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

Monday, March 20, 2017

Ellen D. Mandel, DMH, MPA, MS, PA-C
This Musings post has a personal flavor. You see, my daughter is a special education teacher who has been bitten several times, and fully expects to be bitten again and again in the course of teaching preschool children with autism spectrum disorder (ASD).

This JAAPA issue offers readers a review of evaluating and treating mammalian bites, noting that dog bites are most common, cat bites more often get infected, and human bites account for a meager 2% to 3% of bite-related ED visits. Despite the known infection rate of cat bites, the authors write that human bites contain more than 600 bacterial species, not to mention the risk of hepatitis B and the unlikely risk of tetanus and HIV transmission. We know that bites must be treated with care to prevent significant morbidity. Got it!

However, when it is your own daughter who is bitten while trying to shape behavior in a non-vocal, emotionally charged child on the spectrum, a bite makes a lasting impression. For unlike a bite from a moody cat, or a provoked dog, or a neurotypical child with bullying tendencies, the bite of a child with ASD is different. These bites not only break the skin, they can affect the heart.

These bites originate from a child who may not know a functional way to communicate, yet needs to learn how to adapt to society in some way, shape, or form. Teaching a child with ASD that biting is not a socially acceptable manner to gain attention, avoid an activity, access a tangible, resolve a sensory need, or reveal an emotion to a classroom teacher is more than difficult. For those of you with some experience with this population and the angels who teach them, you know that the biter can rarely be reasoned with, and the teacher continues to teach the child with empathy, compassion, and a goal of finding the method of communication that works best for the child.

When my daughter has been bitten, gone to the ED, received antibiotics and a tetanus booster, and been discharged, the experience does not end. She tells me that it touches her heart that her students bite instead of functionally communicating. That it truly upsets the child’s family. That biting may create a barrier of fear, lessening contact by classmates, teachers, and the community. It may hinder a child’s progress, as teachers fear bites as much as anyone else. As PAs, we need to acknowledge that not all bites are the same, and emotionally support teachers who were bitten, knowing that they will go back to the same classroom with a bandage and antibiotics on board, and continue to nurture children who may bite again and again.

Ellen D. Mandel is a clinical professor in the Department of PA Studies at Pace University-Lenox Hill Hospital in New York City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, March 6, 2017

Amy M. Klingler, MS, PA-C

This year we celebrate 50 years of the PA profession. Just like any golden anniversary, it is a good time to reflect on where we have been and where we have yet to go. A scroll through the timeline on the PA History Society website was an eye-opener for me and I encourage all PAs to visit the site and see how we have evolved over the past half century. One of the key features in the history of PA practice is our relationship with physicians. In this month’s JAAPA Commentary, Margaret Gradison, MD, provides her perspective on the physician-PA relationship. She writes about the importance of mutual respect between smart, dedicated, and hardworking MDs and PAs. Dr. Gradison writes that she has been the supervising physician for numerous PAs over the years and that the PA-MD collaboration in the practice of medicine has been one of the most rewarding aspects of her career.

It is interesting to me that a physician would find the PA-MD relationship so rewarding and yet, many PAs struggle with that very same relationship. The terms supervision and collaboration have become dirty words in the PA lexicon these days, joining the ranks of physician’s assistant and midlevel provider. Although they have been subject to scrutiny for quite some time, the Full Practice Authority and Responsibility (FPAR) debate has made us look a little more critically at the literal and figurative interpretation of these words. One of the four components of the policy proposed by the FPAR task force “support[s] the elimination of provisions in laws and regulations that require a PA to have and/or report a supervisory, collaborating or other specific relationship with a physician in order to practice.” Although I strongly support the other three pillars of FPAR, I struggle with this one. My PA-MD relationship has been a huge part of my identity as a PA until now. In fact, the delegation of services agreement that allows me to practice medicine in the first place is the product of my PA-MD relationship.

Proponents of FPAR say we need to look to the future; that we are already behind the times. We can improve access to care, maintain parity with our advanced practice nurse peers, reduce paperwork, and increase flexibility of our profession. I see their point. I appreciate that FPAR could decrease some administrative hassles if (heaven forbid) I want to change jobs or when I need to recruit locum tenens providers. Yet, it still makes me anxious. Personally, I wouldn’t want to work at my rural health clinic, which is 60 miles from the nearest hospital, if I didn’t have a specific relationship with a physician or group of physicians. I make autonomous clinical decisions every day, but sometimes I need to consult with my physician colleagues for advice or a different perspective on a patient. If the PA-MD relationship is not codified, how will we ensure the medical team continues to exist? And the million dollar question is, how will physicians respond to this proposal? In some ways it will make their lives easier and they will no longer need to accept a level of responsibility for PA practice, but I thought only physicians could practice medicine.

So, under FPAR, where does that leave people like Dr. Gradison and me? What will the PA profession look like in another 50 years? For our patients’ sakes, I hope we remain committed to team-based practice and maintain a close relationship with our physician (and nursing) colleagues that is based on trust, mutual respect, shared knowledge and collegiality. After all, isn’t that what any good relationship is about?

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, February 20, 2017

Zachary Hartsell, MHA, PA-C, DFAAPA
The opioid epidemic in the United States has been well-documented and discussed several times in JAAPA via editorials and blogs.1,2 As a hospital medicine PA, I see that despite better recognition, the opioid epidemic continues to plague our communities and hospitals and carries a high cost. In addition to the tragedy of opioid-related deaths, the complications and comorbidities associated with IV drug abuse can be equally as devastating and are long-lasting. Seeing young patients with endocarditis requiring valve replacement is difficult, but the same population with strokes, emboli, or deep tissue infections requiring massive debridement are often overlooked and leave deep scars.

We are continually presented with data about the epidemic. Evidence not only focuses on the scope and effects of opioids, but more and more is being published about the roles and responsibilities of providers in opioid prescribing. The CDC released its Guidelines for Prescribing Opioids for Chronic Pain in 2016 and some states, including North Carolina, have already adopted these as their prescribing guidelines.3,4 The American College of Physicians (ACP) recently released guidelines for treating acute, subacute, and chronic lower back pain.5 Simply put, the recommendations call for nonpharmacologic and nonsteroidal medications as the first-line treatment for acute, subacute, and chronic lower back pain. The guidelines also recommend using opioids only in patients who fail nonpharmacologic and nonsteroidal therapy and after careful risk/benefit considerations. Because back pain is a common office and ED complaint, this potentially has significant implications for front-line prescribers.

Clearly, the trend is to reduce patient exposure to opioids as a way to prevent long-term addiction. If you are not exposed to it, it is impossible to become addicted to it. This has been especially true in the surgical literature. For example, studies also have looked at the persistence of opioid use after major surgery, which has paved the way for greater consideration of opioid-free surgery.6 As PAs, we must look at our own practice patterns and determine what we can do to help reduce the tide of opioid addiction. Each prescription we write should be given careful consideration after we weigh the risks and benefits to the patient. Although there will always be indications for opioid pain medications, a more thoughtful and deliberate approach to how we prescribe them, when we prescribe them, who we prescribe them to, and how long we prescribe them should accompany each prescription. I look forward to seeing what types of innovation and practice adjustments will be made over the next year and whether these types of changes can reduce the burden of opioid addiction.

Zachary Hartsell is administrative director of the anesthesiology and pain service line at Wake Forest Baptist Health and associate medical director of the PA program at Wake Forest School of Medicine in Winston-Salem, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.       

1. Reed H. Addicted to blame. JAAPA. 2016;29(8):15-16.

2. Klinger A. Opioid prescribing: a love-hate relationship. Musings. September 29, 2014. 

3. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(RR-1):1-49.

4. North Carolina Medical Board. Board adopts CDC opioid guidelines.

5. Qaseem A, Wilt TJ, McLean RM, Forciea MA. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Epub ahead of print February 14, 2017.

6. Soneji N, Clarke HA, Ko DT, Wijeysundera DN. Risks of developing persistent opioid use after major surgery. JAMA Surg. 2016;151(11):1083-1084.


Monday, February 6, 2017

Brian K. Yorkgitis, PA-C, DO

In 2015, the US national healthcare expenditure was $3.2 trillion, or almost $10,000 per person.1 In 2011, it was estimated that $285 to $425 billion of healthcare spending was due to failures in care delivery, coordination, or overtreatment.2 Reasons often given by clinicians for recommending low-value tests and treatments include malpractice concerns, keeping patients happy, fulfilling a patient’s request, reassuring the clinician, and not enough time with patients.

Initiatives to educate clinicians and patients have arisen to combat this issue. One of the most widespread is the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.3 The initiative was started in 2012 with Consumer Reports and includes evidence-based recommendations that providers and patients should discuss—specifically, when tests and procedures are appropriate. Since the campaign’s inception, more than 70 medical societies contributed to lists of more than 450 unnecessary tests and treatments. Common problems physician assistants (PAs) face in clinical practice are included in the campaign. The evidence-based recommendations range from pediatrics to geriatrics and from preventive medicine to disease management.4

Looking closer into the Choosing Wisely campaign at a frequent care issue, antibiotic use, I found 28 recommendations from almost 20 professional societies. Sinusitis and otitis, common ailments that PAs evaluate and treat, appear seven times. With the growth in adverse reactions (including Clostridium difficile infections and antibiotic resistance) from inappropriate antibiotic prescriptions, the medical community is tackling the issue through evidence-based recommendations. The CDC estimates one in three antibiotic prescriptions are unnecessary.5

Although these recommendations exist, implementation remains a challenge. A 2014 survey found that only 21% of physicians were aware of the Choosing Wisely campaign.6 Of these physicians, only 62% reported efforts to reduce unnecessary services. We as a medical community must educate each other on the body of literature that exists to reduce waste and harm.

The next challenge is implementing high-value, evidence-based healthcare. I urge PAs to review the Choosing Wisely recommendations on issues that you routinely encounter in your clinical practice. Think critically each time your order a test or treatment. Is it supported by the literature? Talk to your patient about the campaign and empower them to partner with you in their care. The final challenge is for PAs to come together to produce a set of recommendations as a profession to submit to the Choosing Wisely campaign.

1. Center for Medicare and Medicaid Services. National Health Expenditures 2015 Highlights.

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(4):1513-1516.

3. American Board of Internal Medicine. Unnecessary tests and procedures in the health care system.

4. ABIM Foundation. Choosing Wisely.

5. Centers for Disease Control and Prevention. CDC: 1 in 3 antibiotic prescriptions unnecessary.

6. ABIM Foundation. Survey: physicians are aware that many medical tests and procedures are unnecessary, see themselves as solution.

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.

Tuesday, January 24, 2017

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

As this blog is being written, Congress and the President-elect are preparing to defund key components of the Affordable Care Act (ACA), which would cripple major parts of the legislation and lead to substantial changes to the American healthcare delivery system. The current plan is to defund the financial underpinnings of the ACA using the budget reconciliation process, and eventually replace it at some time in the future with an undetermined alternative. Whether this will actually happen is difficult to predict but let’s assume for the moment this is indeed future course of events.

The most likely first action aimed at repealing the ACA will be the elimination of the taxes and other revenue sources that are fundamental to the ACA’s operations. These revenue streams fund two major pillars of the ACA: subsidies that make it possible for many Americans to buy health insurance plans, and the federal funding that gave the states the ability to greatly expand the number of patients covered by Medicaid. Current projections in the news media estimate that this action alone will result in a loss of health insurance for 20 million Americans who recently had gained it. JAAPA published an editorial by Editor-in-Chief Reamer L. Bushardt, PharmD, PA-C, DFAAPA,  that covers the nuts and bolts of what the repeal of the ACA might entail. If you haven’t read it, I highly suggest you do.

The PA profession has experienced remarkable and consistent growth over the last two decades. In fact, since the 1970s, there have been only two notable time periods where growth in the profession was not vigorous. The first occurred beginning in 1980 with the release of the Graduate Medical Education National Advisory Committee (GMENAC) report that predicted physician surpluses. That period lasted until the managed care delivery model gained popularity among third-party payers beginning in the late 1980s. The second occurred in the late 1990s, and was shorter in duration with less effect than its predecessor. My opinion was that it was caused by provider geographic maldistribution and provider demand changes resulting from the managed care funding model reaching a critical mass that produced reduced provider demand. The GMENAC years were notable in that the report caused a retrenchment in all medical education (including reductions in medical school and GME enrollment) such that it was common to hear discussions of whether the PA profession had a future. No data are available from that time that would address PA supply and demand or salaries; however, during this time, PA enrollment was flat and almost no new PA programs were established.1 In contrast, the stagnant PA demand period of the late 1990s was very mild, at most lasting only a few years, mostly occurred only on the East Coast, affected primarily new graduates and those changing jobs who were unwilling or unable to move to new geographic locations, didn’t affect PA program or enrollment growth, and resulted only in stagnant growth in new graduates’ starting salaries from 1997-1998.2

Multiple factors obviously account for the profession’s impressive growth over the last two decades—the emergence of healthcare teams, increasing demand for healthcare from an aging population, and an increase in the expectation that citizens have a right to healthcare. Since the mid-1990s, there has been a persistent interest in increasing the number of PA programs and students, mostly by educational institutions that have noticed the profession’s growth and the societal factors driving it. In the last decade, many other healthcare professions have observed these factors and also concluded that more providers are needed. Allopathic and osteopathic medical schools and NP programs have also increased in number and enrollment. With the election of Barack Obama in 2008, the consensus was that healthcare would be reformed with a system that would provide medical care for most of those uninsured at the time, and that this was simply going to be yet another huge factor that would require an even bigger future medical workforce. Over the last 8 years, I have spoken to dozens of educational and healthcare system administrators who indicated that from their perspective they saw no end to the future demand for healthcare providers, and in particular PAs.

However, even before the 2016 election, some had begun to predict an end to current high demand for healthcare providers. Medical schools, PA programs, and NP programs have experienced problems providing clinical training sites for increasing enrollment, indicating that there is likely a ceiling to the student capacity of the current healthcare delivery system. Additionally, some workforce experts had begun to publish warnings of an impending surplus of providers—these two articles were written and published before the 2016 election, when repeal of the ACA was considered unlikely by most.3,4

Over the last 6 years, the healthcare industry has been ramping up to provide for patients using the ACA as a blueprint—in fact, vast amounts of money have been invested in a long-term effort to reshape the American healthcare delivery system. Now, many of these investments could be abandoned before being completed. The exit of 20 million patients from the healthcare delivery system will be a substantial event with many unpredictable and likely unintended consequences. Of course, from our pre-ACA experience we know that some of these patients won’t really exit the healthcare system; they will just end up in the ED. Any many will just simply avoid seeking care as long as possible. So, primary care clinics will need fewer providers, as will many areas of hospital care. However, a boom is likely in emergency medicine jobs. With substantially fewer patients in the system overall, however, the number of providers needed probably will decrease, and this decrease could happen relatively quickly as demand rapidly diminishes in response to patients losing their healthcare coverage.

I’m of the opinion that our education systems were on track to meet and possibly exceed the need for healthcare providers sometime in the next 5 years. I anticipated that the increasing scarcity of clinical training sites would be the limiting variable that would modulate the current enrollment growth to eventually adjust to the supply-demand curve of the future. Now, considering the unexpected factor of the defunding and repeal of the ACA following the 2016 election, demand for medical providers may actually suddenly decrease, moving the point of market saturation closer to the present. Could the PA profession be facing its third period of growth retrenchment?

1. Simon A, Link M, Miko A. Thirteenth Annual Report on Physician Assistant Educational Programs in the United States, 1996-97. Association of Physician Assistant Programs, May 1997.

2. Simon A, Link M, Miko A. Fifteenth Annual Report on Physician Assistant Educational Programs in the United States, 1998-99. Association of Physician Assistant Programs, May 1999.

3. Salsberg E, Quigley L. Are we facing a physician assistant surplus? JAAPA. 2016;29(11):40-44.

4. Hooker RS. When will physician assistant supply exceed demand? JAAPA. 2016;29(11):10-12.

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.