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Musings
Blog of the JAAPA editorial board.
Monday, January 25, 2016
Reamer L. Bushardt, PharmD, PA-C, DFAAPA; Harrison Reed, MMSc, PA-C
 
In our research for “Unraveling the recertification conundrum,” (JAAPA, March 2016) we learned about controversial perspectives among physicians about maintaining certification, former and emerging paradigms for physician maintenance of certification, and certification models for many advanced practice registered nurses. We wanted to share some highlights of what we discovered with you.
 
Maintenance of certification for physicians has been a controversial topic, especially in recent years. In 2002, Sharp and colleagues evaluated published studies tracking clinical outcomes and physician certification by an American Board of Medical Specialties member board.1 The authors performed the meta-analysis to shed light on specialty board certification, which they reported is often used as a standard of excellence but with limited systematic review describing the link between certification and clinical outcomes. The authors evaluated published studies tracking clinical outcomes and certification status. Of 33 findings evaluated, 16 reported a significant positive association between certification status and positive clinical outcomes, three revealed worse outcomes, and 14 demonstrated no association. One no-association finding and three negative findings were identified in two manuscripts with insufficient case-mix adjustments in the analyses. The authors also noted that a small minority of published studies (5%) used appropriate research methods for their research questions.
 
Gray and colleagues reported in 2014 results of their quasi-experimental comparison study to measure associations between the original American Board of Internal Medicine (ABIM) certification maintenance requirement and outcomes of care (such as ambulatory care-sensitive hospitalizations) by two groups of internal medicine physicians.2 The first certified group of internists (n=974) treated 69,830 Medicare beneficiaries in the sample, and the second certified group (n=956) treated 84,215 beneficiaries. The annual incidence of ambulatory care-sensitive hospitalizations increased pre- and post-certification maintenance requirement, but the results demonstrated imposition of the certification maintenance requirement was not associated with a difference in this increase in ambulatory care-sensitive hospitalizations.
 
Since 1936, the ABIM has administered written board certification examinations. These tests were time-unlimited before 1990. The requirement was then shifted to passing an examination every 10 years to maintain certification. The ABIM also began requiring physicians to complete ABIM-sanctioned certification maintenance programs before sitting for examinations. In 2015, ABIM changed its labeling for board-certified internists to describe their certification status as well as whether they are participating with maintenance of certification. Hayes and colleagues performed a retrospective analysis of 1 year’s performance data at four Veterans Affairs medical centers to examine whether there were differences in primary care quality between physicians holding time-limited or time-unlimited certification.3 The authors reported no difference in outcomes for patients receiving care by the internists with time-limited or time-unlimited certification, after adjustment for practice site, panel size, years since certification, and clustering by physician.
 
In a commentary published by the New England Journal of Medicine, Paul Teirstein, a physician who launched a web-based anti-certification maintenance petition, challenges the ABIM’s process.4 The author calls attention to inconsistent data linking certification maintenance to quality care, points out physicians that believe that the examination questions are not relevant to their practice or a reliable gauge of physicians' knowledge, and draws attention to financial incentives for the ABIM’s certification maintenance requirements, noting the organization in 2012 received more than $55 million in fees from physicians seeking certification. The author recommends reliance on continuing medical education as a more practical means for maintaining certification.
 
Adult, family, gerontologic, and adult-gerontology NPs are certified by the American Academy of Nurse Practitioners (AANP) certification program and must renew their certification every 5 years after initial certification.5 Recertification is achieved by either meeting current minimum clinical practice and continuing education requirements established by AANP for renewal and maintenance of certification or by taking the appropriate certification examination. The American Board of Nursing Specialties and the National Commission for Certifying Agencies accredit the AANP’s certification and recertification programs. According to the AANP, its certification program is recognized by all state boards of nursing, the Centers for Medicare and Medicaid Services, the Veterans Administration, private managed care organizations, institutions, and healthcare agencies for credentialing purposes.
 
The AANP certification program recognizes state boards of nursing as responsible for the regulation of nursing practice, with the duty to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing, outlining the standards for safe nursing care, and issuing licenses to practice nursing. Their organization also acknowledges that nursing practice varies from state to state, and endorses the national Consensus Model for APRN Regulation, a regulatory model published in 2008 and an initiative to help align state regulation of APRNs across the United States.
 
Recertification, or certification renewal, by AANP aims to assure the public that NPs have met current professional standards of qualifications and adequate knowledge for practice. Two options are available for recertification every 5 years. First, NPs may meet requirements through continuing education (CE) and clinical practice hours: 1,000 hours of clinical practice as an NP appropriate for the population of certification, 75 hours of CE applicable to the NP’s population focus, and a current and unencumbered RN or APRN license during the period of certification. This requirement will change for certifications that expire on or after January 1, 2017, with changes that include requiring 100 hours of CE, including 25 hours in pharmacology. Secondly, NPs may recertify by examination, by taking the appropriate national certification examination consistent with their education, and by holding a current and unencumbered RN or APRN license during the period of certification. Interesting, the changes described for recertification also permit CE credit for precepting advanced practice graduate students within the NP’s role and population focus but may also part of a formal interprofessional education program (such as medicine, dentistry, pharmacy, or PA).
 
As the National Commission on Certification of Physician Assistants (NCCPA) investigates new models for recertification of PAs, we found it helpful to explore current and emerging practices for maintenance of certification among our peers in medicine and APRN roles. Given the unique characteristics of PA practice, we suspect an optimal model for maintenance of certification for PAs will be different from those used by physicians and APRNs.
 
REFERENCES
1. Sharp LK, Bashook PG, Lipsky MS, et al. Specialty board certification and clinical outcomes: the missing link. Acad Med. 2002;77:534-542.
 
 
 
 
5. American Academy of Nurse Practitioners. Purpose of recertification and related documents. Candidate and renewal handbook.
 
Reamer L. Bushardt is professor and chair of the Department of Physician Assistant Studies and a program leader in the Clinical Translational Science Institute at Wake Forest School of Medicine in Winston-Salem, N.C., and editor-in-chief of JAAPA. Harrison Reed practices emergency medicine at Fremont Emergency Services in Las Vegas, Nev., 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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Monday, January 11, 2016
Zachary Hartsell, MHA, PA-C, DFAAPA
 
The shifting role of venture capitalism in healthcare is an interesting new trend. During my coursework for my doctorate of health administration degree, we have explored this at several different levels. I was reminded of some of the discussions we had about the role of innovation when I came across an article in the September 2015 issue of Hospitals & Health Networks.1 The article highlighted the recent shift in the market for developing and commercializing innovations in healthcare from a product-based service to a solutions-based model. Although commercializing innovation has historically played a role in healthcare, many of the earlier models were based on specific products. My own organization is a prime example of this product innovation commercialization through its development and licensing of the vacuum-assisted wound closure device in the 1990s and subsequent development of more than 30 different start-up organizations representing many different innovations.2,3 Other organizations such as the Mayo Clinic, the Cleveland Clinic, and Harvard University have all recognized models to bring innovative medical devices from research to the marketplace.
 
But just as healthcare has changed significantly in the last 10 years, so has the venture capital market in healthcare. As hospitals and healthcare organizations look to solve the complex problems of healthcare today, a provider/hospital solutions-based market has begun to emerge. The earliest examples of this were the information technology-based products. More recent commercialization examples include solutions to patient engagement, chronic disease management, and wellness programs. Another and more thought-provoking difference that has emerged is who is funding these new enterprises. Although venture capitalists will always have a stake, more often health systems are spinning off startups to bring these innovations to the marketplace. A separate entity spun off from a larger organization has many advantages, including ability to develop a new culture and organizational flow at a lower expense while being able to maintain a platform to test products in a real-world environment.1,4 For the healthcare organization, this model can open new revenue streams and patient care innovations on a faster cycle.1
 
I believe there are many significant implications for PAs in this new healthcare trend. First, the success of many of the organizations PAs work for may be tied to the success or failure of these start-up organizations. This can create both added opportunity and risk as we consider employment opportunities. Additionally, the undeveloped nature of this trend allows the opportunity for PAs to take the lead in not only development of innovative solutions, but also the opportunity to bring these innovative solutions to the commercial marketplace. Over my career, I have had the occasion to work with many capable and talented colleagues who have developed solutions to all sorts of everyday problems. Having a platform and process to support the development of these solutions and the understanding the mechanisms to bring these products to markets can create opportunity for PAs to lead in the modern healthcare marketplace.
 
REFERENCES
1. Butcher L. Disrupt your business: control your future.
September 15, 2015. Hospitals & Health Networks.
 
 
3. Wake Forest Innovations. Startups. 2016.
 
4. Coburn C. The future of medical innovation and commercialization. The Health Care Blog. December 17, 2012.
 
Zachary Hartsell is program director and vice chair of operations and workforce development and an associate professor in the PA program at Wake Forest University in Winston-Salem, N.C. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

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Tuesday, December 29, 2015
Amy M. Klingler, MS, PA-C
 
Security cameras. Safe rooms. Bullet-proof vests. Armed security guards. Is this CIA headquarters? No, not quite. It is a description of the security in place at the Planned Parenthood clinic in Colorado Springs where Robert Lewis Dear killed three people and shot and wounded nine others on November 27. These intricate safety measures helped police locate and arrest the shooter while protecting people inside the clinic.
 
Wearing disguises. Never driving your own car to the office. Varying your route to and from home. Buying decoy plane tickets when you travel by air. Abortion providers go to great lengths to elude the stalking and intimidation tactics of anti-abortion protestors.
 
Seeing your picture and pictures your children posted on the internet along with your confidential contact information. Being labeled as part of an “abortion cartel.” Living in fear that you will be the victim of a car bomb every time you put your key in the ignition. As Dr. Diane Horvath-Cosper stated in a recent interview, these are the realities of being an abortion provider in the United States.
 
Unfortunately, these precautions and worries have proven necessary as a result of a long history of threats and violence against individual abortion providers, reproductive health clinics, and those seeking their services. According to the National Abortion Federation’s Violence and Disruption Statistics, between 1977 and 2014 there have been :
• 8 murders
• 17 attempted murders
• 429 death threats
• 199 incidents of assault and battery
• 554 incidents of stalking
• 662 clinic bomb threats.
 
The recent shooting in Colorado Springs has brought renewed attention to the violence and harrassment that abortion providers and reproductive health clinics in the United States have faced for decades. These tactics, used by anti-abortion extremists like Dear, are now being called domestic terrorism by individuals from Planned Parenthood's Chief Experience Office Dawn Laguens to Republican Presidential contender Mike Huckabee. Regardless of one’s position in the abortion debate, these abominable acts towards clinicians and patients cannot be tolerated.
 
Senate Resolution 327, which was introduced in the 114th Congress on December 3, 2015, “denounces the attacks on healthcare centers for women, providers of healthcare for women, and patients; and affirms that all women have the right to access reproductive healthcare services without fear of violence, intimidation, or harassment.” Simple resolutions such as this one are not signed by the President, and are not enforceable by law; rather they are used to “express the sentiments of one house of Congress.” Obviously, it is a symbolic measure, but I am hopeful that it will remind us, after the headlines fade, that our patients and our colleagues deserve to be treated with dignity and respect, not hostility and terror.
 
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, December 14, 2015
Alicia Quella, PhD, MPAS, PA-C
 
This November, I returned from a monthlong training program for 95 first-year physician assistant (PA) students from the College of Health Sciences in the Lao People’s Democratic Republic (Lao PDR).  The didactic curriculum and skill-based training for these Laotian PA students was taught in cooperation with Laotian faculty and with faculty from Health Leadership International (HLI).  HLI is a US-based non-profit organization with volunteer physicians and PAs who have worked in the Lao PDR since 2008.  The President of HLI, Khampho Ohno, PA-C, is a Lao-American who works as a PA in primary care in Guam.
 
From the start, HLI has worked with the Lao Ministry of Health to improve medical knowledge and clinical skills of PAs who practice in rural district hospitals, particularly the districts affected by unexploded ordnances.  An estimated 2 million tons of bombs were dropped on Laos during the Vietnam War, making it one of the heaviest bombed nations in the world.  Laos’ geography, together with a sizable amount of unexploded ordnance, has hindered the development of its healthcare infrastructure.  A priority of HLI is to train the Laotian physicians and PAs who care for patients when unexploded ordnances explode.  In 2014, an emerging goal was to strengthen the primary healthcare skills of providers in rural communities and to address the high rates of mortality from cardiovascular disease.  The Ministry of Health has asked us to focus on primary care education for PA students and to strengthen their curriculum with a strong focus on hands-on, skill-based learning.
 
The HLI group in Laos. From left, Alicia Quella; students Justin Shobe, Ellie Andrews, Sarah Kopke, and Portia Kamps; and HLI Executive Director Reba McIntyre, PhD.
 
 
In 2015, HLI received the second, 3-year memorandum of understanding from the Laotian government to provide and support PA curriculum. These students are training to work in primary care in the rural areas.  Upon graduation from their program, Laotian PAs typically are assigned to district hospitals and village dispensaries, which have been extremely low-resourced.  These providers will become the country’s frontline of healthcare.
 
Our training program is supported by a federal grant from the US Department of State’s Office of Weapons Removal and Abatement, which specifically funds ultrasound donations and training in emergency medicine.  The State Department is very interested in building bridges of cooperation in the Lao PDR in order to reverse the damage left by the extensive bombing during the war and the unexploded ordnances that remain.
 
This year we were awarded a Robert K. Pedersen Global Outreach Grant from the PA Foundation. The grant helped support four American PA students who taught integrated primary care modules to their fellow Laotian PA students.  One of the students, Justin Shobe, developed modules on diabetes and hypertension and led skill-based workshops on measuring BP and checking blood glucose.  The American PA students integrated their teaching curriculum into their master’s projects for graduation. They also gained valuable experience as future PA educators and leaders in global health.
 
I would like to thank AAPA and the PA Foundation for supporting this unique opportunity to help train Laotian PA students who will be working in primary care.  This year we will continue to build relationships with the Laotian faculty and work with the Ministry of Health on building an innovative and skill-based PA curriculum.
 
Alicia Quella is a member of HLI and is associate professor and program director of the PA program at Augsburg College in Minneapolis, Minn. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 

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Monday, November 30, 2015
Ellen D. Mandel, DMH, MPA, MS, PA-C, RDN, CDE
 
Many of you remember the earthquake that struck our clinical psyche in 1999 with the Institute of Medicine’s (IOM) publication of To Err is Human: Building a Safer Health System. Before this geologic event, we were contentedly hiking in and out of patient examination rooms and scaling stairs for codes, confident of our sure footing. Then the tremors began, and the aftershocks have not really ceased. We lost our balance, nearly fell, and realized our risks. We now know that we are all experiencing a protracted clinical shake-up with many fault lines ahead.
 
Just when we may have thought that our human tendency for error had settled down, safely returning error concerns to their rightful submantle space, we are confronted with an even bigger quake to our clinical psyche, namely the Improving Diagnosis in Health Care report recently issued by the IOM.
 
This newly issued quake has an especially high Richter score as it exposes a critical type of medical error—diagnostic error—that, according to this report, has received insufficient attention. Best estimates support that clinicians will likely commit a major diagnostic mistake in their professional lives. I venture to say the one is a low estimate. However, clinicians may not know of their error(s), as it requires a serious retrospective view: autopsy, morbidity and mortality rounds, tumor board, and the all-painful self-assessment.
 
This report defines diagnostic error in a patient-centric fashion as “the failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” PAs are ahead of the curve as trained team players, fostering authentic patient partnerships. However, we should not kid ourselves: our emphasis on patient communication is not without strain, as we struggle with a landscape of faults, hidden chasms, and time constraints.
 
To improve our diagnostic skills, we must ask the right questions (all of them), order cost-effective diagnostics, interpret correctly, and be willing to consider alternatives and them communicate it all around. However, humility, the full awareness of our human frailty and failings, must be part of our patient care equation. The Richter Scale, developed in the 1930s, defines a quake’s magnitude as the logarithm of the ratio of the amplitude of the seismic waves to an arbitrary, minor amplitude. Math not being my strong suit, I convert this definition to Richter Score = severity of an earthquake = damage control. PAs are at the epicenter of our own decisions; let’s keep mistakes to a small tremor, and learn from each one we make.
 
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.
 

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