Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

Monday, January 15, 2018

Richard W. Dehn, MPA, PA-C, DFAAPA

PAs and PA leaders often ask for published articles that might support a specific viewpoint about the profession or to “prove” the profession’s value in the healthcare delivery system. Typically, I end up feeling like the pessimist in the room when I have to explain that more often than not, the requested published data on PAs do not exist. Why does the PA profession lack published research on itself and its contributions to American healthcare? This is a complicated question with no one simple answer.

Likely one important factor is the relative youth of the profession. Other healthcare professions that we observe as having a richer body of literature, for example allopathic medicine, are relatively mature professions with long-established academic and research processes. One would hope that as our profession matures, we would diversify into supporting more PA research. However, several factors contribute to our current lack of published research.

The profession’s relative youth and unique history certainly have contributed to our current quandary. When the profession was created 50 years ago and the first PA programs were established, primarily at academic medical centers, programs were for the most part established by physicians or medical school administrators as non-academic programs offering a certificate at completion or undergraduate academic programs offering a bachelor’s degree. In most cases, these early programs were typically considered like “technical programs” in the academic structures of the time, and they were administered not by PAs but mostly by physicians. Typically in these programs, the PA faculty, due to their lack of advanced degrees, didn’t have true faculty status in their institutions, and thus were likely not part of their institution’s traditional research mission. Thus as more PA programs developed in the 1970s and 1980s, they followed the examples of the earliest programs and were designed as programs focused on teaching and not research. The faculty and staff workloads of PA programs were calculated without the expectation of research activity. In the first 20 years of the profession’s history, PA programs were not designed to support research, PAs teaching in those programs for the most part were not trained as researchers, and faculty workloads were not calculated to account for the time necessary to perform research. Thus, research published in the first decade of the profession’s history was performed mostly by the physicians and doctoral degree holders who in that era were the program directors.1,2 In the 1990s, PA educators were increasingly concerned about the lack of research activity in the profession, a concern that still persists today.3,4

Starting in the late 1980s and accelerating in the early 2000s, PA programs began to convert to conferring master’s degrees. This led to a trend in the institutions that housed PA programs to let PA faculty hold professorial appointments, as well as a move toward organizing PA programs as distinct academic departments. Along with these changes came the traditional duties of professorial appointments, including the expectation that faculty produce scholarly work. Although this expectation increased the pressure on PA faculty to perform research, PA research publications increased only modestly.The proportion of PA faculty who have written at least one publication in their career has increased from 39.6% in 2002 to 49.5% in 2015.
Most PAs have never had any formal research training other than the curriculum from their PA training designed to help them search and interpret the clinical medical literature. Training for becoming a researcher is traditionally done at the doctoral level. In 2016, only 560 of 109,593 certified PAs possessed a doctorate, or only 0.5% of all PAs.5 Even in PA education, only 7.7% of the PA faculty nationally in 2015 had doctorates.6,7 And only 19% of PA faculty have tenure-track appointments, positions that are more likely to mandate protected time for performing research than non-tenure positions.7 Thus, few PAs or PA faculty have been trained as researchers.

However, the biggest barrier to increasing PA research output is the lack of money available for PA research. In today’s higher education environment, workload allocations for performing research require funding, and very little external funding is available for PA research in the form of external grants. This is illustrated by the fact that only a handful of PA faculty have positions with research workload allocations of 40% or higher. Without additional external research funding, PAs who train as researchers by earning a doctorate will be challenged to find a faculty position that provides them the protected time and resources to conduct much research. However, the PA profession is not unique in its challenges to produce more research on itself. Other healthcare professions that have recently increased entry degree requirements report that despite requiring their faculty and students to conduct more research, the results in quantity of publications have been below disappointing.8

Certainly, more research needs to be conducted on the PA profession, preferably by PA researchers.9 However, increasing the output of good quality research on the PA profession will likely require multiple initiatives. Of course, we need encourage more PAs to train as researchers, particularly in rigorous doctoral programs. However, we also need more external funding available for PA research to help persuade those PAs with doctorates from working in non-research positions. Additionally, we need to have more PA programs consider how to configure additional faculty positions for PA researchers who have a funded and protected research workload. Part of our lack of research can be attributed to the relative youth of our profession but it is likely that our current predicament is the result of our profession not consistently supporting PA research over the long run. It is time for the PA profession to get serious about research so that the data needed to guide our future will be available.

REFERENCES

1. Dehn RW, Everett CM, Hooker RS. Research on the PA profession: the medical model shifts. JAAPA. 2017(30)5:33-42.

2. Cawley JF, Dehn RW. Physician assistant educational research fifty years on. J Physician Assist Educ. 2017;28(3S):56-61.

3. Blessing JD, Dehn RW, Glicken AD, et al. Physician assistant research. Physician Assistant Journal. 1999;22(4):76-93.

4. Cawley JF, Ritsema, TS. Where are the PA researchers? JAAPA. 2013;26(5):13,22.

5. National Commission on Certification of Physician Assistants. 2016 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants.

6. Hegmann T. Benchmarking scholarship activities of physician assistant faculty. J Physician Assist Educ. 2008;19(3):13-17.

7. Physician Assistant Education Association. Physician Assistant Program Faculty and Directors Survey Report, 2015.

8. Seegmiller JG, Nasypany A, Kahanov L, et al. Trends in doctoral education among healthcare professions: an integrative research review. Athletic Training Education Journal. 2015;10(1):47-56.

9. Dehn RW. Missing the mark: why is some research on PAs just wrong? JAAPA. 2014;27(12):9.

Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Tuesday, January 2, 2018

Amy M. Klingler, MS, PA-C

Burnout is what happens when you try to avoid being human for too long. —Michael Gungor

Looking back, I should have seen it coming. I was getting kind of grouchy. It’s not that I dreaded going to work, but I certainly didn’t look forward to it. My difficult patients became exasperating. The EHR update changed everything I thought I knew and I felt like I had to relearn the entire system. It seemed like none of my patients wanted to listen to my advice or, if they did, they had an adverse reaction to the medication or treatment I prescribed. Sometimes, I simply couldn’t figure out what was wrong and I felt defeated as I had to send yet another patient to a specialist. I was missing spending time with my family and despite all of the hours I was putting in at work, I didn’t feel like I was making a difference.

What I failed to recognize was that emotional exhaustion, depersonalization and a sense of low personal accomplishment are the three components of burnout syndrome and I was suffering from all of them.1 Burnout doesn’t happen overnight. It develops “incrementally due to chronic increases of stress, inefficiency, and excessive workload.”2 Studies show that about  1 in 3 physicians suffers from burnout syndrome and 48% of physicians exhibit at least one symptom of burnout.3,4 I assume the statistics are similar for PAs, even though I couldn’t find studies of practicing PAs to support my assumption.

We all seem to have increasing stress, inefficiency, and excessive workload in our lives. The question is: what do we do about it? Although I don’t have all of the answers, it makes sense that finding meaning through work rather that avoiding work can make a huge difference.1

The following “Helpful Hints to Start Your Day” can be found in a packet from the University of North Carolina-Charlotte’s University Center for Academic Excellence. They were distributed during a critical incident stress debriefing several years ago to help our EMTs and firefighters manage stress. The first time I read them, many of the hints resonated with me and I recently reviewed them as I tried to decrease my own symptoms of burnout. I hope you find them as helpful as I have.

Helpful Hints to Start Your Day

1. Get up earlier in order to allow yourself more time before you get to work.

2. Before entering your office, pause to look around outside. What kind of day is it? Look for beauty.

3. Try to pay less attention to time. Learn to pace yourself.

4. Make a “to do” list that is realistic in number, and prioritize.

5. During lunch or breaks, avoid discussing work, eat slowly, and take your full lunch time.

6. Go to lunch with an enthusiastic person—high energy can be catching

7. Make a list of your “hyper habits;” share it with a friend to be sure you have included everything. Then make a contract to alter some specific behaviors that will let you slow down.

8. Find a specific place where you can go to sit quietly for 5 minutes or take a brief walk nearby.

9. Compose written reminders for yourself and place them where you will read them.

10. Be willing to say “no” when you need to.

11. Ask for help!

12. Focus on an immediate goal, especially one that you enjoy. Work on it until it is completed.

13. Collect appreciation that is due to you—visit some people who help make you feel good about yourself at work. Place yourself with positive, proactive people.

14. When you are feeling down and out, make a list of all the reasons you do not need to be—the vacations you are planning, why you are in this job, and what you like about it. Count your blessings.

15. Keep track of your down moods on a calendar. If cycles can be traced, prepare for them.

16. Re-energize yourself through relaxation techniques or meditation.

17. Talk to a significant other for love and support.

18. Pay attention to your health, diet, and sleep. If you “don’t have time,” ask yourself if you have the time to be sick.

19. Exercise daily.

20. Rid yourself of dead, self-defeating relationships.

21. Practice changes in behavior for 21 days. These positive behaviors will then have time to become habits.

22. CELEBRATE SUCCESSES! REWARD YOURSELF!

REFERENCES

1. Shanafelt T. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340.

2. Swenson S, Shanafelt T, Mohta N. Leadership survey: why physician burnout is endemic and how health care must respond. N Engl J Med Insights, December 8, 2016.

3. Shanafelt T, Sloan J, Habermann T. The well-being of physicians. Am J Med. 2003;114(6):513-517.

4. Shanafelt T. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-1385.

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.


Monday, December 18, 2017

Jennifer M. Coombs, PhD, PA-C

The news is unrelenting about the serious problem college campuses have with student drinking. At Penn State, a 19-year-old man died while at a fraternity drinking party. A 20-year-old at Florida State died at a fraternity pledge party, and a 19-year-old woman nearly died on her birthday while attending a fraternity event at Penn State. In November, Ohio State University suspended most of its fraternities due to hazing and alcohol violations.

The prevalence and consequences of college drinking are well-documented. Each year, nearly 2,000 college students die from alcohol-related injuries, including motor vehicle injuries.1 An estimated 700,000 alcohol-related assaults occur each year on college campuses.2,3 Alcohol-related sexual assault on college campuses is estimated annually at almost 100,000 students.4 According to a study from the National Epidemiologic Study on Alcohol and Related Conditions, nearly 20% of college students meet the criteria for alcohol use disorder.5

Yet, despite decades of research, millions of dollars spent on mandatory alcohol reduction training for college freshmen, and fraternity suspensions, the problem remains and appears to be getting worse. The reaction is to ban fraternities, yet binge drinking also occurs in dormitories and at football tailgating parties.3 Students are encouraged to find and join social groups and clubs in college. Belonging to these groups in college is common and a great way to find new friends. Yet these groups can influence students to drink. Members of fraternities, sororities, and sports teams are much more at risk of engaging in risky alcohol behaviors and running into alcohol-related problems such as fights, unwanted sexual advances, date rape, and property damage.6 Students who feel the need to join in or be rejected are most likely to respond to group pressure, which puts them at additional risk if they belong to a group that pressures students to drink.

The excuses and blame are endless and unproductive. Didn’t everyone drink in college? Won’t they just “grow out of it?” It’s a fraternity, what did they expect? Blame is either a boys-will-be-boys attitude or a she-shouldn’t-have-attended-that-party victim-shaming excuse. Meanwhile the social drinking is getting worse. Students have moved from beer to hard liquor and more college students report they are out not just to get drunk but to black out. One estimate involving 119 schools and the Harvard School of Public Health College Alcohol Study estimated 1 in 20 women reported being raped in college, and two-thirds of those rapes occurred while the women were intoxicated.4,7

In 2007, the National Institute on Alcohol Abuse and Alcoholism issued a report calling for changing the culture of drinking at US colleges via interventions such as screening for alcohol use or counseling referrals.8 Colleges were urged to implement social norming interventions such as campuswide alcohol training and comprehensive programs. An example of this is the AlcoholEdu online course that is required for incoming freshmen at many colleges. According to the AlcoholEdu website, more than half a million college students will take the program before attending school for the first time.  An industry of college orientation training, now delivered online, has cost millions of dollars (primarily covered by student fees). Studies are ongoing as to their effectiveness.9,10

Strategies to prevent alcohol abuse on campus have run the gamut over the last few decades. School administrators have swung between cracking down on alcohol-related violations or throwing up their hands and doing very little. Mandatory alcohol abuse training for freshmen often makes parents and administrators feel they are at least doing something. Many campuses in fact do nothing. Policing dorms, bars, tailgate parties, and fraternity parties is an impossible task, and college presidents are reluctant to end money-generating traditions such as football tailgating.

One thing that public health officials agree on is that strategies to reduce college drinking should be multifactorial. College Aim is a National Institutes of Health program designed for college administrators to use and plan research-driven interventions at the individual and community levels. A worksheet tracks the intervention, cost, number of students affected, and the outcome of the intervention. It can be used comprehensively and over time to see if strategies are working, measure costs and make changes if necessary. Some of the research-driven strategies at the individual level include brief motivational interviewing and personalized feedback intervention tools. These individual strategies are on a grid from lowest to highest cost and lowest to highest effectiveness.  Individual interventions can be targeted to students at the highest risk, such as athletes and fraternity members. The website Collegedrinkingprevention has numerous resources for college campuses, links to articles, special features, and college drinking statistics.

What are students doing to prevent the harms associated with college drinking? Campus leaders and fraternity and sorority members are at the center of the alcohol issue and potentially most well-positioned to make changes. Dormitory resident advisors are the start of a referral hub into campus staff that can help especially vulnerable students. Fraternity and sorority leaders can increase student involvement in fundraising activities, outdoor activities, and social activities that strengthen relationships and discourage risky behavior related to alcohol.

Parents are being asked to talk to their children about drinking before they drop them off at college. Some topics to cover include:
• Binge drinking, defined as 5 or more drinks over the course of 2 hours for men or 4 or more drinks in 2 hours for women.
• Hard alcohol such as shots of liquor can be deadly because they can quickly lead to alcohol poisoning.
• Some states have drop-off laws that let people drop some at the ED without fear of law enforcement.
• Students should monitor each other for signs of being dangerously overintoxicated and should call 911.
• Encourage students to take a taxi or ride-share service instead of driving when intoxicated or riding with someone who is intoxicated.
• Because most undergraduates are between ages 18 and 21 years, nearly all of college drinking is underage drinking and illegal. Students could face charges of underage drinking, public intoxication, or being drunk and disorderly.
• High-stakes consequences such as the loss of an academic or athletic scholarship can actually discourage students from doing the right thing.
• Review resources such as on-campus wellness centers and student health services, healthcare insurance, and access to healthcare on and off campus.

A renewed call to action by public health and campus health organizations should be of paramount importance. Working together, communities, parents, campus leaders, and college administration can help students have a fun and socially meaningful college experience without the pitfalls and problems associated with college drinking culture.

REFERENCES

1. Hingson RW, Zha W, Weitzman ER. Magnitude of and trends in alcohol-related mortality and morbidity among US college students ages 18-24, 1998-2005. J Stud Alcohol Drugs Suppl. 2009(16):12-20.

2. Hingson RW, Zakocs RC, Heeren T, Winter MR, Rosenbloom D, DeJong W. Effects on alcohol related fatal crashes of a community based initiative to increase substance abuse treatment and reduce alcohol availability. Inj Prev. 2005;11(2):84-90.

3. Hingson RW, Zha W, White AM. Drinking beyond the binge threshold: predictors, consequences, and changes in the US. Am J Prev Med. 2017;52(6):717-727.

4. Abbey A, Wegner R, Pierce J, Jacques-Tiura AJ. Patterns of sexual aggression in a community sample of young men: risk factors associated with persistence, desistance, and initiation over a one year interval. Psychol Violence. 2012;2(1):1-15.

5. Blanco C, Okuda M, Wright C, et al. Mental health of college students and their non-college-attending peers. Results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psychiat. 2008;65(12):1429-1437.

6. Turrisi R, Mallett KA, Mastroleo NR, Larimer ME. Heavy drinking in college students: who is at risk and what is being done about it? J Gen Psychol. 2006;133(4):401-420.

7. Mohler-Kuo M, Dowdall GW, Koss MP, Wechsler H. Correlates of rape while intoxicated in a national sample of college women. J Stud Alcohol. 2004;65(1):37-45.

8. Hingson R, White A. New research findings since the 2007 Surgeon General's Call to Action to Prevent and Reduce Underage Drinking: a review. J Stud Alcohol Drugs. 2014;75(1):158-169.

9. Paschall MJ, Antin T, Ringwalt CL, Saltz RF. Effects of AlcoholEdu for college on alcohol-related problems among freshmen: a randomized multicampus trial. J Stud Alcohol Drugs. 2011;72(4):642-650.

10. Barry AE, Hobbs LA, Haas EJ, Gibson G. Qualitatively assessing the experiences of college students completing AlcoholEdu: do participants report altering behavior after intervention? J Health Commun. 2016;21(3):267-275.

Jennifer M. Coombs is an associate 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, November 27, 2017

Morris J. Lipnik, MD

One of the problems facing clinicians is the patient who presents with a rash of several months duration that appears to defy the usual corticosteroid and anti-itch creams that we normally prescribe.

If the patient has recently had an infection and has taken an antibiotic such as penicillin, sulfa drugs, tetracycline, clindamycin, or a fluoroquinolone, the diagnosis is clear: We know that these types of drugs will cause hives, peeling, erythema, or a generalized rash that manifests within a week or two of ingestion of the drug. When a patient comes in with no history of recent antibiotics but is older and taking many different medications, determining the cause of the rash is more challenging.1-4

The patient may have a sunburn-type of eruption on covered areas or uncovered areas. The rash may occur on the extremities only, or on the torso only, and may have been present for several weeks to 3 to 4 years. Many of these patients have consulted other healthcare providers and have not received relief for their problem despite using strong topical corticosteroids, injectable corticosteroids, and other medications.

When faced with this problem, clinicians must obtain a detailed medication history from the patient.  Aspirin, ibuprofen, laxatives, sedatives, and even candies such as mints that might convert to salicylates all must be taken into account to help clinicians diagnose the rash.

When I see these patients. I examine their drug lists for:

Thiazide diuretics. Many patients have an allergy to these drugs. Some patients do not know that they are taking a diuretic because they may be taking a mixed drug such as losartan-hydrochlorothiazide, and do not realize that they are taking a sulfa drug that can cause a rash.5,6

Calcium channel blockers. Drugs in this group may be a frequent cause of dermatitis.5,6 They usually are identified by a drug name ending in -pine, such as amlodipine, felodipine, and nisoldipine.  However, some calcium channel blockers don’t end in -pine, such as bepridil, diltiazem, and verapamil.

Statins. These drugs generally do not seem to bother people when they are in a moderate climate but can cause a sunburn-type reaction in patients who come to Florida. The rash will appear on sun-exposed areas as opposed to areas that are protected from light.

When the diagnosis is in doubt, a biopsy may help. Many times, the pathologist will make a direct diagnosis of drug reaction or dermatitis medicamentosa from the slide presented.  Other times, the diagnosis is spongiotic dermatosis, rule out: contact dermatitis, id reaction, and drug reaction. If eosinophils are present and the skin rash shows no obvious contact dermatitis or large festering sores that might be causing an id reaction, the clinician must conclude that the biopsy is positive for a drug reaction and try to eliminate suspect drugs from the patient’s regimen. A better practice is to eliminate one drug type at a time in trying to identify the culprit drug. The referring clinician must be notified of this suspicion and cooperate in changing the patient’s medication (forwarding a copy of the biopsy listing a drug reaction can help with this.)

Once a drug reaction is identified, the speed of patient recovery depends on the drug’s half-life. Some drugs are bound to fat and other tissues in the body and have a half-life of a month or longer. Others, such as the sulfa drugs, have shorter half-lives and elimination of the offending drug generally results in the rash clearing in a couple weeks.

Therapy is simple: A mild topical corticosteroid cream to help with the itching associated with the rash. Injectable corticosteroids are given for generalized rashes together with colloid baths and antihistamines.

The keys to making this diagnosis are obtaining a thorough patient drug history, a biopsy that shows the presence of eosinophils (sign of a drug allergy), and a trial of drug elimination that results in clearing the rash. In this way we seek, discover, and eliminate the offending drug.

The scientific method requires having the patient retake the drug to see if it produces the rash but many patients are loathe to repeat the experience if it might cause another itchy eruption.

REFERENCES

1. Bresler R, Bahl JJ. Principles of drug therapy for the elderly patient. Mayo Clin Proc. 2003;78(12):1564-1577.

2. Ahmed AM, Pritchard S, Reichenberg J. A review of cutaneous drug eruption. Clin Geriatr Med.  2013;29(2):527-545.

3. Carneiro SC, Azevedo-e-Silva MC, Ramos-e-Silva M. Drug eruptions in the elderly. Clin Derm. 2011;29(1):43-48.

4. Smith D. The simple math of polypharmacy: many drugs equal more risk. Caring for the Ages. 2013;14(2):20.

5. Summers EM, Bingham CS, Dahle KW, et al. Chronic eczematous eruptions in the aging. JAMA Dermatol. 2013;149(7):814-818.

6. Sontheimer RD, Henderson CL, Grau RH. Drug-induced subacute cutaneous lupus erythematosus: a paradigm for bedside-to-bench patient-oriented translational clinical investigation. Arch Dermatol Res. 2009;301(1):65-70.

Morris J. Lipnik is former chief of dermatology at NCH Healthcare System in Naples, Fla. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, November 13, 2017

Brian T. Maurer, PA-C

My eldest son turned 40 this year. We celebrated his first birthday midway through the first year of my PA program. I graduated back in 1979; currently, I’m ticking off the months in my 38th year of practice.

Throughout this year, in the pages of JAAPA, we have been celebrating the 50th anniversary of the PA profession. Be they birthdays, graduation days, or anniversaries, we tend to measure our lives by milestones, those significant dates and times that help to define who we are and give meaning to our existence.

When I graduated from the Hahnemann PA program (now defunct, subsumed into Drexel some time ago), there were less than 9,000 PAs practicing in the country. This year, our ranks have swelled to more than 115,000 PAs in clinical practice—and counting. Once considered a fringe experiment designed to improve access to primary care in the United States, the PA concept has morphed into a bona fide profession recognized by the medical establishment, third-party payers, federal and state governments, and the pharmaceutical industry. PA practice has also expanded exponentially in depth and scope over the course of my professional career.

In its relatively young life, our profession has experienced significant growing pains, gains and setbacks. Largely through grassroots efforts sustained over the lean years of the 1980s, we have managed to survive and flourish.

Newly graduated PAs continue to receive excellent training. Good-paying jobs are plentiful. Yet student debt remains at an all-time high. Today’s PA students sink more than $100,000 into their education—small wonder that new grads tend to seek out more lucrative positions in the medical and surgical subspecialties, with fewer and fewer opting for careers in primary care.

As a PA who has practiced pediatric medicine for most of my career, I find myself once again in the minority. Fewer than 3% of all PAs opt for a career in pediatrics. In my current position, I actually earn less than most new graduates, but making money was never my primary professional goal. I have devoted my career to the pursuit of humane medical practice through the art of medicine, striving to focus on the patient as person, not as a disease entity or diagnosis. You could say that I’ve been grandfathered in as a bit of an odd duck, part of a profession that at one time had been viewed as somewhat of an odd duck itself.

My youngest grandchild just turned 6 months old. By virtue of his birth I have once again been grandfathered in—another milestone of sorts, imparting some semblance of meaning in this life through my role as father, grandfather, and pediatric PA.

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.