Musings: Blog of the JAAPA Editorial Board
Musings
Blog of the JAAPA editorial board.

Monday, February 20, 2017

Zachary Hartsell, MHA, PA-C, DFAAPA
 
The opioid epidemic in the Unites States has been well-documented and discussed several times in JAAPA via editorials and blogs.1,2 As a hospital medicine PA, I see that despite better recognition, the opioid epidemic continues to plague our communities and hospitals and carries a high cost. In addition to the tragedy of opioid-related deaths, the complications and comorbidities associated with IV drug abuse can be equally as devastating and are long-lasting. Seeing young patients with endocarditis requiring valve replacement is difficult, but the same population with strokes, emboli, or deep tissue infections requiring massive debridement are often overlooked and leave deep scars.

We are continually presented with data about the epidemic. Evidence not only focuses on the scope and effects of opioids, but more and more is being published about the roles and responsibilities of providers in opioid prescribing. The CDC released its Guidelines for Prescribing Opioids for Chronic Pain in 2016 and some states, including North Carolina, have already adopted these as their prescribing guidelines.3,4 The American College of Physicians (ACP) recently released guidelines for treating acute, subacute, and chronic lower back pain.5 Simply put, the recommendations call for nonpharmacologic and nonsteroidal medications as the first-line treatment for acute, subacute, and chronic lower back pain. The guidelines also recommend using opioids only in patients who fail nonpharmacologic and nonsteroidal therapy and after careful risk/benefit considerations. Because back pain is a common office and ED complaint, this potentially has significant implications for front-line prescribers.

Clearly, the trend is to reduce patient exposure to opioids as a way to prevent long-term addiction. If you are not exposed to it, it is impossible to become addicted to it. This has been especially true in the surgical literature. For example, studies also have looked at the persistence of opioid use after major surgery, which has paved the way for greater consideration of opioid-free surgery.6 As PAs, we must look at our own practice patterns and determine what we can do to help reduce the tide of opioid addiction. Each prescription we write should be given careful consideration after we weigh the risks and benefits to the patient. Although there will always be indications for opioid pain medications, a more thoughtful and deliberate approach to how we prescribe them, when we prescribe them, who we prescribe them to, and how long we prescribe them should accompany each prescription. I look forward to seeing what types of innovation and practice adjustments will be made over the next year and whether these types of changes can reduce the burden of opioid addiction.

Zachary Hartsell is program director and vice chair of operations and workforce development and an associate professor in the PA program at Wake Forest University in Winston-Salem, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.       


REFERENCES
1. Reed H. Addicted to blame. JAAPA. 2016;29(8):15-16.

2. Klinger A. Opioid prescribing: a love-hate relationship. Musings. September 29, 2014. 

3. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(RR-1):1-49.

4. North Carolina Medical Board. Board adopts CDC opioid guidelines.

5. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Epub ahead of print February 14, 2017.

6. Soneji N, Clarke HA, Ko DT, Wijeysundera DN. Risks of developing persistent opioid use after major surgery. JAMA Surg. 2016;151(11):1083-1084.


 


Monday, February 6, 2017

Brian K. Yorkgitis, PA-C, DO

In 2015, the US national healthcare expenditure was $3.2 trillion, or almost $10,000 per person.1 In 2011, it was estimated that $285 to $425 billion of healthcare spending was due to failures in care delivery, coordination, or overtreatment.2 Reasons often given by clinicians for recommending low-value tests and treatments include malpractice concerns, keeping patients happy, fulfilling a patient’s request, reassuring the clinician, and not enough time with patients.

Initiatives to educate clinicians and patients have arisen to combat this issue. One of the most widespread is the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.3 The initiative was started in 2012 with Consumer Reports and includes evidence-based recommendations that providers and patients should discuss—specifically, when tests and procedures are appropriate. Since the campaign’s inception, more than 70 medical societies contributed to lists of more than 450 unnecessary tests and treatments. Common problems physician assistants (PAs) face in clinical practice are included in the campaign. The evidence-based recommendations range from pediatrics to geriatrics and from preventive medicine to disease management.4

Looking closer into the Choosing Wisely campaign at a frequent care issue, antibiotic use, I found 28 recommendations from almost 20 professional societies. Sinusitis and otitis, common ailments that PAs evaluate and treat, appear seven times. With the growth in adverse reactions (including Clostridium difficile infections and antibiotic resistance) from inappropriate antibiotic prescriptions, the medical community is tackling the issue through evidence-based recommendations. The CDC estimates one in three antibiotic prescriptions are unnecessary.5

Although these recommendations exist, implementation remains a challenge. A 2014 survey found that only 21% of physicians were aware of the Choosing Wisely campaign.6 Of these physicians, only 62% reported efforts to reduce unnecessary services. We as a medical community must educate each other on the body of literature that exists to reduce waste and harm.

The next challenge is implementing high-value, evidence-based healthcare. I urge PAs to review the Choosing Wisely recommendations on issues that you routinely encounter in your clinical practice. Think critically each time your order a test or treatment. Is it supported by the literature? Talk to your patient about the campaign and empower them to partner with you in their care. The final challenge is for PAs to come together to produce a set of recommendations as a profession to submit to the Choosing Wisely campaign.

REFERENCES
1. Center for Medicare and Medicaid Services. National Health Expenditures 2015 Highlights.

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(4):1513-1516.

3. American Board of Internal Medicine. Unnecessary tests and procedures in the health care system.

4. ABIM Foundation. Choosing Wisely.

5. Centers for Disease Control and Prevention. CDC: 1 in 3 antibiotic prescriptions unnecessary.

6. ABIM Foundation. Survey: physicians are aware that many medical tests and procedures are unnecessary, see themselves as solution.

Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Tuesday, January 24, 2017

Richard W. Dehn, MPA, PA-C, DFAAPA

As this blog is being written, Congress and the President-elect are preparing to defund key components of the Affordable Care Act (ACA), which would cripple major parts of the legislation and lead to substantial changes to the American healthcare delivery system. The current plan is to defund the financial underpinnings of the ACA using the budget reconciliation process, and eventually replace it at some time in the future with an undetermined alternative. Whether this will actually happen is difficult to predict but let’s assume for the moment this is indeed future course of events.

The most likely first action aimed at repealing the ACA will be the elimination of the taxes and other revenue sources that are fundamental to the ACA’s operations. These revenue streams fund two major pillars of the ACA: subsidies that make it possible for many Americans to buy health insurance plans, and the federal funding that gave the states the ability to greatly expand the number of patients covered by Medicaid. Current projections in the news media estimate that this action alone will result in a loss of health insurance for 20 million Americans who recently had gained it. JAAPA published an editorial by Editor-in-Chief Reamer L. Bushardt, PharmD, PA-C, DFAAPA,  that covers the nuts and bolts of what the repeal of the ACA might entail. If you haven’t read it, I highly suggest you do.

The PA profession has experienced remarkable and consistent growth over the last two decades. In fact, since the 1970s, there have been only two notable time periods where growth in the profession was not vigorous. The first occurred beginning in 1980 with the release of the Graduate Medical Education National Advisory Committee (GMENAC) report that predicted physician surpluses. That period lasted until the managed care delivery model gained popularity among third-party payers beginning in the late 1980s. The second occurred in the late 1990s, and was shorter in duration with less effect than its predecessor. My opinion was that it was caused by provider geographic maldistribution and provider demand changes resulting from the managed care funding model reaching a critical mass that produced reduced provider demand. The GMENAC years were notable in that the report caused a retrenchment in all medical education (including reductions in medical school and GME enrollment) such that it was common to hear discussions of whether the PA profession had a future. No data are available from that time that would address PA supply and demand or salaries; however, during this time, PA enrollment was flat and almost no new PA programs were established.1 In contrast, the stagnant PA demand period of the late 1990s was very mild, at most lasting only a few years, mostly occurred only on the East Coast, affected primarily new graduates and those changing jobs who were unwilling or unable to move to new geographic locations, didn’t affect PA program or enrollment growth, and resulted only in stagnant growth in new graduates’ starting salaries from 1997-1998.2

Multiple factors obviously account for the profession’s impressive growth over the last two decades—the emergence of healthcare teams, increasing demand for healthcare from an aging population, and an increase in the expectation that citizens have a right to healthcare. Since the mid-1990s, there has been a persistent interest in increasing the number of PA programs and students, mostly by educational institutions that have noticed the profession’s growth and the societal factors driving it. In the last decade, many other healthcare professions have observed these factors and also concluded that more providers are needed. Allopathic and osteopathic medical schools and NP programs have also increased in number and enrollment. With the election of Barack Obama in 2008, the consensus was that healthcare would be reformed with a system that would provide medical care for most of those uninsured at the time, and that this was simply going to be yet another huge factor that would require an even bigger future medical workforce. Over the last 8 years, I have spoken to dozens of educational and healthcare system administrators who indicated that from their perspective they saw no end to the future demand for healthcare providers, and in particular PAs.

However, even before the 2016 election, some had begun to predict an end to current high demand for healthcare providers. Medical schools, PA programs, and NP programs have experienced problems providing clinical training sites for increasing enrollment, indicating that there is likely a ceiling to the student capacity of the current healthcare delivery system. Additionally, some workforce experts had begun to publish warnings of an impending surplus of providers—these two articles were written and published before the 2016 election, when repeal of the ACA was considered unlikely by most.3,4

Over the last 6 years, the healthcare industry has been ramping up to provide for patients using the ACA as a blueprint—in fact, vast amounts of money have been invested in a long-term effort to reshape the American healthcare delivery system. Now, many of these investments could be abandoned before being completed. The exit of 20 million patients from the healthcare delivery system will be a substantial event with many unpredictable and likely unintended consequences. Of course, from our pre-ACA experience we know that some of these patients won’t really exit the healthcare system; they will just end up in the ED. Any many will just simply avoid seeking care as long as possible. So, primary care clinics will need fewer providers, as will many areas of hospital care. However, a boom is likely in emergency medicine jobs. With substantially fewer patients in the system overall, however, the number of providers needed probably will decrease, and this decrease could happen relatively quickly as demand rapidly diminishes in response to patients losing their healthcare coverage.

I’m of the opinion that our education systems were on track to meet and possibly exceed the need for healthcare providers sometime in the next 5 years. I anticipated that the increasing scarcity of clinical training sites would be the limiting variable that would modulate the current enrollment growth to eventually adjust to the supply-demand curve of the future. Now, considering the unexpected factor of the defunding and repeal of the ACA following the 2016 election, demand for medical providers may actually suddenly decrease, moving the point of market saturation closer to the present. Could the PA profession be facing its third period of growth retrenchment?

REFERENCES
1. Simon A, Link M, Miko A. Thirteenth Annual Report on Physician Assistant Educational Programs in the United States, 1996-97. Association of Physician Assistant Programs, May 1997.

2. Simon A, Link M, Miko A. Fifteenth Annual Report on Physician Assistant Educational Programs in the United States, 1998-99. Association of Physician Assistant Programs, May 1999.

3. Salsberg E, Quigley L. Are we facing a physician assistant surplus? JAAPA. 2016;29(11):40-44.

4. Hooker RS. When will physician assistant supply exceed demand? JAAPA. 2016;29(11):10-12.

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.


Monday, January 9, 2017

Steve Wilson, PA-C      

It’s over. The inflection of the voice establishes the context of that phrase. It can be a response to acceptance, relief, or finality. It is possible to experience all three emotions at the same time. I just had that experience. With a click of the mouse on the NCCPA website, I learned that I had passed the PARNE one more time. More importantly, I had passed it for the last time. After more than 40 years in the process, I can’t imagine that I shall need to return to that examination booth again 11 years from now. 40 years in surgery but certified in primary care….

I have sat for PANRE every 6 years since 1975. This time, given all of the future uncertainty of the examination process, I took it a year early. I have never looked at the recertification as anything more than a process required to provide some assurance about my continued cerebral function to those who do not work directly with me and who spend their day in an administrative office. I never believed that it measured my competency. I certainly never felt it provided me with any useful information about necessary medical knowledge. I know that having passed it meant nothing to my patients. To me, it has always been a hoop through which to jump.

Don’t get me wrong. I had anxiety about taking it. I believe it was in 1987 and well into my surgical career that I sat for the examination and encountered questions about a problem called Lyme disease. It was after that examination that I decided that maybe I should really do some studying before the examination. One year, I went to a review course. I decided that it really did not help me much. It was before the “blueprint,” and some of the lectures provided up-to-date information instead of information that was 2 to 3 years old (examination questions are notoriously out of date). I started buying review books after that and this year I downloaded a review course. These were very helpful and could be easily managed for the 4 weeks of review I committed to before each examination. Of course, with this cavalier attitude, you would imagine that at some point I would slip up. Well, I did—but I didn’t. I was one of many PAs in 2011 who suffered due to the grading debacle at the NCCPA. I can tell you that receiving notice that I had failed, only to learn several weeks later that “oops, we made a mistake,” is not the examination experience you want late in your career. I was a little surprised that I did not hear about lawsuits against the NCCPA after that, but I guess we were all just relieved that we got another 6 years.

After sitting for all of these examinations, one thing is for sure: I am in complete awe of anyone who has worked in primary care. You have to know a lot, according to the examination. I remember early on actually getting feedback from the commission after the examination: “Dear Mr. Wilson: You have successfully completed the recertification exam. We would recommend remediation in pediatrics, ob-gyn, and psychiatry.” I suppose that reading up on those topics may have been helpful to me, but having dedicated myself to surgery, I have never looked in a child’s ear or estimated the age of a fetus, and I haven’t helped someone with bulimia since PA school. On the other hand, maybe I should be concerned about my knowledge base because the examination, according to some information, is supposed to contain information that all PAs should know. That is why we are so flexible in moving from one area of medicine to another.

I am told that, as PAs, we change our areas of practice a lot and frequently move from one specialty to another unrelated specialty. This surprises me. I can see going from general surgery to cardiac surgery— like I did, or from primary care to emergency medicine, but I have always had a difficult time imagining transitioning from pediatrics to neurosurgery. Maybe pediatric neurosurgery? As you know, there has been movement over the last few years to develop a more meaningful process that actually addresses the educational needs of PAs who practice in specialties. The amount of work necessary to accomplish the recertification process, the expense, the career threat to those who do not complete all of the requirements, the potential of specialty certification pigeonholing us into specific career paths, as well as reimbursement ramifications, has met with resistance by the profession. The NCCPA blinked— they’re doing more research, but still plan to change the PANRE steadily over the next several years. However, I can’t say that I disagree with all that the NCCPA was proposing.

Granted, I have always been skeptical that the recertification process was more relevant to academia than clinical practice, but some of their recent proposals have merit. We should be required to demonstrate a level of medical knowledge that is consistent with our area of clinical practice. Hopefully, there are enough of us now in different specialties that it is cost-effective for the NCCPA to address these areas through a meaningful continued educational process rather than a punitive examination. Otherwise, we are only kidding ourselves, the public, and our employers as to our maintenance of medical knowledge that is relevant to the patient population we serve. I am a perfect case in point. Although it is nice to believe that I could now give up the long hours in surgery and after-hours call for a nice 9-to-5 job in dermatology, I would suggest that if you should ever find yourself with me assessing your regular-irregular-raised-smooth-discolored-uniform-itchy-blancing lesion, please know that I will be more interested in cutting it out for pathologic evaluation than reviewing the differential diagnosis for such a lesion. But, as I mentioned, none of this matters to me anymore. I feel safe in my knowledge base after passing my last PANRE. Should the next patient I meet in the OR have the first case of Peyronie disease I have ever seen, my recent examination certifies that I know which layer of tissue is involved. I will also know to call the PA in urology. I leave it to my colleagues and my hospital’s medical staff to determine whether I am knowledgeable enough to address a patient with a falling pH and rising inotropic support postop coronary artery bypass.

I jumped through the hoop and never got burned.

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.


Friday, December 23, 2016

Jennifer M. Coombs, PhD, PA-C

In 2014, I wrote a Kevin MD article, “5 predictions for physician assistants in the era of healthcare reform.” What a difference 2.5 years makes. We now have healthcare reform whiplash, as the Republicans will surely repeal the Affordable Care Act as we know it, replacing it with an as-of-yet undetermined plan. What can this end of the year bring in terms of predictions for PAs? The PA profession is turning 50. Born out of a time of great change (the Vietnam War) in the 1960s, the profession was nurtured by visionaries, leaders, and great reformers in medicine. What will the next 50 years bring? I’ll be 100 years old then, so for purposes of prediction, I’ll stick to 5 years in the future.

PAs will experience continued unprecedented growth, based on the number of new programs, now 218. Looking ahead, there are potentially 32 additional new programs in the works. It does appear that new programs will continue to be accredited or that many, if any, established programs will shut down. The resources to negotiate new program expansion are, if not unlimited,  adequate to help these programs sustain themselves. Certainly charging a substantial tuition does not hurt, and the students and their graduate school debt appear for now to be vast.1
PAs will eventually oversupply the profession, but not soon, and not enormously.2,3 Demand for healthcare workers is hard to estimate.  Supply is an easier target to predict, although healthcare researchers have made erroneous predictions in the past. Making predictions about the number of clinicians necessary in the workforce is clouded by the fact that the variables are constantly changing.  Certainly healthcare reform is one variable that has been completely unpredictable, but there are other variables as well. Technology has been nearly impossible to factor into productivity. Ten to 15 years ago, the prediction was that electronic medical records (EMRs) would make physicians, PAs, and NPs immensely productive. Instead, we spent years as highly paid typists filling in colossally ill-designed records. This will change, but how to factor productivity into supply models is yet unreliable. One thing that is sure is that the population is in need of healthcare, and the country has pockets of gross undersupply, such as rural areas and inner cities. This may be job security for PAs interested in filling these gaps.
PA practices will expand in practice authority but will never give up their relationship with physicians. The names may change—supervision, collaboration—but the basic unassailable fact is that PAs work with physicians, day in, day out, for the good of the patient, the good of the practice, and the good of the profession.
Sexism in medicine will end with changes in value and in the hierarchical educational structure. Teams are the safest way to take care of patients, and PAs, NPs, and physicians will work more efficiently and collaboratively in the future. The mothers and grandmothers who are now housestaff in large enough numbers mean that the demeaning and sexist training is a thing of the past. Have female PAs largely skipped over the horrors of the belittlement, shaming, and outright sexual harassment of the past? Being pregnant during training and raising children while practicing full-time will never be easy. There is still a huge pay gap to overcome. There are self-doubts and outright lack of family and society support for women who decide to focus on careers. There is still a sexist and bullying culture to hold the line against; young women will still be doubted for being full-time workers and not full-time mothers, but things are slowly changing. The “on ramps” and “off ramps” for women to work part-time or work at home for periods of time will need to be expanded. Childcare and elder care solutions need to be available for everyone. Fair and adequate maternity and paternity leave policies are needed to support new parents.
The PA profession will not become more diverse, but will continue the trend toward well-educated white women in the workplace. Efforts must be made to reach out to qualified diverse potential PAs. This is a tremendous opportunity to look like we as a profession should look, given our mission for social good. Social justice, the good that we can do as PAs, should be the pride of our professional identity.  A diverse and inclusive profession will benefit society, and is our raison d'être. However, with the cost of undergraduate education, out of reach for many, this many not change quickly.
The American Academy of PAs and the National Commission on the Certification of PAs will continue to fight about absolutely nothing. Like siblings, these two important organizations will vie for our attention. Like little children, they will fight over who is loved most, who matters most, and who can get our money. The siblings only grow up to be able to hurt each other more and get into bigger arguments. The irony is, just like grown children, we love them both for what they bring to the table, and their own unique talents. But somehow the setup for fighting is too much for them to resist. The leadership can’t contain the odd feelings of jealousy, and the only question is who will play the role of Cain and who will be Abel.

I hope to look back at my predications again, in a few years and see where I was too bold or not bold enough in my future predictions. As our profession turns 50, and healthcare providers collectively look forward, I do feel the future is bright. 

REFERENCES
1. Snyder J, Nehrenz G, Danielsen R, Pedersen D. Educational debt: does it have an influence on initial job location and specialty choice? J Physician Assist Educ. 2014;25(4):39-42.

2. Salsberg E, Quigley L. Are we facing a physician assistant surplus? JAAPA. 2016;29(11):40-44.

3. Hooker RS. When will physician assistant supply exceed demand? JAAPA. 2016;29(11):10-12.

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.