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Musings: Blog of the JAAPA Editorial Board
Monday, September 29, 2014

Amy M. Klingler, MS, PA-C

“I never knew that town had such a drug problem,” my patient, Mrs. S., told me, “until the people in my granddaughter’s apartment building found out that I had hydro 10s. I mean, I gave one to (a friend of her granddaughter) who was doubled over with abdominal pain. Tears were rolling down her cheeks. I know how much I appreciated it when [a friend] gave me a pain pill that one time when I really needed it. But then everyone started asking me for pills. Someone offered me $60 for 12 of them. I told them I had taken the last one and that you weren’t giving me hydro 10s anymore.”

So many things are wrong (and a thing or two is right) about this conversation with Mrs. S. On one hand, I was glad she felt she could talk so honestly to me. I was grateful she had figured out a way to get out of an uncomfortable situation and that she wasn’t going to sell her prescription pain meds. On the other hand, what she had done (giving and receiving prescription opioids) was illegal, and I was forced to remind her of the provisions of her pain contract, especially not to share or sell her medications and that lost or stolen prescriptions would not be replaced. I suggested she hide and secure any remaining pain medication.

I can’t be the only PA who has a love-hate relationship with opioid pain medications. I appreciate what they can do and I need to be able to prescribe and dispense them  to treat certain conditions effectively. But, keeping track of them, holding patients accountable for pain contracts, and ensuring that long- and short-term users aren’t taking advantage of me is nerve-wracking. To introduce another layer of complexity, I provide point-of-care dispensing of many medications. Because I live 60 miles from the closest pharmacy, I believe it is imperative to provide patients with prescriptions. Otherwise, they would, more than likely, seek care in a town that had a pharmacy. I keep prepackaged hydrocodone combination products, among other medications one might need for urgent care, in double-locked cabinets to dispense in accordance with Idaho state law as a prescriber drug outlet.

I am more than a little worried about how my practice and that of my PA colleagues across the country will be affected on October 6 when the DEA reclassifies hydrocodone combination products as schedule II drugs. I am one of the fortunate PAs who practices in a state where we can prescribe schedule II drugs. So, although this will definitely affect my day-to-day practice, at least I still have the legal authority to prescribe these medications. I can’t imagine what PAs will do in states where their prescribing practices are restricted to schedule III and above.

It is no secret that opioids have enormous potential for addiction, abuse, and dependence. I understand that hydrocodone combination products are now more frequently abused than the more tightly regulated oxycodone and oxycodone combination products. (Of course, tighter regulations on oxycodone have also led to increases in heroin use, but that is a topic for another day.) I also understand that adding acetaminophen or ibuprofen does not change the potential for misuse of these products, even if it does lower their street value. The new regulations will result in restricted dispensing, increased storage and destruction rules, more patient phone calls, and more paperwork.

According to recent newsletter from the Idaho Medical Association and several news articles, some of the effects of moving hydrocodone combination products to schedule II include:

• Prescriptions can no longer be called in by phone, faxed to the pharmacy, or transmitted as electronic prescriptions. 
• Prescriptions for any product containing hydrocodone written on or after October 6, 2014, may not contain refills; this means patients will need to obtain a handwritten prescription from their provider for each medication treatment.
• Prescribers will not be allowed to authorize refills for hydrocodone combination products, though they will be allowed to issue up to three prescriptions for 30-day supply each to be filled sequentially for up to a 90-day supply. 
• Patients will have to visit their providers every 3 months to get new prescriptions.
• Note: DEA will permit pharmacies to dispense hydrocodone combination product refills after the effective date of the rescheduling if the prescription was issued before the effective date and the dispensing occurs before April 8, 2015. However, insurance limitations and some pharmacy quality and safety operations and processes may not allow for these prescriptions to be refilled.
• Prescribers will not be able to fax or phone in prescriptions for hydrocodone combination products, though verbal prescriptions will be allowed in emergency situations.

• In some states, pharmacists will have to count the prescriptions themselves because pharmacy technicians are not allowed to do so.

• Registrants will have to use official DEA Forms 222 to transfer hydrocodone combination products, rather than simple invoices or packing slips.

I hope the extra time and energy to control hydrocodone combination products in this manner proves to be effective in reducing diversion. If nothing else, I am pretty sure it will increase prescriptions for tramadol.

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.

Monday, September 22, 2014
Harrison Reed, MMSc, PA-C
“Give me the peak and the pit.”

My friend says it when I return from a trip that is far too long to recount in detail. It’s her quirky way of asking for just the best and worst moments, a tiny highlight reel of the complete emotional breadth.
Elephants and Nausea. Fireworks and Sunburns. Safaris and Ebola.They always end up sounding like rejected book titles.

But if I had to give her the peak and the pit of my medical career, there would only be one answer: people. Without question, the best and worst moments of my job are directly related to the people with whom I shared them. Don’t worry, I’m not going to give you 700 words about how everyone in my hospital stands in a circle and sings “Kumbaya.” Because even though some are in the running for sainthood, others are complete jerks.
No shock value here, folks. If you are old enough to crack open JAAPA or log onto our website, you have probably discovered that not everyone in the world is completely pleasant all the time. Although some of us are merely possessed by jerkhood in moments of weakness, others consider it full-time employment. But in any workplace, and especially the healthcare setting, that negative attitude is toxic.
Although this is typical water-cooler fodder, the issue has been picked up by some prominent sources. A recent JAMA article addressed an epidemic of behavior from physicians that “adversely affects morale, focus and concentration, collaboration, and communication and information transfer, all of which can adversely affect patient care.”1 And an article published in the Harvard Business Review by Robert Sutton (and later turned into a book) proposed a simple premise: Don’t work with jerks.2
My own observations have supported the idea. The solution rests on the principle of dilution. If you fill your workplace with enough positive, respectful professionals, the pleasant culture will buffer the poison of the inevitable jerk or two who slips through. The real trick is to guard the keys to your kingdom.
I know firsthand that several large, prominent hospitals base hiring largely on a candidate’s perceived ability to contribute to a team-based setting in a positive and collegial manner. In other words, the best workplaces will want to recruit tact over talent. That may seem counterintuitive in a capitalist society that favors production above all else, but Sutton’s book, The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t, is filled with hard data that show a true bully ends up costing companies cold hard cash.3
In our last meeting, my team of PAs and NPs discussed the strengths and weaknesses of our unit. The consensus was clear: the true advantage of our group is our internal support and camaraderie. But I have heard enough horror stories to know this was not always the case. And I know we can’t relax.
Maintaining a positive team requires constant stewardship. Negative actions are exponentially more potent than positive ones and, left unchecked, a subtle change in dynamics can result in a monumental shift in culture. Those who are treated badly often turn to jerkhood. That means every new PA represents an opportunity to forever shape a professional personality.
I take pride in many aspects of my profession, but there is one in particular that makes my organs feel fuzzy. We don’t rough up our rookies. We don’t terrorize our trainees or pulverize our protégés. We don’t haze or belittle or break them down. And if we do, we need to stop.
But we must ensure, with firm resolve, that one truth is absolute: Toxins are not welcome. The next time you invite a candidate for an interview, extend a job offer, or begin a new employee’s orientation, think beyond the résumé. Ask yourself what kind of culture you want to promote and protect it at all costs.
It might be the greatest legacy you leave.
1. Sanchez L. Disruptive behaviors among physicians. JAMA. 2014:10:312.
2. Sutton R. More trouble than they’re worth. Harvard Business Review. 2004; 2:18.
3. Sutton R. The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t. New York, NY: Warner Business Books, 2007.
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, September 15, 2014
Brian T. Maurer, PA-C
A clinician friend forwarded the link to an online news article detailing the proposed merger-acquisition of the chain of community hospitals where he practices. These three community hospitals were established by an order of Catholic nuns; the oldest facility dates back to the 19th century. As was the case with most hospitals in that era, these were founded to meet the needs of a relatively poor patient population that had little alternative for medical services at the time.
If all goes according to plan, these institutions will be subsumed into a large healthcare conglomerate that operates in a for-profit venue. It appears as though the relative cost of healthcare is poised to escalate exponentially in that region.
I smiled when I read the comments of the CEO of the existing hospital holding corporation: “We are excited to pursue this relationship with [healthcare corporations X and Y]. Like ours, these organizations are committed to providing high-quality, low-cost, person-centered care.”
As you follow the money, always look for the spin.
A similar development has happened in the area where I practice. Over the past decade three big urban hospitals have worked diligently to acquire any number of smaller outlying community hospitals, now referred to as “campuses,” that is, corporate subsidiaries. Quite obviously, these healthcare conglomerates are in constant competition, each vying for a greater piece of the healthcare market share.
“The takeover of our local hospital system reminds me of large banks that swallow other banks,” my clinician friend wrote. “As these cycles of acquisition ripple through the healthcare system, one wonders what the outcome will be—a form of monopoly capitalism, no doubt. These mergers have driven up healthcare prices in different parts of the country, and I suspect this will happen here.”
These comments brought to mind the consolidation of the big three global superstates in Orwell's 1984: Oceania, Eurasia, and Eastasia. In this dystopian novel, these three political entities wage war perpetually, breaking and forming alliances as they vie for the remaining unconquered parts of the globe.
When you consider current economic trends in our healthcare system, coupled with the widespread adoption and eventual universal mandate for the use of electronic medical records and shared data, the question arises as to what form our healthcare system will ultimately take. How will it all shake out in the end?
We need only look back to the future and peruse the final pages of Orwell's novel to discover one plausible answer to that question.
Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, September 08, 2014
Steve Wilson, PA-C
Not life, but good life, is to be chiefly valued.
I’m always amazed when I realize that there are people who set about the task on a daily basis to put something in print and expect someone to read it. Personally, I have found it difficult to find someone whom I feel has something worthwhile to say on a daily basis—excluding my wife. Either from a personal, practical, educational, or directional standpoint, she always has something to say that is worthy of my attention. However, with so much blogging going on I am not sure that quality is really a consideration for most essays written as a blog. So, whenever I prepare to produce another blog post for JAAPA, I try to find something inspirational to me that I think may be captivating to others. Inspiration has been lacking recently. However, while scanning a recent update from one of many professional alerts that cross my screen, I was directed to another site and came upon this statement:
“In a bygone era, doctors thought every life was important.”1
Ever since my educational mentor Dr. Hu Myers told me that it was important as a PA to achieve the “mindset of the physician,” I have always felt that what was important to physicians was important to me. Hence, I thought “every life” was important to physicians. I checked my deleted and trash files and did not find any notices that this had changed. Needless to say, the blogging author had my attention, so I read on.
“In the 21st century world, resources are the first consideration, and there are plenty of ideas about ways to curb treatment and lower costs. A new analysis finds that doctors could try a little less in the intensive care unit—because otherwise they are causing other ill patients needing medical attention to wait for critical care beds.”
Apparently UCLA and RAND health scholars have produced a paper that demonstrates that deaths occur because “futile” care is being given to patients in the ICU rather than making some hard decisions and making way for someone who may not be as “futile.” OK, I will accept the fact that I am maybe being a bit overzealous in this presentation in order to make a point, but, it is a blog. I have not read the study, but why waste time doing that when I can get the abbreviated blog version.
If I read the study it would supposedly show that 16% of the days when an ICU is full, it contains at least one patient receiving futile treatment. During those days, patients were kept in the ED for more than 4 hours, patients waited more than 1 day to be transferred from an outside hospital, and patient hospital-to-hospital transfers were cancelled after waiting more than 1 day. The bottom line: two patients died at outside hospitals while waiting to transfer to another hospital’s ICU.
Those of us on the front lines are not surprised by this revelation. The demands on the healthcare system are greater than ever in terms of available resources, both financial and physical. With reimbursement being more tightly tied to outcomes, could it be that possibly the desire to transfer patients with potentially fatal issues and the desire not to accept those patients in transfer are closely tied? Could it be that the resources available requiring the transfer and the resources available for accepting the transfer are the same realization with which the public needs to come to grip in terms of cost effective healthcare?
The author of the paper, Dr. Neil Wenger of UCLA, was quoted as saying that: “Many people do not realize that there is a tension between what medicine is able to do and what medicine should do. Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value—such as prolonging the dying process in the intensive care unit when a patient cannot improve."
Ahhhh…. This has nothing to do with whether or not doctors feel every life is important. This is about the fact that doctors (and PAs) value life and in valuing that life believe in death with dignity. We know we cannot heal all. This is about the fact that we need to continue to have those difficult conversations with the public about our science and art of medicine’s inability to rectify all human suffering. It is about society’s need to understand their own responsibilities for their health, the realities of affordable healthcare, the limitations of medical science, family dynamics, and better defining the limits to liability.
Thought I had inspiration for a blog post for a moment. I think I hear my wife calling.
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.

Monday, September 01, 2014
Wanda C. Gonsalves, MD

One thing we know for sure is that our healthcare system is fragmented, expensive, and heavily regulated. As a result, we’ve been trying to fix the problem by creating new models of care. Two such models are the patient centered medical home and the direct primary care model, which are totally different approaches to primary care practice: the former is team-based and the latter retainer-based.
In the response to the cost of care and a physician shortage that threatens patient access to care, the number of physician assistants (PAs) and nurse practitioners (NPs) has soared, as have the number of programs that train them. Healthcare administrators have seen the benefits of adding PAs and NPs to their medical teams because they provide care at lower cost. Adding PAs and NPs frees up physicians to see more patients and to concentrate their efforts on more complex patients.
Medical schools across the country have responded to the physician shortage by increasing their student enrollments or looking for innovative training models. A few medical schools are exploring options to respond to the high cost of medical education by shortening medical school to 3 years. Examples include the Texas Tech University Health Sciences Center School of Medicine in Lubbock and Mercer University in Savannah, Ga.
The increasing medical student enrollment and the changes in medical education may have many effects on the PA profession and PA education. How will the increase in medical students and PAs and NPs alter the healthcare workforce? Is the number of PA programs expanding too quickly? Will fewer PAs enter the profession if the length and therefore the cost of medical education are lowered? Will the increase in medical students reduce the availability of training sites such that PAs and NPs will have less of an opportunity to practice what they are learning?
Only time will tell about the workforce issues. However, across the country, the availability of training sites has become quite competitive for all learners. Many medical schools are paying physician preceptors for taking students, ultimately increasing the cost of tuition and the cost of healthcare. I don’t have all the answers. The PA profession should begin to address these issues that threaten to be with us for some time. I suggest that the PA leadership and physicians work together to answer questions about how PAs might optimally fit into these practice models and others so we can help guide our practice, rather than be the last to the table.
Wanda C. Gonsalves is vice chair of the Department of Family and Community Medicine at the University of Kentucky in Lexington. She also is a steering committee member of Smiles for Life, a national oral health curriculum. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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