Early summer is filled with graduation ceremonies, and quite a few PA programs are among them—including the one that employs me. I spoke to the Wake Forest class of 2012 at their commencement, and I hope my message will resonate with other new graduates and perhaps even with PAs whose graduation is a distant memory.
In 2010, Dr. Atul Gawande wrote a piece for The New Yorker that captured his remarks to new graduates of the Stanford University School of Medicine.1 Gawande revealed a truth of contemporary medicine when he said that the volume and complexity of the knowledge we need to master have grown exponentially beyond our capacity as individuals. New PA graduates have already begun to feel that anxiety in the belly when they think about caring for patients without the security of a preceptor just around the corner. AAPA past president Robert Wooten served as keynote speaker for our ceremony, and he also spoke about this sensation. In fact, he said, if the sensation ever goes away, it is time to change professions. I added that the intensity of the feeling travels up the pain scale a while before it starts to level off. It is daunting to consider the NCCPA blueprint, then acknowledge that even it just barely scratches the surface of the knowledge we need to master.
Gawande also spoke of a fear that this volume and complexity of knowledge might outgrow our capacity as a society to manage. I believe this has already become a reality of contemporary medicine. My great-grandfather—another Reamer—was a physician and surgeon in rural South Carolina where most of my clan still lives. Remnants of this practice and pharmacy have been passed down to me, including stories about patients, medical equipment, formulas for remedies of the day, and even bills sent to patients. Health care was not very costly then. Of course, it was also not so effective either. Gawande explains that today “when we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we're not talking about a problem rooted in economics. We're talking about a problem rooted in scientific complexity.” The days are gone when Granddaddy Doc would deliver your baby for a sack of potatoes or suture a laceration and supply you with ample antiseptic for less than a dollar. Today, there are 68,000 codes within the ICD-10, around 6,000 drugs, and about 4,000 different medical and surgical procedures at our disposal. It is mind boggling.
In 1927, J.D. Adamson wrote a controversial article for the Canadian Medical Association Journal about the specialization of medicine.2 Remember, this is the era when Granddaddy Doc was in action. Adamson would have said that even Doc had specialized, likely in obstetrics and acute illness. He argued the roots of specialty practice went as far back as early Egyptian civilization and that such practice was well-recorded by chronicles of Roman society in AD 150. Adamson wrote, “Specialization is inevitable and will increase.” He hit the nail on the head, and the previously mentioned volume and complexity of medical knowledge will only serve to accelerate it. Medicine will attempt to carve out slices of its practice in which mastery of requisite knowledge is manageable. These pressures already impact our scope of practice and influenced the development of specialty recognition, including specialty exams, by the NCCPA.
I challenge graduates to be cautious of a potential pitfall for PAs within specialty practices: too narrow a focus or practice within a niche that blinds a person to the greater goal, which is to preserve health or improve quality of life for our patients. I also remind graduates entering primary care careers of the need to aggressively pursue lifelong learning in order to stay relevant and competent amidst a seemingly infinite requirement for medical knowledge and rapidly evolving clinical evidence and practice standards. Gawande points out that “more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities.” We are obsessed with the latest drug or gadget, but the art and true testament of the quality of care is how well we assemble those necessary elements in a way that is right for the patient in front of us.
“You will never possess all the knowledge you need. Learn to harness knowledge and recognize your own limitations.”
My grandfather underwent a total knee replacement after years of suffering from osteoarthritis. He was treated by the best surgeons in town. The hospital was immaculate and boasted the best equipment around. The latest point of service technology helped avoid the wrong drug being given to the wrong patient. Every aspect of his knee replacement was carried out with ultimate skill and precision, except for one. A small omission that disrupted proper anticoagulation led to a cerebrovascular event that resulted in multi-infarct dementia, which progressively deteriorated over the next 7 years of his life until he died in a skilled nursing facility not knowing the people around him or having used that new knee for many years. The science is worthless without the art.
Before the US Supreme Court issues its ruling on the health care reform law, I want to share my own perspective. I do not believe there is a national solution for our health care woes. I acknowledge, however, that our current model is fundamentally flawed and not affordable. I have practiced medicine as a PA in two rural towns along the coasts of North and South Carolina, within family practices affiliated with two academic medical centers, in two student-run free clinics, on board a bus outfitted as a mobile clinic for impoverished patients with cancer, and under tents within isolated communities in Nicaragua and Peru. Every experience provided a different set of problems, a unique set of guiding values, and enormous variability in the expectations of patients and the definition of health care. The practice of medicine for me has never been a national phenomenon. It is organic and “local” within every facet of its delivery.
My generation and older generations of health care professionals have failed to resolve critical problems with the delivery of care. New PA graduates are entering our profession when more problems than solutions exist. I also believe that the newest generation of PAs is more prepared than any other to transform our communities and reshape health care in a way that is better and more affordable. They will do what we have failed to do. Our experiences have informed them, our guidance has refined the models and standards for training, and our legacy of service means others will listen to their ideas. Patient care is messy and the knowledge we need to master is voluminous, but this new generation understands problem solving and clinical reasoning. They navigate online databases and clinical informatics systems with ease. They are highly social creatures poised to work in teams. They are agile in their learning.
So, here is some advice for PAs now entering our profession. You are our hope for the future, and we are proud of you. To be successful, you must be responsible for your own learning. You will never possess all the knowledge you need to serve your patients, so learn to harness knowledge and recognize your limitations. Serve the community around you. Robert Wooten says, “See what is missing and provide it, see what is inadequate and enhance it, and see what is effective and embrace it.” Choose the path of leadership, and lead through your character by embracing courage, integrity, self-lessness, empathy, collaboration, and reflection.