Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

Monday, November 13, 2017

Brian T. Maurer, PA-C

My eldest son turned 40 this year. We celebrated his first birthday midway through the first year of my PA program. I graduated back in 1979; currently, I’m ticking off the months in my 38th year of practice.

Throughout this year, in the pages of JAAPA, we have been celebrating the 50th anniversary of the PA profession. Be they birthdays, graduation days, or anniversaries, we tend to measure our lives by milestones, those significant dates and times that help to define who we are and give meaning to our existence.

When I graduated from the Hahnemann PA program (now defunct, subsumed into Drexel some time ago), there were less than 9,000 PAs practicing in the country. This year, our ranks have swelled to more than 115,000 PAs in clinical practice—and counting. Once considered a fringe experiment designed to improve access to primary care in the United States, the PA concept has morphed into a bona fide profession recognized by the medical establishment, third-party payers, federal and state governments, and the pharmaceutical industry. PA practice has also expanded exponentially in depth and scope over the course of my professional career.

In its relatively young life, our profession has experienced significant growing pains, gains and setbacks. Largely through grassroots efforts sustained over the lean years of the 1980s, we have managed to survive and flourish.

Newly graduated PAs continue to receive excellent training. Good-paying jobs are plentiful. Yet student debt remains at an all-time high. Today’s PA students sink more than $100,000 into their education—small wonder that new grads tend to seek out more lucrative positions in the medical and surgical subspecialties, with fewer and fewer opting for careers in primary care.

As a PA who has practiced pediatric medicine for most of my career, I find myself once again in the minority. Fewer than 3% of all PAs opt for a career in pediatrics. In my current position, I actually earn less than most new graduates, but making money was never my primary professional goal. I have devoted my career to the pursuit of humane medical practice through the art of medicine, striving to focus on the patient as person, not as a disease entity or diagnosis. You could say that I’ve been grandfathered in as a bit of an odd duck, part of a profession that at one time had been viewed as somewhat of an odd duck itself.

My youngest grandchild just turned 6 months old. By virtue of his birth I have once again been grandfathered in—another milestone of sorts, imparting some semblance of meaning in this life through my role as father, grandfather, and pediatric PA.

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.
 


Monday, October 23, 2017

Harrison Reed, MMSc, PA-C

If you want to meet colorful characters in medicine, look no further than Jorge Muniz, PA-C. The Florida-based PA has parlayed a love of Saturday morning cartoons into an emerging force in medical education. His signature creation, Medcomic, uses eye-catching comics to illustrate core medical topics and has found an audience with medical professionals around the world.

Muniz represents a growing sect of PAs eager to engage the medical community outside of clinical practice. He hopes the broad appeal of Medcomic will bring additional attention to the profession.

“If you create something that’s very accessible to a wide group, whether it be nurses, medical students, PA students, EMTs—and you have an international medical audience, too—it kind of helps spread the PA profession in a positive way,” he said. “I’m trying to make the PA profession a little more known.”

Muniz’s first book, an independently funded Kickstarter venture, has shipped as far away as Australia. But he hasn’t let the success of his freshman venture—or a massive social media following—satiate his appetite for art. He published a second edition of the Medcomic book earlier this year and is now hard at work on his next project.

The upcoming Medcomic endeavor will use Muniz’s signature style to break into a new educational niche: ECG interpretation. Muniz says it will feature the lead character Sparkson, “an electrical impulse that guides the readers on an adventure in electrophysiology.” He plans to release the book in 2018.

You can find more of Muniz’s work on his website and on the cover of the November issue of JAAPA.

Harrison Reed practices critical care medicine at the University of Maryland Medical Center’s R. Adams Cowley Shock Trauma Center in Baltimore, Md., is an adjunct instructor in the School of Medicine and Health Sciences at George Washington University in Washington, D.C., and is associate editor of JAAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, October 16, 2017

Steve Wilson, PA-C

I was doing some online stuff when I saw that Bill Gates had released his summer reading list. Bill and I are tight. We went to different schools together. So, I decided to see what his interest might be. Turns out that one of the books on his list was Hillbilly Elegy by JD Vance. It is a memoir of a family and his description of a culture in crisis. Now, being from West Virginia, I felt I knew a thing or two about hillbillies. One of my brothers married a McCoy and it was great! She could make homemade doughnuts that are still part of my lipid profile. In fact, hillbilly was one of my passwords until I got hacked. Who knew that cyber criminals would know about being a hillbilly? So, I was about to purchase the book when another brother sent it to me (there were three of us.) He’s a hillbilly also. He and Bill rode different buses.

The story takes place in Middletown, Ohio, between Cincinnati and Dayton and about 156 miles from where I grew up. The hillbillies Vance talks about were actually from Kentucky. Makes sense to me. I was only 171 miles from Lexington, Ky. The Ohio, West Virginia, and Kentucky borders come together at the tristate area of Ironton, Ohio; Huntington, W.Va., and Ashland, Ky., less than an hour from my home. Never thought of being a hillbilly outside of West Virginia, but I’ll give him some literary license. Besides, I often refer to myself as a hillbilly but as my wife often corrects, I was born in Ohio—a Buckeye, as my The Ohio State University alumnus son loves to point out. There were no hospitals in my hometown and my parents drove over the Ohio River to the nearest hospital to welcome this treasure of their life.

So, it turns out that this book is about rising out of the ashes of working-class destitude. I am not sure if it is any different for blacks or whites, but this book is about low-income white families. The story is complex. It revolves around a gun-toting grandmother, an intelligent grandfather, a dependent mother, an absent father, loving strong sister, various degrees of family support, and the success of an individual beyond the expected means due to unconditional love and strong family values, however flawed. Added to this is the military and teachers/professors who met the author’s need for support and direction and encouraged his potential. It is a tragically happy story. But it really opens the debate about what needs to be done to solve the issues of those less fortunate than us. The writer recognizes the flaw in government subsidies but acknowledges their necessity while noting the need to address both issues differently. The author acknowledges that every single person in his family who built a successful home married someone from outside their culture. He felt those members of his family experienced life outside of less-than-desirable circumstances. Maybe they had experienced a cultural diversity beyond their hometown. He acknowledges in the end that we must stop blaming Obama or Bush or faceless companies and ask ourselves what we can do to make things better. He was clear that society in general needs to stop looking at government to fix their problems and need to stop blaming others for their or their children’s problems.

To me, the family unit is the basis of all of these issues. Disruption of family at any level has repercussions throughout the social spectrum. As this book points out, family in any form can produce positive results. The author noted that statistics demonstrated that even single-parent homes produced better outcomes than multiple disrupted family scenarios. How we identify and support that unit is the determining factor toward societal gains vs. personal loses. Enabling continued failure should be addressed. The book is a great sociologic study. We may never solve all the issues expressed in this book, but maybe taking the advice of someone who has been through it would prove more valuable than making programs we think should work.

I would love to know Bill’s review of the book. Maybe I should give him a call….

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.


Monday, October 2, 2017

Amy K. Maurer, MMSc, PA-C

My heart was warmed when my mother told me that my stepfather, Bob, asked her if the PA program would consider admitting a 65-year-old man, meaning himself, as they were driving home from my white coat ceremony at Wake Forest School of Medicine in June 2009. I suspect that he was only half-joking because he was extremely excited after seeing just a glimpse of the opportunities to learn and grow through my PA education and career. As I reflect upon the 50-year history of the PA profession, I realized how close my stepfather was to being among the first PAs who embarked on their careers 50 years ago this month.

(Left, Bob Kendall and Amy Maurer at her PA program hooding ceremony before her graduation on May 16, 2011.)

Eugene A. Stead, Jr., MD, launched the first PA program at Duke University, admitting four former Navy medical corpsmen in 1965. At that time, Bob was 21 years old and planned to pursue a career in respiratory therapy, but the Vietnam War changed his plans. Although he was at the upper limit for age to be drafted into the military, his birthdate resulted in a low sequence number. Knowing that the draft was imminent but wanting some choice as to where he served, Bob enlisted in the US Coast Guard in 1965 with the hope of remaining close to the medical field. He completed the rigorous basic training program required of all servicemen and women and was selected to be a medical corpsman. In 1966, Bob obtained medical training at the Coast Guard Academy in New London, Conn. In 1967, when three of the four Navy corpsmen graduated from Duke, Bob began his work staffing the Coast Guard clinic in Boston, Mass., while preparing to be sent overseas. In late 1967, he was the first medical corpsman stationed in a remote area of Spain known as Estaca de Vares. He was to be the sole medical provider for the 12 other guardsmen and three Spanish civilians staffing the LORAN (Long Range Aid to Navigation) station. When he arrived, he found a sparse clinic supplied with only bandages and aspirin. Shortly after his arrival, one patient was intoxicated and stabbed another one in the hand. Because the suturing supplies had not arrived, Bob had to approximate the wound with tape and was able to achieve a favorable result. Over the next 12 months, he established the clinic through efforts to stock antibiotics, more medical equipment, and even an autoclave.

(Left, Bob Kendall, fourth from right in the second row, with his commanding officer on his right and his fellow Coast Guardsmen at Estaca de Vares, Spain, circa 1967.)

When Bob returned to the United States in 1969, he was stationed in Elizabeth City, N.C., not far from Durham and Duke University and within 300 miles of the PA program established that same year at my alma mater. Bob was honorably discharged from the Coast Guard and moved on with his life by returning to his hometown of Youngstown, Ohio.

Bob did not hear about the PA profession until the 1990s. When I heard that corpsmen were among the founding fathers of our profession, I recalled that Bob had filled that very role in his service to our country. In time, I realized how Bob would have been so well-suited to be among those first PAs. My father passed away when I was young and Bob became a part of my life when I was about 8 years old. During those years, Bob told my sister and me stories about caring for an intoxicated man who presented after trying to drink “one bottle of everything” and sustained multiple facial injuries due to repeated falls. The patient could not figure out why the sidewalk kept rising to hit him in the face. He spoke about a different man who presented with a nearly-amputated ear who had been ejected from his car in an accident because he was not wearing a seatbelt. Before Bob sutured his ear back in place, the patient declined his offer of local anesthetic, insisting that he did not need it, but winced and jumped each time the suturing needle penetrated his skin while continuing to refuse analgesia. It took 43 stitches to reattach his ear. He also shared the story about a serviceman who became psychotic and suicidal on a Coast Guard cutter at sea while on a mission to Antarctica. Bob had to work with five other men to subdue this patient for transport back to the United States for treatment. He had to administer chlorpromazine and remain awake during the long return air trip from the southern tip of South America because there was concern that the patient might attempt to jump out of the aircraft. During the patient’s lucid moments, Bob learned that this serviceman had sold back his leave to financially support his family back home and had not seen his family for 18 months. This, along with prolonged periods at sea, likely contributed to his very unstable condition.

Bob was resourceful, persistent, well-trained, and compassionate to those who were suffering. These stories captivated me and helped pique my interest in medicine. My passion for medicine sustained me educationally and vocationally on my indirect route to becoming a certified PA. One’s career is not exclusively dependent on our own volition, ambition, dedication, or intellect even in the United States, the so-called “land of opportunity.” Sometimes, it also requires one to be in the right place at the right time.

Bob is now 73 years old and PA school is most likely no longer an option for him, but he has had a lifetime of diligent, respectable, altruistic work performed with integrity to look back on. Nevertheless, he retains many of the qualities that make a great PA, including compassion, integrity, and persistence. Becausde he never had the opportunity to be a PA, I hope that my work is a reflection of the values he instilled in me and that my vocation brings him a sense of pride for being the great influence and ardent supporter that he has been in my life.

Our 50th anniversary as a profession is one replete with opportunities: the opportunity to pursue the ideals embodied by the pioneering PAs as we continue to practice medicine in the ever-changing 21st century, the opportunity to serve our communities as the best PAs possible as a testament to the fine PAs and physicians who helped us achieve our goals, and the opportunity to reflect upon how far the profession has come since 1967 while framing our vision for the future. Many people who have not and will likely never receive the opportunity to become a PA or another healthcare professional have inspired us on our journey and invested themselves in our lives in innumerable ways. They seized the opportunity to support us, encourage us, and let us know that the work we do matters. In honor of all of those who have made us who we are personally and professionally, let’s boldly enter the PA profession’s next 50 years, serving our patients well and investing ourselves in the next generation of PAs.

Amy K. Maurer practices at Wake Forest Baptist Health’s Family Medicine-Reynolda in Winston-Salem, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

 


Monday, September 18, 2017

Elyse J. Watkins, DHSc, PA-C; Sheri Lim, DO

Fifteen years have passed since the preliminary results of the Women’s Health Initiative (WHI) upended the hormone replacement recommendations for menopausal symptom management. PAs in primary care and women’s health are at the forefront of recognizing and providing care for women with both vasomotor and vaginal complaints attributed to either natural or surgical menopause. Understanding the history and continued challenges with hormone replacement therapy is important.

In 1991, the National Institutes of Health (NIH) launched the landmark WHI to assess quality of life and major causes of death and disability in postmenopausal women.1 The study was designed to specifically address cardiovascular disease, osteoporosis, colorectal and breast cancer, and the role of hormone therapy in the prevention of these diseases. The three key components were a double-blind, placebo-controlled randomized controlled clinical trial, a community prevention study, and an observational study.

The clinical trial, which enrolled more than 68,000 women ages 50 to 79 years, had three arms: hormone therapy with conjugated equine estrogen and/or medroxyprogesterone acetate, dietary modifications, and calcium/vitamin D supplementation. Women had the option of enrolling in one or all three study arms.1

The community prevention study specifically addressed community-based healthful behavior modification strategies at 11 CDC-funded university-based prevention research centers across the country. It was designed to assess behavior change and disease prevention predominantly among black women.1

The observational study was offered to women who were ineligible for the clinical trial. This study included almost 94,000 women and sought to identify risk factors and biologic markers for disease. The study gave the researchers a population to compare with the clinical trial findings and let them further stratify the population by sociodemographics.1

The clinical trial
Women without a uterus were given either conjugated equine estrogen 0.625 mg every day or a placebo. Women with a uterus were given the same estrogen plus medroxyprogesterone acetate 2.5 mg every day or a placebo. In 2002, the NIH stopped the estrogen plus progestin arm of the study due to concerns about safety. Women taking conjugated equine estrogen and medroxyprogesterone acetate had an increased risk of myocardial events, cerebrovascular events, peripheral thrombotic events, breast cancer, and dementia. In early 2004, the NIH stopped the estrogen without progestin arm of the study due to safety concerns. Women taking conjugated equine estrogens had significantly higher rates of cerebrovascular events and peripheral thrombotic events. However, women taking estrogen had a decreased risk of fracture, but a negligible effect on colorectal or breast cancer.

The fallout
When the findings of the study were released to the public, many PAs and physicians were met with angry and confused patients. Many women abruptly stopped their hormone therapy. Some of us who were working in women’s health asked our office staff to identify all patients on hormone therapy and requested that they come in for an appointment to discuss stopping therapy. The pharmaceutical salespeople representing the estrogen used in the clinical trial were scrambling to maintain a sense of order and actively engaging in damage control. The effects of this pivotal moment in women’s health are still being felt by many prescribers and patients today with continued confusion of the treatment of menopausal symptoms and the role of hormone therapy.

Jewitt and colleagues quantified prescribing patterns after the WHI.2 They analyzed data regarding estrogen plus progestin use from the National Health and Nutrition Examination Survey and the National Prescription Audit 1970-2003. The authors found that estrogen and progestin use tripled in the 1980s compared with the 1970s. Hormone therapy use among women ages 45 to 64 years peaked in 1999 at almost 14%. However, after the WHI, use of hormone therapy in this age group declined to 2.7%. These statistics illustrate the effect of the WHI on hormone therapy prescribing practices across the United States.

Where are we now?
In 2016, deVilliers and colleagues summarized updated guidelines from a 2013 Global Consensus on Menopausal Hormone Therapy paper written by several international menopause and osteoporosis professional organizations.3 This new guideline summarizes the current state of the evidence and offers prescribers a concise guide to hormone therapy. It also allows providers to relay current, evidence-based information to their patients so that they can make informed decisions about whether to use hormone therapy.

Summary of the evidence
The consensus is that the benefits of estrogen therapy are likely to outweigh risks if estrogen therapy is initiated within 10 years of menopause or by age 60 years.4-6 However, the addition of a progestin to an estrogen regimen reveals a less robust benefit.3 A progestin is required in a women with an intact uterus if she is to take oral or transdermal estrogens to decrease the risk of endometrial hyperplasia. Data indicate that women who take estrogen and progestin in a combined hormone regimen have a statistically significant increased risk for breast cancer and thromboembolic events. Use of estrogen alone does not increase the overall risk for breast cancer, but the addition of medroxyprogesterone (the progestin used in the WHI), increases the overall risk, independent of age at initiation of hormone therapy. An increased risk for the development of cardiovascular disease in combined regimens was not statistically significant.7 Women with a lower baseline risk of cardiovascular disease also appear to benefit more from hormone therapy.5 Women who have risk factors for heart disease, thrombotic events, and breast cancer must be assessed individually with careful attention paid to modifiable risk factors and patient expectations.

Treatment strategies
Healthcare providers are advised to use the lowest dose to achieve maximal effectiveness in patients opting to use hormone therapy, and to use FDA-approved products that have undergone rigorous safety and efficacy testing. As such, individually compounded hormone regimens, including those that use micronized progesterone and/or estradiol, are not recommended due to concerns about potency, purity, and variability in bioavailability.4 The current recommendation based upon the most recent evidence about treatment duration is to use estrogen with progestin for no more than 5 years, and estrogen alone for no more than 10 years.3 Transdermal hormone therapy may offer a lower risk of thromboembolic events, including stroke.3 Women with symptomatic vulvovaginal atrophy with little or no vasomotor symptoms should be treated with nonhormonal lubricants first. If this therapy fails to ameliorate symptoms, patients should be offered treatment with topical vaginal estrogen.7 Available vaginal agents include creams, gels, rings, and pellets. Women with a uterus who use vaginal estrogens do not require progestin therapy. Systemic estrogen for women with vulvovaginal symptoms should only be considered if vasomotor symptoms occur as well.      

Overall quality of life, such as mood, sleep, and sexual function, may improve with hormone therapy. Estrogen may provide a benefit for early postmenopausal women experiencing depression and anxiety but antidepressant therapy is still first-line treatment for mood disorders.4-6 The antidepressants most often used are selective serotonin reuptake inhibitors and norepinephrine-serotonin reuptake inhibitors. In a study by Yaday and Volkar, gabapentin reduced menopausal hot flashes and nighttime awakenings.8

Menopausal hormone therapy is the only intervention that reduces post-menopausal hip and vertebral fractures, including in women with preexisting osteopenia. In women age 60 years and older, hormone therapy is considered second-line therapy for fracture prevention. Bisphosphonates are still first-line pharmacologic options for the prevention of osteoporotic fractures in postmenopausal women considered to be at high risk for a fracture per the National Osteoporosis Foundation guidelines.9

Cardioprotection may occur when estrogen alone is used within 10 years of menopause and among women younger than age 60 years. Data suggest that estrogen use in this population may decrease the risk of myocardial infarction and all-cause mortality but the US Preventive Services Task Force advises against using hormone therapy for cardiovascular disease prevention.3,6,10 Estrogen plus progestin in women within 10 years of menopause and younger than age 60 years reveals less compelling evidence of benefit.

Premature ovarian failure and surgical menopause
Women who undergo premature ovarian failure and surgical menopause before age 40 years have an increased risk of adverse cardiovascular events and osteoporosis.4-6 The addition of estrogen for these women has been shown to mitigate these risks. However, women with premature ovarian failure who still have a uterus will need treatment with a progestin in addition to estrogen to help prevent endometrial hyperplasia. Use of estrogen in women with premature ovarian failure has not shown an overall reduction in risk of dementia, but further studies may help elucidate this relationship. Hormone therapy for these women should be prescribed until about age 50 years, the average age of menopause. Longer duration of therapy requires individualized assessment not only of risks, but symptom severity. Patient preference and expectations must also be taken into account.

Alternatives for menopausal symptoms
Level A recommendations for prescription alternatives to hormone therapy include selective serotonin reuptake inhibitors and norepinephrine inhibitors, gabapentin, and ospemifene. Paroxetine is the only FDA-approved nonhormonal intervention indicated for relief of vasomotor symptoms. Ospemifene, an oral selective estrogen receptor modulator, is approved for postmenopausal moderate-to-severe dyspareunia but not vasomotor symptoms.4 In late 2016, the FDA approved the use of a dehydroepiandrosterone (DHEA) vaginal suppository for menopausal dyspareunia due to vaginal and/or vulvar atrophy.11

All women should be counseled with respect to achieving or maintaining a healthful weight, obtaining adequate exercise, stopping tobacco use, minimizing alcohol consumption, and preserving a positive quality of life. Some women may ask about complementary and alternative therapies, such as acupuncture and nutriceuticals, but there is no clear evidence to recommend for or against the use of these therapies.

Conclusion
Women younger than age 60 years who are within 10 years of menopause and are experiencing moderate to severe symptoms of menopause, such as hot flashes, may benefit from hormone therapy. Women desiring hormone therapy should use the lowest effective dose for the shortest duration of time to relieve symptoms. Women experiencing only vaginal symptoms should receive topical vaginal estrogen if lubricants fail to relieve symptoms.

Therapy should be individualized and consideration given to individual risk factors and expectations for quality of life. The route of administration and duration of treatment should align with the patient’s baseline risk assessment after a careful analysis of risk and benefit as well as patient preference. Lastly, hormone therapy should not be used solely for the prevention of chronic diseases, such as cardiovascular disease or osteoporosis.

REFERENCES

1. National Institutes of Health. Women’s health initiative.

2. Jewitt PI, Gangnon RE, Trentham-Dietz A, Sprague BL. Trends of postmenopausal estrogen plus progestin prevalence in the United States between 1970 and 2010. Obstet and Gynecol. 2014;124(4): 727-733.

3. de Villiers TJ, Hall JE, Pinkerton JV, et al. Revised global consensus statement on menopausal hormone therapy. Climacteric. 2016;19(4):313-315.      

4. American College of Obstetricians and Gynecologists. Practice Bulletin: Management of menopausal symptoms. Obstet Gynecol. 2014;123(1), 202-216.

5. Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol. 2015;126(4): 859-876.

6. Moyer VA. US Preventive Services Task Force. Menopausal hormone therapy for the primary prevention of chronic conditions: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158:47-54.

7. Boardman LA. What is new in hormonal management and menopause? Best articles from the past year. Obstet Gynecol. 2014;123(3):661-663.

8. Yaday M, Volkar J. Potential role of gabapentin and extended-release gabapentin in the management of menopausal hot flashes. Int J Gen Med. 2013;6:657-664.      

9. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014;25(10):2359-2381.

10. Nabel EG. The Women's Health Initiative—a victory for women and their health. JAMA. 2013;310:1349-1250.

11. US Food and Drug Administration. FDA approves Intrarosa for postmenopausal women experiencing pain during sex.

Elyse J. Watkins and Sheri Lim are assistant professors at High Point (N.C.) University. The views expressed in this blog post are those of the authors and may not reflect AAPA policies.