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Musings
Blog of the JAAPA editorial board.
Monday, October 31, 2016

​Virginia McCoy Hass, DNP, FNP-C, PA-C

I confess to being obsessed with our current presidential election, and the debate (or lack thereof) it has inspired. These last 18 months or so have highlighted a pervasive and growing problem in US society—the failure to find common ground in the midst of deeply rooted ideological differences. We live in a culture and in communities that have become increasingly polarized over the past two decades. According to a 2014 study by the Pew Research Center, both Democrats and Republics have shifted to more ideological extremes, with the percentage of Americans holding consistently conservative or consistently liberal opinions doubling from 10% to 21% since 1994.1 Simultaneously, hostility between the two major political parties more than doubled. Most disturbing is that a substantial percentage of study participants from each party (27% of Democrats and 36% of Republicans) responded that they “believe the opposing party’s policies are so misguided that they threaten the nation’s well-being” (emphasis added).1 This is not a perspective that encourages open exchange of ideas.

Further accentuating the divide, respondents in the Pew study demonstrated self-segregation along their ideological beliefs. A majority (63%) of those with consistently conservative views and almost half (49%) of those with consistently liberal views indicated that their close friends share their political ideology. The same pattern was seen with regard to community of choice. Fifty percent of consistently conservative respondents and 35% of consistently liberal respondents responded affirmatively to the statement, “It’s important to me to live in a place where most people share my political views.”1

We express our politics through our lifestyle choices— where we live, what we eat, what we buy, and how we are entertained. Coverage of our current presidential campaign on TV and radio shows, YouTube, podcasts, Facebook memes, Instagram, and Twitter reflect partisan bias and are shared and reshared among social groups, reinforcing the communal perspective. Living, working, and playing in increasingly polarized communities challenges our commitment to long-held values of democratic society—tolerance, civil discourse, and mutual respect. And our ideas of what is the common good of the community become similarly narrowed. This too is reflected in the 2014 Pew study—respondents with the most consistently liberal or consistently conservative viewpoints were least likely to say that an ideal agreement between President Obama and congressional Republicans was one in which a 50/50 compromise was reached.1

The problems we face as a society, both at home and abroad, are significant—the economy, the environment, human rights, terrorism, and others. Although we may be polarized in our beliefs about how to solve these problems, one thing seems intuitive—we cannot solve them by disregarding or disadvantaging any one segment of our society. The presidential campaign will soon be over. Once we have chosen our next president and the legislature with which he or she will work, we have another choice to make. How do we restore civility, tolerance, and respect for others to our public debate? It will be work to achieve a sufficient consensus to allow us to move forward. And it will take an educated populace. Former Justice David Souter commented on “the dangers of American civic ignorance” in 2012, saying,

 

I don’t worry about our losing republican government in the United States because I’m afraid of a foreign invasion. I don’t worry about it because I think there is going to be a coup by the military as has happened in some other places. What I worry about is that when problems are not addressed, people will not know who is responsible. And when the problems get bad enough, as they might do, for example, with another serious terrorist attack, as they might do with another financial meltdown, some one person will come forward and say, “Give me total power and I will solve this problem…” That is the way democracy dies. And if something is not done to improve the level of civic knowledge, that is what you should worry about at night (emphasis added).2

 

Thus, a working democracy is not easy to achieve or maintain; and there is danger in the continuation of political stalemate in Washington. I nonetheless take hope in another statistic from the 2014 Pew study—a majority of respondents self-identified as having a mixed ideological viewpoint and of these more than 50% identified a 50/50 compromise as an ideal agreement between President Obama and congressional Republicans.1 This suggests that despite the polarization we see in self-segregated groups, significant sections of our society are not only open to, but crave, informed debate, compromise, and working together toward solutions for the common good.

As healthcare providers, we know the power of education. Education nurtures the responsible expression of individual liberty and the skills required to create and cultivate diverse, inclusive, sustainable communities. In part, this requires that we openly and honestly reassess what is the common good in a rapidly changing national and global community. It means embracing differences (diversity) with open minds. We can begin to this work by using the communication skills we have as healthcare providers—listening, tolerance, and respect to name a few—in our own spheres of influence to initiate and sustain a dialogue with those whose ideology is divergent from our own.


“If you want to bring an end to longstanding conflict, you have to be prepared to compromise.”—Aung San Suu Kyi

 

REFERENCES​
1. Pew Research Center. Political polarization in the American public.

2. PBS News Hour. Former Supreme Court Justice Souter on the danger of America's “pervasive civic ignorance.”

Virginia McCoy Hass is an assistant clinical professor and nurse practitioner program director in the Betty Irene Moore School of Nursing at the University of California at Davis. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 


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.

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