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Musings: Blog of the JAAPA Editorial Board
Monday, August 10, 2015
Stephen E. Lyons, MS, PA-C, DFAAPA
 
As SCUBA divers, my wife and I learned how to calculate bottom times, single-tank limits, and more. We were thoroughly informed of the whereabouts of the nearest hyperbaric chamber (at a tertiary medical center some 65 miles away), and how to avoid ever ever needing one: Always exhale while ascending, no rapid ascents except in an emergency, and don't exceed your calculated bottom time. Fortunately, the only near-emergency we ever encountered was on our very first dive together, nearly 45 years ago. We were diving in about 80 feet of water in one of the Finger Lakes of upstate New York, swimming in and out of an old paddlewheel boat that sank in the late 1800s. Suddenly my wife gave me the no-air sign—a hand swipe across her throat. We came together and "buddy-breathed" off my regulator while we slowly ascended. I was so proud of her ... and proud of our training. (OK,  I was one of the instructors). But I digress: No hyperbaric chamber necessary—just the replacement of a well-used regulator that had jammed.
 
Recently, we went snorkeling in 15 to 20 feet of warm ocean water a few miles off Honolulu, Hawaii. We wanted to see the huge sea turtles up close. And it was wonderful! I reached out and petted one on the head, earning me some closeup touching of its shell, and an angry tirade from our divemaster, who later reminded me of the potential huge fine for messing with a protected species.
 
The sun was beginning to descend as our dive boat returned to shore. Suddenly we hit a large Pacific wave, and I skidded across the deck, avulsing a large chunk of flesh from my right great toe. It bled and bled, freaking out my fellow divers and my wife. But the captain was prepared and equipped, and after yards of gauze and a hosing down of the deck, we were again headed toward Honolulu. In spite of my best self-care as a seasoned PA, by the time we arrived home in Las Vegas, I knew I was infected. My leg was red, hot, swollen, and painful. I telephoned my primary care provider, who told me to come right in. He cultured the wound, re-bandaged it, and started me on large doses of trimethoprim/sulfamethoxazole (I'm allergic to penicillin). I saw him in 48 hours and looked at the culture results: methicillin-resistant Staphylococcus aureus (MRSA)! My next stop was the wound care center at a nearby hospital. The attending podiatrist carefully and deeply debrided the wound. She ordered plain radiographs and an MRI to rule out osteomyelitis. The radiographs did not reveal osteomyelitis, and I was relieved. She however, noting that I had what my patients call "a touch of sugar," advised me that her instincts told her I had osteomyelitis in spite of the negative diagnostic tests. She proceeded with an open bone biopsy on the spot. Her 25 years of experience and finely tuned instincts served her (and me) well. I did in fact have osteomyelitis.
 
And this is where we come to the reason for the title of this blog post: The physician said that if I wanted a good chance of keeping the toe, I needed hyperbaric oxygen (HBO) chamber therapy. She brought me into the present decade by telling me that nearly every city hospital-based wound care center has its own HBO chambers—no more 65-mile commute like in the early days. And these days, the treatment is used for far more than decompression sickness. Especially in Las Vegas, where there is hardly any water in the middle of the Mojave Desert. HBO therapy now is used for many conditions resulting in tissue hypoxia and can be used to kill anaerobic bacteria by stimulating the bacteriocidal activity of neutrophils.
 
I was to receive 40 treatments, each 2 hours long, at a pressure of 2 atmospheres. I also was evaluated by the  premier infectious disease specialist in the Vegas valley and his two PAs (yay!). After another culture showed that the MRSA had abated, a peripherally inserted central catheter was inserted to deliver a 6-week course of high-dose ceftriaxone to cover the remaining microbes.
 
The following day I was oriented to the HBO chamber (which has nothing to do with television). To reduce the risk of a spark from static electricity, I removed my jewelry, shoes, belt, and wore only all-cotton clothes. My ears were examined by a physician before each session, and into the chamber I went on a special gurney. I was "taken down" to a "depth" of 40 feet in pressure equivalents.
 
Healing was evident after just a few days, but it was ever so slow. An equivocal re-biopsy of bone caused my physician to double the HBO to 80 treatments. I was told that this is not entirely uncommon in people who continue to bear weight (I'm still actively working seeing my own patients), especially if they also have glucose problems.
 
Nearly 7 months after my injury, my foot is healed—intact and functional due to the incredible skill of my podiatrist, and my infectious disease PAs and physician. I have the dubious distinction of having spent the equivalent of a month in the HBO chamber, and I can authoritatively talk about pressure.
 
Stephen E. Lyons is a staff PA at Forte Family Practice in Las Vegas, Nev. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

 

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Monday, July 27, 2015
Richard W. Dehn, MPA, PA-C, DFAAPA
 
Concierge medicine, also called retainer medicine, is a primary care physician practice model in which the patient pays an annual fee or retainer to be a member of the physician’s practice. This fee only provides access to the physician, and does not cover the cost of any of the medical care provided. The goal of this type of practice arrangement is to substantially decrease the number of patients in the physician's practice without decreasing his or her income. In theory, such arrangements let the physician to spend more time with each patient and thus provide more personal and thoughtful care, and as a result the physician will have a more relaxed and enjoyable working environment. In 2014, an estimated 4,000 of 209,000 primary care physicians had converted to concierge practice, accounting for about 2% of the primary care physician workforce.1,2 However, growth of concierge medicine is expected to accelerate in the near future; a 2012 Merritt Hawkins physician survey indicated that 6.8% of all physicians planned to move to a concierge model in the next 3 years, and 7.5% of physicians under age 40 years planned to make that change.3 In that survey sample, one-third of the respondents were primary care physicians, so if the results were adjusted to account for just those in primary care (only primary care physicians would conceivably convert to a concierge medicine model, although the survey question included responses from both primary care and specialty physicians), then that percentage would increase to 10%, or about 20,000 additional primary care physicians who may go concierge over the next 3 years. If that were to occur, the concierge model would then account for more than 8% of the primary care physician workforce.
 
The major feature of this delivery model is that the patient pays up front for better access to the primary care physician. Typical plans provide for longer visits, routine yearly examinations, access to more screening processes and patient education materials, as well as access to the physician by phone and e-mail. In moving to concierge practice, the panel size, which is the total number of patients in the physician's practice, is dramatically reduced. Typically, a primary care physician will have a panel of 2,000 to 2,500 patients, but in a concierge practice the patient panel size is often limited to 500 to 600 patients. Although this may be desirable for patients who can afford or are willing to pay for this type of care, evidence is sketchy as to whether this model produces better outcomes when adjusted for potentially confounding factors such as age, income, education, and prior health status. Physicians practicing this delivery model extol its virtues—they often mention that they have the time with patients that the current conventional healthcare delivery model doesn't allow. And patients who pay to participate in this model, although a biased sample of self-selected individuals, also typically sing praises of personalized attention and the assumption that they are receiving a superior quality of medical care. However, this model is not without critics. Many have accused concierge physicians of abandoning their patients who won't or can't pay the annual practice fee when converting from a traditional practice. Ethicists worry that concierge models further divide patients into the economic haves and the have nots, and some worry that the model's exclusiveness violate a basic principle that primary care access should be universal.4
 
Using the Merritt Hawkins data, if in 3 years the 24,000 primary care physicians who indicate they plan to convert to a concierge model reduce their practice panel sizes by 75%, that would result in 18,000 additional primary care physicians who would be needed to provide care for the patients excluded from these smaller panels.3 Add to this figure one current prediction that 52,000 additional primary care physicians will be needed by 2025.5 Those 70,000 patients ultimately will need to be treated by somebody. Maybe physician assistants (PAs) and nurse practitioners (NPs) will need to step up to care for more of these primary care patients?
 
I suspect that the growth of the concierge model of medical practice has not been factored into current medical workforce supply and demand prediction models. If this trend continues, primary care physicians may end up providing care for fewer patients than was previously calculated. If physicians increasingly elect concierge practices that primarily serve small panels of richer patients, should the training of primary care physicians be subsidized at the level it is currently is, or should funding subsidies for primary care training be shifted to NPs and PAs?
 
REFERENCES
1. Gunderman R. The case for concierge medicine. The Atlantic. July 16, 2014
.
 
2. The Number of Practicing Primary Care Physicians in the United States. Primary Care Workforce Facts and Stats No. 1. Agency for Healthcare Research and Quality, US Department of Health and Human Services.
 
3. A Survey of America's Physicians: Practice Patterns and Perspectives. Survey conducted on behalf of The Physicians Foundation by Merritt Hawkins, September 2012, The Physicians Foundation [PDF].
 
4. Zuger A. For a retainer, lavish care by 'boutique doctors.’ New York Times, October 30, 2005.

5. Petterson SM, Liaw WR, Phillips Jr RL, et al. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012; 10(6):503-509.
 
Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 
 
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Monday, July 13, 2015
Amy M. Klingler, MS, PA-C
 
After attending the AAPA Annual Conference in San Francisco, I was struck by the spectrum of work performed by PAs across the country (and even throughout the world). As someone who has always worked in family medicine and who has spent the last 9 years in frontier (aka “very rural”) medicine, sometimes I can’t even comprehend what my PA colleagues who work in the ICU or cardiovascular surgery do on a day-to-day basis.  In case some of you are likewise wondering what it is like to be a PA practicing in rural medicine, I would like to share a few insights into my practice.
 
You might be a rural medicine PA if…
 
• In the span of a single conversation you may play the role of clinician, friend, nurse, confidant, and social worker.
 
• You still make house calls; sometimes arriving at the patient’s home by foot, car, or snowmobile (depending on the weather).
 
• You are asked to examine canine patients with such regularity that you keep a special box of vet supplies easily accessible. You also may have a cache of dental and orthodontic tools.
 
• You learn more from seeing your patient’s carts at the local grocery store than you do from the answers to the social history questions you ask in the exam room.
 
• You have the privilege of working with extremely dedicated, volunteer EMTs and firefighters who are willing to drop whatever they are doing to respond to an emergency.
 
• Patients bring you gifts … fresh vegetables, homemade jam, potholders, down jackets.
 
• It’s totally acceptable to hug your patients.
 
• Patients look forward to annual physicals with you because you have time to “catch up.”
 
• Right next to your drawer of vet supplies you have a tool drawer (or two) for when you need to fix generators, toilets, leaky faucets, and/or refrigerators.
 
• You take vital signs, perform phlebotomy, and give vaccines because there is no one else to do it for you.
 
• You must be well versed in the details of PPO, HAS, and HMO; Parts A, B; and Tiers 1-3 because it directly affects how your patients access and afford healthcare (and you will hear about it if they have to pay for an expensive prescription or see an out-of-network provider).
 
• You find it easy to talk with your patients about end-of-life care because you know them outside of the clinic and therefore have greater insight into their desires (or not) for the continuum of life-sustaining treatment.
 
• Most of the people in your town have police scanners and therefore know about all of the local emergencies, sometimes before you do.
 
• Patients may make payments on their bills whenever and wherever they happen to run into you; this could be at the grocery store, post office, while you are out at dinner or attending a school function, not just at the office.
 
• You continue to provide care, give advice, or simply call and check in with your patients who are on hospice (without any concern of reimbursement) because you couldn’t imagine leaving them at such a critical time in their lives.
 
• You often answer the clinic phone.
 
• No matter how many times you try to correct them, patients still call you “Doc.” To them it is a term of endearment and respect.
 
• You frequently have to “play dumb” to avoid incurring a substantial HIPAA fine; usually in conversations that begin with, “Did you hear about…”
 
• Your dream job also came with an opportunity for National Health Service Corps loan repayment.
 
• Traffic along your morning commute is more likely to be deer, elk, or antelope than other vehicles.
 
• Your average office visit is significantly longer than 15 minutes and you have been known to spend hours with patients when the disease, social situation, or extensive medication or problem list requires such time.
 
• You choose to wear scrubs while working because your white coat proved to be intimidating and when you wear business attire everyone asks, “Where are you going all dressed up?”
 
• Your autonomous practice of medicine is supported not just by your supervising physician but by his partners and the physicians staffing the ED at the nearest critical access hospital, who take your calls, without hesitation, at any time of the day or night because they appreciate the austere environment in which you practice medicine.
 
• Your work-life balance is pretty well balanced.
 
• A long list of people want your job.
 
Amy 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, June 15, 2015
Zachary Hartsell, MPAS, PA-C, DFAAPA
 
I recently attended a national workforce conference where I presented survey data about PAs in management positions.1 The data presented were from a 2013 PAs Who Are Administrators, Managers, and Supervisors (PAAMS) survey, which provided a snapshot of the characteristics of PAs who have leadership positions in healthcare and were members of the PAAMS listserv. Not unexpectedly, their roles and characteristics were heterogeneous and diverse. For example, survey participants identified 15 different titles used to describe their positions, with nearly 10% of respondents reporting that they had management or leadership responsibilities without an official title.
 
The survey data also suggested that PAs in clinical leadership roles may need additional mentorship and development. Nearly 50% of the respondents reported being in their leadership position for less than 3 years, and fewer than 50% reported any formal business or management training before stepping into their leadership role. Although this information is not necessarily surprising for leaders in a clinical role, only 43% of employers provided any leadership or management training to support these PAs, which is surprising. This represents a gap in what leaders know and potentially need to know to find success in their roles. PAAMS events and the AAPA Clinical Leaders Conference provide valuable resources but are not able to provide the full breadth of what is required from PAs in clinical leader roles.
 
The data were received favorably at the workforce conference and perceived by some as a call to action. A non-PA workforce researcher commented that although he and his colleagues had worked with PA workforce projections for years, they had never once thought about who was going to lead this workforce, which is projected to keep growing.
 
When I speak with colleagues in leadership roles, they identify different ways to overcome these gaps. Some learn on the job. Some get training through their organization, or their organization pays for training. Many attend leadership conferences like the AAPA Clinical Leaders Conference, and some pursue advanced degrees such as master of health administration (MHA) or master of business administration (MBA). I have held leadership positions at two different organizations and had the opportunity to participate in many different forms of leadership training. I chose to obtain an MHA, but this is certainly not the only path to success. Four years ago, for example, I attended the Society of Hospital Medicine (SHM) Leadership Academy, a valuable intensive workshop for people interested in leading hospital medicine teams. SHM is very supportive of PA involvement and has used PA facilitators at the event regularly in the past. The tools taught and the lessons learned at the event were many of the same principles I learned in my MHA program. The main difference was the scope and context of the discussions. PA leaders have many different paths. The key is identifying the most productive path in a world full of choices.
 
A resource that I am excited to hear more about is AAPA’s Center for Healthcare Leadership and Management (CHLM).2 I hope CHLM can provide resources to help PAs succeed in leadership roles; research on the best models for PA leaders to use; guidance regarding the attitudes, skills, and knowledge PA leaders need to be successful; and support for employers of PAs to help them understand the value of PA leadership. At CHLM’s first event at last month’s AAPA conference in San Francisco, I presented information about operationalizing cost and quality into practice. Through the small group work, I was able to hear from many different PA leaders who had created innovative solutions to common healthcare management problems. This exchange of ideas was valuable, and I hope that CHLM can continue to develop these sessions and resources, obtain data from employers, and collect these stories of innovation. If it can, CHLM will become a valuable resource to the PA leadership community and help address the gaps in knowledge and skills we see today. Being able to take advantage of a recognized, consistent source of management training will allow PAs in leadership positions to move from workforce afterthoughts to being key contributors to the healthcare delivery models of the future.
 
REFERENCES
1. Hartsell  Z, Pickard T. PAs in Administration [Poster]. American Academy of Medical Colleges Workforce Innovation Conference. Washington, DC. 2015.
2. Center for Healthcare Leadership and Management. American Academy of Physician Assistants.
 
Zachary Hartsell is program director and vice chair of operations and workforce development and an associate professor in the PA program at Wake Forest University 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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Monday, June 01, 2015
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE
 
It is that time of the 5-6 year period (on the old system), when my mind ponders the necessity of recertifying, as in taking the PANRE. In addition to the expected feeling of dread, I am also challenged with confronting all that I do not remember (orthopedics), ever recall learning (infectious disease), understand some aspects of (neurology) and dislike topic-wise (no comment). However, for everything else, things are fine.
 
My PANRE quest began with the National Commission on Certification of Physician Assistants (NCCPA) website, where I reaffirmed my limits of stats knowledge. The NCCPA website details and then summarizes the scoring: “This [PANRE] calculation is based on the Rasch model and equates the scores, compensating for minor differences in difficulty across different versions of the exam. Thus, in the end, all proficiency measures are calculated as if everyone took the same exam.”1 Thus started my venture in Eponym Hell.
 
I do the usual lamenting and kvetching (Seinfeld knows, Yiddish for whining) to anyone who will listen.  Several of my coworkers and of course my fellow PA program graduate buddies are on the same recertification cycle, and we compare preparation notes. Here is a smattering of their responses/approaches:
 
• “Did you already book your exam? Am I too late?”
 
• “I haven’t finished all my NCCPA CME credits! Do I need to before I can book my exam?”
 
• “No big deal, I only have to review ECGs and murmurs and I will do fine.”
 
• “I only care if I pass, and I can do that without studying. I gave up on high scores.”
 
• “I don’t plan on taking a review course.  Are you taking one? OMG, I should take a review course. Which one do you take?”
 
• “You (meaning me) are too OCD.  You can pass with your eyes closed.” I replied, “Is OCD egosyntonic or egodystonic?” This resulted in a nasty look. But I made her think.
 
• “I have no time to think about it now.”
 
But then, I get a grip on myself and enter the zone of positive thinking. I consider that if I pass (never good to be cocky), then I will not have to take the PANRE for 10 years. This is good news. However, this means that I will be collecting Social Security benefits, if they still exist at that time.
 
I consider the use of a review book, and locate one with a 2015 copyright. This makes me worry that the information will be too new for the exam; should I select one from 2013? Then I realize that even new review books are often 1 to 2 years behind the times. I tentatively open it and see all the sections. I remind myself to avoid holding my breath. I visit the NCCPA website again, avoiding Rasch, and write the PANRE exam percentages next to each section. If I could read an ECG with precision (soon I will be able to), I would note personal sinus tachycardia, and maybe a tiny PVC.  I make a study schedule of sorts and get to it.
 
As I study, I feel the “eponym effect.”  This presents with subtle chest tightening associated with the preponderance of conditions and syndromes named for famous scientists or doctors who had the time and wherewithal to observe physical signs and symptoms invisible to the average eye (mine).  But, now I must meet them.  Names like Virchow, Jones (more than one), Addison, Crohn, Lisfranc, Colles, Monteggia, Wenckebach (not to be confused with Mobitz), and other names too difficult to type march across the page, reminding me of Jackson (don’t ask).
 
I find myself thinking the same stuff that I tell my students as they prepare for major exams and also their upcoming PANCE: You are smart enough to get into PA school. You have passed all your exams to date. You know how to study and take a test. Never change an answer unless you are certain you misread the question. I admonish them to dig deeply into their physiology lessons and recall that breathing is central to brain oxygenation, important to answer selection.Wow, do I really believe all this stuff? Then reality settles in. I will complete my studying and be prepared to do the best I can do. Why? Because I expect my students and my healthcare providers to know their stuff. Whether I agree in principle with retesting is not important, as this is the rule. So, I will endeavor to think hard and score high. I can then stand at the lectern or my patients’ exam table and feel like a competent PA-C.  What a great feeling it will be!
 
REFERENCE
1. NCCPA:
Exam Development and Scoring. Accessed May 18, 2015.
 
Ellen D. Mandel is a clinical professor in the PA program at Pace University in New York City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 
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