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Musings: Blog of the JAAPA Editorial Board
Monday, December 15, 2014
Harrison Reed, MMSc, PA-C
 
Have you ever seen chrome rims on a hooptie? It might be a foreign concept for some, but if you went to a high school like mine, the trend was impossible to miss.
 
People in other towns may have spent their money on the typical status symbols: jewelry, designer clothes, or handbags. But in ours, any high schooler who scratched up enough dough working at Dunkin’ Donuts or Pizza Hut ran out to buy himself the shiniest set of wheels his retinas could handle. If the gaudy surface could blind a pilot at 30,000 feet, all the better.
 
These rims, however, didn’t grace the exotic imports or high-end luxury vehicles you find valeted at fancy restaurants. The expensive accessories were slapped on hoopties: cars so old and dilapidated they are held together with duct tape and optimism.
 
A hooptie owner can’t roll down the broken window at a drive-through; he opens the door. A hooptie owner avoids left turns because the blinker is more like a winker. A hooptie owner doesn’t turn the ignition without saying a little prayer.
 
If you think the shiny new parts on an archaic vehicle must look ridiculous, you’re right. Trying to cram something modern onto an obsolete frame does neither component any justice. And even though I left my hometown years ago, it’s a concept I still see every day.
 
The traditional medical training model’s roots stretch back centuries. For most of this lifespan, it served as the sole source of medical providers for the Western world. And it works.
 
That is, it functions.
 
But the healthcare workforce has evolved in the relative blink of an eye. In a single generation, new professions have emerged. Multiple disciplines collaborate to provide the care previously under the umbrella of the allopathic physician. Pharmacists, nutritionists, and physical therapists—once peripheral supporting players—are now integral to daily medical care. Physician assistants and nurse practitioners don’t just make doctors’ lives easier; they are quickly becoming an alternative option.
 
Although the PA profession is increasingly comfortable in its own skin (not to mention increasingly accepted by patients and employers alike), some settings have struggled to integrate PAs and retain their full clinical value. Academic medical centers and teaching hospitals, in particular, often misfire in their use of PAs.
 
One major flaw comes from trying to shove a PA-C into the same old machinery of the medical training model.
In some ways, it’s hard to blame them. After all, our training mirrors the schooling of medical students. My education imitated the medical school curriculum at Yale and the advantages of that parallel continue to pay dividends today. But after graduation, many medical centers attempt to place professional PAs into the mold of medical residents.
 
That move can work well at first. The inherent oversight and educational focus is often what attracts newly graduated PAs to the big institutions. But as PAs develop professionally, that grounded foundation becomes a developmental anchor. And forcing PAs into a system intended for trainees can strain professional relations.
 
The misapplication is obvious in the context of traditional academic rounds. Trainees stand and “present” a patient to a senior physician each morning. They relay pertinent events and data from the previous 24 hours. They formulate a plan and propose it and wait for the critique from the physician presiding over the team. An important distinction makes this activity very different for a trainee versus a trained professional: the attending physician is not hearing this to stay informed, but to grade the presenter’s efforts.
 
The difference is subtle but significant. In the traditional format of a patient presentation, the majority of time and energy is spent regurgitating raw information. The patient’s story is given without editorial. The physical examination is described objectively and data from laboratory tests and diagnostic imaging are served straight and cold. This puts the chore of data gathering on one party but the onus of processing it on the other. The value of the presenting clinician is reduced; his critical thinking becomes, at best, redundant and, at worst, a burden on the team.
 
This system works for trainees and students who must dance to justify the efficacy of their training. But for professional clinicians, the practice of patient presentation keeps one party in an inherently submissive position. Instead of two professionals exchanging ideas about the care of a patient, one is providing information and the other is providing the brainpower.
 
Liberating PAs from this system removes an artificial barrier between them and the physicians with whom they collaborate. Colleagues exchange information laterally, on equal levels. Abolishing the custodial tendencies of “patient presentation” allows a higher level of trust to develop. It increases two-way communication on a team. It raises the efficacy (not to mention efficiency) of a PA no longer shackled by a dilapidated training vehicle.
 
PAs who wish to practice at the top of their license cannot continue to roll along with an outdated mindset. If they do, they are just a ridiculous as a set of shiny chrome rims on a hooptie.
 
Harrison Reed practices critical care at the Cleveland Clinic in Cleveland, Ohio. Follow him on Twitter @HarrisonReedPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, December 08, 2014

Brian T. Maurer, PA-C

 

This morning I awoke with thoughts of Ariel on my mind. That’s Ariel, the red-headed little mermaid, of course.

 

Ariel sold her voice to the Sea Witch in exchange for a set of legs to let her visit the world of humans in pursuit of a prince. The problem was that when she encountered him, she had no way of speaking to him. Without a voice, she had a communication problem. And what lover ever thought to woo a beloved without whispering strings of soft, lilting, carefully chosen words of endearment?

 

Unless you happen to be a writer, the chances are fairly good that your voice is essential in your day-to-day interactions with fellow human beings. We use our voices to greet one another; we use them to talk on the telephone. In the working world, we use them to teach, to negotiate and transact business, to entertain. And in medical practice, we use our voices to interview patients, take histories, explain test results, answer questions, prognosticate—hopefully with some degree of empathy and caring in tone and timbre.

 

It’s almost impossible to practice the art of medicine without a voice. Which might be why I awoke this morning with thoughts of the little mermaid in mind.

 

Two days ago I detected a slight tightness in my throat, which gave way to soreness and cough and finally laryngitis. Every time I opened my mouth to speak, my voice would crack. It was almost as though I were passing through puberty again.

 

Losing command of your voice when you are attempting to speak with patients is embarrassing. At some point—usually rather quickly—patients suddenly realize that in all probability you are actually sicker than they are. Sometimes the empathetic shoe shifts to the other foot, and the patient offers a few soothing words of comfort and good wishes. Many patients elect to ignore the obvious, and proceed with their litany of complaints: impromptu organ recitals in the office.

 

Lying in bed this morning, I turn to check the nightstand clock to decide if I can afford to remain under these covers of comfort a bit longer before rising to face the day. I ask myself if perhaps I might consider calling in sick and while away the day on the sofa with a good book and a spot of hot tea. But my absence in the office would mean more work for my comrades-in-arms and distain from my employer, who expects all employees to be at work on time no matter what. And therein lies the dilemma.

 

Medicine is perhaps one of the few professions—indeed, perhaps the only one—where the clinician is not afforded the luxury of recuperating from illness, unless the disease is so severe as to land him or her in the hospital for an extended stay. Open heart surgery is one of the few excuses acceptable for failing to show up at the office.

 

I wonder why that is? Perhaps it has something to do with expectations early on in training; perhaps it is part of the true grit of the card-carrying clinician. We are expected to rise always above and beyond the occasion to the call of duty, no matter how poorly we feel, no matter how ill we might become.

 

I throw back the covers, swing my legs across the bed, drop my feet over the side, and ease into my slippers. I reach for the empty tea cup on the nightstand and trudge downstairs to the kitchen, fill the kettle, and put it on the back burner to boil.

 

A cup of hot tea with honey might do the trick. Perhaps my voice might return to a useful timbre before it’s time for me to slide in behind the wheel and head off to work.

 

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 author has disclosed no potential conflicts of interest, financial or otherwise. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, December 01, 2014
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE
 
My current train commute to Pace University involves joining many finely suited Wall Street types who are uniformly dozing (it is early), or reading the Wall Street Journal. If they are awake, I suspect they are planning their puts and calls, and other assorted transactions to maximize bottom lines, theirs and their firms’. Simply stated, they are considering their short and longer term return on investment (ROI). On Wall Street, ROI serves as a quasi socially acceptable term for “show me the money.” Wall Street also offers complex algorithms to quantify this ROI, from the simple P/E (price to earnings ratio, or how much you are paying for each $1 in earnings per share a stock generates), not to be confused with the V/Q scan, to elaborate derivatives, about which even the power traders admit to being clueless. So, before we consider foreclosure, let me suggest the physician assistant (PA) ROI: mentorship.
 
Comparing the P/E ratio of how much you are paying in stock for each $1 earned may be equated to your professional return (career longevity, stability, income, public respect, happiness) as compared to your mentoring investment (time, expertise, leadership skills). Basically, the “show me the money” of your professional PA future.
 
Our profession enjoys high rankings for best jobs, a rapid expansion of new PA programs and graduates, positive-slope salaries, expanded work avenues, enhanced public awareness, quality clinical outcomes, and research demonstrating our public value. So, from my corner office, our current investment strategy is sound. But markets are strange places (think subprime mortgage crisis), and the present does not always predict the future. Hedging our bet and maximizing our ROI means we must invest in our future, and a little bit goes a long way.
 
Some ideas to promote a good PA ROI: permit prospective PA students to shadow you, lecture at a PA program, precept for CME credit, take on leadership activities in your workplace, write a case or article alone or with a more junior PA for publication, be a team player on the job, demonstrate the versatility of PAs in the workplace, and really enjoy your work and your patients (it will be noticed). PAs enjoy a Fortune 500 status now—mentorship will sustain it.

Ellen D. Mandel is a clinical professor in Department of Physician Assistant Studies, College of Health Professions, at Pace University in New York City  The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 
 

Monday, November 24, 2014
Kim Zuber, PA-C, DFAAPA
 
Since 2010, payment for dialysis treatments has been a bundled charge. The Centers for Medicare and Medicaid Services (CMS) has paid one set fee to dialysis providers for each treatment provided to a Medicare patient; 90% of all dialysis patients in the United States are covered by Medicare. This bundled payment includes laboratory fees, oral and IV medications, staff charges, machine rentals, dialyzers, and any incidentals needed to provide hemodialysis or peritoneal dialysis to a patient. Each year, CMS recalculates the fee and either raises (or lowers) the bundled payment depending on the average cost nationwide. This process lets CMS manage costs and budget for dialysis patients from year to year.
 
The most divisive issue each year is the cost of medications. Medicare has defined seven categories of medications as being dialysis-related and thus part of the bundle payment: antiemetics, anti-infectives, antipruritics, anxiolytics, drugs for managing excess fluid, drugs for fluid and electrolyte management, and analgesics. Because the categories are so large, many medications are included, such as naloxone for drug overdose or diphenhydramine for allergies. Neither of these medications is routinely considered dialysis-related by most practitioners.
 
Thus practitioners, patients and dialysis providers often are confused about whether a medication is dialysis-related or not . From 2010 to 2013, Medicare encouraged a “pay and chase” method for medications that may or may not be dialysis-related. In other words, pharmacies would issue the medication when a patient presented the prescription. If Medicare later determined that the medication was actually dialysis-related, Medicare would refuse to pay the pharmacy and the pharmacy had to turn to the dialysis provider for payment. This put the burden on the pharmacy and Medicare, with Medicare either paying for the medication twice (once to the dialysis provider in the bundle and once to the pharmacy) or the pharmacy having to chase down the payment.
 
As of January 2014, Medicare allowed pharmacies to ask for proof before filling a prescription to determine if a medication was dialysis-related or not. And as one can imagine, everything hit the fan.
 
As scut work rolls downhill, many PAs and NPs were doing preauthorizations for every medication their patient consumed: antihistamines for allergic rhinitis, Tylenol #3 for chronic back pain (remember…no NSAIDS for kidney patients!), hypertension medications, and every antibiotic patients took. A preauthorization was needed for antibiotic coverage for a dental procedure, for a preparation for any surgical procedure, or for any infection that the patient developed. Because patients on dialysis typically are immune-compromised and have diabetes, preauthorizations for antibiotics were taking on a life of their own…and most practitioners were spending 2 to 3 hours a week on them. The National Kidney Foundation (NKF) listserv was burning up with stories of denied medications or hours of phone and computer work to obtain a preauthorization for a $4 amoxicillin prescription.
 
The Renal Physician Association (RPA), NKF, American Society of Nephrology (ASN), and patients’ representatives were all on the same page—this was an untenable situation. E-mails were sent to Medicare, which asked for examples of patients having problems due to preauthorizations.
 
Wayne was a typical dialysis patient—he had diabetes, hypertension, coronary artery disease, peripheral vascular disease, a below-the-knee amputation of one leg, and a chronic open ulcer on the remaining foot. He also had a cheery disposition that belied his medical issues. Wayne presented to the wound center on Friday for his weekly evaluation and it was decided he was to continue his hyperbaric oxygen therapy, oral antibiotics, and whirlpool therapy. His infectious disease physician wrote the antibiotic prescription and sent Wayne on his way. Wayne took the prescription to the pharmacy and was promptly denied because of the need for preauthorization. The physician was notified, could not understand why a preauthorization was needed, and asked the pharmacy to call the nephrology provider for the paperwork. Thus the 5 p.m. call on a Friday night to me.
 
No one is at the other end of a preauthorization phone line after hours on Friday night. I was directed by the phone message to use the website, which promised a result in 1 business day. Useless to me on a Friday night. I sent a blistering e-mail to NKF and RPA, who forwarded it to the right person at Medicare. I pointed out that because a $20 prescription needed a preauthorization, Medicare was going to be out more than $20,000 for unnecessary surgery and rehabilitation, my patient would have a second amputation, and this whole system was not saving any money and was hurting fragile patients. Wayne did not get his antibiotics until Monday night.
 
Medicare was overwhelmed with the volume of complaints. They sent out a letter of explanation about preauthorizations stating that any prescription not written by the nephrologist should be filled without preauthorization. This did not help. As Tricia Marriott of the AAPA will tell you, when Medicare tries to explain something, it only goes from bad to worse.
 
As winter turned to spring, the system continued to founder. The large nephrology societies (RPA, NKF, and ASN) asked for a meeting with the medical director of Medicare. This meeting was set for July 1, and “real providers” were asked to attend in order to ascertain how the system was working in the field. I was invited to share Wayne’s story.
 
Jeffery Kelman, MMSc, MD, chief medical officer for CMS, collected staff involved in the bundled payment system and sat down with us to discuss the issues. The first thing he asked me was how Wayne was doing. I had to admit Wayne had needed a revision surgery on his remaining foot, 30 more days of hyperbaric oxygen therapy, and his chronic foot ulcer was still unhealed. This could have been the outcome even if he had not had a disruption in antibiotic therapy, but the disruption increased his chances of a bad outcome. Dr. Kelman shook his head in agreement.
 
We spent the next hour outlining the issues, explaining our views. Dr. Kelman explained his rulings and detailed how the whole system had developed. I was incredibly impressed by Dr. Kelman’s belief that all Medicare patients were his responsibility to care for using best practices. Yet Dr. Kelman also felt that he answered to the American taxpayer and was responsible to make sure that our tax dollars were not wasted. According to him, every member of his staff felt personally responsible for my patients. They truly wanted my patients to obtain the best care out there. The dialysis preauthorization system denied care and Dr. Kelman was unhappy with that outcome. He agreed with us that something had to change.
 
On July 3, just as most of us were leaving for a holiday weekend, Medicare released new rules for comment that removed antibiotics from the list of medications that need a preauthorization for dialysis patients. Medicare would rather accidently pay for an antibiotic twice than take the chance of a lost leg by another dialysis patient. Wayne’s Rule will save other’s lives and limbs, although Wayne lost most of his second leg. On November 12, Medicare released their final rule removing all seven categories of drugs from the preauthorization schedule.
 
Wayne's Rule was a bigger win that we had dreamed of—no one will be denied antibiotics, pain medications, or fluid medications just because they are on dialysis. Wayne has never been one to complain. He is thrilled that his namesake rule will make a difference to others even though it was too late for him. Wayne feels lucky that someone took the time to write a letter and go talk to CMS. Patients place their trust in their providers and expect the provider to be an advocate. PAs bring more to their practice than just knowledge; they also bring a commitment to patient care and a promise to honor the trust patients have in them.  And sometimes, just sometimes, you can actually make a difference in the lives of those who entrust us with their hopes and dreams.  
 
Kim Zuber practices at Metropolitan Nephrology in Alexandria, Va., and is AAPA Outstanding PA of the Year. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

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