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Musings: Blog of the JAAPA Editorial Board
Monday, July 21, 2014

Kristine A. Himmerick, MPAS, PA-C

Graduation season is upon us. For PA students, this means robes, funny hats, proud families, and a big sigh of relief after surviving 2 to 3 years of intensive medical learning. Looming large just around the bend from the graduation stage is another monumental task…the Physician Assistant National Certifying Examination (PANCE). When the celebrations are over, the content blueprint will be waiting. High-stakes certification examination preparation can be a stressful time, and as a PA educator, I am often asked by students how to prepare for the examination.

The reality is that more than 90% of new graduates pass the PANCE on the first try. PA researchers have explored various measures as predictors of PANCE success. Performance on the Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT) is consistently the best, although far from perfect, predictor of performance on the PANCE across several studies.1-3 Other factors that have been less consistently correlated with PANCE scores are program-specific summative examinations, results of previous multiple-choice examinations in the didactic year, grade point average before and during the PA program, graduate record examination scores, years of healthcare experience, grades on prerequisite courses, and demographics.1-4 None of these predictors can guarantee individual success and a structured study strategy is important to guide preparation for the examination.

One problem students have in preparing for the PANCE is trying to use too many resources. I recommend that you depend on one high-quality resource from each of three categories: a review book, a primary medical reference, and a question book or website. Depending on three main references will help keep studying focused and avoid desktop clutter.

I recommend selecting one board review book. Many PANCE preparation review books are available. Select a review book that has been recently published, covers the NCCPA content blueprint topics, and follows an outline format that you find intuitive.

Next, select one primary medical reference as a go-to book for everyday studying. This might be the medicine text that you studied from in your didactic year, such as Harrison’s Principles of Internal Medicine, Cecil Textbook of Medicine, Current Medical Diagnosis and Treatment, UpToDate online, or many others. Choose a medical reference book with a format that fits your learning style.

Finally, select a single practice question resource. Many vendors are happy to take your money to provide you with practice PANCE questions. You do not need them all! Choose one book or online source that is easy to use and fits your budget.

Once you have selected these three main study references, use these four tips to develop a good study plan:

• Write out a schedule to cover all NCCPA blueprint topics between now and the date of the examination. Plan to spend more time on the largest topics on the blueprint (cardiology, pulmonology, gastrointestinal, and musculoskeletal) and topic areas that are difficult for you.

• Spend time every day studying from each of the three categories. First, use your review text to read about one blueprint topic (or portion of a topic for larger categories). Then move to indepth reading from the medicine text. End each study session with practice questions.

• Take practice questions every day. Preparing for the examination requires learning the question format and style. Complete practice questions in learning mode (reading the answer and rationale after each question) and in test mode (complete 30+ questions at a 1-minute-per-question pace). Writing your own questions is a great way to learn to be a better test taker.

• Keep your study time active. Know your learning style and capitalize on your strengths. For example, don’t spend hours writing flashcards if you are an auditory learner. Find ways to study by comparing and contrasting diseases and treatments. Think about patients you saw during clerkships that embody the disease process you are studying.

Those very patients are awaiting your arrival on the scene as a certified PA. So take a couple days to celebrate the accomplishment of graduating with a highly coveted PA degree, clean up the confetti, and then hit the books (again)!

REFERENCES

1. Higgins R, Moser S, Dereczyk A, et al. Admission variables as predictors of PANCE scores in physician assistant programs: a comparison study across universities. J Physician Assist Educ. 2010;21(1):10-17.

2. Massey SL, Lee L, Young S, Holmerud D. The relationship between formative and summative examination and PANCE results: a multi-program study. J Physician Assist Educ. 2013;24(1):24-34.

3. Ennulat CW, Garrubba C, DeLong D. Evaluation of multiple variables predicting the likelihood of passage and failure of PANCE. J Physician Assist Educ. 2011;22(1):7-18.

4. Brown G, Imel B, Nelson A, et al. Correlations between PANCE performance, physician assistant program grade point average, and selection criteria. J Physician Assist Educ. 2013;24(1):42-44.

Kristine A. Himmerick is an assistant clinical professor in the PA program at Northern Arizona University’s Phoenix Biomedical Campus. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 


Monday, July 14, 2014
Amy M. Klingler, MS, PA-C
 
Like it or not, we live in a world where appearances matter. Opinions and assessments are made in the blink of an eye. Working in rural family medicine and urgent care, I have a moment (which I refer to as “sick/not sick”) when I walk into the examination room and make snap judgments about the patients in front of me. Are they sick? Meaning, do they need an immediate intervention? Or are they not sick? Do we have time to examine, assess, and discuss the issue at hand?
 
Because the actual time we have to spend with our patients can be counted on our fingers, we must ingest information about them through a variety of sensory clues. Understandably, our patients are making similar assessments about us. When we get too focused on our job of diagnosing and treating, we may forget that in every encounter, our patients are judging us and deciding whether or not to trust us with very personal and private information about themselves. I believe that our appearance and that of our surroundings can profoundly affect our interactions with patients.
 
Opinions conflict about the iconic white coats worn by many healthcare professionals and revered in ceremonies at the initiation of medical education. On one hand are recommendations that white coats, wristwatches, jewelry, and neckties should not be worn in medical settings because they can be vectors of disease transmission. White coats have also been vilified as the cause of “white coat hypertension,” that transient rise in patient BP at the mere sight of the white cotton/polyester blend thigh-length jacket. On the other hand, studies demonstrate that patients have greater trust and confidence in a doctor (or, presumably a PA or NP) who wears professional attire and a white coat, regardless of the infection risk.
 
Personally, I follow the standard at each of the clinics where I work. These offices are located in very different communities and have their own personalities and spectrums of acceptable attire. In my primary practice location at a rural health clinic (in a town where a buttondown shirt identifies you as an outsider), I wear tailored, embroidered scrubs; in another more formal practice location, it’s professional attire; and at the local health department, I wear business casual attire and a white coat. As a PA, I want to project competence, trustworthiness, and humility no matter what I am wearing, but I have to admit, I stand a bit straighter while wearing a white coat; especially one that is laundered at least once per week using a bleach solution.
 
If different clinics have different dispositions, what does your building say about you? Have you ever walked in the front door of your office, just as a patient would? Have you ever sat in the waiting room chairs and looked around? What about lying on the examination table and seeing the room (and the ceiling) from a patient’s perspective?
 
I recently supervised a project to remodel the interior of the Salmon River Clinic, my primary office. This was the first major renovation in the history of the 42-year-old clinic, and took several years to plan and several months to execute. I am grateful that the board of directors who operate the clinic saw the value in updating the facility to one that was more modern, clean, and comfortable (see before-and-after photos at right). My argument in support of the renovation was that patients (consciously or unconsciously) judge the type of care they will receive by the surrounding environment. Because many of the patients I treat are tourists who are meeting me for the first time, I feared that if the office itself was outdated and cluttered, patients would expect substandard care, even before they talked to a member of the staff. Now that the work has been completed, I feel a sense of joy when I walk into work each day and a sense of calm that I don’t have to apologize to patients for the state of the facility. So far, the reactions from locals and visitors have been overwhelmingly positive. I believe that patients and their families feel a little less anxious as they walk into an unexpectedly modern office in a rural Idaho town. The city streets may not be paved (really) and you may be 3 hours from Target (true), but there is a real clinic in town.
 
If appearances make an impression, how do you want to be remembered?
 
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.
 

Monday, July 07, 2014
Harrison Reed, MMSc, PA-C
 
Remember that awful nickname your older brother gave you? Or the one mean kids shouted at recess? It made your skin prickle, fists clench, and eyes glow crimson. Now, imagine your boss walks into your office tomorrow and calls you that very name.
 
If the scenario sounds silly, you may not have paid attention to recent national chatter about the physician assistant (PA) profession. The issue of professional title and terminology has embroiled our ranks and—for the second straight year—dominated conversation at national conferences. But the often-discussed idea of changing the profession’s official title has wrestled focus away from another, and perhaps more disturbing, issue: the slew of unofficial nicknames heaped on PAs by outsiders and, far too often, adopted by our own.
 
You have read them in job postings and news articles, each more inaccurate and uninventive than the last: “advanced practice provider,” “non-physician,” “midlevel,” “physician extender.” I’m willing to bet you don’t use them on your resume or to introduce yourself to patients. Nonetheless, these terms have persisted, and even gained acceptance, through sheer repetition.
 
One in particular seems to roll off the tongue of PAs and NPs more than the others. “Midlevel” has become the frontrunner of accepted substitutes. Never mind that it takes more letters to spell than “PA or NP.” This often-used term is also one of the most demeaning.
 
The single word expresses several false implications. The first is that there is a strict tiered hierarchy in healthcare and PAs and NPs occupy the (imaginary) middle rung. I’m not sure who the “low level” providers are, but I bet whoever coined the term “midlevel” imagined registered nurses on that bronze podium. I pity the first human resources representative with the guts to slap “low-level provider” on an RN job list.
 
The term’s ambiguity adds more danger. Does “midlevel” refer to the provider’s training, skill set, or performance? If physicians provide a high level of medical care, then surely a “midlevel” label implies a product of lesser quality. To the contrary, mounting evidence suggests PAs’ patient outcomes and satisfaction are on par with physicians.
 
Major healthcare organizations have noticed the problem with these substitute names. In February, the Society of Hospital Medicine vowed to abolish the use of such terms and instead refer to professions by their official titles. “Admittedly there may be times when using terms like ‘allied health’ are more expedient,” the Society of Hospital Medicine’s official blog stated, “but the potential for alienating members of the hospitalist family outweighs the need for convenience.”
 
Users of these shortcut names rarely have malicious intent. Often, the words come from a perceived convenience and ignorance of the potential for insult. Large organizations in particular, however, should understand the attitudes they unintentionally project toward the very people they hope to attract. Employers send subtle but strong messages through the diction of their websites and recruitment materials.
 
The PA profession has a responsibility to protect its brand. While debate rages about the accuracy and relevance of the term “physician assistant,” it should not distract from—or worse, condone—the generic labels that threaten to dilute our identity. Regardless of the mixed feelings toward our professional name, it is a title we own. Let’s not have it usurped by one that we don’t.
 
Harrison Reed practices critical care at the Cleveland Clinic in Cleveland, Ohio. Follow him on Twitter @HarrisonReedPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

Monday, June 30, 2014
Brian T. Maurer, PA-C

At our IMPACT 2014 conference in Boston, I had the opportunity to attend the PA Foundation’s PAramount awards dinner.
 
This year’s guest speaker was Heather Abbott, a survivor of the 2013 Boston Marathon bombings.
One year ago, Ms. Abbott traveled to Boston with a cohort of friends to take in a Red Sox game at Fenway Park. Afterwards her party ambled over to the finish line of the marathon to await the first runners. Ms. Abbott heard the deafening bang of the first explosion and witnessed the initial panic of the bystanders. Twelve seconds later the force from the second bomb blew her back through the doors of the restaurant immediately behind her.
 
Conscious of a searing pain in her left leg, she cried out for help as panicked spectators dashed dodging tables to the back of the building. Thankfully, one couple stopped to attend her and carry her to an ambulance at the scene.
 
Despite three separate surgeries, doctors were unable to salvage Ms. Abbott's damaged leg. Reluctantly, she consented to a below-the-knee amputation.
 
Over the course of the past year Ms. Abbott healed from her surgery and learned how to walk again, first with crutches and later with a prosthesis. She now has a collection of four prosthetic legs: one for everyday activities, a waterproof one for swimming, one for running, and one for wearing high heels. Eventually, she elected to become a peer counselor, offering guidance and support to other amputees.
 
Ms. Abbott emphasized three key points on her road to recovery:
• accept that which cannot be changed
• seek support from others during the recovery period
• lend assistance and support to others in similar circumstances by “paying it forward.”
 
Before listening to Ms. Abbott’s poignant presentation, in casual conversation over dinner I learned that the woman seated next to me, a fellow PA, had recently spent a year in rehab after surgery for a brain tumor.
 
She first suspected something was up when she developed subtle left-sided weakness and poor coordination of her hand and leg. Timely intervention saved her life. Thankfully, the tumor was benign. She has now returned to clinical practice and is poised to mentor PAs in a new postgraduate training program.
 
Like Ms. Abbott, this woman has elected to pay it forward through continued service to her fellow human beings.
 
Two heroines: one sung, the other unsung. The unsung one seated by my side didn't seem to mind. At the conclusion of Ms. Abbott's talk she applauded just as enthusiastically and just as long as everyone else in the room.
 
Brian T. Maurer practices at Pediatric Walk-In Care in Enfield, Conn 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, June 23, 2014
Richard W. Dehn, MPA, PA-C, DFAAPA
 
Medical educators have recently identified a shortage of clinical training sites as a bottleneck likely to limit training additional primary care providers. This shortage not only affects the training of PAs, but the training of physicians and NPs. A recent report, Recruiting and Maintaining US Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/Clinical Training Site Survey, sponsored by the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the Physician Assistant Education Association, and the Association of American Medical Colleges, summarizes survey responses of member schools to questions designed to describe the current state of clinical education across the four professions.1 The March 2013 survey had an overall response rate of 85% of member institutions, an excellent response rate in today’s environment of survey fatigue. At least 80% of respondents in each discipline expressed concern about the adequacy of clinical training sites, and more than 70% said that developing new sites was more difficult than 2 years ago. The report details many factors that schools find challenging in today’s clinical education environment, and the overall tone and conclusions paint a picture that clinical education sites will be hard to develop, are in short supply, and will be increasingly costly in the near future.
 
This report only documents what medical educators in all four professions have anecdotally observed in recent years; however, it also attempts to identify the major factors that school officials think may be contributing to the problem. Of particular interest is the finding that most schools (more than 70%) think that other schools are paying for clinical sites; relatively few schools actually report that they are paying for sites but expect to be doing so in the near future. This report is very useful because it informs us that the problem is not confined to just our profession, that schools expect the problem to worsen, and that schools are taking several approaches to deal with the current and anticipated shortages. Those approaches include expanding geographical reach, increased use of simulation, and increased student to preceptor ratios. However, in thinking about this problem, the survey appears to me to miss one important factor.
 
Clinical practice, particularly in primary care, is rapidly changing in response to many simultaneous external forces. For some time now primary care practices have been challenged to find providers willing to work in primary care specialties, and demand for providers has chronically exceeded supply for over a decade. The Affordable Care Act has increased the patient load on these practices, forcing providers to see more patients in less time. Additionally, the increasing corporatization of medical care delivery systems has increased the pressure on providers to increase “productivity,” which is typically defined as a time and effort calculation that results in the highest revenue production.  The result of the combination of all these factors is that primary care providers are finding their typical days increasingly demanding.
 
Clinical preceptors are the lifeblood of clinical training sites for physicians, PAs, and NPs. At a time when medical workforce policy experts project an increased need for primary care providers, our workforce of these providers is experiencing a time squeeze that discourages them from taking on students. My evidence is only anecdotal, but recently almost every conversation I have had with primary care practicing clinicians who precept students eventually turns to the topic of clinician exhaustion and how, although they really want to teach, it is just not possible to juggle students with the increasing demands of clinical practice. This has led to many dedicated clinical teachers either reducing the number of students they are willing to train or no longer training any students. If this is a true consequence of the changing environment of primary care clinical practice, we may see shrinkage in the capacity of the clinical education system at the same time as enrollments across all profession increase. “Market forces” of the medical care delivery system may be converging on primary care practice in a way that crowds out the training of our future medical workforce, and the key factor in this phenomenon may not be a system factor, but instead the wellbeing of preceptor.
 
REFERENCE
 
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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