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Musings: Blog of the JAAPA Editorial Board
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.
 

Monday, May 18, 2015
Brian T. Maurer, PA-C
 
Fifty years on, I can still effortlessly conjure up a mental image of the old black Underwood typewriter that sat in my boyhood home. My father had acquired it second-hand during his college years; and in his chosen profession he still put it to good use.
 
My father taught high school business courses: law, bookkeeping, shorthand, office machines, and typewriting. From my bedroom where I sat cloistered at my desk immersed in my studies, many evenings I could hear the familiar rhythm of the keystrokes as my father sat at the kitchen table, typing out assignments for his students.
 
As a boy, I spent hours exploring the intricacies of that old Underwood. It was black and heavy, and boasted all kinds of buttons and levers and cranks that could be pushed and pulled and turned and tapped to produce all sorts of effects. The ribbon could be rewound with a small crank on the side; the carriage was returned by sweeping the long lever at the top left; a small bell dinged when you reached the end of the line. To me the machine itself was a technological wonder.
 
When I pointed out these fascinating facts to my father, he would smile a knowing smile and say: “The typewriter is just a tool for writing—nothing more, nothing less.”
 
In preparation for college, I enrolled in an academic typing class my senior year of high school. Dutifully, I sat at a desk in one of the rows with my fellow classmates in front and back and on either side, fingers on the home row, and practiced striking the corresponding keys as my eyes followed the lines of type in the top-bound instructional manual. Like everyone else, I learned by fits and starts; but by the close of the semester, I had mastered the art of touch typing.
 
The year I started undergraduate school, my father bought me a brand-new Olympia portable typewriter, which still sits in its case in my home office. It was beautiful and sleek, a joy to type on. Unfortunately, I still needed to correct my keystroke mistakes with an eraser or correction tape, one of the banes of that technological era. Later, I discovered erasable bond paper, which allowed easier correction of mistakes. At some point. Wite-Out made its debut: another technological advance to assist the weary error-prone typist.
 
Everything changed with the advent of the word processor and then the desktop computer. Now the typist could make all of the corrections in the machine and run a spell check before printing a flawless document: a perfectionist’s dream.
 
Computers morphed from desktop clunkers to sleek handheld devices with untold computing power, allowing users to communicate instantly around the globe. Data, facts, information, knowledge, news—all were just a touch-tap away. This technology is truly fascinating; and yet, possessing such technological gadgets does not get us off the hook: we still have to think before we tap.
 
Which brings me to the electronic medical record, a modern technological wonder that places seemingly limitless power at our fingertips, power to access information at the tap of a screen and instantly retrieve the necessary knowledge to enhance the quality of care we deliver to our patients. Ideally, the use of such electronic applications can trim medical errors to a minimum and raise the standard of care across the globe—a fascinating technological advance.
 
But these state of the art technologies share one thing in common with my father’s old Underwood: they are tools—highly sophisticated ones to be sure—but in the end, tools nonetheless.
 
As clinicians, it is still up to us to approach our patients as human beings; and when making diagnoses and drafting treatment plans, it is still up to us to pause, to ponder, to think before we touch—and type.
 
Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

Monday, April 20, 2015
Virginia Hass, DNP, FNP-C, PA-C

My muscles are pleasantly achy (no, that is not an oxymoron) after completing another CrossFit workout. I’m not a fitness nut and this is not a blog about fitness. I have enjoyed regular physical activity my entire life, first growing up in a small town that had more bicycles than people, then in adulthood as a long-distance runner and avid hiker. When the going got tough, I would strike out for the bike trail, running path, or for a few days of what our family calls Sierra therapy. What all of these endeavors had in common, aside from contributing to my overall well-being, is that they could be done solo. Team sports just weren’t my cup of tea.
 
Enter CrossFit, which a PA colleague introduced me to about 2 years ago. Let me first explain that CrossFit is many things, but at its core are two principles: optimal fitness and community. Optimal fitness in this case, is defined as increased work capacity across time and in many domains. The spontaneous community that is created when people work out together is the key to its effectiveness.  So back to my PA colleague—she said, “Give it a try, you’ll like it.” I was skeptical—that whole group activity thing—working out with a bunch of other people? Not my style …. Besides, my workout routines had always been effective, hadn’t they? But, like all good healthcare providers, this PA did not try to convince me. Sneaking in the topic with motivational interviewing strategies over lunch, she would connect her training at the gym and her improved performance on a recent long-distance bike ride. We talked about my own fitness goals. Bit by bit, my cognitive dissonance increased—what could I be doing differently? My skepticism gave way to curiosity and here I am 2 years later, happily engaging in an intense communal activity and pondering the similarities between the CrossFit community of which I have become a part, and the elements of a highly functional interprofessional team.
 
At the core of patient-centered care is the use of interprofessional teams in which members are empowered to function at the peak level of their training, knowledge, skills, and licensure. Teams have been defined as, “a small number of people with complementary skills, who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable.”1 I would go a step further to say that the highly functional team also becomes a community; and permitting each member to function at full scope of practice is analogous to the CrossFit principle of optimal fitness.
 
In the CrossFit community, each individual has his or her unique talents and skills. We engage in constantly varied, functional movements performed at high intensity—does this sound similar to any job you’ve done recently?  This person can run faster, that one can jump higher, and another can climb a rope quicker. But when we are all completing a team workout of the day, it is the combined effort of the group that gets the work done. While one team member is doing burpees, another is resting between broad jumps. We coach each other through deadlifts and bench presses, and when one person falls behind, the rest cheer her on—counting reps to completion. Good communication, complimentary and perhaps overlapping skills will make the team faster and more efficient, prevent injuries, and definitely makes the workout more fun!
 
Studies have demonstrated that a team-based approach is integral to improving a variety of outcome quality measures, including patient satisfaction, provider satisfaction (fun – yes, work should be fun!), readmissions, and decreasing errors in healthcare.2,3 Again analogous to CrossFit, successful teams promote development of the individual and team interdependence. All team members are recognized as essential contributors who are equally responsible for the outcome.  This analogy could be made for any team sport—baseball, soccer, pick one you can relate to.
 
The concepts of interprofessional collaboration, practice, and education were first introduced in the Institute of Medicine (IOM) report Educating for the Health Team.4 More than 40 years and multiple IOM reports later, we are still trying to integrate these views broadly across current models of healthcare education and practice. We have evidence that interprofessional teamwork and coordination of care is effective, so I’m left to wonder—why does implementing change take so long? Is it perhaps because we cannot see how the evidence applies to us as individuals and to the healthcare teams we work in and with each day? Because we do not think that the changes our small team of people makes will have a significant effect on the larger system as a whole? Take a few moments to think about the teams you engage with each day—your families, your workout buddies, or the pickup basketball team you play with on weekends. How can you translate the skills you already have to the interprofessional teams you work with to change healthcare?
 
REFERENCES
1. Katzenbach J, Smith D. The discipline of teams. Harvard Business Review. 1993;71(2): 114-120.
 
2. National Quality Forum. Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report. Washington, DC, 2010.

3. Martin JS, Ummenhofer W, Manser T, Spirig R. Interprofessional collaboration among nurses and physicians: making a difference in patient outcomes. Swiss Medical Weekly. 2010;w13062.
 
4. Institute of Medicine. Educating for the Heath Team. Washington, DC: National Academy of Sciences, 1972.
 
Virginia Hass is an assistant clinical professor and nurse practitioner program director in the Betty Irene Moore School of Nursing at the University of California at Davis. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, April 06, 2015
Steve Wilson, PA-C
 
Spring is in the air—almost! At least there was enough sunshine today to cause me to stop in at my local nursery/garden shop. Their spring supply of plants is beginning to trickle in and the agrarian influence in my DNA always makes me want to go outside and dig a hole. That activity is always best received in my household if I plant something also. The possibilities always seem endless. I am sure someone has written an algorithm for plant selection: poor draining soil + partial sun + less than 3 feet tall + midsummer to fall bloom + deer resistant + tolerates drought + attracts butterflies + not already in yard = … Well, you get the drift.
 
On occasion, I have constructed a plan for a certain part of the yard. However, I will admit that most of those plans, drawn during the winter as I’m looking outside while seated with a cup of coffee, never quite make it to final production. But isn’t that the way it is for all creative ventures? It all comes apart at the nursery. I just seem to wander aimlessly trying to keep one step ahead of the different irrigation systems. It is just a great place to be. The workers there must agree, because I see the same ones year after year.
 
It is not easy work. Besides the nursery part, the shop also has a fresh market where a lot of local produce ends up, as well as their own corn and strawberries. The work can be backbreaking, hot, and dirty. The workers don’t shy away. They continue to check on me between their tasks and always have a smile and understand what I need. This last part always disturbs me a little. You see, most of them are Hispanic. They speak among themselves in their native language but always speak English to me. I guess they figure that speaking Spanish is not a possibility for me. Maybe they are right.
 
I have tried to learn some Spanish. I took a special medical Spanish course a few years ago. The problem is that I don’t have many Spanish-speaking patients. When I do care for one, it is too late to brush up on the language again. I am frustrated by this personal shortcoming. I marvel at the owner of this nursery. He was born and raised in the area, but he switches from English to Spanish sometimes in mid-sentence. I believe he has gained a trust from his workers because of this and they have responded by being good workers and recognizing the value of learning another language—English. I would like to gain the trust of the Hispanic patients I see for surgery. Many of them are older and scared and rely on younger family members to translate for them. For liability purposes, the hospital wants us to rely on an interpreter hotline. However, maybe if I could just commit to memory a few key phrases, I could better convey my concern for their health and well-being. It would be like in the movies when the American tourist is relieved to learn that the person with whom they are speaking can converse in English.
 
I understand that English is now accepted as being the international language, particularly in business. But I often wonder if we at least tried to learn another language that maybe this melting pot of a country would have a better understanding of cultural differences and not just linguistic differences. That understanding another’s native language would build a trust that would break down those barriers of prejudice that grow out of fear and misunderstanding. Do I think that people who move to this country should learn English? Sure. I also believe that if I move to France or Germany that I should learn those languages. But I am sure that should that day come, I would still find some solace in sitting with a group of ex-pats over a beer and speaking English. So why should I enact what would be a double standard on those who come here to seek a better life? Many of us have an ethnic heritage from which we draw strength. We celebrate it in many festivals and even in the foods we eat. Language is a part of that same celebration.
 
I took French back in the day, but it was really not the conversational teaching that is needed. Never been to France, so outside of some French restaurants I have not had much practice to keep it up anyway. I will admit that I am a little jealous of those who are fairly fluent in a second language. I know that when I go to an Italian restaurant with my friend who speaks Italian, we are guaranteed a good seat if the owner greets us at the door. I guess that may sound a bit elitist. Almost like a password to a secret club. I don’t look at it that way. I look at it as a key to unlocking a relationship with someone with whom I may not have had the opportunity had I not shown an interest in them through language. This is a big country. It is a big world. But we know it is smaller now than ever before.
 
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.
 
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