Musings: Blog of the JAAPA Editorial Board
Musings
Blog of the JAAPA editorial board.

Monday, January 9, 2017

Steve Wilson, PA-C      

It’s over. The inflection of the voice establishes the context of that phrase. It can be a response to acceptance, relief, or finality. It is possible to experience all three emotions at the same time. I just had that experience. With a click of the mouse on the NCCPA website, I learned that I had passed the PARNE one more time. More importantly, I had passed it for the last time. After more than 40 years in the process, I can’t imagine that I shall need to return to that examination booth again 11 years from now. 40 years in surgery but certified in primary care….

I have sat for PANRE every 6 years since 1975. This time, given all of the future uncertainty of the examination process, I took it a year early. I have never looked at the recertification as anything more than a process required to provide some assurance about my continued cerebral function to those who do not work directly with me and who spend their day in an administrative office. I never believed that it measured my competency. I certainly never felt it provided me with any useful information about necessary medical knowledge. I know that having passed it meant nothing to my patients. To me, it has always been a hoop through which to jump.

Don’t get me wrong. I had anxiety about taking it. I believe it was in 1987 and well into my surgical career that I sat for the examination and encountered questions about a problem called Lyme disease. It was after that examination that I decided that maybe I should really do some studying before the examination. One year, I went to a review course. I decided that it really did not help me much. It was before the “blueprint,” and some of the lectures provided up-to-date information instead of information that was 2 to 3 years old (examination questions are notoriously out of date). I started buying review books after that and this year I downloaded a review course. These were very helpful and could be easily managed for the 4 weeks of review I committed to before each examination. Of course, with this cavalier attitude, you would imagine that at some point I would slip up. Well, I did—but I didn’t. I was one of many PAs in 2011 who suffered due to the grading debacle at the NCCPA. I can tell you that receiving notice that I had failed, only to learn several weeks later that “oops, we made a mistake,” is not the examination experience you want late in your career. I was a little surprised that I did not hear about lawsuits against the NCCPA after that, but I guess we were all just relieved that we got another 6 years.

After sitting for all of these examinations, one thing is for sure: I am in complete awe of anyone who has worked in primary care. You have to know a lot, according to the examination. I remember early on actually getting feedback from the commission after the examination: “Dear Mr. Wilson: You have successfully completed the recertification exam. We would recommend remediation in pediatrics, ob-gyn, and psychiatry.” I suppose that reading up on those topics may have been helpful to me, but having dedicated myself to surgery, I have never looked in a child’s ear or estimated the age of a fetus, and I haven’t helped someone with bulimia since PA school. On the other hand, maybe I should be concerned about my knowledge base because the examination, according to some information, is supposed to contain information that all PAs should know. That is why we are so flexible in moving from one area of medicine to another.

I am told that, as PAs, we change our areas of practice a lot and frequently move from one specialty to another unrelated specialty. This surprises me. I can see going from general surgery to cardiac surgery— like I did, or from primary care to emergency medicine, but I have always had a difficult time imagining transitioning from pediatrics to neurosurgery. Maybe pediatric neurosurgery? As you know, there has been movement over the last few years to develop a more meaningful process that actually addresses the educational needs of PAs who practice in specialties. The amount of work necessary to accomplish the recertification process, the expense, the career threat to those who do not complete all of the requirements, the potential of specialty certification pigeonholing us into specific career paths, as well as reimbursement ramifications, has met with resistance by the profession. The NCCPA blinked— they’re doing more research, but still plan to change the PANRE steadily over the next several years. However, I can’t say that I disagree with all that the NCCPA was proposing.

Granted, I have always been skeptical that the recertification process was more relevant to academia than clinical practice, but some of their recent proposals have merit. We should be required to demonstrate a level of medical knowledge that is consistent with our area of clinical practice. Hopefully, there are enough of us now in different specialties that it is cost-effective for the NCCPA to address these areas through a meaningful continued educational process rather than a punitive examination. Otherwise, we are only kidding ourselves, the public, and our employers as to our maintenance of medical knowledge that is relevant to the patient population we serve. I am a perfect case in point. Although it is nice to believe that I could now give up the long hours in surgery and after-hours call for a nice 9-to-5 job in dermatology, I would suggest that if you should ever find yourself with me assessing your regular-irregular-raised-smooth-discolored-uniform-itchy-blancing lesion, please know that I will be more interested in cutting it out for pathologic evaluation than reviewing the differential diagnosis for such a lesion. But, as I mentioned, none of this matters to me anymore. I feel safe in my knowledge base after passing my last PANRE. Should the next patient I meet in the OR have the first case of Peyronie disease I have ever seen, my recent examination certifies that I know which layer of tissue is involved. I will also know to call the PA in urology. I leave it to my colleagues and my hospital’s medical staff to determine whether I am knowledgeable enough to address a patient with a falling pH and rising inotropic support postop coronary artery bypass.

I jumped through the hoop and never got burned.

Steve Wilson practices cardiac, thoracic, and vascular surgery at Peninsula Regional Medical Center in Salisbury, Md. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Friday, December 23, 2016

Jennifer M. Coombs, PhD, PA-C

In 2014, I wrote a Kevin MD article, “5 predictions for physician assistants in the era of healthcare reform.” What a difference 2.5 years makes. We now have healthcare reform whiplash, as the Republicans will surely repeal the Affordable Care Act as we know it, replacing it with an as-of-yet undetermined plan. What can this end of the year bring in terms of predictions for PAs? The PA profession is turning 50. Born out of a time of great change (the Vietnam War) in the 1960s, the profession was nurtured by visionaries, leaders, and great reformers in medicine. What will the next 50 years bring? I’ll be 100 years old then, so for purposes of prediction, I’ll stick to 5 years in the future.

PAs will experience continued unprecedented growth, based on the number of new programs, now 218. Looking ahead, there are potentially 32 additional new programs in the works. It does appear that new programs will continue to be accredited or that many, if any, established programs will shut down. The resources to negotiate new program expansion are, if not unlimited,  adequate to help these programs sustain themselves. Certainly charging a substantial tuition does not hurt, and the students and their graduate school debt appear for now to be vast.1
PAs will eventually oversupply the profession, but not soon, and not enormously.2,3 Demand for healthcare workers is hard to estimate.  Supply is an easier target to predict, although healthcare researchers have made erroneous predictions in the past. Making predictions about the number of clinicians necessary in the workforce is clouded by the fact that the variables are constantly changing.  Certainly healthcare reform is one variable that has been completely unpredictable, but there are other variables as well. Technology has been nearly impossible to factor into productivity. Ten to 15 years ago, the prediction was that electronic medical records (EMRs) would make physicians, PAs, and NPs immensely productive. Instead, we spent years as highly paid typists filling in colossally ill-designed records. This will change, but how to factor productivity into supply models is yet unreliable. One thing that is sure is that the population is in need of healthcare, and the country has pockets of gross undersupply, such as rural areas and inner cities. This may be job security for PAs interested in filling these gaps.
PA practices will expand in practice authority but will never give up their relationship with physicians. The names may change—supervision, collaboration—but the basic unassailable fact is that PAs work with physicians, day in, day out, for the good of the patient, the good of the practice, and the good of the profession.
Sexism in medicine will end with changes in value and in the hierarchical educational structure. Teams are the safest way to take care of patients, and PAs, NPs, and physicians will work more efficiently and collaboratively in the future. The mothers and grandmothers who are now housestaff in large enough numbers mean that the demeaning and sexist training is a thing of the past. Have female PAs largely skipped over the horrors of the belittlement, shaming, and outright sexual harassment of the past? Being pregnant during training and raising children while practicing full-time will never be easy. There is still a huge pay gap to overcome. There are self-doubts and outright lack of family and society support for women who decide to focus on careers. There is still a sexist and bullying culture to hold the line against; young women will still be doubted for being full-time workers and not full-time mothers, but things are slowly changing. The “on ramps” and “off ramps” for women to work part-time or work at home for periods of time will need to be expanded. Childcare and elder care solutions need to be available for everyone. Fair and adequate maternity and paternity leave policies are needed to support new parents.
The PA profession will not become more diverse, but will continue the trend toward well-educated white women in the workplace. Efforts must be made to reach out to qualified diverse potential PAs. This is a tremendous opportunity to look like we as a profession should look, given our mission for social good. Social justice, the good that we can do as PAs, should be the pride of our professional identity.  A diverse and inclusive profession will benefit society, and is our raison d'être. However, with the cost of undergraduate education, out of reach for many, this many not change quickly.
The American Academy of PAs and the National Commission on the Certification of PAs will continue to fight about absolutely nothing. Like siblings, these two important organizations will vie for our attention. Like little children, they will fight over who is loved most, who matters most, and who can get our money. The siblings only grow up to be able to hurt each other more and get into bigger arguments. The irony is, just like grown children, we love them both for what they bring to the table, and their own unique talents. But somehow the setup for fighting is too much for them to resist. The leadership can’t contain the odd feelings of jealousy, and the only question is who will play the role of Cain and who will be Abel.

I hope to look back at my predications again, in a few years and see where I was too bold or not bold enough in my future predictions. As our profession turns 50, and healthcare providers collectively look forward, I do feel the future is bright. 

REFERENCES
1. Snyder J, Nehrenz G, Danielsen R, Pedersen D. Educational debt: does it have an influence on initial job location and specialty choice? J Physician Assist Educ. 2014;25(4):39-42.

2. Salsberg E, Quigley L. Are we facing a physician assistant surplus? JAAPA. 2016;29(11):40-44.

3. Hooker RS. When will physician assistant supply exceed demand? JAAPA. 2016;29(11):10-12.

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, 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.