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Musings
Blog of the JAAPA editorial board.
Tuesday, June 28, 2016
 

Harrison Reed, MMSc, PA-C

After graduation, how many of your classmates rushed off to a job in primary care? If you program was anything like mine, those new graduates were a small minority. I always thought some specialties were just sexier than others, but perhaps more subtle economic factors are at work.

In the July issue of JAAPA, Perri Morgan, PhD, PA-C, and colleagues tackle the diminishing proportion of primary care PAs in their latest PA workforce research. They focused less on the new graduate psyche, however, and more on the financial factors that might lead to the creation of PA jobs.

The authors point out that fields with huge wage gaps between physicians and PAs (that is, higher-earning physician specialties) tend to draw a higher proportion of PAs. Because PAs make roughly the same amount of money across specialties, physicians with greater earning potential might find more value when they hire a PA, as these physicians are free to spend more time on high-revenue activities like surgery and procedures.

It’s no secret that high-earning specialties like orthopedic surgery have taken advantage of PAs to boost revenue. But, on the other end of the spectrum, lower-paid physician specialties like primary care may suffer the opposite effect. After all, a PA is not that much cheaper than a primary care physician compared with a well-paid surgeon. And if PAs are less profitable in settings like primary care, practices may have less incentive to hire them.

In his commentary in the July issue, Richard W. Dehn, MPA, PA-C, DFAAPA, proposes that the decreasing proportion of PAs might not represent wavering altruism or a shifting employee mindset but a shortage of PA jobs in primary care. He cites anecdotal experience in PA education that seems to agree with the Morgan study’s data. I like the idea of a legion of PAs waiting for a potential primary care opportunity, even if it seems a bit idealistic.

Two points raised in the discussion of PA specialty selection warrant additional attention. First, by virtue of this smaller salary gradient between physicians and PAs, lower-paying physician specialties like primary care appear to be at a massive disadvantage when it comes to employing PAs. Any state laws that further restrict PA practice, like those limiting physician-to-PA ratios, are only hurting primary care access and must be abolished.

Second, in complex systems like workplace economics, legislators and policymakers should meddle with caution. Although it’s tempting to artificially inflate PA salaries to attract workers to underserved areas, doing so could raise the average compensation of PAs in primary care and further decrease the physician-PA pay gradient nationwide. Unsubsidized clinics would have little incentive to employ PAs that are not much more affordable than their physician colleagues. And if Dehn is right about a smaller-than-you-might-think primary care PA job market, that kind of policy move could further restrict PA migration into primary care.

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

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Tuesday, May 31, 2016

Virginia Hass, DNP, FNP-C, PA-C

At a workshop on compassion cultivation training I recently attended, we were guided through an exercise in which we were to contemplate traits in ourselves at various stages of our lives—past, present, and future. For me, the trait that persisted throughout was curiosity. This started me thinking on the nature of curiosity, and its role in both empathy and healthcare.

Curiosity is an intrinsic characteristic of all higher beings. Watch a cat play with a box or bag, or a baby explore her fingers and toes. We are born with innate curiosity to explore our senses and environment. Dr. Erich Loewy suggested that curiosity is the foundation of imagination, which allows us to hypothesize meanings for this input; and then reason, which allows us to test our hypotheses and categorize and sort data.1 The interplay between these three intellectual capacities (curiosity, imagination, and reason) lets us problem-solve. Loewy further suggested that creativity is the product of this interplay.1

Curiosity is the trait that brings many of us to healthcare—whether we start our careers as bench scientists or clinicians. I recall an encounter with a patient early in my nursing career. I was troubleshooting a problem with his IV pump and he commented, “That’s what RN stands for—Registered Nut-turner.” A lively and humorous exchange followed in which we came up with a variety of things “RN” could stand for. I don’t recall them all, but the one that rang truest, and therefore stuck with me, was “Really Nosy.” I laughed and told him, “Yes, and I have a license to ask questions!” Our need for discovery (curiosity) drives our problemsolving and creativity, keeping us engaged.

Empathy (compassion) also requires this interplay of curiosity, imagination, and reason. Curiosity inspires us to ask ourselves, “Who is this person across from me?” And as demonstrated by our interest in the person before us, is perceived by patients as caring, or empathy. We ask, “How can I help you? Who are you? Tell me more about that?” Their story unfolds, and they comment later, “He seemed to really care about me,” and “She spent a lot of time with me” (whether we did or not). Curiosity encourages people to open up to us, sometimes in the most unlikely settings. Most of us have had the experience of standing on line at the market or bank and striking up a conversation with the person next to us. Before we know it, this total stranger is telling us the details of their personal life or physical functions—perhaps things they would not share even with their intimates. Imagination lets us take the encounter a step further—to imagine ourselves in the other’s shoes (that is, to feel empathy) —to hypothesize that this is a person who wants to be well, be happy, and at the end of their days, look back on a life full of meaning. We then use reason to gather empirical data to confirm or disprove our hypothesis.

The best of diagnostic reasoning mirrors this process. We are curious, we form hypotheses, and we reassess our hypotheses as we gather new data. Thus, curiosity is a foundation to our clinical practice. However, maintaining curiosity requires time to think and to reflect. As an educator, I ponder how our methods of education affect the innate curiosity our students bring to PA education. Loewy argued that our “Western…market-oriented and capitalistic milieu…has tended to discourage the development of curiosity and imagination.”1 I would further this argument by stating that our current models of education and certification in healthcare (PA, nursing, and physicians) also stifle curiosity and creativity. As our students learn the “correct” way to gather a history, they become focused on asking the “right” question(s) to obtain the “correct” answer. The person before them becomes a patient from whom they have to gather a checklist of information. The emphasis is on what, and not how, to think. What Loewy calls, “the bulimia model (teach and cram)”1 of education results in students who store information just long enough to pass a test, rather than integrate it into a holistic picture of patient care. In this system, curiosity and imagination – exploring that which intrigues or inspires us to think —is not rewarded. Upon graduation, the situation becomes more dire—relative value units, managed care, and pay for performance encourage us to explore only that which can yield an immediate return on investment (that is, only that which will reduce length of stay or increase productivity) and thus reduce exploration for curiosity’s sake.

So why should we care about curiosity? Curiosity, and its extension—the ability to see ourselves in another’s shoes—inspire us to reach out to others in distress, think about the bigger picture of access to healthcare, and trigger us to work toward policy changes that bring affordable healthcare to millions of people who were previously uninsured. Thus, curiosity and empathy are essential to reducing health disparities. In addition, we know that knowledge has a half-life—what we know to be true changes over time.2 Therefore, clinicians must be lifelong learners with the curiosity to seek out new information.

We need to consider two questions: “How do we encourage/maintain curiosity?” and “Can compassion (empathy) be taught?” My colleagues and I debate this question, and I do not have an answer but I do have some suggestions. We look for these characteristics in the applicants to our PA and NP programs, in the hope that the presence of this raw material will help us forge compassionate clinicians. Given that many (though not all) applicants to PA and NP programs arrive with their innate curiosity intact, I would argue that we should be looking at our system of education—finding ways to ignite and reward curiosity. This is not an easy proposition. Multiple-choice examinations, with their emphasis on knowing the right answer, are relatively simple to construct. They are also the format of the ultimate final examinations (licensing examinations). It is much more difficult to quantify how a person thinks—their curiosity, imagination, and empathy. De-emphasizing the multiple choice examination and using alternative ways of evaluating students’ knowledge, such as reflection, case-based learning, and simulated patient encounters, would reward the persistence of curiosity. In this way we can make the conscious choice to forgo fact-focused curricula in favor of strategies to cultivate compassion, empathy, and lifelong learning.

REFERENCES
1. Loewy EH. Curiosity, imagination, compassion, science and ethics: Do curiosity and imagination serve a central function? Health Care Analysis. 1998;6:286-294.

2. Arbesman S. The Half-Life of Facts: Why Everything We Know Has An Expiration Date. Penguin Group USA: New York, NY. 2012.


Virginia Hass is an assistant clinical professor and nurse practitioner program director in the Betty Irene Moore School of Nursing at the University of California at Davis. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

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Monday, May 16, 2016

Brian T. Maurer, PA-C
 
In the May issue of JAAPA, Salibian and colleagues present an independent research study that examines the use of PAs and NPs in outpatient surgical subspecialty settings.

The investigators draw their data from the National Ambulatory Medical Care Survey published annually by the CDC. Although these data are dated (they stem from surveys conducted in 2007-2008), the results are still somewhat shocking, unsettling at best: PAs and NPs were involved in only 5.9% of outpatient surgical subspecialty office visits, and the percentage of patients evaluated by PAs or NPs alone turned out to be a paltry 1.1%. Interestingly, PAs and NPs often saw the same diagnoses alone (which I take to mean without a supervising surgeon physically present) as their physician counterparts.

The authors conclude that PAs and NPs “have a minor prevalence in the ambulatory surgical workforce during the time period studied.” On a brighter note, the authors argue that “further integration of these providers into the outpatient setting may help optimize efficiency in ambulatory surgical care.”

Because the current rate of surgeons entering the healthcare workforce has been deemed insufficient compared to the projected need, expanding the roles of PAs and NPs could theoretically improve overall access to quality surgical care, and at the same time lower its costs.

This study harkens back to arguments that first surfaced in the medical literature 30 years ago: namely, that expanding the roles of PAs and NPs would improve access to quality care and lower costs. Although the PA and NP workforce has grown exponentially over time, to my knowledge no definitive study has demonstrated that using these providers has actually lowered the cost of medical care.

A closer look at Salibian and colleagues’ data might provide the astute critical reader with a clue as to why this has not occurred. NAMCS data are gleaned from ICD-9-CM diagnostic and procedure codes. The authors allude to the likelihood that most of these diagnostic encounters might have been billed “incident to” the supervising surgeon. It is only required that the surgeon be present in the office during the medical encounter to justify billing at this level. Many of these encounters may have been billed in this fashion, effectively skewing the true incidence of care rendered by PAs and NPs.

Were PAs and NPs generating revenue in less than 6% of office-based surgical encounters, it would not be economically feasible for surgeon employers to keep them on the payroll.

One wonders how such scenarios may play out in the future medical marketplace, as we move from solo-fee-for-service toward universal value-based care.

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

 

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Monday, May 2, 2016

Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE
 
The May issue of JAAPA features an article titled “Recognizing Charcot disease in a man with diabetes.” Reading this article, you will learn about a complication of diabetes with its associated diagnostic modalities and treatment approaches. You also may wonder how to pronounce Charcot. Do you include the final t, as in char-coat (sounds like a new BBQ method), or say shar-co, softening the ch and losing the t? What would the French language police consider proper?

As PAs, we are accustomed to the occasional eponym and recognize that Charcot has at least one. Who is this man, and how did he manage to secure his eponymous fame? Jean-Martin Charcot, a French neurologist, lived from 1825 to 1893. He possesses 15 medical eponyms including those related to an artery, joint, aneurysm, visual syndrome, triad, crystals, and infarct. One of his eponyms, now known as amyotrophic lateral sclerosis (ALS), launched another eponym, that of Lou Gehrig disease. Charcot was able to read scientific articles in his native tongue, French, but also in English, German, and Italian. He completed medical school at age 23 and worked as an intern in the Hôpital de la Salpêtrière. He later joined the faculty, building this Paris hospital into a leading center for neurologic conditions.

Charcot also trained as a pathologist who recognized the important relationship between clinical and anatomical findings. With a sharp clinical eye, he collated his clinical observations with findings on autopsy, an event we rarely see in contemporary medicine. He was highly regarded as a bedside educator, applying an innovative teaching style emphasizing interviewing more than one patient with similar presenting signs and symptoms, demonstrating or acting out patients’ neurologic conditions, drawing pictures, and using his artistic and then newly developed skill with the camera to develop teaching images.

As PAs, we can aspire to come close to his genius: achieving excellence as diagnosticians and educators.

See if you can correctly identify the answers to this Charcot quiz. Charcot would be proud to know his hard work has paid off.

 
1. What are the three components of Charcot Triad for acute cholangitis?

2. Which skeletal condition associated with syphilis and diabetes may begin with acute inflammation, followed by structural bone changes, ending with permanent foot deformity? (Hint: read the article)

3. Which condition, also known as peroneal muscular atrophy and having a triple-eponym, is one of the most common inherited neurologic disorders, affecting 1 in 2,500 patients in the United States?

4. What are the three signs or symptoms in Charcot Triad of multiple sclerosis?

 

Ellen D. Mandel is a clinical professor in the PA program at Pace University in New York City and an associate professor in the PA program at Seton Hall University in South Orange, N.J. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

 

Answers
1) Right upper quadrant pain, jaundice, and fever
2) Charcot joint
3) Charcot-Marie-Tooth disease
4) Nystagmus, intention tremor, and dysarthria

 

 

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Monday, April 18, 2016

Alexandra Godfrey, MS, PA-C

A patient’s mother once threatened to wait for me in the hospital parking lot. She wanted to “take me out.” She was angry that I hadn’t admitted her adult child to the hospital. I had spoken to her on the phone, explaining criteria for admission, the clinical findings and treatment plan. I had discussed the case with the patient’s primary care physician, the hospitalist, and had had my attending physician examine the patient. We were all in agreement: the patient did not have a diagnosis that warranted admission. The mother responded by screaming obscenities down the phone line, first at me, and then at the RN. She told us she would be coming to the ED to “sort things out.” When she arrived, she tried to jump the registration counter, punching the clerk as he attempted to stop her. Her intentions were clear. Hospital police were alerted and they escorted her of the premises. As she left the ED, she swore she would be waiting for me at the end of my shift.

I have been threatened by patients in many different ways during my time in medicine. On one occasion, a patient angered by my refusal to give her opioids tried to force me to write her a prescription by invoking fear of her drug dealer. The patient had a history of violence and drug abuse along with a laundry list of allergies and vague chronic complaints. When I explained to the patient that I was not giving her opioids due to concerns for substance abuse, she announced that she wasn’t into opioids (she knew what they did to people); she was a “pot head.” Instead, she had sold all her scripts for $500 to $700 a pop. She went on to say that if I didn’t give her OxyContin, she would call her dealer and I could deal with him. When I still refused, she called her drug dealer (or so she said) and attempted to hand over her phone, telling me that “if I were sensible” I would talk. I advised her that I did not make deals with drug dealers and suggested we talk about healthier ways to resolve her problems. She stormed out, throwing objects as she left, yelling that her dealer would be waiting for me in the parking lot; I would pay. Hospital police escorted me to my car after my shift. That seemed to be the most sensible response.

Violence can erupt, even in what appear to be well-controlled circumstances. On another occasion, I was taking care of a patient who had been involved in a vicious assault. He alleged he had been assaulted but detectives advised me he was the perpetrator. They asked me to let them know when I would be releasing him. As instructed, I quietly let the police know when my patient was ready for release. Shortly after, a scuffle erupted. The patient, taking advantage of a moment of distraction (a code had come in), had made a run for it. As he ran through the ED with police in pursuit, he threw every piece of equipment he could at his pursuers (and anyone else who happened to get in the way). The police downed him at my feet. Held face down, pinned to the floor, he screamed obscenities and threats, spitting on my ankles. The ED personnel worked quickly to restore safety. The floor was covered in hundreds of packets of sutures, equipment was cracked and broken, and some workers were injured in the process. As I set about suturing the injuries of hospital employees, I thought it was rather like a scene from Grey’s Anatomy—or is it?

It isn’t just Grey’s Anatomy
Unfortunately, violence in healthcare isn’t limited to fictional medical dramas on TV. Aggressive behavior is a significant problem encountered by America’s healthcare workers. According to the Bureau of Labor Statistics, healthcare workers are five times more likely to be a victim of a nonfatal assault than workers in all other industries combined. Between 2003 and 2007, more than 887,000 workers in the healthcare and social assistance industries were victims of assault; nearly three-quarters of these assaults are by patients or residents in a healthcare facility.1 The actual assault rate is probably much higher due to underreporting. There is a commonly held acceptance that threats and violence are simply a part of a healthcare worker’s job. Some workers report fear of retaliation or lack of support from hospital administration as reasons not to report. Data also are scarce due to lack of objective and standardized reporting mechanisms.2 A person who assaults a healthcare worker in the street would likely get arrested but in the hospital they are more likely to be let go without consequence.

Nurses, aides and emergency personnel are at the most risk of assault. I found no data relating specifically to PAs but it is reasonable to extrapolate that the data would be similar to that of RNs and MDs. One study reported that 51% of emergency physicians had been physically assaulted at least once in the previous 6 months. Close to a quarter of nurses in emergency medicine reported being physically attacked more than 20 times in 3 years. Emergency physicians also are frequent targets of stalking and confrontation outside the ED.3,4

EDs are high-risk environments due to multiple factors, including long wait times, overcrowding, presence of patients under the influence of drugs or alcohol, patients with a history of violence or psychosis, and use of EDs for medical clearance of patients arrested for drug- and alcohol-related offenses. These factors are compounded by a lack of access to community mental health services resulting in long psychiatric ED holds, an increase in the number of citizens arming themselves due to perceived threats of violence, and distrust of clinicians who are seen to represent the establishment. Emergency personnel who must by law evaluate all patients for the presence of an emergent medical condition cannot turn a patient away and as a result are placed in the firing line for abusive behavior from frustrated, stressed, intoxicated, and mentally ill patients.5

Workplace violence has many forms, ranging from threats to slapping, beating, and homicide. Violence is most likely to occur when service is denied, providers set limits, or at times of high activity such as visiting time. Aggression typically is triggered when patients or their families feel frustrated, vulnerable, or out of control.

The American College of Emergency Physicians (ACEP) recognizes violence against ED workers as a growing problem and advocates for increased awareness and safety measures to protect staff. At a legislative level, ACEP requests all states to consider maximum penalties for persons who assault emergency personnel.6  The Emergency Nurses Association encourages a policy of zero tolerance for patient or visitor violence.7 In the 2015-2016 policy manual, the American Academy of Physician Assistants “opposes all acts of violence and intimidation and reprisal directed against PAs and other healthcare providers.”

How do we facilitate safety in healthcare workplace?
When I was a student in Detroit, I entered hospitals through metal detectors and my backpack and ID were checked. Surveillance equipment was widely used. The use of metal detectors in one Detroit hospital alone prevented the entry of 33 handguns, 97 mace-type sprays, and 1,324 knives in just 6 months. This hospital is the closest trauma center to Detroit’s infamous 8-mile area and is the receiving center for much of Detroit’s gang violence. As a student, it was my home for 3 months, and although the system was not entirely bulletproof, I appreciated the extra security measures. Such measures may not be cost-effective or necessary at all healthcare institutions. Less radical and more customer-friendly measures might include developing protocols for violent situations, placing physical barriers, easy access to hospital security, installing panic buttons, checking ID on entry, having visitors sign in and show ID, and training staff to prevent, recognize, and manage violent situations.5 Some medical education and nursing programs also are stepping up to the challenge. Students at the University of Michigan’s medical school are required to take a class on violence before their emergency medicine rotation. They are taught how to react to a patient who pulls their hair, how to de-escalate potentially violent situations, and how to stand aside if someone charges them. Nursing students and graduate nurses frequently undergo training that teaches them to diffuse potentially violent situations before they escalate to physical violence. They are taught to manage verbal and physical abuse. Completing Crisis Prevention Institute (CPI) training and certification is mandatory for nurses in many departments before hire and often is incorporated in core nursing education. I have not encountered a PA program that incorporates similar training into its curriculum but certainly modeling the example of our peers in nursing and medicine is worth serious consideration.

Should healthcare personnel carry firearms?
Many of my peers in emergency medicine advise me that although they do not carry weapons into work, they do keep firearms in their vehicles. Too many threats from too many patients have led to this: “Just need to get to my car first” is the most common rationale I have encountered.

Their worries are not unfounded. In 2011, Dmitriy Nikitin, MD, a transplant surgeon in Florida, was targeted by a patient and subsequently assassinated in a hospital parking garage. Despite a successful double transplant, the patient felt dissatisfied with the outcome and blamed the surgeon. Unfortunately, this isn’t an isolated event. There have been numerous reports of injured hospital workers since.

Hospital medical staff carrying firearms is a topic for hot debate and beyond the scope of this blog. Certainly, it would be fraught with liability and safety issues, and is not supported by most professional organizations and institutions. A more reasonable and acceptable approach is for hospital security to carry firearms. Some institutions employ a hospital police service who carry firearms and others train security guards to carry firearms. No national standards or laws govern hospital security. The International Security and Safety Foundation found that just over half of hospital security guards are armed. Having armed security guards on hospital premises increases the facility’s liability. The hospital where I work uses hospital police who are fully trained in the use of firearms and carry them at all times. At my previous workplace, hospital security was not armed but had highly trained officers with a K9 unit. Patients tended to calm down quickly when a German Shepherd turned up. The dogs had the added benefit of providing much needed therapy to patients in need.

Bottom line
After more than two decades in healthcare, I have encountered every type of non-lethal violence. I have been punched, kicked, bitten, groped, and threatened. I am not alone. Managing violence in the workplace is part of our work as PAs. This is especially true of providers who work in specialties such as emergency medicine. The number of threats and the degree of violence encountered by providers is likely underreported. This type of behavior should never be considered an acceptable part of our work. More training, more awareness, more vigilance, are all needed if we are to maintain a safe healthcare environment for patients and workers. Commitment from hospital administrators, department managers, security services, and medical education programs along with support from our professional governing bodies is essential to facilitate continued improvement and to ensure a safer workplace for all PAs. The PA profession is well-placed to address these challenges and might consider adopting some of the strategies employed by our peers in nursing and medicine.

Alexandra Godfrey practices emergency medicine and is an assistant professor in the PA program at Wake Forest School of Medicine 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. US Bureau of Labor and Statistics; Janoch JA, Smith TA. Workplace safety and health in the health care and social assistance industry, 2003-2007.

2. Gacki-Smith J, Juarez AM, Boyett L, et al. Violence against nurses working in US emergency departments. J Nsg Admin. 2009;39 (7-8),340-349.

3. Kowalenko T, Walters BL, Khare RK, Compton S. Workplace violence: a survey of emergency physicians in the state of Michigan. Ann Emerg Med. 2005;46(2):142-147.

4. Kowalenko T, Cunningham R, Sachs C, et al. Workplace violence in emergency medicine. Current knowledge and future directions. J Emerg Med. 2012;43(3):523-531.

5. US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Violence Occupational Hazard In Hospitals. Publication No. 2002-101. June 2014.


6. American College of Emergency Physicians. Emergency department violence fact sheet.

7. Emergency Nurses Association. 50 state survey criminal laws protecting health professionals.

 

 

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Journal of the American Academy of Physician Assistants
Blog of the JAAPA editorial board.