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Monday, January 26, 2015
Alexandra Godfrey, MS, PA-C
The whole purpose of education is to turn mirrors into windows.—Sydney J. Harris
Last week, I taught a group of students the neurologic examination. I had prepared the students by asking them to bring all the necessary equipment: reflex hammer, otoscope, push pins, cotton balls. They came to the laboratory in shorts and T-shirts excited and ready to learn. I had a checklist to follow that had been carefully put together by the faculty in charge of the patient care course. We allotted 2 hours to go through the checklist and practice the various maneuvers. I thought this would be ample time.

The checklist started with mental status screening test and ended with testing for meningeal signs. I began with the importance of looking at the patient: level of consciousness, posture, dress, grooming, affect. As we discussed the nuances of observation, I used clinical vignettes to highlight my teaching. I described the patient with mania who would present to the ED in gaudy makeup and flamboyant clothing. She would spiral and spin into triage, not really having time to sit to talk. I knew just by her clothing that she had stopped taking her lithium and was likely manic. I talked about the patients who wear long sleeves to cover up their scars from self-injury, and the shame and reticence they often feel. We discussed the flat affect of the patient with depression … and how I found that somehow their mood would invariably infuse the entire room and seep into my soul.
We talked about insight, judgment, hallucinations, and super powers. I spoke of the patients brought in for yelling at the children and animals that only they see.  The fear instilled in them and their caregivers.  I described the fight-or-flight response of a paranoid schizophrenic I once saw who was convinced he was being pursued, and how he had reminded me of a gazelle under the eyes of a lioness on a plain in sub-Saharan Africa. I witnessed his fight-or-flight response when he believed he had become prey: his head turning, eyes flickering, muscles contracted, brain deciding where or how to run.

Consequently, the assessment of mental status and behavior took me longer than I expected.
The physical examination was no more straightforward. The students in spite of their reading bombarded me with questions:

What causes ptosis?

What is the meaning of accommodation? 
Do we always have to assess the gag reflex?

What is a fasciculation and when would we see this?
When would reflexes be absent?

And does ankle clonus really matter?

Why would we test extinction?

We talked about neurons—upper and lower, tracts and ganglions, extrapyramidal signs, radiculopathies, cerebrospinal fluid (CSF), speech that is fluent but nonsensical, and speech that is clear but broken We sought clarity and transparency in a complex world of  junctions and pathways and murky CSF. It took us 2 hours to get through the checklist. The analysis, the remembering (and the forgetting), and the application led us down tracts of our own, firing neurons, and creating sparks of curiosity that were followed inevitably by questions.

I wanted the students to understand the rationale, the application, and the meaning of the tests they were learning. We entertained instead of simply accepted each examination maneuver.
I admit I may be guilty of perseveration. I admit I had a discrepancy to address.

So many times as a preceptor I had asked my students the pretest reliability or even the expected normals  or abnormals  of a test or maneuver, and had been met with panic, a blank stare, or confusion.

Teaching the neurologic examination with such application was more difficult. It tested my knowledge and assumptions, checked my stamina, and challenged my practice. Much easier to teach the maneuvers of the checklist and tell students that it is their sole duty to find the meaning. Ultimately, at the end of the session, we wrote out a list of questions to be researched and answered.

A few days later, my students returned to the classroom to again run through the neurologic examination. Now, with questions answered, they could practice with deliberation. I felt proud as they talked about the mechanism of the pupillary response to light, the sluggish reflexes of hypocalcemia, and the effect of hemisphere dominance on aphasias and hemi-neglect. The precision with which they worked was inspiring, and I felt confident they would go on to practice with skill. Seeing the rewards of persistence, witnessing the dissolution of obstacles to learning, watching obfuscation become clarity—mirrors turn to windows; these transformations make my work as a clinician-educator meaningful and precious.

Alexandra Godfrey is an assistant professor in the PA program at Wake Forest University/Appalachian State University in Boone, N.C., and practices in the ED at Catawba Regional Medical Center in Hickory, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, January 12, 2015
Virginia McCoy Hass, DNP, RN, FNP-C, PA-C
Now is the time for full practice authority for physician assistants (PAs). I’ve probably caught your attention, and I will elaborate. But first, in the spirit of full disclosure, let me say that I teach in the only integrated PA and nurse practitioner (NP) education program in the United States. This keeps the topic of interprofessional education and collaboration at the forefront of my thoughts. Interprofessional education, as has been previously alluded to in this blog, has been identified as a key innovation in health professions education and a means to achieve the “triple aim” of improved patient care, improved health outcomes, and more affordable healthcare systems.1 It occurs “When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”2
Interprofessional education, which enhances learner outcomes in the form of competency development and effective collaboration, is the precursor to interprofessional collaborative practice, which enhances patient care outcomes and is essential to build a safer, patient-centered and population-oriented healthcare system.
The general competencies for interprofessional practice and collaboration defined by the Interprofessional Education Collaborative (IPEC) are:
• values and ethics for interprofessional practice
• roles and responsibilities
• interprofessional communication
• teams and teamwork.3

Each of the general competencies is further clarified with specific competencies by the IPEC [PDF] for additional reading. Particularly relevant to the issue of full practice authority for PAs is Specific Roles/Responsibilities Competency RR5: “Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.”3 In order to achieve a healthcare system that delivers care that is safe, equitable, patient-centered, and population-oriented, each of us—PAs, NPs, medical assistants, physicians, pharmacists, physical therapists, and others must use the full scope of our education and training without arbitrary licensing practices that constrain our scope of practice.

PAs are the only remaining healthcare providers who are educated as generalists without mandatory residency or specialization. The analogy I use is that PAs are the “stem cell clinicians” of the healthcare system. Unlike physicians, who complete residency training that narrows their scope of practice, or NPs, who are educated and licensed in specialty tracks, PAs retain the ability to provide care wherever there is need. However, the practice of PAs is artificially limited by the scope of practice of the physicians with whom they work. Despite variation from state to state, the delegated practice of medicine from physician to PA is essentially the same.4 With this delegated practice also comes significant variation in prescribing law,  which creates another unnecessary barrier to practice and patient-centered care.4

With a political will and the logistic capacity of our professional organizations, full practice authority for PAs can be accomplished. There is precedent in the movement toward full practice authority for NPs. To date, legislation authorizing full practice authority for NPs has been successful in 19 states and Washington D.C.5
Interprofessional collaborative practice is synergistic with the team approach to care that is the hallmark of the PA-physician relationship. This is addressed in the general competency of teams and teamwork, in which the knowledge and experience of each profession is used to establish priorities for care and to achieve outcomes. Of note, the leadership role is fluid, moving among team members based upon patient and community needs.3 Some may argue that full practice authority for PAs would disrupt the PA-physician relationship. I contend that full practice authority for PAs will strengthen it. With the Affordable Care Act expanding health coverage to millions of newly insured people, the healthcare system is under increasing pressure. All clinicians should be able to provide care to the full scope of their education and expertise, and all of us need to assume leadership roles. Full practice authority for PAs will balance the qualities of respect, support, and professionalism with the autonomy of practice that will enable PAs to consistently provide high quality care to patients in all settings. I look forward to reading your thoughts on this topic in the comments section below.
1. Institute of Medicine. Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice–Workshop Summary. National Academies Press, 2013.

2. World Health Organization. Framework for action on interprofessional education and collaborative practice. [PDF]Geneva, Switzerland. 2010.

3. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. [PDF] 2011. 

4. American Academy of Physician Assistants. PA State Laws and Regulations, 14th ed. Alexandria, VA, 2014.

5. American Academy of Nurse Practitioners. State Practice Environments. 2014. 
Virginia McCoy 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.

Monday, December 29, 2014
Joshua Newton, MMS, PA-C
When my dad learned to use a computer in college, he carried a stack of punch cards into a cold concrete room full of racks of computer equipment. I learned as a high school student in my basement with a behemoth black-and-white screen filled with command lines and tethered to a floppy drive. And now my daughter carries in her palm a computer more powerful than the supercomputers that filled a room in my dad's time. At 2 years old, and with the simple touch of a hand, she intuitively navigates my iPhone and iPad like it is second nature. To her, phones never have cords or rotary dials, books come on a Kindle, and everything needs batteries or to be charged.
The worlds we each have experienced have shaped our paradigm. Our perception of war, of human interaction, of career ladders, and of the role of technology all vary just because of what we have been exposed to. I find that this dichotomy flows into every piece of life. I can almost hear my grandfather saying that "they just don't make them like they used to." So how much of our perception of medicine depends on our generation? I have older patients who fear hospitals because that "is where people go to die" and young patients who crowd the ED for simple sunburn because they believe care should be accessible at every hour. One generation believes there is a pill for everything and another believes that all pills are just poison and will cause ungodly adverse reactions according to the commercials on TV. And what of providers? For those raised on Facebook and Skype, telemedicine hardly raises a hair. And if a big box store can sell me ice cream, motor oil, shoelaces, and new glasses, why can't they sell me a doctor, too?
As with every decade, we enter a new generation and a new world. Halfway through this decade, we find that technology is no longer a tool but rather the substrate on which we grow our world. We are now infinitely connected through the "internet of things." Our technology is now trained to read and measure us and then anticipate us, but is our healthcare ready for this? My house thermostat is more intimate with my needs then my healthcare provider. It knows when I walk into the house and at what temperature I like it. Yet my clinic still wants paper BP logs and makes me sign in on a sheet when I check in.

As the personal health monitor becomes more popular and Apple and Google begin to drive the market, it brings the Luddite tendencies of healthcare into stark contrast. For the past few decades, we have fought electronic medical records (EMRs) and even now as they become universal, the communication standards between them are almost nonexistent. The longstanding promise of the universal health record is further from reach then a self-driving car. EMRs are by far the most conceptually antiquated and anti-user friendly software tools that I use during the day. Only a few companies have begun to recognize this and alter their approach. As an industry, we almost shun the intrusion of technology on the relationships we bear with our patients, and yet we fail to recognize that technology drives all of their other relationships. How often do we walk into a room to see our patient on an iPhone, iPad, Android phone, or Kindle? At least of one-third of the communications I have with patients are driven by information they have found on the Internet about their respective disease. Probably half or more of this information is erroneous, and that which is correct is often misinterpreted. WebMD tells us all that we have cancer, but what resources do I supply to help educate my patients? I might use a few paper handouts, and if I am lucky, a portal with some links to basic info from Mayo Clinic or Medline. So why should I blame my patient for using what is at their fingertips?
Now that we are on the cusp of devices that could reap copious amounts of health information on patients, are we ready? How are we going to tap into the data, harvest the crucial pieces, and direct patients appropriately. If Google sees me search the word “cruise,” it knows to post an ad for Norwegian Cruise Lines. Why can’t healthcare devices see that my pulse rate is irregularly irregular and when I search chest pain that evening, it might post an ad for local cardiologist? Or when I search home remedies for a cold and the device sees I have a fever of 103° F, it suggest I contact my primary care provider. Beyond the hurdles of HIPAA and data security lies a goldmine of expanded knowledge and patient interaction if our industry can just see it and seize it. We could offer tailored patient education documents, chronic disease management, telemedicine straight from your phone, health stats that your provider can track in real time, and technology that can alert you both when something is askew. Technology must become a fabric that we weave into medicine and a tool that we take control of, rather than a tool that we let control us. The generation of the ePatient has arrived, and a massive opportunity for innovation and forward progress lies ahead of us.
Joshua Newton practices family medicine in Pittsburg, Kans. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, December 22, 2014
Amy M. Klingler, MS, PA-C
It is that time of year again. Seasonal holiday beverages at the coffee shop, twinkling lights, and (sniff) colds and influenza. I should know. I am on day 10 of an upper respiratory infection myself.
Getting sick is frustrating. No one has time to be sick, certainly not PAs. When I was not contemplating my body's ability to produce copious amounts of mucus, I spent time counseling myself as I would a patient. I have nearly drowned myself in tea and water. Ibuprofen has eased my aches and helped reduce the inflammation in my nose. Over-the-counter cough meds gave me heartburn, so I only used those once. But, I have consistently applied essential oils to my chest, and I have used my Sinus Rinse bottle religiously morning and night. Then today, as I could breathe out of both nostrils at the same time, hardly coughed at all, and could go on a brisk walk without feeling like I was climbing Mt. Everest, I said a quick thank you that I didn’t need any antibiotics.

It is interesting how times change. I used to have to apologize for not giving patients antibiotics. I had a long speech I would give about viruses and bacteria, and I would placate patients by offering to call in antibiotics if their condition persisted or worsened over the next 3 to 7 days (perhaps indicating a bacterial cause for their illness). These days, I have altered my spiel a little bit. I tell patients, “It appears to be a viral infection, which is good, because at least you don’t need antibiotics,” while reviewing symptomatic care and follow-up instructions.
Antibiotics are wonders of modern medicine. Last year, when my son had a severe left lower lobe pneumonia, I was grateful for the shot of ceftriaxone and the azithromycin suspension that cured him; especially after a nurse reminded me that in the era before antibiotics, he probably would have died from his illness. But the fact remains that, from our medical offices and hospitals to our farms, antibiotics are overused in our society, and that is a problem.
An article in Nature compared antibiotic resistance to climate change, stating, “Both are processes operating on a global scale for which humans are largely responsible. In antimicrobial resistance, as in climate change, the practices of one country affect many others.” Drug-resistant strains of tuberculosis, malaria, HIV, and pneumococci along with methicillin-resistant Staphylococcus aureus have spread between continents and are now prevalent worldwide.1 Although a global effort is needed to reduce inappropriate antibiotic use, we must begin with ourselves.

November 17-23, 2014, was the CDC’s annual Get Smart Week. According to the promotional materials, the purpose of the Get Smart campaign is to “raise awareness of the threat of antibiotic resistance and the importance of appropriate antibiotic prescribing.” Among the resources available on the CDC’s website are treatment guidelines for upper respiratory infections for adults and children, which serve as good reminders of appropriate antibiotic prescribing practices. Several handouts are available to educate patients about the proper use of antibiotics.
Our world operates on the principal that we will have ways to fight and prevent infections in people and in agriculture. Treatment of infectious diseases, surgeries, cancer, and organ transplants would be impossible without a readily available arsenal of medications.1 We must be responsible prescribers and use our influence to encourage our national and international colleagues and world leaders to do the same.

If someone I care about gets an infection, I want to make there is a drug to treat it, don’t you?

Woolhouse M, Farrar J. Policy: An intergovernmental panel on antimicrobial resistance. Nature. 2014;509:555-557.
Amy M. Klingler practices at the Salmon River Clinic in Stanley, Idaho. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

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.
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