Secondary Logo

Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

Monday, October 8, 2018

Brian T. Maurer, PA-C

In a recent research article, Coplan and colleagues looked at burnout, job satisfaction, and stress levels of PAs. Analysis of data gleaned from the 2016 American Academy of PAs salary survey shows that, in general, PAs experience modest levels of burnout at work. Nearly 57% of PA respondents rated spending too many hours at work as an important contributor to stress. Job dissatisfaction correlates with lack of opportunities for promotion, relatively low income given the level of clinical responsibilities, an inability to provide patients with the quality of care they need, too many bureaucratic tasks, increasing computerization of practice, too many difficult patients, and difficult colleagues or staff in the workplace.

Suggested strategies to reduce burnout and improve the work lives of clinicians include interventions to streamline workflows, strengthen teamwork, and promote flexibility and work-life balance.

In a separate opinion piece in STAT, Talbot and Dean take the issue of clinician burnout to another level, that of moral injury, defined as an inability to provide high-quality care and healing in the context of healthcare delivery.

“[B]urnout is itself a symptom of something larger: our broken health care system,” they write. “The increasingly complex web of providers’ highly conflicted allegiances—to patients, to self, and to employers—and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.”

In their opinion “without understanding the critical difference between burnout and moral injury, the wounds will never heal and physicians and patients alike will continue to suffer the consequences.”

Talbot and Dean argue that establishing clinician wellness programs won’t solve the problem. “Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques, or participate in cognitive-behavior therapy and resilience training.”

Instead, they propose “[a] truly free market of insurers and providers, one without financial obligations being pushed to providers, [to] allow for self-regulation and patient-driven care.”

In a subsequent STAT opinion piece, Morris-Singer, Pollack, and Lewis offer an additional take on addressing the issue of healing moral injury:

“While the sources of professional dissatisfaction vary, the sources of fulfillment are consistent: It’s all about connection—to patients, to colleagues, and to the calling of medicine. Indeed, nearly three-fourths of providers view their relationships with patients as the most meaningful part of their work.

“[U]niting and building community must be the first step” in the process of healing moral injury.

Brian T. Maurer has practiced general pediatrics for more than 30 years. He is the author of Patients Are a Virtue and blogs at http://briantmaurer.wordpress.com. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


Monday, July 30, 2018

Ellen D. Mandel, DMH, MPA, MS, PA-C

What does close reading mean to you? Do you think it means holding a book close to your eyes due to myopia? Maybe it means reading about a close relative or a topic close to your heart? Well, these are not even close to the definition. In the realm of narrative medicine, close reading means reading for a purpose, to discover things that would not be discovered or discerned with a casual reading approach. According to Rita Charon, MD, PhD, professor of medicine and director of the narrative medicine program at Columbia University, close reading might help train clinicians to notice more about what their patients are communicating, leading to many benefits. It helps us to read between the lines, and thus better communicate. Communication is a two-way street.1

In close reading, readers train themselves to clearly register a work of prose, poetry, and even musical lyrics, in terms of genre, narrator, diction, timing, space, plot, choice of vocabulary, and images.1 If your eyes are glazing over, thinking of Shakespeare, Henry James, Ayn Rand, or Walden Pond, I’m sorry. However, good quality literature lets us enter worlds that are unknown to us. It is especially important to do close reading if you had an idyllic and wonderful childhood, easily found the perfect life partner, achieved every goal with limited fuss, have more money than you know what to do with, had no one close die (pet or human), never been stereotyped or discriminated against, and generally have experienced nothing awful. Well then, honestly, close reading is essential. Frankly, you don’t know what you don’t know—scary. The reality is, every clinician will benefit.

Close reading lets clinicians see and nearly feel via the vehicle of a well-written work, domestic violence, murder, betrayal, lying, substance abuse, theft, adultery, death of the innocent, medical malpractice and a host of other unsavory activities, all from the safety of a comfy sofa (comforter included). It reveals individual and group differences in thought and behaviors based on religion, culture, morals, and ethics. It trains the PA student (often referenced as a millennial and by commonly voiced opinion, having an attention span of a short YouTube video), to carefully read a story and keep track of multiple characters, move back and forth in time (recall foreshadowing from English class), note discrepancies in plot, and stay on top of a story. Not so unlike collecting a history from a patient who does not present information in the accepted template order: possibly one with a low score on a mental status examination?2

Physicians, who have historically been fed a diet of myths about their perfection, are experiencing burnout, substance abuse, relationship fall-out, and suicide. Narrative medicine helps here, too.3 If it helps the physician, it will help the PA. Remember, we are trained in the medical model and also are subject to its risks and benefits. Close reading in groups has been shown to improve coping, resilience, and job happiness.4

So, set aside some time every day to ready a juicy book. Take it all in. Discuss it with others. Avoid War and Peace for now. Enter another world and fall into it. And please, take millennials by the hand, and bring them into close reading. All of you will learn, improve your patient communication skills, and get some relief from the less-than-rosy world we inhabit.


REFERENCES

1. Charon R. The Principles and Practice of Narrative Medicine. Oxford University Press, 2017.

2. Charon R. To see the suffering. Acad Med. 2017;92(12):1668-1670.

3. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: systematic review and meta-analysis. Lancet. 2016;338:2272-2281.

4. Sanchez-Reilly S, Morrison LJ, Carey E, et al. Caring for oneself to care for others: physicians and their self-care. J Support Oncol. 2013;11(2):75-81.

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, July 2, 2018

Brian K. Yorkgitis, PA-C, DO

Throughout my career, I have committed to serving patients in a safety-net hospital. The ability to care for all who need care is a great reward. Last summer, I happened to be on call for every summer holiday: Memorial Day, Fourth of July, and Labor Day. I was receiving requests for transfer from hospitals that often do not send certain diagnoses to our facility. After several requests, I began asking; “Does your specialist not handle this type of case?” The answers were often similar: “We do not have anyone on call for the holiday,” “the OR is too busy for the holiday,” and other seemingly analogous answers. We have a policy to accept all in need and I accepted every patient. After all, these patients were falling through the cracks of the holiday and needed a safety net to catch them.

On any other day, these patients would receive their healthcare at their originating facility but for varying reasons required transfer to the safety-net hospital. I wondered if their reason for not choosing the safety-net hospital first was because they thought it provided lower-quality care compared with their first choice.

Working at safety-net hospitals over the past 16 years, I realized that often, complex patients are transferred to our facility once they have reached the limit of their initial facility’s capabilities. This always struck me as odd—wouldn’t you want to choose the facility that can care for any curveball thrown at it in case you have a rocky course? That is exactly what these hospitals do; hit those curveballs when the count is full. With increased scrutiny on quality of care, I have noticed that complex patients are being transferred to our facilities more often. Unfortunately, most quality measures can only risk-adjust for a few variables rather than the whole patient picture. This creates a selection bias when safety-net hospitals are sampled. The question I always have is whether a transferred patient should be included in the quality metrics. It’s like blaming a losing game on the relief pitcher who takes the mound in the 9th inning.

So, I began looking at the literature for quality measures for these hospitals. Examining esophagectomies, one of the most complex and high-risk surgical procedure performed, Gurien and colleagues found that compared with a national sample, patients treated at a safety-net hospital had fewer complications and reoperations along with a shorter hospital length of stay.1 Dhar and colleagues showed that treatment and survival after resection of pancreatic cancer (another complex and high-risk surgery) was equivalent at safety-net hospitals and non-safety-net hospitals.2

Won and colleagues examined the quality of two of the most common surgical procedures, appendectomy and cholecystectomy. Patients undergoing appendectomies at safety-net hospitals had similar morbidity and cost to those at non-safety-net hospitals. Not surprisingly, safety-net hospitals more often took care of patients with complicated cases of appendicitis, including rupture, while achieving the same morbidity as for patients with less complicated disease treated at non-safety-net hospitals.3 When looking at cholecystectomy, safety-net hospitals performed similarly in regards to morbidity but achieved the same quality with lower costs.4

The literature is also riddled with opposite results. The playing field is not often level. Social determinants of health are known to play a vital role in outcomes but most studies fail to include all aspects of this key factor. If we were able to capture all the aspects of social determinants, would the safety-net hospitals look even better?

If safety-net hospitals are good enough on a holiday, one might say they are better than their comparison, as they stand ready each day to catch any patient any time. Showing up for the game is the first step at winning. I know I would want my parachute to work every time, not just on non-holidays.

REFERENCES
1. Gurien LA, Tepas JJ, Lind DS, et al. How safe is the safety net? Comparison of Ivor-Lewis esophagectomy at a safety-net hospital using the NSQIP database. J Am Coll Surg. 2018;226(4):680-683.

2. Dhar VK, Hoehn RS, Young K, et al. Equivalent treatment and survival after resection of pancreatic cancer at safety-net hospitals. J Gastrointest Surg. 2018;22(1):98-106.

3. Won RP, Friedlander S, Lee SL. Outcomes and costs of managing appendicitis at safety-net hospitals. JAMA Surg. 2017;152(11):1001-1006.

4. Won RP, Friedlander S, de Virgillo C, Lee SL. Addressing the quality and cost of cholecystectomy at a safety net hospital. Am J Surg. 2017;214(6):1030-1033.

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, June 18, 2018

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

Interest in becoming a PA appears to be higher than anytime in in the profession’s history. The applicant pool for PA program admissions continues to increase despite the development of an increasing number of new programs and an increasing number of enrollment slots in existing programs. The projected future demand for PAs in addition to the large and increasing number of good quality applicants vying to gain admission to PA programs further encourages educational institutions to develop new programs and for existing programs to further expand enrollment.  However, despite this substantial increase in the number of PA enrollment slots, the cost of becoming a PA continues to increase. The average cost of completing a PA program (tuition, fees, and required expenditures) in 2015-2016 was $49,317 for a resident at a public institution, $83,981 for a non-resident at a public institution, and $89,723 at a private institution.1 This an increase of 13%, 15%, and 14%, respectively, from only 2 years earlier, and roughly three times greater than the increase in the Consumer Price Index over the same time period.2

The phenomenal increase in the cost of PA education has an obvious consequence—most current PA graduates enter the profession with very high debt loads. The 2014 Physician Assistantn Education Association Matriculating Students Survey reported that 91% of matriculating students anticipated that they would hold some level of debt following their PA education, and that 48% held an average student debt of $35,717 incurred before enrolling in a PA program.3 The Class of 2016 reported an average PA education loan debt of $94,947.4 In many regions of the United States, the average cost of completing a PA program has surpassed the average new PA graduate salary, and the combined student load debt from undergraduate and PA education is likely much higher. The 2016 average PA education loan debt of $94,947 would require a $1,100 monthly payment for 10 years at the current interest rate. If the cost of PA education continues to rise at this rate, is there a point where those contemplating a career as a PA will question whether the profession will provide a reasonable return on investment?

A 2016 publication described a model comparing current net present value (NPV) of physician and PA training for women practicing in family medicine.5 The model was created using 2011-2012 data on salary, and took into account the cost and time involved in training as well as projected future income from the beginning of training at age 25 years to permanent retirement at age 67 years. Although the NPV for a female family physician was 15.1% higher than for a female PA in family medicine, the authors concluded that there was only a relatively small financial difference between the two choices. In contrast with today’s medical education environment, this study used the weighted average total tuition and fees for PA programs in 2011, or $31, 975, equal to about $35,000 in today’s dollars.

It would be interesting to repeat this study model using current data, and expand it to other subpopulations and specialties. Additionally, it would be interesting to apply similar NPV models to other providers such as NPs and separating physicians by MD and DO, because the cost and length of education of each of these professions differs. Will the substantial increase in PA and physician educational costs, and the resulting increase in student debt load, eventually result in a dampening effect on one’s interest in becoming a PA? We need more research on how educational costs affect career choices, the effect of rising costs on who decides to enter our profession, how these costs are passed on into the healthcare delivery system in the form or demands for higher salaries or choice of specialties, and the effect of student debt on the practice and employment choices of PA graduates. 

REFERENCES
1. Physician Assistant Education Association. By the Numbers: Program Report 32: Data from the 2016 Program Survey, Washington, DC: PAEA; 2017.

2. US Department of Labor. Bureau of Labor Statistics. CPI inflation calculator. 

3. Hamann RA, Jeffery C, Miller AA. Physician assistant educational debt: results from two surveys [abstract]. JAAPA. 2016, 29(10):1-2.

4. Physician Assistant Education Association. By the Numbers: Student Report 1. Washington, DC: PAEA, 2017.

5. Essary AC, Coplan BH, Cawley CF, et al. Women, family medicine, and career choice: an opportunity cost analysis. JAAPA. 2016;29(9):44-48.

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.

Monday, June 4, 2018

Amy M. Klingler, MS, PA-C

To pay attention, this is our endless and proper work.Mary Oliver

How do you know what to pay attention to these days? When so much information is being spread across print and digital platforms, it is easy to miss important stories that affect our lives and the lives of our patients. To be honest, I think I swiped right past the article titled “Serena Williams on Motherhood, Marriage, and Making Her Comeback” when it first appeared in my newsfeed. Little did I know that that January 2018 Vogue article would bring my attention to something else I had missed–the appalling statistics on maternal mortality in the United States. This month’s issue of JAAPA includes a commentary by Tami Ritsema and myself that discusses maternal morbidity and mortality in the United States and offers suggestions for how PAs can have a positive effect on this public health crisis.

Since we wrote the article, I have been changing the way I talk to women who are pregnant or who are thinking of becoming pregnant. I take better advantage of opportunities to discuss the importance of preconception medical and dental care with them and try to ensure their chronic medical conditions are managed properly before they try to conceive. Rather than shy away from discussing potential complications of childbirth, I present them in greater detail to my pregnant patients and their partners. Just as importantly, I empower them to speak up when they have concerns. The POST-BIRTH acronym is a great tool that can be quickly taught to expectant mothers and their families to help them recognize and seek help for complications of childbirth.

 

Call 911 if you experience:

Pain in chest

Obstructed breathing or shortness of breath

Seizures

Thoughts of hurting yourself or your baby

 

Call your healthcare provider (or call 911 if your healthcare provider is unavailable) if you experience:

Bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger

Incision that is not healing

Red, swollen leg that is painful or warm to touch

Temperature of 100.4° F (38° C) or higher

Headache that does not get better, even after taking medicines, or a headache with vision changes.

 

I also make sure to take advantage of well-child checks to screen moms for postpartum depression (and check in with their partners, too) as recommended by the American Academy of Pediatrics. I have contacted my representatives in Congress about House Bill 1318 and Senate Bill 1112, which seek to establish maternal mortality review committees and eliminate disparities in maternal healthcare outcomes. They were introduced in 2017 and are gaining support in their respective houses of Congress, but have yet to pass. None of these acts take much effort on my part but they could mean the difference between life and death for one of my patients. Now, that is something worth paying attention to.

Amy M. 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. The views expressed in this blog post are those of the author and may not reflect AAPA policies.