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Blog of the JAAPA editorial board.
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 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.


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.

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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Monday, April 4, 2016
Amy M. Klingler, MS, PA-C

They say that the eyes are the windows to your soul. You can tell a lot about a person by looking in their eyes. Being the daughter of a dentist, I believe the mouth is a window to the body. You can learn a lot by examining someone’s mouth. Poor oral health correlates with poor systemic health. The nature of the relationship and cause and effect are still being studied; however, evidence is mounting in support of a theory of inflammation caused by gum disease that spreads to other parts of the body.1

Here is a quick primer on gum disease and caries:

• Gingivitis is the mildest form of gum disease. The gums become red, swollen, tender, and bleed easily. Gingivitis is caused by plaque buildup due to inadequate oral hygiene, but is reversible with good dental care (daily flossing and twice-daily brushing).2

• Periodontitis is inflammation around the tooth. In periodontal disease, the deeper supporting structures of the teeth that connect the tooth root to surrounding bone become inflamed and weakened.2 Opportunities for infection increase as plaque, which contains bacteria, proliferates below the gumline causing a chronic inflammatory response. This inflammatory response is implicated in systemic illness such as cardiovascular disease, diabetes, and stroke. Periodontitis also is associated with poor pregnancy outcomes. Korean researchers studying oral health recently concluded that “oral hygiene may be considered an independent risk factor for hypertension and that maintaining good periodontal health habits may prevent and control the condition.”3

Tooth decay, on the other hand, is caused when the bacteria in the mouth transform foods (especially sugar) into acids that deteriorate the enamel and create dental cavities (technically called caries). When the root canal system is breached by decay, untreated dental caries can lead to dental abscesses.

Gum disease and tooth decay often coexist and are totally preventable, but good oral hygiene needs to start early. Pediatric oral health services are now considered an essential health benefit under the Affordable Care Act. (This means it must be available, but parents are not required to buy it.) Amazingly, dental care for adults is not considered an essential health benefit and insurers are not required to offer dental coverage to individuals. Even with insurance, everyone does not have equal access to dental care. Nearly every state has areas of dental professional shortage.

The current issue of JAAPA contains a commentary and special article about exciting changes in the US oral health system that focus on prevention of dental disease. The DENTEX program at the University of Washington trains dental therapists, a new dental health profession in the United States. Dental therapists are dental professionals who are skilled at the prevention and treatment of dental caries. Alaska was the first state to allow dental therapists to practice (under the supervision of a dentist) and other states such as Minnesota and Maine are following their model.

The similarities between dental therapists and PAs are impressive, as are the barriers they face. But like so much in medicine, our current system is inadequate. We need improved dental health access, affordable dental care, and a focus on good oral hygiene. Dental therapists may be part of the solution when it comes to dental health disparities.

When we look past our patients’ mouths to check their throats, we are missing a treasure trove of information and a fantastic teaching opportunity. By working with our dental colleagues, be they dentists, dental hygienists, or dental therapists to improve our patients’ oral health we can actually prevent disease rather than simply manage illness.


1. Kim J, Amar S. Periodontal disease and systemic conditions: a bidirectional relationship. Odontology/the Society of the Nippon Dental University. 2006;94(1):10-21.

2. American Academy of Periodontology. Types of gum disease.

3. Choi HM, Han K. Associations among oral hygiene behavior and hypertension prevalence and control: the 2008 to 2010 Korea National Health and Nutrition Examination Survey. J Periodontol. 2015;86(7):866-873.


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.



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Monday, March 21, 2016

Carol A. Hildebrandt

The 2008 position paper from the National Rural Health Association on physician assistants (PAs) practicing in rural areas elucidates the barrier to care experienced by rural residents due to practitioner shortages, especially primary care practitioners.1 The unequal distribution in rural areas of the United States represented one of the most pressing health policy problems in 2008 and it appears not much has changed. Rural areas still represent one of the largest practitioner-underserved populations in the country, while the recruitment and retention of healthcare professionals in rural areas remains a continuing challenge. Residents in rural areas are faced with a multitude of problems including financial stress, isolation, lack of public transportation, absence of job opportunities, high food costs, and unreliable access to healthcare services such as primary care, dental care, behavioral healthcare, and emergency services. The practitioner shortage has serious implications for access to care, quality of care, and the health of patients living in these areas. Strategies to recruit more PAs and NPs who feel the call of the pastoral lifestyle must be devised, as well as ways to make it desirable for them to practice in rural, underserved areas.

JAAPA’s recent article "Physician assistants in rural communities," provides some facts about the status of PAs practicing in primary care.2 Data were taken from the 2013 American Academy of Physician Assistants Annual Survey. As the article points out, medical providers are more inclined to practice in a rural area if they come from that type of area. Our program data underscore this trend, as our experience has been that a graduate’s decision to practice in a rural, underserved community is more contingent on where they grew up or spent a substantial amount of time than on how many primary care or underserved rotations they completed during their second year. Cawley and colleagues write about various reasons PAs make the choice not to practice in rural areas or why they do not stay if they do choose to practice there; among those are professional isolation, salary, and lack of career opportunities.2 Some of the positive reasons for choosing practice in a rural region are a greater amount of freedom, flexibility, and control; smaller practices that allow more direct contact with management; and a more supportive relationship with patients.3 PAs and NPs have in the past been a mainstay of the rural healthcare workforce, however the proportion entering the rural primary care workforce has been declining. The JAAPA article points out that the number of PAs practicing in rural settings decreased from 17% in 2005 to 12% in 2013.2 Healthcare employers in conjunction with PA programs need to develop strategies to recruit providers for rural areas and to retain providers who choose, for a variety of reasons, to practice in rural America.

Parallel to primary care workforce issues is the ever increasing need of clinical teaching sites. There are many factors leading to the challenge of finding and maintaining clerkships and clinical training sites, including a larger number of students enrolled in distance education programs and off-shore medical schools, an ever-increasing number of PA programs, and the trend towards paying for clerkship and preceptor slots.4 A 2012 report from the Association of American Medical Colleges documented in great detail the mounting concern of health discipline schools in the growing shortage of clinical training sites.4 In light of professional isolation being the much-cited reason for not accepting or leaving a position in a rural area, along with PA programs facing the mounting difficulty recruiting quality clinical rotation sites, a partial solution to both problems may be for rural practices and hospital systems to make more rotations available.2 This would pair PAs and other healthcare providers who feel professionally isolated with students who need to complete rotations in primary care. The AAMC paper reported that 78% of respondents to their 2012 survey indicated that one of the strategies they used to address the shortage of clinical training sites was to expand their radius of search.5 Invariably, this would lead to expanding into previously untapped rural areas. Facilitating professional relationships with coworkers, other providers, and especially with clinical-year PA students could go a long way toward alleviating feelings of professional isolation. Concurrently, facilitating primary care providers practicing in rural, underserved communities as role models can reinforce graduates’ attraction to rural medicine and guide an increasing number of them toward choosing a career in primary care. Optimistically, this strategy might attract more PA graduates to rural America. As the JAAPA article points out, “rural PAs appear to be cost-effective and safe, and in certain cases, increase the access to care.”2 The article demonstrates that recruiting PAs to a community can have a positive effect on economics, patient care, and quality of life.

1. National Rural Health Association. Workforce Series: Physician Assistants
2. Cawley JF, Lane S, Smith N, Bush E. Physician assistants in rural communities. JAAPA. 2016;29(1):42-45.
3. Hart G. Why NPs and PAs choose to work in rural settings.
4. American Association of Medical Colleges. Recruiting and maintaining US clinical training sites.

Carol A. Hildebrandt is research coordinator 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.


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