Blog of the JAAPA editorial board.
Monday, October 17, 2016
Brian T. Maurer, PA-C
As we head into the 50th year of the PA profession, the October 2016 issue of
JAAPA houses a true historical gem: a reappraisal of the 1981 Graduate Medical Education National Advisory Committee (GMENAC ) report and how it nearly derailed the growth of the fledgling PA profession.
The GMENAC was convened in 1976 to forecast the supply and demand for physicians nationwide in 1990 and 2000. Despite the use of sophisticated analytic models, predicted trends ultimately missed the mark in breadth and scope.
GMENAC predicted a surplus of 70,000 physicians in the United States workforce by 1990, with escalation to a surplus of 145,000 physicians nationwide by the year 2000. Accordingly, the committee recommended limiting the number of students admitted to US medical schools, as well as curtailing the influx of foreign medical graduates. In response to these recommendations, Congress passed legislation designed to limit the number of US medical school graduates; but in a quirk of legislated fate, enhanced payments to teaching hospitals designed to bolster graduate medical education and research ultimately encouraged the widespread hiring of foreign medical graduates to fill intern and residency slots.
The predicted oversupply of physicians raised doubts about the need for physician extenders. From 1981 to 1990, no new PA programs were established, and several existing programs at major medical teaching institutions were closed. Two landmark events allowed the PA profession to survive in this tenuous environment: the passage of an amendment granting reimbursement for PA services under Medicare Part B in 1986 and the attainment of commissioned officer status for PAs in the uniformed services in 1988.
These two milestones, coupled with continued efforts by the American Academy of PAs to lobby legislators and educate the public about PAs, led to exponential growth of the PA profession in the 1990s and into the new millennium.
When I had my nose to the grindstone from 1977 to 1979 as a student in a now-defunct PA program, I had no idea of the challenges the PA profession would be facing the following decade. Now, as I approach the final years of my clinical career, historical hindsight permits a certain appreciation for those turbulent times; it was dogged perseverance and hope that brought us through.
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, October 3, 2016
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE
In the pilot episode of the medical drama
Grey's Anatomy, Meredith Grey refers to the mnemonic: "Wind, water, wound, walking, wonder drugs.” This mnemonic transported me back more than two decades to my PA surgery rotation when, peering at the chest radiograph of a “feverish” postop patient, I desperately tried to see the line of atelectasis that the residents claimed to see so clearly. I was advised in a
serious tone by the intern du jour that the timing clearly supported the source: the lungs. If it had been the next day, the indwelling urinary catheter would be to blame. How simple! Humility encourages a broader perspective, as patients follow their own immununologic calendar. In the current issue of JAAPA, Maday and colleagues discuss the challenges of evaluating postoperative fever.
Fever, a vital sign, signals something amiss, prompting laboratory tests, imaging, and our clinical attention. There are many routes to registering fever: the forehead, tympanic membrane, axilla, sublingual, and the back of mom’s hand. Many an attending trained in the good old days espouses the rectal route as best. In my urgent care practice, asking parents if they documented their infant’s fever with some device often results in a negative head-nod. Asking if they have a rectal thermometer at home results in even stranger looks. I don’t ask anymore. Also, any temperature above 98.6° F (37° C), regardless of how ascertained, qualifies as fever. Children seem to run normal temperatures below 96° F (35.6° C) with tremendous frequency, too. Clinicians know better, parents may be antibiotic-hunting.
Why so many fever tools and numbers; just what is the history?
Hippocrates recognized fever as a sign of acute disease. Galen (131-201 CE) described
calor praeternaturam, or preternatural heat; other terms for fever were hot skin, quick pulse, and
turbid urine.1 Seems like Galen was up on the water cause. Galen pretty much ruled the physiology world until the Renaissance, when Galileo (1561-1636) invented the thermascope and differentiated normal and abnormal body temperatures. Gabriel Fahrenheit invented the mercury thermometer in 1714, thinking it might be medically useful.1 Physiologists argued the cause of fever, with Pierre Laplace proposing a widely accepted explanation attributing “animal heat to the combustion of oxygen with hydrogen and carbon during respiration.”1 He was one smart cookie.
Early thermometers were not accurate: medical literature reported fevers of 118° to 122° F (47.8° to 50° C) in the early 19th century. By the mid to late 19th century, thermometers attained good accuracy and Becqueral and Breshet established the mean temperature of a healthy adult as 98.6° F (37° C). However, credit for the first classical study of clinical thermometer use goes to Carl Reinhold Wunderlich (1815–1877).1 The name
Wunderlich translates as a moody or capricious person, but he was anything but mercurial. Over 15 years, he recorded more than 100,000 temperature observations and determined that diseases “obeyed fixed laws that could be shown by the course of the temperature.”1 These observations helped distinguish typhoid fever from other infections of the day and were embraced by physicians around the world for diagnosis and treatment monitoring.
The initial measurement route most favored was the axilla, while by 1890 the oral thermometer became the standard. The availability of a reliable oral thermometer permitted sophisticated fever pattern recognition of initial, effervescent/pyrogenic, full fever/fastigium, and the final phase as defervescence to normal body temperature. Thermometers and fever knowledge rapidly spread from Europe to America. Soon, mothers could diagnose children’s fevers, a shift in social power.
The 5 W mnemonic often fits. However, don’t forget that the patient has the fever, not the thermometer. With a little help from our historical friends, we can reliably measure, track, and treat fever, regardless of its source.
1. Haller JS. Medical thermometry–a short history.
West J Med. 1985;142(1):108-116.
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.
Monday, September 19, 2016
Amy M. Klingler, MS, PA-C
“Those who learned to know death, rather than to fear and fight it, become our teachers about life.”
—Elisabeth Kubler-Ross (On Children and Death, 1985)
My mother died at home this summer after being on hospice for 14 days. Her oncologist called it “a good death” and hoped I wasn’t offended by the term. I completely agreed with her. My mom’s last 2 weeks on this earth were at times heart-wrenching, exhausting, frightening, and beautiful. But in each moment we were guided by her explicit end-of-life directives.
I never saw my mom in any other stage of dying than acceptance. She didn’t waste time with denial, anger, bargaining, or depression.
After receiving her terminal diagnosis, she invited friends and family for brief visits, made phone calls to loved ones across the country, and met with her priest to plan certain aspects of her funeral to “make sure it wouldn’t be too depressing.” When it came to her end-of-life care, she had two desires: to not be in pain and to die quickly. Her clarity of thought and the dignity with which she accepted death were the greatest gifts she could have given my father, my brother, and me. It allowed us to be fully present with her and we never had to question the decisions we made when she could no longer make them for herself. It has allowed us to continue to live our lives knowing we helped her live and die exactly as she wanted.
None of this would have been possible if my mom didn’t consider, or wasn’t asked, questions about her values, her goals, and her wishes for living. Questions such as “What are your fears or worries about your illness or medical care?” “What do you hope for your family and loved ones?” “What needs or services would you like to discuss?” “If you have to choose between living longer and living more comfortably or energetically, how would you approach this balance?” These questions are the cornerstones of palliative medicine, and can be found on the American Academy of Hospice and Palliative Medicine’s (AAHPM)
According to the AAHPM, “palliative care relieves suffering and improves quality of life for people of any age at any stage in a serious illness, whether that illness is curable, chronic, or life-threatening.” Hospice is palliative care that is provided to people who have a terminal illness (usually 6 months or less to live). Palliative medicine addresses the cares, needs, fears and worries of patients and their families and is provided by teams of health care professionals including doctors, nurses, social workers, pharmacists, clergy, dieticians, and volunteers. PAs are notably absent from the list of palliative medicine team members on the
The fundamentals of PA education and practice, including physician collaboration and the belief in the team approach to health care, make PAs particularly well suited to work in a medical specialty of interdisciplinary teams of health care professionals providing holistic care to help patients live well. Yet, significant barriers exist which prevent PAs from providing palliative and, specifically, hospice care. This month’s issue of
JAAPA includes a special article titled
"The benefits of expanded physician assistant practice in hospice and palliative medicine." The article describes hospice and palliative care, explains the challenges to PA practice in hospice and palliative medicine, and highlights some current federal and state legislative issues that have a direct effect on PA provision and reimbursement for hospice and palliative care services. Because it is in the best interest of our patients, PAs are called to “put the PA in palliative medicine” through advocacy, clinical education, and research.
Palliative medicine teams and the care they provide are a far cry from the “death panels” that so terrified Americans during the debates about the Affordable Care Act in 2009. These teams provide healthcare that is consistent with patient desires, balances medical treatments and interventions with patient goals and wishes, and let patients live their best lives for as long as possible. It is simply good medicine. And without good medicine we cannot have a good life … or a good death.
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, August 29, 2016
Steve Wilson, PA-C
“There are lies, damned lies, and statistics.” —attributed to Mark Twain
For those of you clicking on this blog expecting to see the latest YouTube video sensation, I apologize. This is actually the title of a book by Samer Nashef, published in 2015, that I just completed reading. The subtitle for the book is “the power and peril of transparency in medicine.” I found it an easy read that was extremely informative as well as a little entertaining in the manner in which the author discusses how addressing outcomes in medicine affects the way we practice.
Dr. Nashef is a cardiac surgeon in Great Britain. He was involved with the development of the EuroSCORE (European System for Cardiac Operative Risk Evaluation), a preoperative risk assessment tool similar to the Society of Thoracic Surgeons’ score used to predict
operative mortality for patients. Poor outcomes in some British medical institutions led Dr. Nashef into the area of risk management for cardiac surgery. Today, no other specialty or surgery undergoes such intensity scrutiny as cardiac surgery and coronary artery bypass grafting surgery (CABG). It is certainly understandable that surgery would be the first to undergo such close evaluation. As Dr. Nashef points out, when a healthy patient enters the hospital alive and has an operation but does not leave the hospital alive, it is easy to believe the surgeon was at fault. As he put it: “…the temporal, if not causal, relationship between the operation and the outcome speaks with a resonant eloquence that is impossible to ignore.
In this book, Dr. Nashef outlines how surgery has stepped out of the dark ages. Great men entered the operative field and did some miraculous things based on a belief it could be done, and the outcome was accepted by the patient and the public. Now, due to some very high-profile unfortunate and unacceptable situations, in more modern times the field of surgery—particularly cardiac surgery—is held to a different standard. The outcomes can be compared and surgeons held accountable to their peers and the public. What Dr. Nashef explores is how this new transparency has affected surgeons and how it will soon affect all physicians. For surgeons, the death of a patient is more often than not absorbed by the surgeon as a failure on his or her part; in general medicine, a patient death is related to the patient’s failure to respond to treatment. In this new era, all will be held accountable for the outcomes of their patients regardless of whether a steel blade is involved.
The benchmark operation, as I mentioned, is CABG. The crude first sign of quality control and performance was the mortality for any given patient undergoing CABG. This has been complimented by the addition of the P value to ascertain the significance of any differences between hospitals and/or surgeons as well as risk factors for any group of patients. The further refinement by the computation of confidence interval and the further qualification of risk-adjusted survival over time has armed statisticians with an overwhelming ability to dissect information about CABG done anywhere. Dr. Nashef’s explanation of all of these factors is refreshing. How any of this information may be reported and used by insurance companies, newspapers, and professional organizations could be misrepresented and be extremely misleading. He clearly defines how hospitals and surgeons who perform well can be made to look bad and vice versa.
The book explores the personality of the surgeon, the culture of the surgical suite, how surgical decisions are made or should be made, and even when not to have surgery. (There were no statistically significant times, but you may want to stay home if your surgery is scheduled for the day before the surgeon going on vacation.) After reading this book, I certainly felt better informed about all of these scary outcomes measurements and how to interpret and better use the information. But the book also left me with the nagging question as to what all this transparency will mean to our future ability to provide needed care. Dr. Nashef describes the surgical paradox: “the more the operation is likely to kill you, the better it is for you.” This may be a little overstated, but it does describe those high-risk patients caught between failing medical therapy and an operation that may help. However, in this new environment, the real fear is that surgeons begin to shy away from these needy and sometimes desperate patients. Too much risk coupled with too poor outcomes will not bode well for some talented and caring surgeons. In addition to the potential soiling of a surgeon’s reputation, there is the additional issue of loss of reimbursement and even closure of surgical programs due to lost revenue. In states now experimenting with capitated systems where the Centers for Medicare and Medicaid Services provides a lump sum for all cardiac surgery for the year, the potential loss from high-risk patients may be too great for any institution to absorb. So what happens when even renowned institutions refuse to accept high-risk patients?
Of course, there are no black and white answers. If people took better care of themselves, we would still need cardiac surgery, although maybe not the high risks seen in that patient population. Walking through the corridors of my institution, seeing patients and their families, I don’t see that happening any time in the next 20 years. Until then, we need to be very careful about how all this public reporting is handled. The outcomes need to be reported in a manner that fully explains what is being measured—particularly in terms of risk adjustments. This reporting needs to be done without sensationalism. Methods of correction for those outside the norms need to be implemented without punishment. Some institutional or specific surgeon allowance needs to be made for some high-risk patients who decide to go with surgery despite the risk. Otherwise, the value gained by transparency in medicine in terms of good patient care will be lost to the provision of no medical care for fear of financial ruin.
Hand the surgeon a robe. It can get cold out there.
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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Friday, August 12, 2016
Jennifer M. Coombs, PhD, PA-C
In the current issue of
JAAPA, Kayingo and Bruce discuss the implementation of universal screening for HIV at a community health center in Connecticut. Not surprisingly, before universal screening, significant sex and racial differences were found among patients screened for HIV. This individual clinic quality improvement project also demonstrated the achievable goal of the
Practical Playbook to combine
population health with primary care. The Practical Playbook, developed in conjunction with the Duke University physician assistant (PA) program, has many resources and examples of quality improvement projects that can be implemented into an individual PA practice. Kayingo and Bruce’s project exemplifies the confident approach advocated by the Practical Playbook.
Yet, what an opportunity bungled by the National Commission on the Certification of Physician Assistants (NCCPA) to introduce the concept of quality improvement projects to PAs in a poorly understood and ill-conceived roll out of both self-improvement (SI) and practice improvement (PI) type CME credits. Will PAs be forced to implement PI projects without forethought or planning? Although I respect the can-do attitude of a humble before and after quality improvement project and the inspiration of the Practical Playbook, forced quality improvement for CME and licensure is hasty and unwise. Is it a stretch to say out loud, “What will NCCPA think of next?” when it comes to recertification changes?
Also in this issue is the editorial "Addicted to Blame," a cautionary tale of opioid use and abuse in this country. Perhaps nothing will define this next generation more than the specter of the deaths of tens of thousands of young people to addiction. The title further points out the irony of the rush to remedy the situation with a nearly wholesale ignorance of the data and established evidence-based recommendations from public health experts and healthcare providers. The editorial notes this causticness and serves up a strong reflection on who shall be blamed and who shall suffer. Real harm can be done by public health measures ignored or badly implemented.
What is to be done about a world with too many rules, too poorly applied, with little evidence to back them up? The fact that evidence will be ignored does not mean that an evidence-based approach should be abandoned. Although PA programs teach evidence-based medicine, we do little to prepare PAs for evidence-based public health. It feels a bit slow in the uptake, especially in recommendations for vaccine use (think human papillomavirus vaccine), mental health issues, and universal screening recommendations. The
US Preventive Services Task Force, always the most cautious and highly evidence-based, is looked upon disparagingly by healthcare providers who distrust the ever-evolving, revolving door of advice. After all, they aren’t the ones in the room with the patient, trying to make sense and explain the screening recommendations in a timely way using living-room language.
Compounding the issue is the distrust of our changing healthcare system, the lack of stable healthcare insurance, confusing rules about coverage, and providers with little time to arbitrate the payers with those who are sick and need care. But to disparage is to lose hope that a solution can be found to the toughest problems we face: to care for those who are the sickest, such as those with addiction and those vulnerable to HIV.
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.