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Musings: Blog of the JAAPA Editorial Board
Monday, March 23, 2015
Harrison Reed, MMSc, PA-C
 
I returned from a trip to another hemisphere, but it could have been another planet. It was the type of place where you could hear a half-dozen languages spoken at a single restaurant and, from the color of someone’s skin, you couldn’t guess which continent they were from, much less the neighborhood. And although my foreign language skills need work, I was much more embarrassed by how foreign a different concept felt: social responsibility.
 
You’ll see it in other countries. It’s the kind of thing that makes a baker set extra bread on the outside stoop at night or the reason stray dogs still somehow stay plump and alive. It’s not charity. It doesn’t come from pity. It comes from understanding what separates the prosperous from the impoverished.
 
From knowing the only difference between a pet and a stray is a piece of fabric around the neck.
 
“Every success, and every mistake, only happens as the result of 500 successes or mistakes before it,” the Chilean bartender says as he slides me an India Pale Ale—the beer itself is the happy result of a shipping mistake hundreds of years ago. “There are infinite opportunities along the way to prevent something. And many people have the power to do so. Even if they choose not to."
 
The bartender has never heard of Atul Gawande or read Complications or seen the inside of a modern OR. At least not that he remembers.
 
But a sniper’s bullet tore through his chest in Kosovo, so I imagine he understands the concept of mistakes and millimeters.
 
Right here, he points to a scar just south of his clavicle. I remember enough from anatomy class to know he is lucky to have the use of that arm, much less his life.
 
I asked him why a man would leave the tranquility of his native harbor town to learn English and fight for peace in a bomb-riddled country he had never heard of. He shrugged.
 
“Because no one else would do it.”
 
I wondered in that moment how many in modern medicine would take a metaphorical bullet because it was the right thing to do, because no one else would.
 
I’ve certainly seen that kind of steel resolve when it comes to fighting for reimbursement. When it comes to government officials and corporate administrators justifying their jobs. When it comes to hospital mergers and buyouts. When it comes to performance measures or legislation or loopholes.
 
But I’ve spent enough time on conferences and meetings and media outlets to know that the conversation usually focuses more on what’s efficient and effective than what is just and right.
 
My grandfather moved his wife and seven children to rural Virginia because the people there needed him. Because he felt a social responsibility. Now his grandson works in an industry that has more in common with Walmart than well-being.
 
Of course, commercial success is nothing to disparage. But I wonder if those at the top of the healthcare mountain remember the 500 prior successes that led to each of theirs. And the people who made it happen. I wonder how they would treat those same people if they were in one their hospital beds right now. When the ledger is balanced at the end of the day, I wonder if there is enough change left over to invest in some social responsibility.
 
Or if that is merely a foreign concept.
 
And if that idea does feel strangely absent, I can tell you where to find it. It’s on another hemisphere, on another continent, in a little bar in a little harbor town, in a man with a case of beer on one shoulder and a scar under the other.
 
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, March 09, 2015
Jennifer M. Coombs, PhD, PA-C
 
Conducting community-based participatory research (CBPR) can be a daunting task for busy clinicians. Many PAs have had public health training and many more have a passion for taking care of populations they serve beyond the individual provider-patient dyad. PAs can follow several models to empower stakeholders to partner with public health providers. CBPR is defined as a collaborative approach to research that involves all partners in the research process and recognizes the unique strength that each brings. CBPR begins with a research topic important to the community, and seeks to combine knowledge with action to achieve social change to improve health outcomes and eliminate health disparities. Ask the community you serve, “What are you interested in?” and “What are the problems you want to solve?” This is not the typical top-down approach of obtaining a grant to help a population do what outside experts think is best for them. This is not about being the person with all the knowledge with your own ideas about what the community needs. This is about helping the community to make a change. This is about the ideals of shared decisionmaking and equal partnerships. CBPR also does not aim to make an individual PA a researcher: it is a rational process to organize the health practitioner’s thinking from an assessment, intervention, and evaluation approach.
 
The model that can help a community-oriented PA is the Precede-Proceed Model. The model has five steps, including assessing attitudes within a community. Another step is to assess the resources—for example, are the neighborhoods walkable, are fresh fruits available or does the community have food deserts? The assessment and resource steps are critical in truly understanding the community and the people the PA is serving.
 
The final steps include deciding the intervention and evaluating the outcomes. Providers often think of the intervention and outcome first: “I want to do something about the people in my community that are overweight and obese,” or “I want to educate teenagers about STIs.” This is putting the cart before the horse in CBPR. For example, in Alaska the rates of suicide are four times the national average; in rural villages, young people between ages 14 and 25 years are especially at risk. Focus groups that ask for community input about healthcare problems can elicit these issues. The Association of Asian Pacific Community Health Organizations has a helpful CBPR toolkit with a great set of resources. Another good resource, Practical Playbook, was developed in partnership with the Duke University PA program, has links to success stories and ideas with real practical solutions. The Guide for Assessing Primary Care and Public Health Resources, developed in partnership with the Association of State and Territorial Health Officials, the CDC, and the University of Utah, is another excellent resource.
 
We should not wait until population health and clinical medicine work out their differences. Nor should we stand by feeling helpless to make a small change with a small project. DIY public health for the busy clinician is possible with the plethora of toolkits and resources readily available.
 
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, February 23, 2015
Lawrence Herman, MPA, PA-C, DFAAPA

Like many PAs, I’ve practiced in a host of specialties over my two-decades-plus career. I started in emergency medicine and concurrently did some moonlighting as a hospitalist, in occupational medicine, urgent care, and then moved into full-time family practice, other internal medicine subspecialties, and finally education. What has been the singular constant is that every one of these specialties had a void, what is sometimes referred to as a vacuum. What I am describing is an area with a specific need that nobody was consistently filling. In mentoring students and new graduates, I have always recommended seeking out that void and moving into it.
 
Bright and forward-thinking PAs, perceptive in their areas of expertise, have seen these voids and responded. Locally, we have a hospital system in which the PAs have seen voids and taken the initiative by developing and implementing new and innovative programs.
 
The first instance that comes to mind is a program associated with developing protocols—as well as training advanced practice providers—with respect to central venous access devices (CVADs). In this hospital, PAs independently developed a protocol to determine which patients needed a CVAD, how to monitor the CVAD, and when to remove the device. They also developed an educational program to train providers who would be inserting the CVADs. The focus of the protocol was on reducing CVAD infection rates. Were they successful? Yes, but beyond reducing CVAD infection rates (beneficial to patients and costs on multiple levels), they also reduced length of stay, something that was not necessarily anticipated.
 
The second example is a discharge protocol for hospitalized patients with heart failure. These patients are at high risk for early readmission, largely an avoidable circumstance, but only if the patient can be monitored and heart failure medications adjusted proactively. What this healthcare system does is unique: the day of patient discharge, they install a Wi Fi-enabled scale in the patient’s home, including cable internet if needed, and all at the cost of the healthcare system. The patient steps on the scale every morning; if the patient has gained 3 pounds overnight, the patient is called and picked up for a same-day appointment and medication adjustment. This system has dramatically reduced heart failure readmission rates.
 
The third example is how a health system handles patients who have had major thoracic surgery. A few days after patients are discharged, a surgical PA is sent to the home to re-evaluate the patient. Initially the thought was that this would reduce postoperative wound infections and readmissions. But what rapidly became apparent was that this also allowed the adjustment of chronic medicines and a more holistic approach to the patient, reducing readmission for not just wound infections but for a multitude of issues.
 
So why do I mention these? What am I driving at?
 
Regardless of where you work, there are incredible voids. There are things we notice virtually every day that interfere with seamless patient treatment. Some are small and some are huge and most are systems problems. But at least some of these systems problems have a clear solution. Resolving some of these problems can result in a tremendous long-term payoff and involve a relatively small upfront investment. And some of these solutions require that we step out of our comfort zone and do things that we normally wouldn’t do, such as make home visits.
 
These days most of us are asked to do much more with fewer resources. Outcomes and satisfaction levels are being measured at every step of the way. And sometimes a solution, albeit initially painful, has the downstream result of reducing or even eliminating more work later on. Kind of like the old cartoon asking, “Shoot me now, or shoot me later.” Only sometimes this is, “Shoot me now once, or shoot me later over and over again.”
 
My recommendation is first to identify that void in your practice setting. And you know your practice setting well enough as to where those voids exist. (Your bigger problem may be to narrow this down to a single problem to attack.) Once you have identified the one problem you want to solve, the next step is to consider getting a group together to craft a potential solution. And finally, the next step is to move that solution up the chain of command. I acknowledge that this isn’t going to be easy. Progress—and change—never is.  And clearly medicine itself isn’t easy. And what most would label the business of medicine may be the most complex part of the equation.
 
But you have been trained to fix problems your entire career. Let’s roll up our sleeves, run to the void and get to work.
 
Lawrence Herman is an associate professor and chair of the Department of Physician Assistant Studies at the New York Institute of Technology in Old Westbury, N.Y., and chair of the board of directors and immediate past president of AAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

Monday, February 09, 2015
Steve Wilson, PA-C
 
Men who serve in battle receive ribbons to wear on their chests to indicate their wars and actions served, their bravery and commitment to fulfilling their duty. Young girls wear ribbons in their hair as a way of addressing the practical need to keep the hair out of their face and to accent their outfit and/or their vibrant personalities. Tying a yellow ribbon around an old oak tree has become a symbol of warmth, welcome, and promise (I have always felt conflicted about that sentiment as the song is about someone getting out of prison. I will stick with the reference to wives and girlfriends of cavalry men wearing a yellow ribbon in their hair as devotion to their husbands and boyfriends). The sentiments of bravery, beauty, and optimism somehow have become captured in a simple ribbon.
 
With the NFL season ending, we cannot but help recognize the effect of this symbol as a potential focus for the cause of raising funds for breast cancer. Nothing like a bunch of testosterone-infused men running around with pink shoes, socks, and sweatbands to heighten awareness to a cause. In fact, the pink ribbon has morphed into just the color pink as being enough to direct your attention to the need to support the battle against breast cancer. This marketing ploy has been a tremendous benefit to the cause and I applaud the effort. My wife has worked as a radiologic technologist and performed mammograms for a large part of her career. She has particularly taken up the cause to fight this disease. But, in my line of work, I find myself facing a steady stream of patients with pulmonary malignancy and I recently asked myself: “What color is the ribbon for lung cancer?”
 
To be sure, I understand some of the societal issues in considering the two diseases. One involves more physical disfigurement than the other, one potentially affects a younger population, and one generally is considered by many to be self-inflicted. But in these times where value analysis plays a part in determining where healthcare dollars go, should the funds raised for cancer not be distributed evenly based on disease prevalence?
 
According to the American Cancer Society (ACS) , lung cancer is the second most common cancer in both men and women. Although prostate cancer is more common in men and breast cancer is more common in women, lung cancer is second only if you separate by sex. Research, judicious screening, and aggressive treatments have reduced deaths for some cancers, yet more people die each year from lung cancer than from colon, breast, and prostate cancers combined—about 27% of all cancer deaths. Lung cancer is becoming more of an equal-opportunity killer as over a lifetime, about 1 in 13 men and 1 in 16 women will get lung cancer—regardless of whether or not they smoke. So, where does federal funding go?
 
The National Cancer Institute cut of the National Institutes of Health’s fiscal 2013 budget was $4.8 billion. Over the last 8 years this budget figure has been pretty much the same, with the average being $4.9 billion. Although spending for fiscal year 2014 is not yet known, for fiscal year 2013, lung cancer received $296.8 million and breast cancer received $624.1 million. Prostate and colorectal rounded out the top four with $288.3 and $265.1 million, respectively. The ACS reports that their grants by cancer types (as of August 1, 2014) were 196 grants for breast, 102 for colon and rectal, and 93 for lung cancers. These figures do not include the other charitable organization involved with these diseases, and certainly tabulating these would be beyond the scope of this post. But, I think that it is clear that if I intend to heighten awareness of funding for preventing and combating lung cancer I need to have a great ribbon.
 
According to Choose Hope, the ribbon color for lung cancer is (drum roll) white. Yep. White. OK, so white is clean and pure and “driven snow” and all that, but in terms of trying to bring attention to a cause is it really where you would like to be? Sure, it could be brain cancer grey, but then lymphoma lime green is really much more catchy. Who assigns these things? Where is the marketing director for lung cancer? We need to get a better ribbon color for lung cancer! We need to see a spike in grants and federal funding to prevent and treat this disease. We need a campaign to capture the public interest. We need a way to enhance interest in those five-lobed, pink, squishy organs that are critical for life! Maybe couple it with a campaign that couples it with all lung diseases. I can see it now, a pink-and-white polka-dotted ribbon next to the slogan “Save the Billows!”
 
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, January 26, 2015
Alexandra Godfrey, MS, PA-C
 
The whole purpose of education is to turn mirrors into windows.—Sydney J. Harris
 
Last week, I taught a group of students the neurologic examination. I had prepared the students by asking them to bring all the necessary equipment: reflex hammer, otoscope, push pins, cotton balls. They came to the laboratory in shorts and T-shirts excited and ready to learn. I had a checklist to follow that had been carefully put together by the faculty in charge of the patient care course. We allotted 2 hours to go through the checklist and practice the various maneuvers. I thought this would be ample time.

The checklist started with mental status screening test and ended with testing for meningeal signs. I began with the importance of looking at the patient: level of consciousness, posture, dress, grooming, affect. As we discussed the nuances of observation, I used clinical vignettes to highlight my teaching. I described the patient with mania who would present to the ED in gaudy makeup and flamboyant clothing. She would spiral and spin into triage, not really having time to sit to talk. I knew just by her clothing that she had stopped taking her lithium and was likely manic. I talked about the patients who wear long sleeves to cover up their scars from self-injury, and the shame and reticence they often feel. We discussed the flat affect of the patient with depression … and how I found that somehow their mood would invariably infuse the entire room and seep into my soul.
 
We talked about insight, judgment, hallucinations, and super powers. I spoke of the patients brought in for yelling at the children and animals that only they see.  The fear instilled in them and their caregivers.  I described the fight-or-flight response of a paranoid schizophrenic I once saw who was convinced he was being pursued, and how he had reminded me of a gazelle under the eyes of a lioness on a plain in sub-Saharan Africa. I witnessed his fight-or-flight response when he believed he had become prey: his head turning, eyes flickering, muscles contracted, brain deciding where or how to run.

Consequently, the assessment of mental status and behavior took me longer than I expected.
 
The physical examination was no more straightforward. The students in spite of their reading bombarded me with questions:

What causes ptosis?

What is the meaning of accommodation? 
 
Do we always have to assess the gag reflex?

What is a fasciculation and when would we see this?
 
When would reflexes be absent?

And does ankle clonus really matter?

Why would we test extinction?

We talked about neurons—upper and lower, tracts and ganglions, extrapyramidal signs, radiculopathies, cerebrospinal fluid (CSF), speech that is fluent but nonsensical, and speech that is clear but broken We sought clarity and transparency in a complex world of  junctions and pathways and murky CSF. It took us 2 hours to get through the checklist. The analysis, the remembering (and the forgetting), and the application led us down tracts of our own, firing neurons, and creating sparks of curiosity that were followed inevitably by questions.

I wanted the students to understand the rationale, the application, and the meaning of the tests they were learning. We entertained instead of simply accepted each examination maneuver.
 
I admit I may be guilty of perseveration. I admit I had a discrepancy to address.

So many times as a preceptor I had asked my students the pretest reliability or even the expected normals  or abnormals  of a test or maneuver, and had been met with panic, a blank stare, or confusion.

Teaching the neurologic examination with such application was more difficult. It tested my knowledge and assumptions, checked my stamina, and challenged my practice. Much easier to teach the maneuvers of the checklist and tell students that it is their sole duty to find the meaning. Ultimately, at the end of the session, we wrote out a list of questions to be researched and answered.

A few days later, my students returned to the classroom to again run through the neurologic examination. Now, with questions answered, they could practice with deliberation. I felt proud as they talked about the mechanism of the pupillary response to light, the sluggish reflexes of hypocalcemia, and the effect of hemisphere dominance on aphasias and hemi-neglect. The precision with which they worked was inspiring, and I felt confident they would go on to practice with skill. Seeing the rewards of persistence, witnessing the dissolution of obstacles to learning, watching obfuscation become clarity—mirrors turn to windows; these transformations make my work as a clinician-educator meaningful and precious.

Alexandra Godfrey is an assistant professor in the PA program at Wake Forest University/Appalachian State University in Boone, N.C., and practices in the ED at Catawba Regional Medical Center in Hickory, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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