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Musings: Blog of the JAAPA Editorial Board
Monday, April 20, 2015
Virginia Hass, DNP, FNP-C, PA-C

My muscles are pleasantly achy (no, that is not an oxymoron) after completing another CrossFit workout. I’m not a fitness nut and this is not a blog about fitness. I have enjoyed regular physical activity my entire life, first growing up in a small town that had more bicycles than people, then in adulthood as a long-distance runner and avid hiker. When the going got tough, I would strike out for the bike trail, running path, or for a few days of what our family calls Sierra therapy. What all of these endeavors had in common, aside from contributing to my overall well-being, is that they could be done solo. Team sports just weren’t my cup of tea.
 
Enter CrossFit, which a PA colleague introduced me to about 2 years ago. Let me first explain that CrossFit is many things, but at its core are two principles: optimal fitness and community. Optimal fitness in this case, is defined as increased work capacity across time and in many domains. The spontaneous community that is created when people work out together is the key to its effectiveness.  So back to my PA colleague—she said, “Give it a try, you’ll like it.” I was skeptical—that whole group activity thing—working out with a bunch of other people? Not my style …. Besides, my workout routines had always been effective, hadn’t they? But, like all good healthcare providers, this PA did not try to convince me. Sneaking in the topic with motivational interviewing strategies over lunch, she would connect her training at the gym and her improved performance on a recent long-distance bike ride. We talked about my own fitness goals. Bit by bit, my cognitive dissonance increased—what could I be doing differently? My skepticism gave way to curiosity and here I am 2 years later, happily engaging in an intense communal activity and pondering the similarities between the CrossFit community of which I have become a part, and the elements of a highly functional interprofessional team.
 
At the core of patient-centered care is the use of interprofessional teams in which members are empowered to function at the peak level of their training, knowledge, skills, and licensure. Teams have been defined as, “a small number of people with complementary skills, who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable.”1 I would go a step further to say that the highly functional team also becomes a community; and permitting each member to function at full scope of practice is analogous to the CrossFit principle of optimal fitness.
 
In the CrossFit community, each individual has his or her unique talents and skills. We engage in constantly varied, functional movements performed at high intensity—does this sound similar to any job you’ve done recently?  This person can run faster, that one can jump higher, and another can climb a rope quicker. But when we are all completing a team workout of the day, it is the combined effort of the group that gets the work done. While one team member is doing burpees, another is resting between broad jumps. We coach each other through deadlifts and bench presses, and when one person falls behind, the rest cheer her on—counting reps to completion. Good communication, complimentary and perhaps overlapping skills will make the team faster and more efficient, prevent injuries, and definitely makes the workout more fun!
 
Studies have demonstrated that a team-based approach is integral to improving a variety of outcome quality measures, including patient satisfaction, provider satisfaction (fun – yes, work should be fun!), readmissions, and decreasing errors in healthcare.2,3 Again analogous to CrossFit, successful teams promote development of the individual and team interdependence. All team members are recognized as essential contributors who are equally responsible for the outcome.  This analogy could be made for any team sport—baseball, soccer, pick one you can relate to.
 
The concepts of interprofessional collaboration, practice, and education were first introduced in the Institute of Medicine (IOM) report Educating for the Health Team.4 More than 40 years and multiple IOM reports later, we are still trying to integrate these views broadly across current models of healthcare education and practice. We have evidence that interprofessional teamwork and coordination of care is effective, so I’m left to wonder—why does implementing change take so long? Is it perhaps because we cannot see how the evidence applies to us as individuals and to the healthcare teams we work in and with each day? Because we do not think that the changes our small team of people makes will have a significant effect on the larger system as a whole? Take a few moments to think about the teams you engage with each day—your families, your workout buddies, or the pickup basketball team you play with on weekends. How can you translate the skills you already have to the interprofessional teams you work with to change healthcare?
 
REFERENCES
1. Katzenbach J, Smith D. The discipline of teams. Harvard Business Review. 1993;71(2): 114-120.
 
2. National Quality Forum. Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report. Washington, DC, 2010.

3. Martin JS, Ummenhofer W, Manser T, Spirig R. Interprofessional collaboration among nurses and physicians: making a difference in patient outcomes. Swiss Medical Weekly. 2010;w13062.
 
4. Institute of Medicine. Educating for the Heath Team. Washington, DC: National Academy of Sciences, 1972.
 
Virginia 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, April 06, 2015
Steve Wilson, PA-C
 
Spring is in the air—almost! At least there was enough sunshine today to cause me to stop in at my local nursery/garden shop. Their spring supply of plants is beginning to trickle in and the agrarian influence in my DNA always makes me want to go outside and dig a hole. That activity is always best received in my household if I plant something also. The possibilities always seem endless. I am sure someone has written an algorithm for plant selection: poor draining soil + partial sun + less than 3 feet tall + midsummer to fall bloom + deer resistant + tolerates drought + attracts butterflies + not already in yard = … Well, you get the drift.
 
On occasion, I have constructed a plan for a certain part of the yard. However, I will admit that most of those plans, drawn during the winter as I’m looking outside while seated with a cup of coffee, never quite make it to final production. But isn’t that the way it is for all creative ventures? It all comes apart at the nursery. I just seem to wander aimlessly trying to keep one step ahead of the different irrigation systems. It is just a great place to be. The workers there must agree, because I see the same ones year after year.
 
It is not easy work. Besides the nursery part, the shop also has a fresh market where a lot of local produce ends up, as well as their own corn and strawberries. The work can be backbreaking, hot, and dirty. The workers don’t shy away. They continue to check on me between their tasks and always have a smile and understand what I need. This last part always disturbs me a little. You see, most of them are Hispanic. They speak among themselves in their native language but always speak English to me. I guess they figure that speaking Spanish is not a possibility for me. Maybe they are right.
 
I have tried to learn some Spanish. I took a special medical Spanish course a few years ago. The problem is that I don’t have many Spanish-speaking patients. When I do care for one, it is too late to brush up on the language again. I am frustrated by this personal shortcoming. I marvel at the owner of this nursery. He was born and raised in the area, but he switches from English to Spanish sometimes in mid-sentence. I believe he has gained a trust from his workers because of this and they have responded by being good workers and recognizing the value of learning another language—English. I would like to gain the trust of the Hispanic patients I see for surgery. Many of them are older and scared and rely on younger family members to translate for them. For liability purposes, the hospital wants us to rely on an interpreter hotline. However, maybe if I could just commit to memory a few key phrases, I could better convey my concern for their health and well-being. It would be like in the movies when the American tourist is relieved to learn that the person with whom they are speaking can converse in English.
 
I understand that English is now accepted as being the international language, particularly in business. But I often wonder if we at least tried to learn another language that maybe this melting pot of a country would have a better understanding of cultural differences and not just linguistic differences. That understanding another’s native language would build a trust that would break down those barriers of prejudice that grow out of fear and misunderstanding. Do I think that people who move to this country should learn English? Sure. I also believe that if I move to France or Germany that I should learn those languages. But I am sure that should that day come, I would still find some solace in sitting with a group of ex-pats over a beer and speaking English. So why should I enact what would be a double standard on those who come here to seek a better life? Many of us have an ethnic heritage from which we draw strength. We celebrate it in many festivals and even in the foods we eat. Language is a part of that same celebration.
 
I took French back in the day, but it was really not the conversational teaching that is needed. Never been to France, so outside of some French restaurants I have not had much practice to keep it up anyway. I will admit that I am a little jealous of those who are fairly fluent in a second language. I know that when I go to an Italian restaurant with my friend who speaks Italian, we are guaranteed a good seat if the owner greets us at the door. I guess that may sound a bit elitist. Almost like a password to a secret club. I don’t look at it that way. I look at it as a key to unlocking a relationship with someone with whom I may not have had the opportunity had I not shown an interest in them through language. This is a big country. It is a big world. But we know it is smaller now than ever before.
 
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, 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.
 
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