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Musings: Blog of the JAAPA Editorial Board
Monday, November 16, 2015
Virginia Hass, DNP, FNP-C, PA-C
“Low-class people do low-class things.” This disparaging comment, quoted by Matt Taibbi in The Divide, is uttered by a private attorney hired by New York State to defend low-income defendants in criminal court.1 It follows an exchange between Taibbi and this attorney about the case of Andrew Brown, a 35-year-old black man arrested for obstructing pedestrian traffic while standing in front of his home talking with a friend:
Taibbi: “…we just watched, in court, a policeman admitting to falsely arresting someone. You don’t find that interesting?”
Attorney shrugs.
Taibbi: “Also, have you ever heard of a white person being arrested for obstructing pedestrian traffic?”
Attorney: “Well, white people don’t live in those neighborhoods.”
Taibbi: “But white people live somewhere, and nobody arrests them for obstructing pedestrian traffic.”
Attorney: “That’s because that’s not where the crime is. The crime is out there (gesturing toward Brooklyn). Low-class people do low-class things.”
In The Divide, Taibbi demonstrates that unequal wealth is producing grossly unequal outcomes in criminal justice. He cites as evidence examples of white-collar crime in the financial sector and the virtual immunity from criminal prosecution that has resulted from a belief that prosecution of banks that are “too big to fail” (and more importantly, the real people who are behind the decisions made in those corporations) would cause economic collapse. Meanwhile, though violent crime in the United States fell by almost 49% between 1994 and 2013, over the same period the prison population increased by 50%, with a disproportionate population of black and poor inmates.2,3 Public pressure to crack down on crime is coupled with technology that tracks and scores police productivity by numbers of arrests. Further, municipal revenue is enhanced by the fines and fees generated. Taibbi illustrates this point with many exemplars, such as Andrew Brown, and Ann Marie Selby, a 36-year-old Portland, Ore., writing teacher who was arrested for suspicion of prostitution while walking home after missing her bus.
This justice by attrition—a process whereby police dragnets sweep up citizens for quality of life misdemeanors such as public drunkenness, loitering, smoking inside a building, passing out on a subway, disorderly conduct, or riding a bike on the sidewalk, is disproportionately applied to the poor and people of color. Not only do innocent people get caught in the net; the sentence is disproportionately hard on those who are guilty. For example, in one of multiple cases cited in the US Department of Justice Investigation of the Ferguson Police Department:
Ferguson’s municipal court practices combine to cause significant harm to many individuals who have cases pending before the court. Our investigation has found overwhelming evidence of minor municipal code violations resulting in multiple arrests, jail time, and payments that exceed the cost of the original ticket many times over. One woman, discussed above, received two parking tickets for a single violation in 2007 that then totaled $151 plus fees. Over seven years later, she still owed Ferguson $541—after already paying $550 in fines and fees, having multiple arrest warrants issued against her, and being arrested and jailed on several occasions.4
Thus has poverty become criminalized. We are living in a time where debtors prison have returned, though they were outlawed over a century ago. As Taibbi summarizes in The Divide:
Obsessed with success and wealth and despising failure and poverty, our society is systematically dividing the population into winners and losers, using institutions like the courts to speed the process. Winners get rich and get off. Losers go broke and go to jail.1
By now, you may be asking yourself, “What is the relevance of these problems to healthcare, and what does this have to do with me as a PA?” It is unlikely that any of us moonlight as police officers, court appointed attorneys, or the CEO of a corporation “too big to fail.” Reading these accounts is distressing, terrifying, and frustrating. It is tempting to look away. But as healthcare providers, we have a responsibility to act. My colleagues and I have been discussing this recently in our interprofessional book club. There is ample evidence that these types of everyday hassles (as one of my colleagues described them)—racism, discrimination, and abuses by systems that appear to be complicit in their actions—have negative effects on physical and mental health.5-7 And we have to consider our roles and responsibilities as healthcare providers in both perpetuating and responding to the types of everyday hassles faced by many of the people we care for. We generally perceive ourselves to be enlightened, compassionate people who chose a profession in healthcare because we want to serve and to help others. However, we have evidence that discrimination based on race and class persists in healthcare, and negatively affects quality of care.8 Further, we know that racism affects the health of communities, in that the squander of social capital that results negatively affect all residents of the community through increased mortality.9
As self-reflective practitioners, we have to ask ourselves difficult questions: “Am I in some way complicit in systematic injustice?” “Do I perpetrate microaggressions against _____ in everyday life?” You can fill in the blank in this sentence with any marginalized group—people of color, women, people in the LGBTQI community, the poor, the mentally ill. Microaggressions are “brief and commonplace daily verbal, behavioral and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group.”10 The key here is that microaggressions are commonly implicit and unconscious. These questions are tough because they make us examine ourselves, and this can be uncomfortable. Research indicates that when perpetrators of microaggression become aware of their implicit biases, they experience guilt, fear, defensiveness, and behaviors that may further damage relationships with the marginalized group or individual.11
So what to do? We can take action at multiple levels. On a personal level, we can awaken awareness to our hidden biases (yes, we all have them) by going to the Project Implicit website and taking the implicit association test (IAT). The IAT, “…measures attitudes and beliefs that people may be unwilling or unable to report” and may uncover an implicit attitude that you did not know you held.12 Only by bringing such attitudes and beliefs to conscious awareness can we begin to change their expression in daily life. Further action at the individual level involves being aware of what is happening in your city or town. For example, who is running for district attorney, superior court judge, county sheriff? Exercise your right to vote, and be active in campaigns to assure that candidates with a track record of social justice are elected. At a group level, our interprofessional book club, which provides a safe place to have these difficult conversations, is one example of a way to open the dialogue and get support as we explore our implicit assumptions. This group is composed of clinicians, students, staff, and faculty from a diverse mix of racial, ethnic, and socioeconomic backgrounds. Using books such as The Divide as a launching point, we talk about the effect of racism, microaggression, and injustice on health and our community; and our responsibility to respond as citizens and healthcare providers.
Finally, healthcare providers can have significant influence at the community level on social policy. We have knowledge, data, and we are trusted by the public and policy makers. In Marin County, Calif., a therapeutic justice program, Support and Treatment After Release (STAR), represents a multidisciplinary collaboration between the justice and healthcare systems.13 This innovative program is targeted toward a historically marginalized group—those with mental illness—who often end up incarcerated for minor offenses rather than receiving treatment. The STAR program links arrestees who have mental illness to intensive treatment programs, housing, job training, and services, rather than incarceration. In addition to providing culturally competent, integrated services to its clients, since its inception in 2001 the STAR program has decreased homelessness by 83%, decreased psychiatric hospitalizations by 54%, decreased incarceration by 83% and decreased arrests by 93% within its target population.14
Outlining these strategies is not meant as an exhaustive list or to imply that they are the answers. They are meant as a launching point for dialogue. What are your thoughts on race, equity, and social justice in America? What can you do to narrow the divide?
1. Taibbi M. The Divide: American Injustice in the Age of the Wealth Gap. Spiegel & Grau: New York.
2. Federal Bureau of Investigation. Crime in the United States, 2013. 
3. Bureau of Justice Statistics. Key statistic: Total correctional population
4. US Department of Justice Civil Rights Division. Investigation of the Ferguson Police Department. March 4, 2015.
5. Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32:20-47.
6. Sims M, Diez-Roux AV, Dudley A, et al. Perceived Discrimination and hypertension among African Americans in the Jackson Heart Study. Am J Public Health. 2012;102:S258–S265.
7. Pascoe EA, Richman LS. Perceived discrimination and health: A meta-analytic review. Psychol Bull. 2009 July;135(4):531-554.
8. Sorkin DH, Ngo-Metzger Q, Israel De Alba I. Racial/ethnic discrimination in health care: impact on perceived quality of care. J Gen Intern Med. 2010 May;25(5):390-396.
9. Lee Y, Muennig P, Kawachi I, Hatzenbuehler ML. Effects of racial prejudice on the health of communities: a multilevel survival analysis. Am J Public Health. 2015;Nov;105(11):2349-55.
10. Sue DW, Capodilupo CM, Torino GC, et al. Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist.2007;62:271-286.
11. Sue DW. Microagressions in Everyday Life: Race, Gender, and Sexual Orientation. 2010. John Wiley & Sons.
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, November 02, 2015

Brian T. Maurer, PA-C


It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way—in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.—Charles Dickens, A Tale of Two Cities


Back in 1983 during my time in graduate school, I took a course titled Community Psychology. Admittedly, I remember little from it; but one concept has stuck with me over the decades of my subsequent career: There are always resources available in the community; you merely need to seek them out.

The latest resource available to members of the PA community made its debut at this year’s annual AAPA conference in San Francisco. An online open-access forum for PAs, the Huddle, became an overnight phenomenon. Folks were signing up left and right, introducing themselves to the community at large and starting all sorts of discussion threads apropos PA practice. Students posted requests for advice on how to make it through the demands of a PA education, when to start looking for their first job, and tips in studying for the PANCE; while veteran PAs logged in to voice concerns about diverse topics such as credentialing and recertification, relocating to other areas of the country, the best way to become certified in ultrasonography, strategies on how to deal with competition from our NP colleagues, suggestions on the best way to move into administration, or how to go about transitioning to a new field in medical practice. As near as I could tell, many of the recommendations and much of the advice seemed to be spot on.

My Community Psychology professor was right: resources always are available in the community; one merely needs to seek them out. The Huddle has proven itself to be a great resource venue for members of the PA profession. Modern electronic technology and social media made it all happen. For practicing PAs, it’s been the best of times.

Unfortunately, it’s also been the worst of times, for any number of reasons. The same electronic technology that gave us those unlimited resources in the Huddle has also promised to undermine the efficiency of medical practice. The electronic medical record (EMR) has not proven itself to be the boon it was promised to be. Entering data into the individual patient’s health record has become a tedious chore for most clinicians. By some accounts it has decreased productivity 30% and added hours of extra work to the exhausted clinician’s workday. When the system goes down, everything stops: data can not be accessed. When the system is up and running it works like a charm—except most EMR systems are incompatible with each other.

Frankly, I’m not so sure that these systems have improved healthcare delivery to any great extent. If anything, the laptop/notebook/tablet has certainly interfered with the caring clinician-patient encounter. When a newly-minted clinician asked for the salient points regarding a mature patient’s menses, the exasperated patient jumped up and thrust her hands between the clinician’s eyes and the electronic screen on his lap. “Look at me,” she cried, “I’m 65 years old! Do I look like I’m still having my period?”

Recently I was asked to precept an NP student during his ambulatory pediatric rotation. As it turned out this fellow had been practicing as a chiropractor for the past 10 years. He elected to complete his nursing degree and NP program online, thinking to incorporate the equivalent of primary care into his chiropractic practice. “In this state, advance practice nurses can move from collaborative to independent practice in 3 years,” he told me. “PAs are required to maintain supervisory practice for their entire careers.” His words cut deep.

Shortly after this conversation, I stopped off to chat with an NP at a retail clinic in one of the local commercial pharmacies. She was very cordial when she learned that I was in my 36th year of practice as a PA. “You guys are so much better trained that we are,” she told me. “So much of what I encounter here is outside my scope of practice, so I end up referring nearly everything out.” Then she made a telling remark. “It’s too bad PAs can’t practice in a venue like this,” she said. “They always have to work under direct supervision. None of the doctors want to have to sign off on a PA’s charts; they’ve got enough of their own work to do to keep up with their incentives.”

How right she was! Her words were substantiated in a discussion thread in the Huddle. PAs are being replaced by NPs and APRNs exactly for that reason. In spite of what many might refer to as our superior training in the medical model, by definition PAs are still required to work under supervision—at least on paper.

So yes; lately, it’s been the best of times, it’s been the worst of times. The words of Charles Dickens ring as true today as when he first penned them nearly two centuries ago. I wonder how it will all shake out in our time.

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at The views expressed in this blog post are those of the author and may not reflect AAPA policies. 


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Monday, October 19, 2015
Pat Kenney-Moore, EdDc, PA-C; Antoinette Polito, MHS, PA-C; Laura Zeigen, MA, MLIS, MPH, AHIP
From its humble beginnings with four students at Duke University in 1967 to a workforce today of about 100,000 practitioners and more than 180 training programs, the physician assistant (PA) profession has established itself as a “PArtner in Medicine.” Yet many people remain unfamiliar with the PA profession and the role of the PA on the healthcare team.
To highlight the history of this recently developed profession and to expand community and professional awareness of the PA role in medicine, Oregon Health & Science University (OHSU) PA program faculty designed and implemented a museum-quality exhibit in collaboration with OHSU library faculty and archival experts from the History of Medicine office. The exhibit featured an overview of the PA profession, including its national and regional history, and introduced some of the early PA pioneers. Several glass cases of artifacts and continuously running video footage were curated to illustrate PA practice, the medical education of PAs, and the legislative efforts that brought the first PA program in the state to OHSU in the early 1990s. Key contributions to the exhibit were received from private donations, the Physician Assistant History Society, the American Academy of Physician Assistants, the OHSU PA program, the Pacific University PA program, and the Oregon Society of Physician Assistants. After installation in the library foyer, the exhibit remained in place for 4 months to allow employees, patients, and visitors the opportunity to see artifacts illustrative of the profession.
The process of developing this type of a professional exhibit using archival materials can be time-consuming and laborious, but the outcome provides an outstanding opportunity to highlight the PA profession in a new and exciting manner. Other PA programs and constituent organizations may consider expanding awareness of the PA profession in their communities through similar outreach and advocacy activities.
At Oregon Health & Science University in Portland, Pat Kenney-Moore is an associate professor in the PA program, Antoinette Polito is an assistant professor in the PA program, and Laura Zeigen is an assistant professor and liaison librarian in the Biomedical Information Communication Center. The views expressed in this blog post are those of the authors and may not reflect AAPA policies.


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Monday, October 05, 2015
Harrison Reed, MMSc, PA-C
If you have any doubt about the popularity of American football, consider this: the fantasy version of the sport, in which fans construct a hypothetical roster and compete against each other in fictional match-ups, just became a billion-dollar industry.1 That’s right; the made-up version of a made-up game couldn’t move its money with a fleet of forklifts.
That probably means more than a few JAAPA readers are football fans. Count me among them. But as a medical provider and sports junkie, I often have a conflicted conscience.
The safety of professional sports makes headlines these days and the nation’s most profitable sports organization, the National Football League, has made high-profile rule changes over the last few years to protect players. But while millionaire athletes make the headlines, we often forget about a more important population: young amateur athletes.
October’s issue of JAAPA features the article "Postconcussive syndrome in a high school old athlete" and outlines the condition that can potentially affect thousands of sports participants. Perhaps just as important, our current edition also shares the voice of a patient that illustrates the potentially devastating effects of the condition.
As medical providers, we promise to safeguard the health of all of our patients. We often advise lifestyle changes to avoid the risks of preventable illness. But clinicians face an uncomfortable question: Do we tell our young patients to quit playing the sports we love to watch? And should the PA profession as a whole take a stance on the danger of violent sports?
There’s no easy answer and plenty of room for debate. But while we digest the topic, I find it tougher to ignore the real question: what is an acceptable level of our own hypocrisy?
1. Isidore C. How fantasy sports changed the NFL. CNN Money. September 11, 2015.
Harrison Reed practices emergency medicine at Fremont Emergency Services in Las Vegas, NV, and is associate editor of JAAPA. Follow him on Twitter @HarrisonReedPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


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Monday, September 21, 2015

Steve Wilson, PA-C

At the American College of Surgeons’ annual meeting in 2006, I was asked to represent the PA profession at a roundtable discussion on disruptive physician behavior. The Joint Commission had issued standards to address this issue. Many of our institutions developed zero-tolerance policies that continue to evolve. I addressed what I had seen throughout my career by dividing it into three categories of behavior:

Assumed ignorance

In these situations the physician becomes angry about something done by a nurse or other provider and does not let that person explain his or her decision. The physician does not entertain possible justification or even the possible revelation of information. The physician demands corrective action without the educational process that might prevent a similar event in the future.

Freezing assets

Because of a history of disruptive behavior, staff become paralyzed to act for fear of doing something that would bring an angry response. This inaction can be problematic in addressing patient care needs and can lead to serious medical issues. Staff begin to find ways not to be available to assist a physician. The disruptive tendency then becomes compounded due to the lack of help or lack of suitable help. Once again, patients may suffer due to lack of adequate or experienced assistance. Certain routine or urgent care protocols may be delayed or not provided until an actual order is written due to lack of support for a given knowledge base (see “Assumed ignorance”). Finally, critical communication is lost as staff look to avoid contact with the disruptive physician.

Man in the middle

When physicians have issues with the care provided by other physicians involved with the same patient there is sometimes no reconciliation of the issue with face-to-face discussions. To a certain extent this is also true with physician and patient family issues as well as physician and administrative disagreements. Staff are left to try and sort out a resolution and spend a great deal of time going between the parties trying to determine what should be done. I have always found this to be very curious behavior but I have also observed that this tactic allows for a certain amount of deniability. When the two parties involved are finally forced to discuss an issue there is often the denial of what was said or a reinterpretation of the intention.

As PAs we have to be on guard against becoming an enabler of these behaviors. I don’t think it is unusual for a PA to adopt to a certain extent the identity and attitude of the physicians with which they are most associated. In large groups it could be less of a consideration as there are multiple personalities and the tendency would be to connect to the one most like yours. However, in smaller practices this option may not be available and the pull toward a perceived power base may result in unintended consequences.

The other concern for PAs is becoming an “ambassador” for the disruptive physician with whom they are most closely connected. Making excuses for the behavior, explaining the complicated situation, seeking to reconcile the relationship with those offended, or providing the education needed to avoid similar situations becomes a daily activity. All the while trying to rebuild fallen egos and/or diffuse angry responses.

The final concern for the PA is rejection of the disruptive behavior. Then the fear for personal embarrassment, accusations of professional ineptitude, and loss of employment are all very real and often painful considerations and realities. Strong personal attitudes, future options and peer support need to be in place for this brave action. The reward could be surprising.

I would be remiss not to provide a word of caution before the tag of “disruptive” is attached to any provider. The disruptive tag could be applied to practitioners trying to introduce new technology, or a new innovative system of care, change of any status quo, “whistle blowing” on a corrupt system, or even support of a new type of health care provider. It was really not that long ago that those physicians that employed a PA were really challenged by their peers.

Steve Wilson practices cardiac, thoracic, and vascular surgery at Peninsula Regional Medical Center in Salisbury, Md. The views expressed in this blog post are those of the author and may not reflect AAPA policies.



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