Blog of the JAAPA editorial board.
Friday, August 12, 2016
Jennifer M. Coombs, PhD, PA-C
In the current issue of
JAAPA, Kayingo and Bruce discuss the implementation of universal screening for HIV at a community health center in Connecticut. Not surprisingly, before universal screening, significant sex and racial differences were found among patients screened for HIV. This individual clinic quality improvement project also demonstrated the achievable goal of the
Practical Playbook to combine
population health with primary care. The Practical Playbook, developed in conjunction with the Duke University physician assistant (PA) program, has many resources and examples of quality improvement projects that can be implemented into an individual PA practice. Kayingo and Bruce’s project exemplifies the confident approach advocated by the Practical Playbook.
Yet, what an opportunity bungled by the National Commission on the Certification of Physician Assistants (NCCPA) to introduce the concept of quality improvement projects to PAs in a poorly understood and ill-conceived roll out of both self-improvement (SI) and practice improvement (PI) type CME credits. Will PAs be forced to implement PI projects without forethought or planning? Although I respect the can-do attitude of a humble before and after quality improvement project and the inspiration of the Practical Playbook, forced quality improvement for CME and licensure is hasty and unwise. Is it a stretch to say out loud, “What will NCCPA think of next?” when it comes to recertification changes?
Also in this issue is the editorial "Addicted to Blame," a cautionary tale of opioid use and abuse in this country. Perhaps nothing will define this next generation more than the specter of the deaths of tens of thousands of young people to addiction. The title further points out the irony of the rush to remedy the situation with a nearly wholesale ignorance of the data and established evidence-based recommendations from public health experts and healthcare providers. The editorial notes this causticness and serves up a strong reflection on who shall be blamed and who shall suffer. Real harm can be done by public health measures ignored or badly implemented.
What is to be done about a world with too many rules, too poorly applied, with little evidence to back them up? The fact that evidence will be ignored does not mean that an evidence-based approach should be abandoned. Although PA programs teach evidence-based medicine, we do little to prepare PAs for evidence-based public health. It feels a bit slow in the uptake, especially in recommendations for vaccine use (think human papillomavirus vaccine), mental health issues, and universal screening recommendations. The
US Preventive Services Task Force, always the most cautious and highly evidence-based, is looked upon disparagingly by healthcare providers who distrust the ever-evolving, revolving door of advice. After all, they aren’t the ones in the room with the patient, trying to make sense and explain the screening recommendations in a timely way using living-room language.
Compounding the issue is the distrust of our changing healthcare system, the lack of stable healthcare insurance, confusing rules about coverage, and providers with little time to arbitrate the payers with those who are sick and need care. But to disparage is to lose hope that a solution can be found to the toughest problems we face: to care for those who are the sickest, such as those with addiction and those vulnerable to HIV.
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.
Monday, July 11, 2016
Richard W. Dehn, MPA, PA-C, DFAAPA
The current demand for physician assistants (PAs) appears insatiable. New PA graduates are being offered positions that just a few years ago were only available to more experienced clinicians, and starting salaries for new graduates now commonly exceed the salaries of PA faculty who have decades of job experience. Of course, as the saying goes, what goes up must come down, so the big question is not if but when will the supply of graduating PAs satisfy the demand?
Although we are a relatively young profession, we do have some experience with PA workforce supply and demand mismatches. Although we don’t have very good data describing our early years, inferences can be made that increases in numbers of PA educational programs
and increases in national first-year student enrollment size typically are the result of demand for PAs exceeding supply. The number of PA programs in the United States was reported in 1977 to be 46, and by 1984 had grown to 53 programs with an average first-year enrollment of 23.9 students .1,2 By 1994, the number of programs had increased to 63 enrolling a first-year class of 37 students.3 In the class of 1983, an estimated 70.6% of the 1,166 graduates were employed as PAs shortly after graduation, compared with 87.2% of the estimated 1,896 graduates of the class of 1993.2,3 These data indicate an increasing number of PA graduates experiencing a higher employment rate as PAs over that decade, which can be interpreted as programs meeting an increasing demand for PAs with not all graduates finding employment as practicing PAs, but with a tighter job market at the end of the decade.
The PA world changed drastically starting in the early 1990s. The managed care model of healthcare delivery became prevalent during that time and encouraged the use of PAs for the delivery of medical care previously only provided by physicians. A major attempt was made to reform the healthcare delivery system in 1993—the Clinton healthcare reform proposal—but failed to pass Congress. The Budget Reconciliation Act of 1997 provided for Medicare reimbursement of PA services, commencing PA reimbursement for hospital settings for the first time. Both of these events substantially increased the demand for PAs, and over the next decade the number of PA programs, cohort size, and the number of PAs in practice increased dramatically.
By 2004, the 133 PA programs enrolled an average of 38.2 students in their first-year cohort. The class of 2003 graduated an estimated 4,554 PAs; 71.7% of them reported being employed as a PA shortly after graduation.4 During most of that time period, PA demand was very strong, with starting salaries rising every year. However, near the end of the 1990s, the effect of managed care began to reduce the overall demand for medical care, which resulted in a perceptible decrease in available positions for new PA graduates. This was noted particularly in the northeastern US, where a large proportion of the recently-developed PA programs were located. Anecdotal information at the time reported a change in the job environment for new graduates in that geographic region, from an environment where many positions in multiple specialties were available locally to new graduates to one where graduates might need to relocate to find a job. Most other regions of the United States did not experience saturation in the demand for PAs, and this mini-glut of PA graduates in the Northeast only lasted for a few years. Evidence of this temporary saturation of the PA job market can be found in an article by Cawley and colleagues published in 2000.5
Following the decrease in demand for PAs in the late 1990s that was likely attributable to the managed care payment model combined with a substantial increase in the number of PA graduates mostly concentrated in the Northeast, demand for PAs has steadily increased despite a significant increase in PA programs and cohort size. By 2014, there were 186 programs enrolling an average of 39 students in their first-year cohort, and the class of 2014 was estimated to contain 7,556 graduates.6 The Physician Assistant Education Association (PAEA) no longer reported the employment rate for graduating cohorts, but it was anecdotally moderately strong with annually rising starting salaries. Currently, demand for PAs is exceptionally strong, which is again attracting more institutions to develop PA programs and existing programs to establish distant campuses and increase enrollments. Currently there are 210 PA programs with 64 institutions reportedly seeking to develop new programs.
With the recent substantial increases in MD, DO, NP, and PA enrollment, the demand for medical providers eventually will be met. Additionally, the critical shortage of clinical training sites may limit further growth of all of these professions, which may slow or even stop further increases in enrollment and program expansion. However, at some point the demand for new graduates will decrease–likely first emerging in the highest-paid specialties, in desirable communities, and in regions of the country that have the highest concentrations of educational programs. But we know from history that it is difficult for professions to match their educational capacity with the demands of the marketplace. Thus expansion typically continues until the market saturates and potential applicants decide that it might be best to seek a different career and educational institutions realize that the applicant pool can’t fill their classes with qualified applicants. It will happen, the question is not if, but when.
1 Oliver D, Laube D, Gerstbrien J, Wombacher N. Distribution of primary care physician’ss assistants in the state of Iowa.
J Iowa Medical Soc. 1977:320-323.
2 Oliver D, Conboy J, Donahue W. First Annual Report on Physician Assistant Education Programs in the United States 1984-1985. Association of Physician Assistant Programs, May 1985.
3 Oliver D, Kreiter C. Tenth Annual Report on Physician Assistant Education Programs in the United States 1993-199. Association of Physician Assistant Programs, June 1994.
4 Simon A, Link M. Twentieth Annual Report on Physician Assistant Educational Programs in the United States, 2003-2004. Association of Physician Assistant Programs, August 2004.
5 Cawley J, Simon A, Blessing JD, Pedersen D, Link M. Marketplace Demand for Physician Assistants: Results of a National Survey of 1998 Graduates.
J Physician Assist Educ. 2000;11(1):12-17.
6 Physician Assistant Education Association. By the Numbers: 30th Report on Physician Assistant Educational Programs in the United States, 2015. Washington, DC: 2015.
Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, chair of the university's Department of Physician Assistant Studies, and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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Tuesday, June 28, 2016
Harrison Reed, MMSc, PA-C
After graduation, how many of your classmates rushed off to a job in primary care? If you program was anything like mine, those new graduates were a small minority. I always thought some specialties were just sexier than others, but perhaps more subtle economic factors are at work.
In the July issue of
JAAPA, Perri Morgan, PhD, PA-C, and colleagues tackle the diminishing proportion of primary care PAs in their latest PA workforce research. They focused less on the new graduate psyche, however, and more on the financial factors that might lead to the creation of PA jobs.
The authors point out that fields with huge wage gaps between physicians and PAs (that is, higher-earning physician specialties) tend to draw a higher proportion of PAs. Because PAs make roughly the same amount of money across specialties, physicians with greater earning potential might find more value when they hire a PA, as these physicians are free to spend more time on high-revenue activities like surgery and procedures.
It’s no secret that high-earning specialties like orthopedic surgery have taken advantage of PAs to boost revenue. But, on the other end of the spectrum, lower-paid physician specialties like primary care may suffer the opposite effect. After all, a PA is not that much cheaper than a primary care physician compared with a well-paid surgeon. And if PAs are less profitable in settings like primary care, practices may have less incentive to hire them.
In his commentary in the July issue, Richard W. Dehn, MPA, PA-C, DFAAPA, proposes that the decreasing proportion of PAs might not represent wavering altruism or a shifting employee mindset but a shortage of PA jobs in primary care. He cites anecdotal experience in PA education that seems to agree with the Morgan study’s data. I like the idea of a legion of PAs waiting for a potential primary care opportunity, even if it seems a bit idealistic.
Two points raised in the discussion of PA specialty selection warrant additional attention. First, by virtue of this smaller salary gradient between physicians and PAs, lower-paying physician specialties like primary care appear to be at a massive disadvantage when it comes to employing PAs. Any state laws that further restrict PA practice, like those limiting physician-to-PA ratios, are only hurting primary care access and must be abolished.
Second, in complex systems like workplace economics, legislators and policymakers should meddle with caution. Although it’s tempting to artificially inflate PA salaries to attract workers to underserved areas, doing so could raise the average compensation of PAs in primary care and further decrease the physician-PA pay gradient nationwide. Unsubsidized clinics would have little incentive to employ PAs that are not much more affordable than their physician colleagues. And if Dehn is right about a smaller-than-you-might-think primary care PA job market, that kind of policy move could further restrict PA migration into primary care.
Harrison Reed practices critical care medicine at the University of Maryland Medical Center’s R. Adams Cowley Shock Trauma Center in Baltimore, Md., and is associate editor of JAAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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Tuesday, May 31, 2016
Virginia Hass, DNP, FNP-C, PA-C
At a workshop on compassion cultivation training I recently attended, we were guided through an exercise in which we were to contemplate traits in ourselves at various stages of our lives—past, present, and future. For me, the trait that persisted throughout was curiosity. This started me thinking on the nature of curiosity, and its role in both empathy and healthcare.
Curiosity is an intrinsic characteristic of all higher beings. Watch a cat play with a box or bag, or a baby explore her fingers and toes. We
are born with innate curiosity to explore our senses and environment. Dr. Erich Loewy suggested that curiosity is the foundation of imagination, which allows us to hypothesize meanings for this input; and then reason, which allows us to test our hypotheses and categorize and sort data.1 The interplay between these three intellectual capacities (curiosity, imagination, and reason) lets us problem-solve. Loewy further suggested that creativity is the product of this interplay.1
Curiosity is the trait that brings many of us to healthcare—whether we start our careers as bench scientists or clinicians. I recall an encounter with a patient early in my nursing career. I was troubleshooting a problem with his IV pump and he commented, “That’s what RN stands for—Registered Nut-turner.” A lively and humorous exchange followed in which we came up with a variety of things “RN” could stand for. I don’t recall them all, but the one that rang truest, and therefore stuck with me, was “Really Nosy.” I laughed and told him, “Yes, and I have a license to ask questions!” Our need for discovery (curiosity) drives our problemsolving and creativity, keeping us engaged.
Empathy (compassion) also requires this interplay of curiosity, imagination, and reason. Curiosity inspires us to ask ourselves, “Who is this person across from me?” And as demonstrated by our interest in the person before us, is perceived by patients as caring, or empathy. We ask, “How can I help you? Who are you? Tell me more about that?” Their story unfolds, and they comment later, “He seemed to really care about me,” and “She spent a lot of time with me” (whether we did or not). Curiosity encourages people to open up to us, sometimes in the most unlikely settings. Most of us have had the experience of standing on line at the market or bank and striking up a conversation with the person next to us. Before we know it, this total stranger is telling us the details of their personal life or physical functions—perhaps things they would not share even with their intimates. Imagination lets us take the encounter a step further—to imagine ourselves in the other’s shoes (that is, to feel empathy) —to hypothesize that this is a person who wants to be well, be happy, and at the end of their days, look back on a life full of meaning. We then use reason to gather empirical data to confirm or disprove our hypothesis.
The best of diagnostic reasoning mirrors this process. We are curious, we form hypotheses, and we reassess our hypotheses as we gather new data. Thus, curiosity is a foundation to our clinical practice. However, maintaining curiosity requires time to think and to reflect. As an educator, I ponder how our methods of education affect the innate curiosity our students bring to PA education. Loewy argued that our “Western…market-oriented and capitalistic milieu…has tended to discourage the development of curiosity and imagination.”1 I would further this argument by stating that our current models of education and certification in healthcare (PA, nursing, and physicians) also stifle curiosity and creativity. As our students learn the “correct” way to gather a history, they become focused on asking the “right” question(s) to obtain the “correct” answer. The person before them becomes a patient from whom they have to gather a checklist of information. The emphasis is on what, and not how, to think. What Loewy calls, “the bulimia model (teach and cram)”1 of education results in students who store information just long enough to pass a test, rather than integrate it into a holistic picture of patient care. In this system, curiosity and imagination – exploring that which intrigues or inspires us to think —is not rewarded. Upon graduation, the situation becomes more dire—relative value units, managed care, and pay for performance encourage us to explore only that which can yield an immediate return on investment (that is, only that which will reduce length of stay or increase productivity) and thus reduce exploration for curiosity’s sake.
So why should we care about curiosity? Curiosity, and its extension—the ability to see ourselves in another’s shoes—inspire us to reach out to others in distress, think about the bigger picture of access to healthcare, and trigger us to work toward policy changes that bring affordable healthcare to millions of people who were previously uninsured. Thus, curiosity and empathy are essential to reducing health disparities. In addition, we know that knowledge has a half-life—what we know to be true changes over time.2 Therefore, clinicians must be lifelong learners with the curiosity to seek out new information.
We need to consider two questions: “How do we encourage/maintain curiosity?” and “Can compassion (empathy) be taught?” My colleagues and I debate this question, and I do not have an answer but I do have some suggestions. We look for these characteristics in the applicants to our PA and NP programs, in the hope that the presence of this raw material will help us forge compassionate clinicians. Given that many (though not all) applicants to PA and NP programs arrive with their innate curiosity intact, I would argue that we should be looking at our system of education—finding ways to ignite and reward curiosity. This is not an easy proposition. Multiple-choice examinations, with their emphasis on knowing the right answer, are relatively simple to construct. They are also the format of the ultimate final examinations (licensing examinations). It is much more difficult to quantify how a person thinks—their curiosity, imagination, and empathy. De-emphasizing the multiple choice examination and using alternative ways of evaluating students’ knowledge, such as reflection, case-based learning, and simulated patient encounters, would reward the persistence of curiosity. In this way we can make the conscious choice to forgo fact-focused curricula in favor of strategies to cultivate compassion, empathy, and lifelong learning.
1. Loewy EH. Curiosity, imagination, compassion, science and ethics: Do curiosity and imagination serve a central function?
Health Care Analysis. 1998;6:286-294.
2. Arbesman S.
The Half-Life of Facts: Why Everything We Know Has An Expiration Date. Penguin Group USA: New York, NY. 2012.
Virginia Hass is an assistant clinical professor and nurse practitioner program director in the Betty Irene Moore School of Nursing at the University of California at Davis. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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Monday, May 16, 2016
Brian T. Maurer, PA-C
In the May issue of
JAAPA, Salibian and colleagues present an
independent research study that examines the use of PAs and NPs in outpatient surgical subspecialty settings.
The investigators draw their data from the National Ambulatory Medical Care Survey published annually by the CDC. Although these data are dated (they stem from surveys conducted in 2007-2008), the results are still somewhat shocking, unsettling at best: PAs and NPs were
involved in only 5.9% of outpatient surgical subspecialty office visits, and the percentage of patients evaluated by PAs or NPs alone turned out to be a paltry 1.1%. Interestingly, PAs and NPs often saw the same diagnoses alone (which I take to mean without a supervising surgeon physically present) as their physician counterparts.
The authors conclude that PAs and NPs “have a minor prevalence in the ambulatory surgical workforce during the time period studied.” On a brighter note, the authors argue that “further integration of these providers into the outpatient setting may help optimize efficiency in ambulatory surgical care.”
Because the current rate of surgeons entering the healthcare workforce has been deemed insufficient compared to the projected need, expanding the roles of PAs and NPs could theoretically improve overall access to quality surgical care, and at the same time lower its costs.
This study harkens back to arguments that first surfaced in the medical literature 30 years ago: namely, that expanding the roles of PAs and NPs would improve access to quality care and lower costs. Although the PA and NP workforce has grown exponentially over time, to my knowledge no definitive study has demonstrated that using these providers has actually lowered the cost of medical care.
A closer look at Salibian and colleagues’ data might provide the astute critical reader with a clue as to why this has not occurred. NAMCS data are gleaned from ICD-9-CM diagnostic and procedure codes. The authors allude to the likelihood that most of these diagnostic encounters might have been billed “incident to” the supervising surgeon. It is only required that the surgeon be present in the office during the medical encounter to justify billing at this level. Many of these encounters may have been billed in this fashion, effectively skewing the true incidence of care rendered by PAs and NPs.
Were PAs and NPs generating revenue in less than 6% of office-based surgical encounters, it would not be economically feasible for surgeon employers to keep them on the payroll.
One wonders how such scenarios may play out in the future medical marketplace, as we move from solo-fee-for-service toward universal value-based care.
Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at
http://briantmaurer.wordpress.com. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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