Musings: Blog of the JAAPA Editorial Board
Musings
Blog of the JAAPA editorial board.

Monday, July 24, 2017

Brian K. Yorkgitis, PA-C, DO

The growing opioid epidemic increases pressure on the healthcare community to tackle this issue. The rate of opioid-related deaths has increased over time. The CDC estimated more than 33,000 deaths in 2015% were attributed to opioids. Included in this number is deaths caused by prescription medications, which was estimated at close to 22,500 in 2015.1 In 2013, the NIH estimated 2 million people suffered from substance use disorder related to prescription opioid pain medications, with the number only expected to rise. Each day, 1,000 people are treated in EDs for inappropriate prescription opioid use.2

No one chooses to become part of this statistic; they have a disease. As clinicians, we must focus on how we can help patients through prevention and treatment. We must think carefully each time we prescribe an opioid. Every time I approach a patient in pain, I hope to get it RIGHTT…

Risk for adverse event—Look for patient risk factors for opioid abuse or misuse (use the opioid risk tool developed by Webster).3 Use your state’s prescription drug monitoring program if available.

Insight in to pain—Set functional goals for pain relief rather than a number. Most of the time, you can’t make patients pain-free so the goal is to keep them functional.

Going over pain plan—Discuss with your patient a stepwise approach to analgesia. Use nonopioids first, such as NSAIDs, acetaminophen, gabapentin, or pregabalin. If opioids are needed, use them in conjunction with nonopioid adjuncts to allow the minimal dose of opioid possible.

Halting opioids—Opioid duration should be as short as possible. Communicate with your patient the duration that you would expect a patient with that condition to require opioids. Advise them that longer durations are associated with increased risk of dependence.

Throwing away unused medications—Discuss methods to dispose of unused opioids to prevent diversion (local drop-off locations, mixing unused pills in kitchen waste or cat litter).

Trouble—If you feel your patient is developing trouble with opioids, offer assistance instead of chastising.

Be a PArtner in this growing problem through these simple steps. Invest the time in getting it RIGHTT; the return on your investment could be lifesaving.

REFERENCES
1. National Institutes of Health, National Institute on Drug Abuse. Overdose death rates. 

2. Centers for Disease Control and Prevention. Prescription opioid overdose data.

3. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the opioid risk tool. Pain Med. 2005;6(6):432-442.

Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, July 10, 2017

Richard W. Dehn, MPA, PA-C, DFAAPA

The profession’s natural maturation toward less-restrictive state regulation and more collaborative practice environments, currently branded as optimal team practice (OTP), was the centerpiece of the recent AAPA conference in Las Vegas. As we celebrate the 50th anniversary of the profession and review some of the historical manuscripts recently published that describe how we as a profession have progressed, it appears to me that for its entire existence, the profession has followed a trend of widening scope of practice and increasing independence. This trend began with the early days of the first state practice enabling legislation, followed by prescribing legislation, followed by enabling legislation in all 50 states, and now includes the incremental removal of practice barriers on a state-by-state basis. The trend has been one of consistent improvement in the practice environment, resulting in PAs practicing much more autonomously now than in the early days of the profession.

However, painful compromises often are a byproduct of progress, and that will likely be true of implementing OPT to attain a more independent practice environment. The profession will continue on its 50-year trend of widening scope of practice and increasing independence by implementing OPT; in fact, doing so may be the profession’s only real option to remain vibrant and growing. However, there will also be costs. In my opinion, OPT is likely to increase specialization, reduce specialty mobility, and increase the length and cost of training. Additionally, I expect the implementation to pressure to profession to move toward adopting a doctoral degree as the entry academic credential. Some of the rationales often given that support an entry-level doctoral degree include keeping up with other professions that grant doctoral degrees, changes in healthcare delivery and reimbursement systems that favor providers who do not require supervision, and state practice regulations and institutional processes that serve as barriers to PAs practicing at the top of their capabilities.

I read comments and frequently have conversations with PAs, PA students, and PA applicants who strongly support having the profession move toward an entry-level doctoral degree. These conversations often contain the assumption that increasingly independent PA practice will simply require a doctorate because a doctoral degree fundamentally is a prerequisite for independence. If the profession were to require this change universally, most likely through a change in the accreditation standards, the short-run consequences would be substantial.

First, the most serious consequence of a quick mandated move to the doctoral degree would be a substantial decrease in diversity in the profession. In 2000, PA education supported a gradual move to an entry-level master’s degree, which the Accreditation Review Commission on Education for the PA integrated into the fourth edition of its accreditation standards by requiring that all new programs be developed at the master’s level and all existing programs grant a master’s degree by 2021. Currently, 92.2% of programs grant a master’s degree.1 Thus, PA education has been on a 20-year odyssey to implement the master’s degree as the entry-level degree, which is still a work in process. This process was certainly not a painless one, as the diversity of students enrolled and graduating from PA programs has decreased since 2000, and several programs institutionally unable to grant a master’s degree that enrolled diverse student bodies have either closed or plan to close by 2021.2 Higher entry-level degree requirements would result in decreased student diversity, a phenomenon well documented in other healthcare professions that have raised their degree requirements.3

Second, PA education is not prepared to move to granting a doctoral degree. Most higher education institutions require that faculty possess at least the same degree they grant their students at graduation. However, only 17.4% of PA faculty hold a doctoral degree.4 Mandating that PA programs confer a doctoral degree would result in most programs being unable to comply with their institution’s expectations due to a lack of doctoral-trained faculty, resulting in a likely a precipitous decrease in PA enrollment. Additionally, many PA programs reside at institutions not regionally accredited to grant a doctoral degree, or not allowed to move to granting a higher degree without the approval of a state agency. Although I often hear the opinion that the PA education establishment would relish the opportunity to move to an entry-level doctoral degree, because lengthening curriculum and increased tuition would certainly make PA education more profitable, nothing could be further from the truth. Very simply, PA education is still in the process of adjusting to the recent move to the master’s degree, and most PA programs are ill-prepared to make the move to granting a doctoral degree at this time.

The profession’s long progression from its humble start to becoming an established member of the healthcare team has been a 50-year process, and the movement toward a more independent place in the healthcare system through OTP is the next natural extension of that process. However, the profession will most certainly encounter many challenges along the way, just as it did in its first 50 years. We must anticipate these challenges and address them rationally, considering in our calculations the greater good for our profession and our patients as we attempt to manage the inevitable costs of change. 

REFERENCES
1. Physician Assistant Education Association. By the Numbers: Program Report 31. Washington, DC, 2016.

2. Coplan B, Dehn R, Bautista T. PA program characteristics and diversity in the PA profession. JAAPA, in press.

3. Snyder CR, Stover B, Skillman SM, Frogner BK. Facilitating facial and ethnic diversity in the health workforce. Seattle, WA: University of Washington Center for Health Workforce Studies, 2015.

4. Physician Assistant Education Association. Physician Assistant Program Faculty and Directors Survey Report, 2015. Washington, DC, 2015.

Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, June 12, 2017

Jennifer M. Coombs, PhD, PA-C

The wi-fi password at the AAPA conference in Las Vegas last month was, aptly, “Beyond50,” or past perfection, as the joke goes about those beyond the ripe age of 50 years. The debates on the House of Delegates (HOD) floor were excellent, and after conversations with students, PAs, and fellow PA faculty, I felt both buoyant and ambivalent about the future. The debate was heated and historic representing the uncertainty and the optimism that the next 50 years will be as bright and successful as the last 50. I want to sum up what I gleaned from the final vote in the HOD. The AAPA leadership implored that we not quote from the HOD document as it needs to be cleaned up and spelling and synaptic errors removed. But I will sum up what it means to me, with the caveat on accuracy. I like the term optimal team practice (OTP), although I know it sounds like a euphemism, akin to calling a prison camp a relocation center.

According to the HOD final report from the conference, Reference Committee A, “Optimal team practice is when PAs have the ability to consult with a physician or other qualified medical professional, as indicated by the patient’s condition and the standard of care, and in accordance with the PA’s training, experience, and current competencies.” Furthermore, the report states, “the evolving medical practice environment requires flexibility in the composition of teams and the roles of team members to meet the diverse needs of patients. Therefore, the manner in which PAs and physicians work together should be determined at the practice level.” This very important point is that the physician-PA partnership should be decided at the practice level. As well, chart cosignatures should be decided at the practice level and not prescribed in law or statue. A PA should be able to receive a license from a medical board made up by PAs, nor should PA licenses be tied in any way to physicians. PAs also should not have to obtain letters of recommendation from physicians (who may not be involved in their training) to receive a license. The phrase supervising physician has evolved to collaboration and beyond, to be removed altogether from state laws. PAs should be included in all legislation in all states that list providers, NPs, physicians, and PAs. A complete and total uncoupling from the language of supervising physician but with this proviso: only in states that can and wish to do so. Already, model legislation has been passed in some states that removes the word supervision from the PA practice law.

Now we can let the handwringing begin. Will we as PAs be able to move from specialty to specialty or to primary care? Will PAs lose the support of their physician partners? Will all PAs be required to obtain doctorates? Does this mean independent practice and why did I become a PA anyway? Isn’t the dependent (but autonomous) relationship with physicians the definition of our profession, our very raison d'etre? What about PA programs? Will programs in schools of medicine be asked to leave? Will physicians read the news and think the worst, that PAs no longer wish to be team players, in spite of the term optimal team practice? What will happen if rural PA providers lose their supervision?

Other issues were discussed in the testimony of many participants in the HOD. The most important is the loss of job share to NPs. There was compelling data that office managers consider hiring a PA to be complicated, technical, and with onerous paperwork. The perceived ease of hiring someone who doesn’t need supervision (and the completely assumed lack of front-end paperwork) makes it hard for even experienced PAs to get hired. The loss of job share to NPs solely due to licensing issues is a problem overdue for a fix. The Veterans Administration (VA) has notoriously struggled to maintain job share to the NPs who have often been paid better. The lack of parity in the treatment of NPs and PAs in the VA has frustrated those inside and outside the system. PA leadership in the VA moved to use the word collaboration, pushing and pulling the language from the NPs’ own rules.

Not only the administrators but the physicians themselves have told PAs they don’t want to supervise any longer. When the PA profession began, PAs made physicians’ lives easier by letting them see more patients and letting money flow back into the practice. Now physicians are being hired by large healthcare organizations. Supervision adds to their workload instead of reducing it. They are saying, “You’re not getting us home earlier, so why do it?” It is like they are making a choice: “Do you want me to produce or supervise?” They do the same amount of collaboration at the end of the day, even if they hire a NP over a PA, but it is the perception that supervision will take more time than collaboration. The other perception is legal. Who is responsible? If the PA makes a mistake, and the physician is the supervisor, ensuing litigation may involve the physician.

As we move into our next decade of practice, past perfection, the 60-year celebration should be even more interesting and significant than this 50th year. As I write this, the questions asked of me by a group of non-medical students are, “What is the difference between a PA and a doctor?” and “What can’t you do?” The answer may appear in the future.

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.


 


 


Friday, May 19, 2017

Thanks for joining us at AAPA 2017. We’ll be publishing a selection of poster abstracts online later this yearbe sure to visit jaapa.com to read them.

Don’t miss these great sessions today:
Common Patient Presentations With Unusual Diagnoses: Think Zebras, Not Horses, presented by James Van Rhee MS, PA-C, from 10-11 a.m. in Level 3, South Seas Ballroom CDF.

Postoperative confusion in older adults, presented by Freddi Segal-Gidan, PA, PhD, from 4-5 p.m. in Level 3, South Seas Ballroom ABE.

Be sure to mark your calendar for AAPA 2018 (May 19-23 in New Orleans) and AAPA 2019 (May 18-22 in Denver). And come visit us at the Wolters Kluwer booth!

 


Thursday, May 18, 2017

Today is the last day for the exhibit hall, which is open from 9 a.m. to 2 p.m. Come visit JAAPA at booth 1007. Snap a selfie at the booth, upload it to social media with the hashtag #jaapa50, and receive a gift.

More than 250 exhibitors showcase the latest medical technology, education and career resources, pharmaceutical therapies, and treatment tools. Wear your comfortable shoes, get your 10,000 steps in, and have brunch at 11 a.m. from various "brunch bites" stations in the exhibit hall.

The King is dead; long live the King: Get a photo with Elvis from 11 a.m.-2 p.m. today. Fun fact: Elvis can trace his ancestry back to a small Long Island town called Southold, making him a distant cousin of a JAAPA editor.

Want a chance to win cash? Play Medical Pursuit and enter to win a daily cash prize. Playing is easy–just use the playing card found in your conference bag and visit booths to get answers to your questions. Once you have all of your answers, drop off your card into one of the designated boxes at the entrance to the exhibit hall for your chance to win!