plan on retiring?” “Is that his second wife?” “Did you hear he/she passed away?”
 
Many of us reflected on how medicine had changed. Physician extenders were now an important part of our practices. Most of us had hired either physician assistants (PAs) or nurse practitioners. And of course, I commented how PAs were better-prepared to practice with physicians. We all felt we were working harder for less reimbursement. I complained that primary care physicians at the University of Kentucky were expected to see patients every 20 minutes, whether the patients were new or established. Some of my colleagues from other institutions had even shorter appointment visits. And everyone complained that the electronic medical record required more documentation than paper charts and consumed way too much of our time. Most of us were doing our documentation after work, because running from room to room left little time to complete our records. All but a few of us worked for a company, university, or medical specialty group.
 
 
Drs. Wanda and Gerald Gonsalves
 
 
A few days later things had settled down from the parties. I was visiting with friends and lunched at Keeneland to see the horse races, I began to reflect more about my own future and the changes in medicine. What would I do if I did retire? I knew that I would always want to make a difference in the lives that I touched. I thought about the students and the residents I precept in my clinic. I thought about the patients and the bond that I have with them
 
I firmly believe that physicians and other healthcare professionals have a social responsibility toward those whom they serve. Each time I’m with a learner, I try to emphasize our responsibility as medical professionals. That goal definitely becomes much harder when we’re running around “like chickens with our heads cut off” between each patient room, but the goal is still something we should keep in mind as role models to our learners. I can’t retire. I still have much to offer and to much more I’d like to accomplish.
 
Wanda C. Gonsalves is vice chair of the Department of Family and Community Medicine at the University of Kentucky in Lexington. She also is a steering committee member of Smiles for Life, a national oral health curriculum. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Tuesday, November 11, 2014

Jennifer M. Coombs, PhD, PA-C

I was recently asked to give a webinar with my colleague Christine Everett, PhD, PA-C, called “Filling the Primary Care Gap: Opportunities and Challenges Facing Rural Physician Assistants.”  The webinar was part of a rural workforce webinar series put on by Vanderbilt University’s Center for Interdisciplinary Health Workforce StudiesI spoke about the history of PAs in rural areas, distribution, scope, and retention challenges. Dr. Everett described some of her latest research on clinical roles and the effect on cost, quality, and access in the rural setting. You can see our talks here

Much can be said about rural healthcare providers now that PAs and NPs together outnumber family medicine physicians.1,2 Promises made because of changes as a result of the Affordable Care Act (ACA) may increase the number of insured Americans, especially in rural areas. The New York Times recently reported that 10 million more people have insurance coverage this year than last as a direct result of the ACA. According to the paper, some of the biggest gains were in rural areas.

Michael Powe from the American Academy of Physician Assistants (AAPA) reported in May that the Centers for Medicare and Medicaid Services (CMS) eliminated the requirement for physicians to be physically on site once every 2 weeks at a certified rural health clinic, federally qualified health center, or critical access hospitals.

PAs will still need to follow their state laws, which contain a considerable amount of variation in terms of adopting the AAPA's “6 key elements of a modern PA practice act” (PDF). The issue is this: only 9% of US physicians practice in rural areas, and among the 2,050 rural counties in this country, 77% are designated health professional shortage areas. 62 million Americans, or 20% of the population, live in rural areas.  Are PAs are ready willing and able to fill those gaps in underserved areas?

I decided to call my friend Amy M. Klingler, MS, PA-C, who lives in a rural and remote area of the country—Stanley, Idaho—and ask what changes she has noticed as a result of the ACA. According the New York Times, Custer County, the central Idaho county where Stanley is located, has gone from 14% uninsured in 2013 to 9% uninsured in 2014. Ms. Klingler is 60 miles from the nearest critical assess hospital and a 45-minute life flight to the nearest major level 2 trauma center. Idaho has no level 1 trauma centers. Her supervising physician visits her clinic once a month. This is a mutually agreed upon supervisory arrangement, and before the latest ruling from the CMS, Ms. Klingler and her supervising physician were able to obtain a waiver allowing for the once monthly visit rather than every 2 weeks.

According to the AAPA, Idaho has only four of the six elements of a modern state practice act. Importantly for a rural state, the delegation of service agreement lets the PA or physician decide the appropriate scope of practice for each PA.  The ratio of physicians to PAs is 1:3; a waiver can be obtained to allow a ratio of 1:6. Most state practice laws allow the flexibility for physicians and PAs together to determine the delegated medical tasks and the method of supervision. Some states require physicians to review a certain percentage of charts; the percentage may depend on how long the PA has been in practice. Being able to decide together how and when Ms. Klingler’s supervising physician was able to visit her is certainly important and critical to her ability to practice so remotely. Her supervising physician or alternate physician are always available by phone. According to the AAPA, 25 states impose some type of travel time or distance limits to their supervision requirements for PAs.

Another important feature to be able to practice remotely is the ability to prescribe controlled substances in categories 2 through 5. All states allow PAs to prescribe medications, but 14 place some limitations on the types of medications PAs can prescribe, a limitation that can hamper PAs practicing in remote areas.

One of Ms. Klingler’s biggest challenges is durable medical equipment and obtaining hospice care for the terminally ill residents in her county.  Older adults make up 13% of the US population, but account for as much as 45% of the population in some rural areas. Hospice and palliative care, Medicare, and rural long-term care facilities are issues facing those aging in remote places.

For Ms. Klingler, living and working in a small town was the reason she went to PA school in the first place. Becoming an MD would not have allowed her to practice in her chosen rural area, where physicians work in the clinics 1 to 2 days per week.  Although most PAs practice in urban areas, PAs and NPs are more prevalent in rural and underserved areas than physicians.3-5 Many rural counties in the United States face serious challenges to provide sufficient healthcare services. The ability of PAs to practice in rural and remote areas is highly variable and depends on many factors, both economic and political. Shortages of PAs and the inefficient use of PAs are the two next great issues in our profession.  As we consider the many changes on the horizon for PAs, aligning our laws and regulations to the needs of rural PAs is paramount. Only then can the maldistribution of providers and shortages of PAs in all areas of medicine be solved.

Jennifer M. Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


REFERENCES

1. Stange K. How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. J Health Econ. 2014;33:1-27.

2. Auerbach DI. Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Med Care. 2012;50(7):606-610.

3. Hooker RS, Muchow AN. Supply of physician assistants: 2013-2026. JAAPA. 2014;27(3):39-45.

4. Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012;20(1):20-31.

5. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Amer Coll Surgeons. 2011;212(6):991-999.


Monday, November 03, 2014
Richard W. Dehn, MPA, PA-C, DFAAPA
 
It has become quite obvious recently that PAs are in short supply. New graduates in my neck of the woods have many employment options, and starting salaries appear to be very good. In the world of PAs, life is good.
 
However, whenever the PA job market gets really hot, recruiting and retaining PA educators gets even more challenging than usual. In my opinion, the reason for this is that clinical salaries typically are more responsive to supply and demand forces than salaries in academic institutions, so when demand increases, clinical salaries rise faster than academic salaries. Those rapidly increasing salaries offered by easy-to-find clinical positions will attract many PA faculty back to full-time clinical practice, leaving many faculty positions vacant. The PA faculty shortage cuts across the entire academic landscape, which needs more qualified program directors, didactic coordinators, clinical coordinators, as well as core PA faculty. The faculty shortage was hard to ignore at the recent PAEA education forum in Philadelphia; an entire display board was dedicated to posting academic vacancies, the conference materials included a whole book of available faculty jobs, and deans and program directors in active recruitment mode were everywhere. From my vantage point, we have definitely reached a PA faculty shortage crisis.
 
This shortage of PA program directors and faculty couldn’t happen at a worse time. In response to the increasing demand for clinical PAs, many new PA programs are being developed. These programs need competent program directors and faculty. The baby boom generation of faculty, many who have been in their positions for decades, is beginning to retire. Additionally, many program directors are being promoted to higher administrative positions in educational institutions, leaving fewer experienced program directors. Two of these factors, the retiring of an older generation of faculty and the promotion of PA program directors to higher positions, would normally be considered a good thing illustrating the longevity and increasing acceptance of the profession in academia. However, in the current environment, these factors substantially contribute to the faculty shortage.  Although one might think that the PA program director and faculty shortage is a problem mostly affecting newly developing PA programs, the shortage has even affected legacy programs. Faculty are attracted away from these programs by opportunities in developing programs or the higher salaries of clinical practice.
 
PAs typically enter PA education after 3 to 5 years in clinical practice, usually after having served as a clinical preceptor or lecturer for a PA program. In most cases, they trade a salary decrease for a somewhat more flexible work schedule and the opportunity to teach students rather than treat patients. Most programs consider that an entry-level new faculty member will need about 2 years of training and mentoring to get up to speed. Most program directors would prefer that most of their faculty have program experience, such that at any given time the number of new faculty recently having entered education from clinical practice in a program do not constitute more than the program can comfortably afford to mentor. The current faculty shortage has resulted in some programs containing a majority of inexperience faculty.
 
How can PA education attract enough qualified and competent faculty to educate the number of PAs needed to meet healthcare’s current needs? Many processes have been proposed, such as educator rotations and teaching fellowships designed to attract early-career PA to an academic career. However, all of these also require the participants to accept less pay than clinical PA positions would offer. The unfortunate irony of the PA profession’s current success, as measured by the high demand for PAs, is that there simply may not be enough qualified PA educators to train all of the PAs that the market demands.
 
Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, October 27, 2014
Kim Zuber, PA-C, DFAAPA; Jane Davis, DNP
 
A hush falls over the OR. Every day we do our jobs but today is an unreal day for us. We are losing a family member but know that his death will give life to many others. Two days earlier, the husband of one of our OR nurses was riding his bicycle when he was hit by a car. We had passed him riding his bike on the way to work and 3 hours later he was in our ED. We gathered with our colleague in the ED, drawn by a need to do something. We held her hand while the burr hole was placed in his skull to try to stop the swelling of the closed head injury. After 24 hours in the ICU, when we had tried everything, he was declared brain dead. We all knew what it meant when representatives from the local transplant center came to talk to her. We knew what her answer would be “of course his death must help others,” but that did not make today any easier. A young and ardent bicycle rider, he was in excellent physical shape. She asked that we help with the donation and we said, “of course.” So here we are, in a lounge in the OR, holding her hand and watching as groups of surgeons come in and out.
 
After thanking the ICU staff, she walked with her husband’s bed and nurse anesthetist to the OR. She said goodbye in the darkened, quiet OR (quite unlike the usual scene), thanked the anesthesia providers, and was walked to the OR lounge by the head nurse. Magically, the first group of surgeons appeared, coming in the door opposite the one she had left. The anesthetist stayed and monitored the ventilator.
 
The transplant teams had been notified by Donor Net, a computerized alert system that contacts all local transplant programs as soon as a donor has been found. Information regarding age, race, BMI, laboratory results, medical history, and cause of death along with results of testing (CT, MRI, and other specialized testing) is sent via a beeper system to either transplant coordinators or surgeons at each local program. The local transplant programs have 1 hour to respond or the organs are offered nationally. Due to cold ischemic time, priority is always given to the local area to increase the survival of the donated organs.
 
As the teams set up to do the donation, the lung team does a quick bronchoscopy to check lung condition and a sample is sent for arterial blood gas analysis. The heart will be the first organ removed, but each surgeon preps his or her particular organ before the heart is cross-clamped. After each organ is prepared, the cardiac surgeons stand on either side of the OR table. The procurement teams know each other well and work in a manner of a choreographed ballet. The chest is opened quickly from the sternal notch to the pubic bone and the skin and fat are retracted. The heart surgeons work with expert, experienced hands and quickly isolate the heart. They cross-clamp the aorta, lift the heart out of the body, free it from the attached structures and flush it with cold preservation solution. The clock starts at this moment. They have 6 hours to get this heart into the recipient or all will be lost. They race out the door, heart in ice, and into the evening traffic on their way to the heart hospital, where the rest of their team has the recipient in the OR already prepared for his new heart.
 
Ice is packed into the donor body cavity and the next team steps up. The lungs have been determined to be excellent and they are the next organs to be taken. Again the cold preservation solution is used for flushing and the lungs are on their way to another lucky patient. The abdomen teams are next. The liver and/or lungs can be taken with the heart but today each of the organs is designated for a different recipient. The abdominal surgeons work quickly and take the liver and pancreas, flush them with the cold preservation solution and pack them in ice for the trip to another transplant center. The liver will be split between two recipients but the dissection of the liver will be done at the transplant hospital. The cold ischemic time for livers should be less than 5 hours; although livers can survive up to 12 hours, travel to the more distant transplant center can be slow, so the team quickly gets on the road.
 
The small bowel is now sent to the same transplant center as the heart. The kidneys are taken and flushed with the cold preservation solution. Because kidneys have the longest cold ischemic survival time, they always are the last of the abdominal organs to be taken. One of the kidneys will be traveling quite a distance, so it is placed on a pump and continually flushed with the preservation solution. The local kidney is packed up in ice and transported to a waiting patient.
 
At this point the local organ procurement office (OPO) steps in. The OR, bustling with noise and surgeons just 10 minutes ago, is now quiet. The donor’s corneas, skin, and bone are taken by the OPO staff. The PAs who have stayed behind to stitch the donor listen while the OPO shares stories of each of the recipients. A 20-year-old with cystic fibrosis will receive one lung and a longtime government worker whose kidneys have been ravaged by diabetes will be free from dialysis. A blind man in Baltimore will see with the corneas. A grandmother waits for the liver. A young mother with postpartum cardiomyopathy will get the heart.
We finish our stitching, and he looks so peaceful. His wife walks back in and says a final goodbye, while the OPO staff thank her for her gift.
 
(For more on transplantation, see the authors' article in the current issue of JAAPA.)
 
Kim Zuber practices at Metropolitan Nephrology in Alexandria, Va., and is AAPA Outstanding PA of the Year. Jane S. Davis is a nurse practitioner at the University of Alabama at Birmingham and a member of the National Kidney Foundation’s board of directors and the American Society of Nephrology’s CME committee. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, October 06, 2014
Joshua Newton, MMS, PA-C
 
In 2011, when I moved to Kansas, I had no idea that to get my job, I would have to convince a company that I could get a law changed. As a fresh graduate of the Wake Forest PA program, I was in love with rural medicine and I longed to practice in a high-need community. I happened upon that community in a little town called Pittsburg, nestled in southeastern Kansas. Pittsburg was home to the largest community health center in all of Kansas, and they offered a cadre of tools to serve the most impoverished counties in Kansas. They also were heavily staffed by NPs because of a thriving NP school just a few blocks away, and because of a chart co-signature law that had been hampering PA practice for years.
 
At the time I was new to medicine and knew little about politics. But my passion for rural health drove me to convince a practice that had never hired a PA to give me a shot. I just needed the chart signature requirement fixed so that I was competitive with my NP colleagues. And truth be told, I had a little secret. I already knew that the state of Kansas was changing their co-signature law, and so all I had to do was write a letter to help plead my case and then rely on the arduous work of our Kansas legislative committee. Since that milestone legislation, our legislative committee has continued to make strides on updating our practice act and has set an example of forward momentum. We are now increasing the number of PAs a physician can supervise and we've been included in the state healthcare stabilization fund. And the little practice I joined has grown from one PA to six PAs, with many more to follow.
 
As the need for advanced practitioners grows in our nation and in a state dominated by rural health needs, we continue to develop and define the rules and regulations of collaborative relationships, so that we can both reach these populations and offer them optimal care. Legislation is just one piece. With concepts such as telemedicine blossoming, and federally qualified community health centers further expanding due to our underinsured population, the role of the PA in Kansas is shifting and developing each day. I came to Kansas originally because I believed that family medicine is the heart of the PA profession, and I saw the heartland as the best training ground to understand that heart. My goal was to immerse myself in the challenging world of rural medicine and fight for those who were unable to fight for themselves. Over the next year I will step into my new role as president of the Kansas Academy of Physician Assistants (KAPA) for 2014, and I realize that many of the battles I will fight are broader than representing the medically underserved. Some battles even stem from our own internal professional turmoil.
 
KAPA is tackling the same issues as many constituent organizations around the United States. Our elections are all uncontested and our membership base is shrinking. We have a small dedicated group of volunteers who are overworked and in need of a respite. We struggle with a disenfranchised older generation that is busy in the lives they have built and a disengaged younger generation that is struggling to build the lives they want. We have a decentralized population of PAs scattered throughout far-flung rural communities that we toil to connect to our organization, and so we rely heavily on our urban centers for leaders. And our students and young PAs, though passionate, fail to remain in the fold for long as they labor with the balance of family, work, and professional involvement.
 
For an organization that has fought so valiantly for its constituents and made such progress, it is hard to imagine that we rest on such a precarious foundation. But the paradigm of PA leadership is changing and must change, and KAPA is no different. If our base extends beyond a few major population centers, then we have to harness the available technology and reach that base. Video conferencing is now the norm, social media is ubiquitous, and if medicine can be broadcast over an ethernet line, why can’t professional involvement? We can no longer be organizations of pen, paper, and face-to-face meetings. We have to embrace the fact that technology has allowed us each to be the center of our own universe and has allowed us to operate with the freedom of universal interconnectivity. And if our early-career constituents are lost to follow-up, then we must build stronger relationships with them and deepen their roots in our family, so that they are quick to return. We have to meet the needs of our constituents and if that means meeting them on their terms, then so be it. Where is the mentorship in our profession? How can we expect the next generation to be better than the last if we don’t impart those experiences? We also have to retain the wisdom and experience of previous leadership by spreading the workload, and using their skills as generals rather than foot soldiers. Leadership is by definition guiding a group and the solitary pack mule mentality only ends in burnout and frustration.
 
Our profession has fought valiantly to make it where we are, but I believe that right now we face a wave of new challenges, which may require new paradigms, new approaches, and new leaders. If we don’t want to be lost in the mix, we have to be out front leading the charge. And in the state of the Kansas, we will continue to rally the troops and charge forward.
 
Joshua Newton practices family medicine in Pittsburg, Kans. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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