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Musings
Blog of the JAAPA editorial board.
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) patient website.

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 AAHPM website.

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.


Monday, July 11, 2016

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

The current demand for physician assistants (PAs) appears insatiable. New PA graduates are being offered positions that just a few years ago were only available to more experienced clinicians, and starting salaries for new graduates now commonly exceed the salaries of PA faculty who have decades of job experience. Of course, as the saying goes, what goes up must come down, so the big question is not if but when will the supply of graduating PAs satisfy the demand?

Although we are a relatively young profession, we do have some experience with PA workforce supply and demand mismatches. Although we don’t have very good data describing our early years, inferences can be made that increases in numbers of PA educational programs and increases in national first-year student enrollment size typically are the result of demand for PAs exceeding supply. The number of PA programs in the United States was reported in 1977 to be 46, and by 1984 had grown to 53 programs with an average first-year enrollment of 23.9 students .1,2 By 1994, the number of programs had increased to 63 enrolling a first-year class of 37 students.3 In the class of 1983, an estimated 70.6% of the 1,166 graduates were employed as PAs shortly after graduation, compared with 87.2% of the estimated 1,896 graduates of the class of 1993.2,3 These data indicate an increasing number of PA graduates experiencing a higher employment rate as PAs over that decade, which can be interpreted as programs meeting an increasing demand for PAs with not all graduates finding employment as practicing PAs, but with a tighter job market at the end of the decade.

The PA world changed drastically starting in the early 1990s. The managed care model of healthcare delivery became prevalent during that time and encouraged the use of PAs for the delivery of medical care previously only provided by physicians. A major attempt was made to reform the healthcare delivery system in 1993—the Clinton healthcare reform proposal—but failed to pass Congress. The Budget Reconciliation Act of 1997 provided for Medicare reimbursement of PA services, commencing PA reimbursement for hospital settings for the first time. Both of these events substantially increased the demand for PAs, and over the next decade the number of PA programs, cohort size, and the number of PAs in practice increased dramatically.

By 2004, the 133 PA programs enrolled an average of 38.2 students in their first-year cohort. The class of 2003 graduated an estimated 4,554 PAs; 71.7% of them reported being employed as a PA shortly after graduation.4 During most of that time period, PA demand was very strong, with starting salaries rising every year. However, near the end of the 1990s, the effect of managed care began to reduce the overall demand for medical care, which resulted in a perceptible decrease in available positions for new PA graduates. This was noted particularly in the northeastern US, where a large proportion of the recently-developed PA programs were located. Anecdotal information at the time reported a change in the job environment for new graduates in that geographic region, from an environment where many positions in multiple specialties were available locally to new graduates to one where graduates might need to relocate to find a job. Most other regions of the United States did not experience saturation in the demand for PAs, and this mini-glut of PA graduates in the Northeast only lasted for a few years. Evidence of this temporary saturation of the PA job market can be found in an article by Cawley and colleagues published in 2000.5

Following the decrease in demand for PAs in the late 1990s that was likely attributable to the managed care payment model combined with a substantial increase in the number of PA graduates mostly concentrated in the Northeast, demand for PAs has steadily increased despite a significant increase in PA programs and cohort size. By 2014, there were 186 programs enrolling an average of 39 students in their first-year cohort, and the class of 2014 was estimated to contain 7,556 graduates.6 The Physician Assistant Education Association (PAEA) no longer reported the employment rate for graduating cohorts, but it was anecdotally moderately strong with annually rising starting salaries. Currently, demand for PAs is exceptionally strong, which is again attracting more institutions to develop PA programs and existing programs to establish distant campuses and increase enrollments. Currently there are 210 PA programs with 64 institutions reportedly seeking to develop new programs.

With the recent substantial increases in MD, DO, NP, and PA enrollment, the demand for medical providers eventually will be met. Additionally, the critical shortage of clinical training sites may limit further growth of all of these professions, which may slow or even stop further increases in enrollment and program expansion. However, at some point the demand for new graduates will decrease–likely first emerging in the highest-paid specialties, in desirable communities, and in regions of the country that have the highest concentrations of educational programs. But we know from history that it is difficult for professions to match their educational capacity with the demands of the marketplace. Thus expansion typically continues until the market saturates and potential applicants decide that it might be best to seek a different career and educational institutions realize that the applicant pool can’t fill their classes with qualified applicants. It will happen, the question is not if, but when.

REFERENCES

1 Oliver D, Laube D, Gerstbrien J, Wombacher N. Distribution of primary care physician’ss assistants in the state of Iowa. J Iowa Medical Soc. 1977:320-323.

2 Oliver D, Conboy J, Donahue W. First Annual Report on Physician Assistant Education Programs in the United States 1984-1985. Association of Physician Assistant Programs, May 1985.

3 Oliver D, Kreiter C. Tenth Annual Report on Physician Assistant Education Programs in the United States 1993-199. Association of Physician Assistant Programs, June 1994.

4 Simon A, Link M. Twentieth Annual Report on Physician Assistant Educational Programs in the United States, 2003-2004. Association of Physician Assistant Programs, August 2004.

5 Cawley J, Simon A, Blessing JD, Pedersen D, Link M. Marketplace Demand for Physician Assistants: Results of a National Survey of 1998 Graduates. J Physician Assist Educ. 2000;11(1):12-17.

6 Physician Assistant Education Association. By the Numbers: 30th Report on Physician Assistant Educational Programs in the United States, 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, chair of the university's Department of Physician Assistant Studies, 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.

 

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Tuesday, June 28, 2016
 

Harrison Reed, MMSc, PA-C

After graduation, how many of your classmates rushed off to a job in primary care? If you program was anything like mine, those new graduates were a small minority. I always thought some specialties were just sexier than others, but perhaps more subtle economic factors are at work.

In the July issue of JAAPA, Perri Morgan, PhD, PA-C, and colleagues tackle the diminishing proportion of primary care PAs in their latest PA workforce research. They focused less on the new graduate psyche, however, and more on the financial factors that might lead to the creation of PA jobs.

The authors point out that fields with huge wage gaps between physicians and PAs (that is, higher-earning physician specialties) tend to draw a higher proportion of PAs. Because PAs make roughly the same amount of money across specialties, physicians with greater earning potential might find more value when they hire a PA, as these physicians are free to spend more time on high-revenue activities like surgery and procedures.

It’s no secret that high-earning specialties like orthopedic surgery have taken advantage of PAs to boost revenue. But, on the other end of the spectrum, lower-paid physician specialties like primary care may suffer the opposite effect. After all, a PA is not that much cheaper than a primary care physician compared with a well-paid surgeon. And if PAs are less profitable in settings like primary care, practices may have less incentive to hire them.

In his commentary in the July issue, Richard W. Dehn, MPA, PA-C, DFAAPA, proposes that the decreasing proportion of PAs might not represent wavering altruism or a shifting employee mindset but a shortage of PA jobs in primary care. He cites anecdotal experience in PA education that seems to agree with the Morgan study’s data. I like the idea of a legion of PAs waiting for a potential primary care opportunity, even if it seems a bit idealistic.

Two points raised in the discussion of PA specialty selection warrant additional attention. First, by virtue of this smaller salary gradient between physicians and PAs, lower-paying physician specialties like primary care appear to be at a massive disadvantage when it comes to employing PAs. Any state laws that further restrict PA practice, like those limiting physician-to-PA ratios, are only hurting primary care access and must be abolished.

Second, in complex systems like workplace economics, legislators and policymakers should meddle with caution. Although it’s tempting to artificially inflate PA salaries to attract workers to underserved areas, doing so could raise the average compensation of PAs in primary care and further decrease the physician-PA pay gradient nationwide. Unsubsidized clinics would have little incentive to employ PAs that are not much more affordable than their physician colleagues. And if Dehn is right about a smaller-than-you-might-think primary care PA job market, that kind of policy move could further restrict PA migration into primary care.

Harrison Reed practices critical care medicine at the University of Maryland Medical Center’s R. Adams Cowley Shock Trauma Center in Baltimore, Md., and is associate editor of JAAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.  

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Journal of the American Academy of Physician Assistants
Blog of the JAAPA editorial board.