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Musings: Blog of the JAAPA Editorial Board
Monday, September 15, 2014
Brian T. Maurer, PA-C
A clinician friend forwarded the link to an online news article detailing the proposed merger-acquisition of the chain of community hospitals where he practices. These three community hospitals were established by an order of Catholic nuns; the oldest facility dates back to the 19th century. As was the case with most hospitals in that era, these were founded to meet the needs of a relatively poor patient population that had little alternative for medical services at the time.
If all goes according to plan, these institutions will be subsumed into a large healthcare conglomerate that operates in a for-profit venue. It appears as though the relative cost of healthcare is poised to escalate exponentially in that region.
I smiled when I read the comments of the CEO of the existing hospital holding corporation: “We are excited to pursue this relationship with [healthcare corporations X and Y]. Like ours, these organizations are committed to providing high-quality, low-cost, person-centered care.”
As you follow the money, always look for the spin.
A similar development has happened in the area where I practice. Over the past decade three big urban hospitals have worked diligently to acquire any number of smaller outlying community hospitals, now referred to as “campuses,” that is, corporate subsidiaries. Quite obviously, these healthcare conglomerates are in constant competition, each vying for a greater piece of the healthcare market share.
“The takeover of our local hospital system reminds me of large banks that swallow other banks,” my clinician friend wrote. “As these cycles of acquisition ripple through the healthcare system, one wonders what the outcome will be—a form of monopoly capitalism, no doubt. These mergers have driven up healthcare prices in different parts of the country, and I suspect this will happen here.”
These comments brought to mind the consolidation of the big three global superstates in Orwell's 1984: Oceania, Eurasia, and Eastasia. In this dystopian novel, these three political entities wage war perpetually, breaking and forming alliances as they vie for the remaining unconquered parts of the globe.
When you consider current economic trends in our healthcare system, coupled with the widespread adoption and eventual universal mandate for the use of electronic medical records and shared data, the question arises as to what form our healthcare system will ultimately take. How will it all shake out in the end?
We need only look back to the future and peruse the final pages of Orwell's novel to discover one plausible answer to that question.
Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, September 08, 2014
Steve Wilson, PA-C
Not life, but good life, is to be chiefly valued.
I’m always amazed when I realize that there are people who set about the task on a daily basis to put something in print and expect someone to read it. Personally, I have found it difficult to find someone whom I feel has something worthwhile to say on a daily basis—excluding my wife. Either from a personal, practical, educational, or directional standpoint, she always has something to say that is worthy of my attention. However, with so much blogging going on I am not sure that quality is really a consideration for most essays written as a blog. So, whenever I prepare to produce another blog post for JAAPA, I try to find something inspirational to me that I think may be captivating to others. Inspiration has been lacking recently. However, while scanning a recent update from one of many professional alerts that cross my screen, I was directed to another site and came upon this statement:
“In a bygone era, doctors thought every life was important.”1
Ever since my educational mentor Dr. Hu Myers told me that it was important as a PA to achieve the “mindset of the physician,” I have always felt that what was important to physicians was important to me. Hence, I thought “every life” was important to physicians. I checked my deleted and trash files and did not find any notices that this had changed. Needless to say, the blogging author had my attention, so I read on.
“In the 21st century world, resources are the first consideration, and there are plenty of ideas about ways to curb treatment and lower costs. A new analysis finds that doctors could try a little less in the intensive care unit—because otherwise they are causing other ill patients needing medical attention to wait for critical care beds.”
Apparently UCLA and RAND health scholars have produced a paper that demonstrates that deaths occur because “futile” care is being given to patients in the ICU rather than making some hard decisions and making way for someone who may not be as “futile.” OK, I will accept the fact that I am maybe being a bit overzealous in this presentation in order to make a point, but, it is a blog. I have not read the study, but why waste time doing that when I can get the abbreviated blog version.
If I read the study it would supposedly show that 16% of the days when an ICU is full, it contains at least one patient receiving futile treatment. During those days, patients were kept in the ED for more than 4 hours, patients waited more than 1 day to be transferred from an outside hospital, and patient hospital-to-hospital transfers were cancelled after waiting more than 1 day. The bottom line: two patients died at outside hospitals while waiting to transfer to another hospital’s ICU.
Those of us on the front lines are not surprised by this revelation. The demands on the healthcare system are greater than ever in terms of available resources, both financial and physical. With reimbursement being more tightly tied to outcomes, could it be that possibly the desire to transfer patients with potentially fatal issues and the desire not to accept those patients in transfer are closely tied? Could it be that the resources available requiring the transfer and the resources available for accepting the transfer are the same realization with which the public needs to come to grip in terms of cost effective healthcare?
The author of the paper, Dr. Neil Wenger of UCLA, was quoted as saying that: “Many people do not realize that there is a tension between what medicine is able to do and what medicine should do. Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value—such as prolonging the dying process in the intensive care unit when a patient cannot improve."
Ahhhh…. This has nothing to do with whether or not doctors feel every life is important. This is about the fact that doctors (and PAs) value life and in valuing that life believe in death with dignity. We know we cannot heal all. This is about the fact that we need to continue to have those difficult conversations with the public about our science and art of medicine’s inability to rectify all human suffering. It is about society’s need to understand their own responsibilities for their health, the realities of affordable healthcare, the limitations of medical science, family dynamics, and better defining the limits to liability.
Thought I had inspiration for a blog post for a moment. I think I hear my wife calling.
Steve Wilson practices cardiac, thoracic, and vascular surgery at Peninsula Regional Medical Center in Salisbury, Maryland. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, September 01, 2014
Wanda C. Gonsalves, MD

One thing we know for sure is that our healthcare system is fragmented, expensive, and heavily regulated. As a result, we’ve been trying to fix the problem by creating new models of care. Two such models are the patient centered medical home and the direct primary care model, which are totally different approaches to primary care practice: the former is team-based and the latter retainer-based.
In the response to the cost of care and a physician shortage that threatens patient access to care, the number of physician assistants (PAs) and nurse practitioners (NPs) has soared, as have the number of programs that train them. Healthcare administrators have seen the benefits of adding PAs and NPs to their medical teams because they provide care at lower cost. Adding PAs and NPs frees up physicians to see more patients and to concentrate their efforts on more complex patients.
Medical schools across the country have responded to the physician shortage by increasing their student enrollments or looking for innovative training models. A few medical schools are exploring options to respond to the high cost of medical education by shortening medical school to 3 years. Examples include the Texas Tech University Health Sciences Center School of Medicine in Lubbock and Mercer University in Savannah, Ga.
The increasing medical student enrollment and the changes in medical education may have many effects on the PA profession and PA education. How will the increase in medical students and PAs and NPs alter the healthcare workforce? Is the number of PA programs expanding too quickly? Will fewer PAs enter the profession if the length and therefore the cost of medical education are lowered? Will the increase in medical students reduce the availability of training sites such that PAs and NPs will have less of an opportunity to practice what they are learning?
Only time will tell about the workforce issues. However, across the country, the availability of training sites has become quite competitive for all learners. Many medical schools are paying physician preceptors for taking students, ultimately increasing the cost of tuition and the cost of healthcare. I don’t have all the answers. The PA profession should begin to address these issues that threaten to be with us for some time. I suggest that the PA leadership and physicians work together to answer questions about how PAs might optimally fit into these practice models and others so we can help guide our practice, rather than be the last to the table.
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.

Monday, August 25, 2014
Karen M. Johnson, MA; Joseph M. Shipp, PA-C, MPAS
The Center for Sustainment of Trauma and Readiness Skills (C-STARS) in St. Louis, Mo., is a small Air Force unit geographically separated from its command due to its specialized mission. The CSTARS Simulation Center is based at the St. Louis University School of Medicine, and trains Air Force medical providers, nurses, and technicians in trauma medicine. We are budgeted to support medical deployment training requirements of the Air Force; therefore, our task performance requirements and user needs are taken from the Emergency Medical Squadron model our platform simulates. We use task trainers and high-fidelity manikins to train students in skills for preparation with live patients. Our students go from the point of equipment and manikin familiarization on their first day of training directly into their first of five simulation scenarios the very next day.
In all situations our efforts with the simulators strive to improve how quickly and efficiently the patient is addressed and assessed with proper interventions, especially under duress, and as a team. Both the high- and low-fidelity simulators enable our cadre to change up the level of difficulty according to the student’s skill level, giving the “out of practice” student a safe environment to build confidence. This is paramount within our program because students have varied levels of experience. And although our students rotate through the St. Louis University Hospital ED, it can never mimic what our military medics will see in a wartime environment. Consequently, our high-fidelity simulators are moulaged to mimic everything from explosive blast wounds to a traumatic brain injury. However, our task trainers (low-fidelity) more legitimately call for the hands-on skills needed to address the injuries mentioned above. For example, an explosive blast injury may cause a tension pneumothorax, which would call for chest tube placement. The high-fidelity simulator we use to mimic this injury already comes with holes for the chest tube and cannot be cut on. However, the chest tube task trainer can be cut on, sewed up, and reconfigured multiple times for several learners. For this reason, we teach all our course providers the fundamental skills in preparation for deployment.
We average one physician assistant (PA) per 2-week class. In most cases, the PA will come to our course with little or no trauma experience. PA class members come to C-STARS from both the active duty component as well as National Guard units throughout the United States and overseas. The PA class members from the National Guard are assigned to units that are tasked to respond to homeland emergencies and natural disasters. Active duty PA class members are assigned to a wide variety of specialties ranging from primary care to emergency medicine. The C-STARS platform is designed to enhance knowledge and skills associated with trauma resuscitation needed during any given deployment activity, both overseas and within the United States. The simulation center provides instruction and the ability to practice trauma resuscitation according to advanced trauma life support guidelines in a safe, non-threatening environment while also enhancing communication skills, teamwork, and managing chaos in a stressful environment. In addition to trauma resuscitation, PA class members utilize low fidelity training manikins to gain experience in skills such as central line insertion, chest tube placement, focused assessment with sonography for trauma (FAST) examinations, and endotracheal intubation. At the end of the 2-week training program, a mass casualty capstone simulation allows the PA to perform in the role of triage officer, managing multiple casualties with limited resources.
At the Center for Sustainment of Trauma and Readiness Skills (CSTARS) at St. Louis (Mo.) University Hospital, Karen M. Johnson is a simulation operator and Joseph M. Shipp is simulation director. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, August 18, 2014
Jennifer M. Coombs, PhD, PA-C
Technology in healthcare holds great promise for increased productivity and decreased errors. I have the great fortune of getting to see a variety of clinics as I visit PA students in their clinical rotations. Although some clinics that I visit have not adopted new electronic medical records (EMRs), that is now increasingly rare. Medical providers have a love-hate relationship with their medical records. For the most part, EMRs fall into three categories:

• The good—systems that are fast, well-integrated into other systems, and don’t have too many bells and whistles to overcome for the increasingly busy and complex offices.
• The bad—systems that require opening lots of screens, frequent changing back and forth between screens, require repeated log-ins with a password, and are exceedingly slow.
• The ugly—medical records that crash and are not reliably saved, records that can easily be marked incorrectly, and systems that encourage copying and pasting from templates, making it impossible to  determine which information is relevant and which is filler.
In the past, medical providers complained about how clunky their EMRs were and how much time was lost typing into the record. I have seen some of our students handle the medical records much faster than in the past, using their tech-savvy skills to create shortcuts for things they do repeatedly. These shortcuts can be paths to medical errors, but for the most part, when implemented carefully and reread for accuracy, they can be timesavers.
Here is an example of an efficient office practice using a PA student and physician preceptor that I observed the other day. The physician was fortunate enough to have a well-functioning assistant who took patients to the examination rooms and obtained initial histories efficiently. He used three rooms. After a patient was put into the first room, he sent the student in to do the history and physical.

The student signed into the record and begin writing in the chart. The physician would see another patient while the student did the history and physical examination. The student talked to the patient and told the patient that he needed to check with his preceptor and would be back soon. Then the student and the preceptor would head into the room and the student would present the case in front of the patient. I know this is not the usual way of doing things, but the physician would check in with the patient and do the physical again while the student was presenting. Also the physician would write things down on a whiteboard in the room. I have also seen scribes used in this capacity, to write down everything that is said by the student and the physician in the room. In this example, there was no scribe.

The preceptor then sat down at the computer with the EMR and wrote the prescriptions while the student talked to the patient. Then the preceptor switched seats with the student, who finished up the chart note on the EMR and printed the prescriptions. I saw them switch seats at the computer three times. When they left the room, the patient, the student, and the preceptor had all talked and rechecked the plan, the physician had repeated the physical examination, and the student and the preceptor had read and reread the prescriptions. The preceptor picked up an error in one of the prescriptions when he reread the printed script.

Medicine is an increasingly complex system and EMRs have drastically changed the way healthcare is delivered. Initially, the technology can be bulky and counterintuitive. Problem-solving specific issues with individual medical records can help providers increase their productivity at work and even incorporate students efficiently into their busy practices.
Jennifer M. Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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