Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

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.

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.