Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Monday, March 12, 2018

Ellen D. Mandel, DMH, MPA, MS, PA-C
It is often said that the past informs the future, and this easily applies to the informed consent principle. The term informed consent emerged in the 1950s, although its foundation is rooted with the Hippocratic Oath in the 5th to 4th centuries BCE.1 This common graduation expectation reminds physicians, with Apollo, Asclepius, Hygeia, and Panacea bearing witness, of the importance of respecting their teachers, promoting key health concepts such as good dietary habits, not administering lethal medicines, and considering their scope of practice in wielding a scalpel. Although important concepts, they bear little resemblance to our 21st century informed consent doctrine.1

During PA school, we likely learned of clinician and researcher ethical breaches such as the Tuskegee Study of Untreated Syphilis in the Negro Male. This study by the US Public Health Service began in 1932, working with the Tuskegee Institute in recording the natural history of syphilis and hoping to justify treatment programs for black men. The study was conducted without the benefit of patients’ informed consent—the researchers told the men they were being treated for “bad blood,” which among this population meant syphilis, anemia, and other conditions. The study was originally projected to last 6 months but lasted for 40 years, long after penicillin was an effective cure. Clearly the Public Health Service failed in such areas as integrity of its research protocol and allowed a readily treatable infection to go uncured, affecting future generations.2

Less than a decade after the Tuskegee study started, medical experiments committed during the Nazi regime by German physicians during World War II were exposed in the Nuremberg trials, leading to the Nuremberg Code, which focused on research more than clinical medical practice. Codified were requirements for the voluntary consent of the human subject, describing key terms such as capacity, and the patient’s ability to exercise free power of choice without elements of force, fraud, deceit, duress or coercion.3 The patient must demonstrate sufficient knowledge and comprehension of the subject matter to make an enlightened decision. It served as the basis of the institutional review board for present-day research.

A landmark 1957 US legal decision, Salgo v. Leland Stanford, Jr., University Board of Trustees, spotlighted procedural informed consent, emphasizing that consent for a treatment’s nature and consequences was not enough, and posing the question of whether the consent itself was adequately informed?4 In this malpractice action the jury awarded the defendant (the deceased patient’s family) $250,000 against the defendants (physicians and facility) as the indicated procedure and its associated risks were not thoroughly explained. This award in today’s value is $2.25 million. Clearly, malpractice claims with resulting large awards have been around for more than 50 years. Other cases followed.

In the 1970s, informed consent gained momentum as physicians became fearful of malpractice, leading to solidification that both physicians and researchers have not just a legal duty but a moral obligation to obtain consent for certain procedures.5 Current biomedical ethics maintains that informed consent must support autonomous choice by patients, knowing full well, that on some level absolute informed consent is not possible.5

Nevertheless, the PA must endeavor to secure patients’ understanding while respecting patients’ rights. Informed consent conundrums are increasing in such areas as genome regulation, fecal microbiome transplantation, and continuing relative to research among vulnerable populations.6,7 An additional area of inquiry is societal stewardship, which addresses how medical providers may consider moral and justice-related aspects of distributing our limited financial resources and the significant percentage of medical care dollars used for end-of-life care and serious chronic illnesses and functional debility.8 These issues will challenge PAs professionally and personally. Best to begin thinking about them sooner than later.

1. National Library of Medicine. Greek medicine.

2. U.S. Public Health Service. Syphilis Study at Tuskegee. The Tuskegee timeline.

3.  Shuster E. Fifty years later: the significance of the Nuremberg Code.  N Engl J Med. 1997; 337:1436-1440.

4. Salgo v. Leland Stanford Jr. University Board of Trustees, 317. P.2d 170. (1957). 

5. Beauchamp TL. Informed consent: its history, meaning, and present challenges. Cambridge Quarterly of Healthcare Ethics. 2011;20(4):515-523.

6.  Appelbaum P. Models of consent for genomic sequencing. Eur Neuropsychopharmacol. 2017;27(3):S477.

7.  Bunnik EM, Aarts N, Chen LA. Physicians must discuss potential long-term risks of fecal microbiota transplantation to ensure informed consent. Am J Bioethics. 2017;17(5):61-63. 

8.  Aldridge MD, Kelley AS. The myth regarding the high cost of end-of-life care. Am J Public Health. 2015;105(12):2411-2415.

Ellen D. Mandel is a clinical professor in the Department of PA Studies at Pace University-Lenox Hill Hospital in New York City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, February 26, 2018

​Steve Wilson, PA-C

I must begin this post with the acknowledgement that I am not an educator in terms of providing the day-to-day needs of minds willing to undergo the rigors of PA education. Sure, I was a clinical coordinator for a couple of years early in my career, but that only convinced me that I needed to get back into clinical practice. I believe I have done well with providing PAs bedside education, when needed, but I am not cut out for the demands and patience of academia. I do have experience with taking PAs out of their educational experience and training them to be PAs in cardiothoracic surgery.

We just celebrated 50 years of success as a profession. At a time when other healthcare professions have existed for years, we have proven favorable in the needs for the provision of healthcare today. This was in no small part due to the designing of a diverse but compact educational program allowing for the graduation of a practitioner who could immediately accommodate the needs of a diverse healthcare system. These innovative ideas of education are heralded beyond the confines of PA or medical education. Although my alma mater, Alderson-Broaddus College (now University), championed the idea of a 4-year degree program beginning in 1968, the 2-year certificate program was the norm at the beginning. Whether you would like to blame it on legislative pressures, healthcare system requirements, professional competition, academic interest, or public demand, the 4-year degree became the standard. This was soon followed by the master’s degree. The Accreditation Review Commission on Education for the Physician Assistant (ARC-PA)’s Standards of Accreditation, 4th edition, was published in 2010. Clarifying changes were made at least yearly from 2010 to 2014. The last clarification was made in 2016.1 Although it goes without saying that significant academic changes have been made as a requirement for an advanced degree, much of the core curriculum has not changed significantly over the decades. The clinical requirements certainly are familiar and unchanged to PAs of any generation:

B3.03 Supervised clinical practice experiences must provide sufficient patient exposure to allow each student to meet program expectations and acquire the competencies needed for entry into clinical PA practice with patients seeking: a) medical care across the life span to include, infants, children, adolescents, adults, and the elderly, b) women’s health (to include prenatal and gynecologic care), c) care for conditions requiring surgical management, including pre- operative, intra-operative, post-operative care and d) care for behavioral and mental health conditions.B3.04 Supervised clinical practice experiences must occur in the following settings:

ANNOTATION: While patients often use emergency departments for primary care complaints, students are expected to interact with patients needing emergent care in this setting. Urgent care centers may be used for supervised clinical practice experiences, but do not replace the requirement to have students in emergency departments.

a) outpatient, b) emergency department, c) inpatient and d) operating room.2


From the perspective of someone who has almost spent his entire 44-year PA career in surgery, I have seen the steady growth and demand for PAs in surgery. Are we keeping up educationally with the demand clinically? Beyond the requirements for certification, which is the opening window for all PAs, are our programs meeting the demands for the opportunities that are available to graduates? The National Commission on Certification of Physician Assistants’ (NCCPA) 2016 Statistical Profile of Certified Physician Assistants by Specialty indicated that 21.5% of certified PAs are in a surgical specialty.3 Original research published in this journal on job openings for PAs by specialty clearly identified that the job postings back in 2014 for adult surgical specialties was at 28%. More job opportunities than in emergency medicine/urgent care and primary care combined. The opportunity is obvious. Unfortunately, I believe, graduates are not appropriately prepared to enter into these jobs upon graduation.

Once, reimbursement was different and surgical practices could afford to take new graduates and spend the time necessary to train them. Now, administrators question the necessity to slowly integrate new graduates into the surgical workforce, despite my explanation that leaving PA school is like leaving medical school, and in terms of surgical expertise, the graduate is entering their surgical residency. Only the biggest of surgical programs can absorb a recent graduate into the program and spend the year or two required to develop surgical skills and patient care knowledge. Sure, some are more prepared than others. There also is an intrinsic capability to working in surgery that some candidates have and some do not. I have had graduates who integrated quickly. I have had graduates who need to learn how to hold a needle driver. What is the solution?

Some postgraduate surgical residency-type programs exist. For some, their value in terms of a formal educational process versus a cheap labor force is debatable. ARC-PA’s official position with regard to standardized accreditation of these programs is that they hold any consideration in abeyance.4 So, maybe the solution is in a re-engineering of PA education.

Early in my career, when I was working at a private cardiothoracic practice, I went on a recruiting trip to the University of Alabama PA program. It was well-known at the time that graduates of this program could successfully complete the requirement of NCCPA certification and provide a practitioner ready for integration into a surgical practice. The program had a surgical emphasis that gave students an edge toward pursuing a career in surgery. Unfortunately, that search did not provide us with interested candidates. Soon after, I reviewed the resume of a candidate from the Cuyahoga Community College PA program in Cleveland, Ohio, which is known for its surgical emphasis. Our practice was very pleased to gain this graduate. The integration to full surgical practice was relatively seamless. Is that common now? Are we providing the healthcare system with the providers needed after PA school?

PA education has always been on the cutting edge. It is time to sharpen this tool to meet the needs of a profession in change after 50 years. As with our physician colleagues, the competition for positions in controlled lifestyle career paths will be easily met. The job openings are going to be in the less-controlled lifestyles, such as surgery. This is an opportunity for PA education to shine once again in providing a healthcare workforce necessary for the times.


1. Accreditation Review Commission on Education for the Physician Assistant. Standards of Accreditation.

2. Accreditation Review Commission on Education for the Physician Assistant. Standards of Accreditation, 4th ed.

3. National Commission on Certification of Physician Assistants. 2016 Statistical Profile of Certified Physician Assistants by Specialty. Johns Creek, GA.

4. Accreditation Review Commission on Education for the Physician Assistant. Postgraduate programs. 
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.

Monday, February 12, 2018

Jaclyn Rohan, PA-C

The Republic of Ireland is among the latest countries hoping to incorporate physician associates into its healthcare system. Through the Royal College of Surgeons in Ireland and Beaumont Hospital in Dublin, a 27-month pilot program started in July 2015. The program employed experienced American, Canadian, and Scottish-trained PAs in surgical specialties including vascular, general, colorectal, and orthopedic surgery. Over the duration of the pilot program, data and feedback were collected to demonstrate the effect PAs had on various aspects of healthcare delivery. With anticipation of a favorable response to PA introduction, a 24-month master’s of physician associate studies program enrolled its first cohort of students in January 2016, second cohort in January 2017, and a third cohort of 12 students in January 2018. The conclusion of the pilot program in October 2017 leaves proponents of the profession optimistic but cautious, as they await approval and regulation of the PA role by the Irish Department of Health.

As with any new venture, challenges are expected, and the introduction of the PA pilot in Ireland was no exception. Initial PA recruits experienced setbacks, primarily related to their use and the expectation surrounding the role. By the time I joined the pilot in November 2016, these hurdles had been continuously tended to and although not completely resolved, were in a state of improvement. As part of the pilot, not only did I work with my PA colleagues to develop and deliver the PA program curriculum, I also had the pleasure of working alongside many physicians, nurses, and allied health professionals in the Irish healthcare system. Although pockets of resistance were present, a significant number of my colleagues were either were familiar with the PA role and could see its place in the Irish healthcare system, or had themselves witnessed the effect of PAs during the course of the pilot and supported the role’s continued growth in Ireland. This support was encouraging as it demonstrated that the role had, and if handled properly, would continue to speak for itself.

As is the case with most healthcare systems aiming to include PAs in their medical model, the ultimate goal is to educate and assimilate PAs of their own. However, until such a time, internationally sourced, seasoned PAs are critical to establishing and maintaining the workforce. In the case of Ireland, experienced PAs would be crucial to bridge the gap between the conclusion of the pilot program and assimilation of newly graduated Irish PAs into their professional responsibilities. The guidance of experienced PAs along with full governmental support, like that seen in Northern Ireland, England, and other European Union countries, is essential for successful implementation of the profession. Experienced PAs can help to define the role into one that is specifically tailored to meet the needs facing the Irish healthcare system, while not compromising the integrity of the profession.

To continue being the “boots on the ground” as a PA in Ireland, and fostering the development and growth of future PAs in Ireland would have been a welcome honor. However, most unfortunately, at the conclusion of the pilot program in October 2017, my employment permit was not extended beyond the life of the pilot. Having worked diligently to immerse myself socially and medically in the Irish community, I was faced with having to return to the United States after just 1 year. My departure came at a critical time when the PA model was showing a positive effect on the services piloted, and colleagues as well as supervisors were eager to continue developing the role. Although this result was always possible, it was unexpected. For PAs traveling overseas to countries piloting the PA role, these are outcomes that may not be highlighted and warrant further discussion.

Pilots such as the Irish one are both a top-down and bottom-up initiative but policy and systemic barriers remain. So after 2.5 years of PA practice in Ireland, we pass the torch to those first students now set to graduate from the program. My hope is that these newly qualified Irish-trained PAs, the medical community, and the governmental bodies that have embraced this concept will fight strongly to secure the role’s future. Perhaps then in a few short years from now, just as in the United States, we will see PAs listed among the top healthcare roles for those wishing to practice medicine in Ireland.

Jaclyn Rohan is a 2011 graduate of the University of Florida PA program. Since then, she has worked as a surgical PA based in Florida, specializing in general and breast surgery. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, January 29, 2018

Brian K. Yorkgitis, PA-C, DO

With demands and complexities of healthcare, PAs and other healthcare professionals face challenges to care for their patients while caring for themselves. Our innate considerate disposition to deliver high-quality, compassionate care often fails to encompass our own self-care.

We are faced with difficult clinical decisions, delivering bad news, and witnessing tragedy and complications from therapies. These are burdens that we carry each day. On top of the direct patient care, administrative duties are ever-present; charting, billing, and coding, the list goes on. Our shoulders are big, but are they big enough to shoulder the overwhelming emotional, physical, and mental trials a PA faces each day?

Each of us is burdened with these difficulties. We are taught to treat patients but when were we taught to care for ourselves? With provider burnout at alarming rates, a new focus has come to light: taking care of providers so they may continue to provide excellent healthcare to patients.

There are ways to combat this threat to our well-being and career. Time management is the cornerstone of well-being. You must schedule dedicated time for yourself that is non-negotiable—exercising, hobbies, family time, travel, vacations, reading, or whatever you enjoy. Make this time free of work-related activities and avoid checking electronic medical records and work e-mails. Set a limit to the time you are going to put in for the day. For example: After the last patient, I am going to do administrative activities for 30 minutes then call it a day. Negotiate time with your employer that is dedicated to allow you to catch up on administrative tasks. Your employer’s return on this investment is increased employee productivity, morale, and job satisfaction, and lower PA turnover.

We all have faced difficult patient encounters, especially when the outcome is less than desired or a complication arises. When you are faced with a difficult, stressful situation, do not go it alone—phone a friend when trouble arise. This may be your supervisor, a colleague, or the employee assistance program. When I worked in emergency medical services (EMS) and law enforcement, we had a system—critical incident stress debriefing (CISD)—to address providers’ experiences after a difficult call, As a PA and a surgeon, I have never been offered CISD after a difficult case. We should learn from our EMS colleagues and make this resource available when these types of situations arise.

Defining personal and professional goals lets a person set priorities, achieve balance, and provide self-reflection. Through an inventory of goals, we can objectively examine our current state. We can make adjustments between our professional and personal lives to achieve these goals. At times, we may face competing priorities and may need to adjust one to achieve the other. The goal when you entered the PA profession remains the foundation; for most of us, this to help others. To reach other goals, we must help ourselves; this provides a solid foundation to continue to build a successful career.

During my time in EMS and law enforcement, I was taught that in dangerous situations, ensuring your safety is always first. You can’t help others if you are injured, and the terrible situation you are in doesn’t need you as another victim. Take time to care for yourself, so you can care for others.

Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

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.


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.