Skip Navigation LinksHome > Blogs > Musings
Musings: Blog of the JAAPA Editorial Board
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.

Monday, January 12, 2015
Virginia McCoy Hass, DNP, RN, FNP-C, PA-C
 
Now is the time for full practice authority for physician assistants (PAs). I’ve probably caught your attention, and I will elaborate. But first, in the spirit of full disclosure, let me say that I teach in the only integrated PA and nurse practitioner (NP) education program in the United States. This keeps the topic of interprofessional education and collaboration at the forefront of my thoughts. Interprofessional education, as has been previously alluded to in this blog, has been identified as a key innovation in health professions education and a means to achieve the “triple aim” of improved patient care, improved health outcomes, and more affordable healthcare systems.1 It occurs “When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”2
 
Interprofessional education, which enhances learner outcomes in the form of competency development and effective collaboration, is the precursor to interprofessional collaborative practice, which enhances patient care outcomes and is essential to build a safer, patient-centered and population-oriented healthcare system.
 
The general competencies for interprofessional practice and collaboration defined by the Interprofessional Education Collaborative (IPEC) are:
• values and ethics for interprofessional practice
• roles and responsibilities
• interprofessional communication
• teams and teamwork.3

Each of the general competencies is further clarified with specific competencies by the IPEC [PDF] for additional reading. Particularly relevant to the issue of full practice authority for PAs is Specific Roles/Responsibilities Competency RR5: “Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable.”3 In order to achieve a healthcare system that delivers care that is safe, equitable, patient-centered, and population-oriented, each of us—PAs, NPs, medical assistants, physicians, pharmacists, physical therapists, and others must use the full scope of our education and training without arbitrary licensing practices that constrain our scope of practice.

PAs are the only remaining healthcare providers who are educated as generalists without mandatory residency or specialization. The analogy I use is that PAs are the “stem cell clinicians” of the healthcare system. Unlike physicians, who complete residency training that narrows their scope of practice, or NPs, who are educated and licensed in specialty tracks, PAs retain the ability to provide care wherever there is need. However, the practice of PAs is artificially limited by the scope of practice of the physicians with whom they work. Despite variation from state to state, the delegated practice of medicine from physician to PA is essentially the same.4 With this delegated practice also comes significant variation in prescribing law,  which creates another unnecessary barrier to practice and patient-centered care.4

With a political will and the logistic capacity of our professional organizations, full practice authority for PAs can be accomplished. There is precedent in the movement toward full practice authority for NPs. To date, legislation authorizing full practice authority for NPs has been successful in 19 states and Washington D.C.5
 
Interprofessional collaborative practice is synergistic with the team approach to care that is the hallmark of the PA-physician relationship. This is addressed in the general competency of teams and teamwork, in which the knowledge and experience of each profession is used to establish priorities for care and to achieve outcomes. Of note, the leadership role is fluid, moving among team members based upon patient and community needs.3 Some may argue that full practice authority for PAs would disrupt the PA-physician relationship. I contend that full practice authority for PAs will strengthen it. With the Affordable Care Act expanding health coverage to millions of newly insured people, the healthcare system is under increasing pressure. All clinicians should be able to provide care to the full scope of their education and expertise, and all of us need to assume leadership roles. Full practice authority for PAs will balance the qualities of respect, support, and professionalism with the autonomy of practice that will enable PAs to consistently provide high quality care to patients in all settings. I look forward to reading your thoughts on this topic in the comments section below.
 
REFERENCES
1. Institute of Medicine. Interprofessional Education for Collaboration: Learning How to Improve Health from Interprofessional Models Across the Continuum of Education to Practice–Workshop Summary. National Academies Press, 2013.

2. World Health Organization. Framework for action on interprofessional education and collaborative practice. [PDF]Geneva, Switzerland. 2010.

3. Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. [PDF] 2011. 

4. American Academy of Physician Assistants. PA State Laws and Regulations, 14th ed. Alexandria, VA, 2014.

5. American Academy of Nurse Practitioners. State Practice Environments. 2014. 
 
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, December 29, 2014
Joshua Newton, MMS, PA-C
 
When my dad learned to use a computer in college, he carried a stack of punch cards into a cold concrete room full of racks of computer equipment. I learned as a high school student in my basement with a behemoth black-and-white screen filled with command lines and tethered to a floppy drive. And now my daughter carries in her palm a computer more powerful than the supercomputers that filled a room in my dad's time. At 2 years old, and with the simple touch of a hand, she intuitively navigates my iPhone and iPad like it is second nature. To her, phones never have cords or rotary dials, books come on a Kindle, and everything needs batteries or to be charged.
 
The worlds we each have experienced have shaped our paradigm. Our perception of war, of human interaction, of career ladders, and of the role of technology all vary just because of what we have been exposed to. I find that this dichotomy flows into every piece of life. I can almost hear my grandfather saying that "they just don't make them like they used to." So how much of our perception of medicine depends on our generation? I have older patients who fear hospitals because that "is where people go to die" and young patients who crowd the ED for simple sunburn because they believe care should be accessible at every hour. One generation believes there is a pill for everything and another believes that all pills are just poison and will cause ungodly adverse reactions according to the commercials on TV. And what of providers? For those raised on Facebook and Skype, telemedicine hardly raises a hair. And if a big box store can sell me ice cream, motor oil, shoelaces, and new glasses, why can't they sell me a doctor, too?
 
As with every decade, we enter a new generation and a new world. Halfway through this decade, we find that technology is no longer a tool but rather the substrate on which we grow our world. We are now infinitely connected through the "internet of things." Our technology is now trained to read and measure us and then anticipate us, but is our healthcare ready for this? My house thermostat is more intimate with my needs then my healthcare provider. It knows when I walk into the house and at what temperature I like it. Yet my clinic still wants paper BP logs and makes me sign in on a sheet when I check in.

As the personal health monitor becomes more popular and Apple and Google begin to drive the market, it brings the Luddite tendencies of healthcare into stark contrast. For the past few decades, we have fought electronic medical records (EMRs) and even now as they become universal, the communication standards between them are almost nonexistent. The longstanding promise of the universal health record is further from reach then a self-driving car. EMRs are by far the most conceptually antiquated and anti-user friendly software tools that I use during the day. Only a few companies have begun to recognize this and alter their approach. As an industry, we almost shun the intrusion of technology on the relationships we bear with our patients, and yet we fail to recognize that technology drives all of their other relationships. How often do we walk into a room to see our patient on an iPhone, iPad, Android phone, or Kindle? At least of one-third of the communications I have with patients are driven by information they have found on the Internet about their respective disease. Probably half or more of this information is erroneous, and that which is correct is often misinterpreted. WebMD tells us all that we have cancer, but what resources do I supply to help educate my patients? I might use a few paper handouts, and if I am lucky, a portal with some links to basic info from Mayo Clinic or Medline. So why should I blame my patient for using what is at their fingertips?
 
Now that we are on the cusp of devices that could reap copious amounts of health information on patients, are we ready? How are we going to tap into the data, harvest the crucial pieces, and direct patients appropriately. If Google sees me search the word “cruise,” it knows to post an ad for Norwegian Cruise Lines. Why can’t healthcare devices see that my pulse rate is irregularly irregular and when I search chest pain that evening, it might post an ad for local cardiologist? Or when I search home remedies for a cold and the device sees I have a fever of 103° F, it suggest I contact my primary care provider. Beyond the hurdles of HIPAA and data security lies a goldmine of expanded knowledge and patient interaction if our industry can just see it and seize it. We could offer tailored patient education documents, chronic disease management, telemedicine straight from your phone, health stats that your provider can track in real time, and technology that can alert you both when something is askew. Technology must become a fabric that we weave into medicine and a tool that we take control of, rather than a tool that we let control us. The generation of the ePatient has arrived, and a massive opportunity for innovation and forward progress lies ahead of us.
 
Joshua Newton practices family medicine in Pittsburg, Kans. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
 
Blogs Archive