Randy D. Danielsen, PhD, PA-C, DFAAPA

In the United States, the private sector has always played a dominant role in the delivery of health care services, due to our American sense of self-reliance and avoidance of government regulation.¹ We have steadfastly resisted attempts to establish the federal government as the controlling power of the health care system. 

Yet in 2010, Congress passed the Affordable Care Act (ACA)—considered to be the most significant regulatory overhaul of US health care since the passage of Medicare and Medicaid. The ACA has a staged implementation (starting in 2014) that will drastically affect the practice of medicine over the next three to five years. Knowledge of the key provisions of this act and its anticipated impact on care is essential for PAs and NPs to optimize the opportunities and deal with the challenges presented by this program.

Most of us would agree that the ultimate goal for the US health care system is to provide affordable, high-quality health care services to everyone, while preserving the entrepreneurial benefits of a private practice medical system. For the past 30 years, the media buzzwords have been low cost, high quality, and universal access.² Yet it seems nearly impossible to achieve all three together. Most economists agree you can have two, but not all three, at the same time.

The US spends a significantly higher percentage of gross domestic product on health care than most other countries, but there are questions whether the incremental benefits outweigh the overall costs to our economy. One in five citizens in this country has poor access to health care, and an estimated 33 million people will be added to the insured rolls once the ACA is fully implemented. (This does not include an estimated 25 million undocumented immigrants who will need health care and who are currently excluded from ACA coverage but are legally entitled to access emergency care at US hospitals.) Who will care for them?

The country will need 16,000 new health care providers to achieve an “ideal” provider-to-patient ratio of 1:2,000—or at a minimum, 8,000 new providers to achieve an “acceptable” ratio of 1:4,500. The American Association of Medical Colleges’ Center for Workforce Studies predicts a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by the year 2020.³

The ACA is basically insurance reform and expansion funded by massive transfer payments and tax increases and backstopped by an expansion of the Medicaid system. Considered actuarially unsound by most health care economists, the program will require substantial new sources of revenue, coupled with decreasing expenditures, if it is to achieve its aims. One of the fundamental problems is that American medicine has had mixed experiences with cost-cutting efforts and centralized planning administered by government entities.

Most providers (physicians, PAs, and NPs) have practiced in a volume-based environment: The more you do, the more you get paid. Since the 1980s, hospitals and physicians have been reimbursed on mutually incompatible payment schemes for federal patients; hospitals are paid on a case-rate or fixed episode-of-care basis, while physicians have been paid based on volume.  The most recent studies by Medicare over the past two years show no significant change in outcomes or cost from capitation-based payment schemes such as Accountable Care Organizations (ACOs).

There is no doubt that the ACA will cause major changes. However, the program continues to be in a state of flux and under attack. The presumption that health care will significantly improve continues to be debated in a country that has an inadequate primary care infrastructure. Clearly, the shortage of primary care providers means access will likely be a major short-term problem—particularly given the aging of our population.

Additionally, there is no malpractice reform on the horizon, because it is irrelevant to the matter at hand (being less than 1% of health spending), and it is unclear whether the medical community will be able to alter its practice sufficiently to meet the challenges of providing more evidence-based, cost-effective care with a changing focus from treatment to prevention. Lastly, finding motivators for the US population to participate in promoting its own health, by adopting a healthier lifestyle, will continue to be a major challenge.⁴

In the face of these significant changes, what can we, as PAs and NPs—and particularly the leaders of our professional associations—do? Some may say nothing—others may say we should stand for something. My ideas for our national and state associations are outlined in the box.

We also need more research across the board: robust data on clinical and other outcomes measures associated with patient-centered medical homes, retail clinics, and community clinics; and research that clarifies and tests ACOs and other financing models that shift away from fee-for-service and more toward payments that support the key tenets of primary care.

Futhermore, we need to promote the development of workforce supply-and-demand models that are interprofessional in nature and designed to accommodate predictable aspects of the future, and to explore the costs and benefits, including productivity, of using innovative technology as a mode to delivering primary care.

We should expect change and be ready for it. Yes, we will work harder for less money, and patient outcomes will be measured. We should also anticipate the trend toward a two-tiered system of primary care, with PAs and NPs taking over a major part of initial patient care from physicians (at a lower reimbursable rate from health plans) to continue. Lastly, we must become proactive in representing the role of PAs and NPs when negotiating ACO contracts.

I must admit I do not conclude this editorial with an overall optimistic feeling, since the ACO models and the ACA ultimately are not likely to curb our spending sufficiently to avoid bankrupting the next generation. That aside, we have to deal with them today. While this is a very complicated discussion, I hope you will feel compelled to weigh in and share your thoughts with me at [email protected].

REFERENCES
1. Danielsen R, Ballweg R, Vorvick L, Sefcik R. The Preceptor’s Handbook for Supervising Physician Assistants. Jones & Bartlett Learning. 2012:3.

2. Pipes S. The Top Ten Myths of American Health Care: A Citizen’s Guide. Pacific Research Institute. 2008:5.

3. American Association of Medical Colleges. 2010.

4. Bukata WR. Obamacare: the basics. Emergency Medical Abstracts. 2013;37(4).

In the United States, the private sector has always played a dominant role in the delivery of health care services, due to our American sense of self-reliance and avoidance of government regulation.¹ We have steadfastly resisted attempts to establish the federal government as the controlling power of the health care system. 

Yet in 2010, Congress passed the Affordable Care Act (ACA)—considered to be the most significant regulatory overhaul of US health care since the passage of Medicare and Medicaid. The ACA has a staged implementation (starting in 2014) that will drastically affect the practice of medicine over the next three to five years. Knowledge of the key provisions of this act and its anticipated impact on care is essential for PAs and NPs to optimize the opportunities and deal with the challenges presented by this program.

Most of us would agree that the ultimate goal for the US health care system is to provide affordable, high-quality health care services to everyone, while preserving the entrepreneurial benefits of a private practice medical system. For the past 30 years, the media buzzwords have been low cost, high quality, and universal access.² Yet it seems nearly impossible to achieve all three together. Most economists agree you can have two, but not all three, at the same time.

The US spends a significantly higher percentage of gross domestic product on health care than most other countries, but there are questions whether the incremental benefits outweigh the overall costs to our economy. One in five citizens in this country has poor access to health care, and an estimated 33 million people will be added to the insured rolls once the ACA is fully implemented. (This does not include an estimated 25 million undocumented immigrants who will need health care and who are currently excluded from ACA coverage but are legally entitled to access emergency care at US hospitals.) Who will care for them?

The country will need 16,000 new health care providers to achieve an “ideal” provider-to-patient ratio of 1:2,000—or at a minimum, 8,000 new providers to achieve an “acceptable” ratio of 1:4,500. The American Association of Medical Colleges’ Center for Workforce Studies predicts a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by the year 2020.³

The ACA is basically insurance reform and expansion funded by massive transfer payments and tax increases and backstopped by an expansion of the Medicaid system. Considered actuarially unsound by most health care economists, the program will require substantial new sources of revenue, coupled with decreasing expenditures, if it is to achieve its aims. One of the fundamental problems is that American medicine has had mixed experiences with cost-cutting efforts and centralized planning administered by government entities.

Most providers (physicians, PAs, and NPs) have practiced in a volume-based environment: The more you do, the more you get paid. Since the 1980s, hospitals and physicians have been reimbursed on mutually incompatible payment schemes for federal patients; hospitals are paid on a case-rate or fixed episode-of-care basis, while physicians have been paid based on volume.  The most recent studies by Medicare over the past two years show no significant change in outcomes or cost from capitation-based payment schemes such as Accountable Care Organizations (ACOs).

There is no doubt that the ACA will cause major changes. However, the program continues to be in a state of flux and under attack. The presumption that health care will significantly improve continues to be debated in a country that has an inadequate primary care infrastructure. Clearly, the shortage of primary care providers means access will likely be a major short-term problem—particularly given the aging of our population.

Additionally, there is no malpractice reform on the horizon, because it is irrelevant to the matter at hand (being less than 1% of health spending), and it is unclear whether the medical community will be able to alter its practice sufficiently to meet the challenges of providing more evidence-based, cost-effective care with a changing focus from treatment to prevention. Lastly, finding motivators for the US population to participate in promoting its own health, by adopting a healthier lifestyle, will continue to be a major challenge.⁴

In the face of these significant changes, what can we, as PAs and NPs—and particularly the leaders of our professional associations—do? Some may say nothing—others may say we should stand for something. My ideas for our national and state associations are outlined in the box.

We also need more research across the board: robust data on clinical and other outcomes measures associated with patient-centered medical homes, retail clinics, and community clinics; and research that clarifies and tests ACOs and other financing models that shift away from fee-for-service and more toward payments that support the key tenets of primary care.

Futhermore, we need to promote the development of workforce supply-and-demand models that are interprofessional in nature and designed to accommodate predictable aspects of the future, and to explore the costs and benefits, including productivity, of using innovative technology as a mode to delivering primary care.

We should expect change and be ready for it. Yes, we will work harder for less money, and patient outcomes will be measured. We should also anticipate the trend toward a two-tiered system of primary care, with PAs and NPs taking over a major part of initial patient care from physicians (at a lower reimbursable rate from health plans) to continue. Lastly, we must become proactive in representing the role of PAs and NPs when negotiating ACO contracts.

I must admit I do not conclude this editorial with an overall optimistic feeling, since the ACO models and the ACA ultimately are not likely to curb our spending sufficiently to avoid bankrupting the next generation. That aside, we have to deal with them today. While this is a very complicated discussion, I hope you will feel compelled to weigh in and share your thoughts with me at [email protected].

REFERENCES
1. Danielsen R, Ballweg R, Vorvick L, Sefcik R. The Preceptor’s Handbook for Supervising Physician Assistants. Jones & Bartlett Learning. 2012:3.

2. Pipes S. The Top Ten Myths of American Health Care: A Citizen’s Guide. Pacific Research Institute. 2008:5.

3. American Association of Medical Colleges. 2010.

4. Bukata WR. Obamacare: the basics. Emergency Medical Abstracts. 2013;37(4).

In the United States, the private sector has always played a dominant role in the delivery of health care services, due to our American sense of self-reliance and avoidance of government regulation.¹ We have steadfastly resisted attempts to establish the federal government as the controlling power of the health care system. 

Yet in 2010, Congress passed the Affordable Care Act (ACA)—considered to be the most significant regulatory overhaul of US health care since the passage of Medicare and Medicaid. The ACA has a staged implementation (starting in 2014) that will drastically affect the practice of medicine over the next three to five years. Knowledge of the key provisions of this act and its anticipated impact on care is essential for PAs and NPs to optimize the opportunities and deal with the challenges presented by this program.

Most of us would agree that the ultimate goal for the US health care system is to provide affordable, high-quality health care services to everyone, while preserving the entrepreneurial benefits of a private practice medical system. For the past 30 years, the media buzzwords have been low cost, high quality, and universal access.² Yet it seems nearly impossible to achieve all three together. Most economists agree you can have two, but not all three, at the same time.

The US spends a significantly higher percentage of gross domestic product on health care than most other countries, but there are questions whether the incremental benefits outweigh the overall costs to our economy. One in five citizens in this country has poor access to health care, and an estimated 33 million people will be added to the insured rolls once the ACA is fully implemented. (This does not include an estimated 25 million undocumented immigrants who will need health care and who are currently excluded from ACA coverage but are legally entitled to access emergency care at US hospitals.) Who will care for them?

The country will need 16,000 new health care providers to achieve an “ideal” provider-to-patient ratio of 1:2,000—or at a minimum, 8,000 new providers to achieve an “acceptable” ratio of 1:4,500. The American Association of Medical Colleges’ Center for Workforce Studies predicts a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by the year 2020.³

The ACA is basically insurance reform and expansion funded by massive transfer payments and tax increases and backstopped by an expansion of the Medicaid system. Considered actuarially unsound by most health care economists, the program will require substantial new sources of revenue, coupled with decreasing expenditures, if it is to achieve its aims. One of the fundamental problems is that American medicine has had mixed experiences with cost-cutting efforts and centralized planning administered by government entities.

Most providers (physicians, PAs, and NPs) have practiced in a volume-based environment: The more you do, the more you get paid. Since the 1980s, hospitals and physicians have been reimbursed on mutually incompatible payment schemes for federal patients; hospitals are paid on a case-rate or fixed episode-of-care basis, while physicians have been paid based on volume.  The most recent studies by Medicare over the past two years show no significant change in outcomes or cost from capitation-based payment schemes such as Accountable Care Organizations (ACOs).

There is no doubt that the ACA will cause major changes. However, the program continues to be in a state of flux and under attack. The presumption that health care will significantly improve continues to be debated in a country that has an inadequate primary care infrastructure. Clearly, the shortage of primary care providers means access will likely be a major short-term problem—particularly given the aging of our population.

Additionally, there is no malpractice reform on the horizon, because it is irrelevant to the matter at hand (being less than 1% of health spending), and it is unclear whether the medical community will be able to alter its practice sufficiently to meet the challenges of providing more evidence-based, cost-effective care with a changing focus from treatment to prevention. Lastly, finding motivators for the US population to participate in promoting its own health, by adopting a healthier lifestyle, will continue to be a major challenge.⁴

In the face of these significant changes, what can we, as PAs and NPs—and particularly the leaders of our professional associations—do? Some may say nothing—others may say we should stand for something. My ideas for our national and state associations are outlined in the box.

We also need more research across the board: robust data on clinical and other outcomes measures associated with patient-centered medical homes, retail clinics, and community clinics; and research that clarifies and tests ACOs and other financing models that shift away from fee-for-service and more toward payments that support the key tenets of primary care.

Futhermore, we need to promote the development of workforce supply-and-demand models that are interprofessional in nature and designed to accommodate predictable aspects of the future, and to explore the costs and benefits, including productivity, of using innovative technology as a mode to delivering primary care.

We should expect change and be ready for it. Yes, we will work harder for less money, and patient outcomes will be measured. We should also anticipate the trend toward a two-tiered system of primary care, with PAs and NPs taking over a major part of initial patient care from physicians (at a lower reimbursable rate from health plans) to continue. Lastly, we must become proactive in representing the role of PAs and NPs when negotiating ACO contracts.

I must admit I do not conclude this editorial with an overall optimistic feeling, since the ACO models and the ACA ultimately are not likely to curb our spending sufficiently to avoid bankrupting the next generation. That aside, we have to deal with them today. While this is a very complicated discussion, I hope you will feel compelled to weigh in and share your thoughts with me at [email protected].

REFERENCES
1. Danielsen R, Ballweg R, Vorvick L, Sefcik R. The Preceptor’s Handbook for Supervising Physician Assistants. Jones & Bartlett Learning. 2012:3.

2. Pipes S. The Top Ten Myths of American Health Care: A Citizen’s Guide. Pacific Research Institute. 2008:5.

3. American Association of Medical Colleges. 2010.

4. Bukata WR. Obamacare: the basics. Emergency Medical Abstracts. 2013;37(4).

There are three things that are bothering me this month as I contemplate this editorial and the beginning of a new year. The first is, I am getting older. OK, I can’t do anything about that.

The next is that I am spending more time in specialty offices than I care to—another thing I can’t seem to do much about.

The third thing that’s bothering me is being both a clinician and a patient. For many clinicians, their role as healer precludes thoughts of ever getting sick themselves. When they do, it initiates a profound shift, not only in their sense of self, which is invariably bound up with the invincible role of clinician, but also in the way that they view their patients and the clinician-patient relationship.

We have all heard that “doctors make difficult patients.” I suspect that is true for most clinicians, and I am no different. Perhaps it is because the role reversal is so profound, or perhaps it is a perceived loss of control or … dare I say it? … trust.¹

While a number of books have been written from a first-person perspective by clinicians who get sick (eg, Oliver Sacks), and even though TV shows like House and a number of great movies (like The Doctor with William Hurt) touch on the topic, it never really means anything until it happens to you. So I am taking this bully pulpit and selfishly giving advice to those clinicians who take care of me—or any of us. Here goes.

1. Please do not come in, sit down, and start filling out the electronic health record (EHR) without introducing yourself. In fact, do not spend more time filling out the EHR than you do talking to (or looking at) me. Actually, forget the EHR! Do the history and physical, then leave the room and fill out the EHR. (OK, I realize I may have just stepped over the line.)

2. When you see me as a patient, please ask me what I do for a living. It is important to me to know that you care about what I do and it should be important to you, if only as part of an occupational history, to know what I do. Bernardino Ramazzini, who is considered the father of occupational medicine, aptly emphasized the importance of knowing your patient’s work environment.²

3. Do not assume anything. Please don’t assume I know what’s wrong with me. If you’re explaining something to me about an illness, a disease process, or a test, don’t assume I understand it all just because you know what I do professionally. Do not assume that I understand all the reasoning of your subspecialty. I might, but please make sure I have as much information from you as you would give patients without my medical background. Like all patients, I would like you to treat me as you would if I were your family member.

4. Having said that, I would ask you to gear your communication to a higher level of knowledge. Respect my fund of knowledge, but give me as much information as you would any other patient. I am there because I want to be a patient. I am there to get your advice. If you know I’m a clinician, either because you asked or I told you (to avoid being talked to like a fifth-grader), continuing to assume that I don’t know anything can be a patronizing approach. On the other hand, don’t assume that I know everything, as my condition may be outside the areas that I know much about. This could leave me clueless, unless I ask for clarification. Either way, if you ask me how much I know about a particular disorder and its treatment, and then tailor the talk to my knowledge level, the conversation will proceed much better.

5. Make it easy for me to have full access to my medical records.

6. After taking a history, ask me if there is any other relevant information that has not been covered. Always ask me what I think and what my preferences would be. Engage me in shared decision making.

7. Please don’t assume I know what you’re thinking. Do not avoid the “hard” behavioral questions.

8. If I have a serious diagnosis, it does not matter if I am a clinician; it is still a devastating diagnosis. Don’t treat me like a clinician at that point; treat me like a human being who just got bad news. Most likely I can start to formulate nasty scenarios faster than a nonclinician patient, so be prepared to be honest and realistic, but supportive and caring. Yes, caring!

Lastly, I am of the opinion that clinicians need to take great care to be objective and even a little detached in spite of their nature. There is always the tendency to give patients what they want instead of what they need. Please don’t confuse compassion with medical servitude or with a desire to be liked.

These cautions aside, the clinician who is compassionate will be much more therapeutically effective, to my mind, and more thoughtful in patient care than those who are not, and will be highly regarded among patients and colleagues alike. I highly recommend it!

I’d love to hear about your experiences as a patient and/or your advice to clinicians who are seeing you (send an email to [email protected]). Thanks for listening!        

REFERENCES
1. The art of patient care: compassion in patient care (2011). www.art-of-patient-care.com/compassion.html?&lang=en_us&output=json. Accessed December 17, 2012.

2. Bernardino Ramazzini (2004). Encyclopedia of World Biography. www.encyclopedia.com/doc/1G2-3404707887.html. Accessed December 17, 2012.

There are three things that are bothering me this month as I contemplate this editorial and the beginning of a new year. The first is, I am getting older. OK, I can’t do anything about that.

The next is that I am spending more time in specialty offices than I care to—another thing I can’t seem to do much about.

The third thing that’s bothering me is being both a clinician and a patient. For many clinicians, their role as healer precludes thoughts of ever getting sick themselves. When they do, it initiates a profound shift, not only in their sense of self, which is invariably bound up with the invincible role of clinician, but also in the way that they view their patients and the clinician-patient relationship.

We have all heard that “doctors make difficult patients.” I suspect that is true for most clinicians, and I am no different. Perhaps it is because the role reversal is so profound, or perhaps it is a perceived loss of control or … dare I say it? … trust.¹

While a number of books have been written from a first-person perspective by clinicians who get sick (eg, Oliver Sacks), and even though TV shows like House and a number of great movies (like The Doctor with William Hurt) touch on the topic, it never really means anything until it happens to you. So I am taking this bully pulpit and selfishly giving advice to those clinicians who take care of me—or any of us. Here goes.

1. Please do not come in, sit down, and start filling out the electronic health record (EHR) without introducing yourself. In fact, do not spend more time filling out the EHR than you do talking to (or looking at) me. Actually, forget the EHR! Do the history and physical, then leave the room and fill out the EHR. (OK, I realize I may have just stepped over the line.)

2. When you see me as a patient, please ask me what I do for a living. It is important to me to know that you care about what I do and it should be important to you, if only as part of an occupational history, to know what I do. Bernardino Ramazzini, who is considered the father of occupational medicine, aptly emphasized the importance of knowing your patient’s work environment.²

3. Do not assume anything. Please don’t assume I know what’s wrong with me. If you’re explaining something to me about an illness, a disease process, or a test, don’t assume I understand it all just because you know what I do professionally. Do not assume that I understand all the reasoning of your subspecialty. I might, but please make sure I have as much information from you as you would give patients without my medical background. Like all patients, I would like you to treat me as you would if I were your family member.

4. Having said that, I would ask you to gear your communication to a higher level of knowledge. Respect my fund of knowledge, but give me as much information as you would any other patient. I am there because I want to be a patient. I am there to get your advice. If you know I’m a clinician, either because you asked or I told you (to avoid being talked to like a fifth-grader), continuing to assume that I don’t know anything can be a patronizing approach. On the other hand, don’t assume that I know everything, as my condition may be outside the areas that I know much about. This could leave me clueless, unless I ask for clarification. Either way, if you ask me how much I know about a particular disorder and its treatment, and then tailor the talk to my knowledge level, the conversation will proceed much better.

5. Make it easy for me to have full access to my medical records.

6. After taking a history, ask me if there is any other relevant information that has not been covered. Always ask me what I think and what my preferences would be. Engage me in shared decision making.

7. Please don’t assume I know what you’re thinking. Do not avoid the “hard” behavioral questions.

8. If I have a serious diagnosis, it does not matter if I am a clinician; it is still a devastating diagnosis. Don’t treat me like a clinician at that point; treat me like a human being who just got bad news. Most likely I can start to formulate nasty scenarios faster than a nonclinician patient, so be prepared to be honest and realistic, but supportive and caring. Yes, caring!

Lastly, I am of the opinion that clinicians need to take great care to be objective and even a little detached in spite of their nature. There is always the tendency to give patients what they want instead of what they need. Please don’t confuse compassion with medical servitude or with a desire to be liked.

These cautions aside, the clinician who is compassionate will be much more therapeutically effective, to my mind, and more thoughtful in patient care than those who are not, and will be highly regarded among patients and colleagues alike. I highly recommend it!

I’d love to hear about your experiences as a patient and/or your advice to clinicians who are seeing you (send an email to [email protected]). Thanks for listening!        

REFERENCES
1. The art of patient care: compassion in patient care (2011). www.art-of-patient-care.com/compassion.html?&lang=en_us&output=json. Accessed December 17, 2012.

2. Bernardino Ramazzini (2004). Encyclopedia of World Biography. www.encyclopedia.com/doc/1G2-3404707887.html. Accessed December 17, 2012.

There are three things that are bothering me this month as I contemplate this editorial and the beginning of a new year. The first is, I am getting older. OK, I can’t do anything about that.

The next is that I am spending more time in specialty offices than I care to—another thing I can’t seem to do much about.

The third thing that’s bothering me is being both a clinician and a patient. For many clinicians, their role as healer precludes thoughts of ever getting sick themselves. When they do, it initiates a profound shift, not only in their sense of self, which is invariably bound up with the invincible role of clinician, but also in the way that they view their patients and the clinician-patient relationship.

We have all heard that “doctors make difficult patients.” I suspect that is true for most clinicians, and I am no different. Perhaps it is because the role reversal is so profound, or perhaps it is a perceived loss of control or … dare I say it? … trust.¹

While a number of books have been written from a first-person perspective by clinicians who get sick (eg, Oliver Sacks), and even though TV shows like House and a number of great movies (like The Doctor with William Hurt) touch on the topic, it never really means anything until it happens to you. So I am taking this bully pulpit and selfishly giving advice to those clinicians who take care of me—or any of us. Here goes.

1. Please do not come in, sit down, and start filling out the electronic health record (EHR) without introducing yourself. In fact, do not spend more time filling out the EHR than you do talking to (or looking at) me. Actually, forget the EHR! Do the history and physical, then leave the room and fill out the EHR. (OK, I realize I may have just stepped over the line.)

2. When you see me as a patient, please ask me what I do for a living. It is important to me to know that you care about what I do and it should be important to you, if only as part of an occupational history, to know what I do. Bernardino Ramazzini, who is considered the father of occupational medicine, aptly emphasized the importance of knowing your patient’s work environment.²

3. Do not assume anything. Please don’t assume I know what’s wrong with me. If you’re explaining something to me about an illness, a disease process, or a test, don’t assume I understand it all just because you know what I do professionally. Do not assume that I understand all the reasoning of your subspecialty. I might, but please make sure I have as much information from you as you would give patients without my medical background. Like all patients, I would like you to treat me as you would if I were your family member.

4. Having said that, I would ask you to gear your communication to a higher level of knowledge. Respect my fund of knowledge, but give me as much information as you would any other patient. I am there because I want to be a patient. I am there to get your advice. If you know I’m a clinician, either because you asked or I told you (to avoid being talked to like a fifth-grader), continuing to assume that I don’t know anything can be a patronizing approach. On the other hand, don’t assume that I know everything, as my condition may be outside the areas that I know much about. This could leave me clueless, unless I ask for clarification. Either way, if you ask me how much I know about a particular disorder and its treatment, and then tailor the talk to my knowledge level, the conversation will proceed much better.

5. Make it easy for me to have full access to my medical records.

6. After taking a history, ask me if there is any other relevant information that has not been covered. Always ask me what I think and what my preferences would be. Engage me in shared decision making.

7. Please don’t assume I know what you’re thinking. Do not avoid the “hard” behavioral questions.

8. If I have a serious diagnosis, it does not matter if I am a clinician; it is still a devastating diagnosis. Don’t treat me like a clinician at that point; treat me like a human being who just got bad news. Most likely I can start to formulate nasty scenarios faster than a nonclinician patient, so be prepared to be honest and realistic, but supportive and caring. Yes, caring!

Lastly, I am of the opinion that clinicians need to take great care to be objective and even a little detached in spite of their nature. There is always the tendency to give patients what they want instead of what they need. Please don’t confuse compassion with medical servitude or with a desire to be liked.

These cautions aside, the clinician who is compassionate will be much more therapeutically effective, to my mind, and more thoughtful in patient care than those who are not, and will be highly regarded among patients and colleagues alike. I highly recommend it!

I’d love to hear about your experiences as a patient and/or your advice to clinicians who are seeing you (send an email to [email protected]). Thanks for listening!        

REFERENCES
1. The art of patient care: compassion in patient care (2011). www.art-of-patient-care.com/compassion.html?&lang=en_us&output=json. Accessed December 17, 2012.

2. Bernardino Ramazzini (2004). Encyclopedia of World Biography. www.encyclopedia.com/doc/1G2-3404707887.html. Accessed December 17, 2012.

Recently, I have been dismayed to learn that some of our PA and NP colleagues have been caught up in serious federal fraudulent-billing cases. There is, of course, no precise measure of health care fraud, nor is there any doubt that the majority of PAs and NPs are honest and well intentioned.

In 1997, Congress authorized payments to NPs and PAs for Medicare-provided services; the attendant rules and regulations have become more complex over time, creating a new area of liability for both professions. Failure to follow billing rules typically results in payment denial and/or repayment of fees already paid.

However, in cases deemed egregious, the penalties can include criminal prosecution, punitive damages, and exclusion from participation in federally funded health care programs. Should you be excluded, for all practical purposes your medical career is over. Medicare forbids hospitals and health plans to employ excluded persons or contract with organizations that employ them.

Here are a couple of recent examples from the public record:

A multistate urgent care company was sued by the US Department of Justice (DoJ) and five states for implementing unethical corporate-wide initiatives aimed at generating additional income. The scheme included setting quotas for the performance of medically questionable—and often unnecessary—testing for allergy problems, regardless of the presenting condition. In addition, clinicians were required to “hard sell” immunotherapy drops not approved by the FDA, which in most cases were not effective.

This company employed many PAs and NPs, who were required to meet daily quotas or risk being fired, in order to offset the company’s struggling finances. The suit with the DoJ was settled in the multimillion-dollar range; however, the company and its principals are still at risk for lawsuits from private individuals and private health plans that were defrauded.

This significant settlement highlights the danger of putting greed before ethics and good patient care. Clinicians work very hard to attain their clinical license and should not let others put their career goals at risk.

In another case, a PA was convicted on multiple criminal counts of conspiracy, health care fraud, and aggravated identity theft in connection with a multimillion-dollar Medicare fraud scheme. The PA wrote fraudulent prescriptions  and orders for medically unnecessary durable medical equipment (DME; eg, power wheelchairs) and diagnostic tests, which were used by fraudulent DME supply companies and medical testing facilities to bill Medicare. The PA wrote the prescriptions and ordered the tests on behalf of physicians whom he had never met and who had not given their authorization. In this particular case, there was no blurring of the lines: It was a clear case of deliberate misconduct.

Now let me be clear: I am certain that these cases are rare and do not represent the high level of integrity that both PAs and NPs in our health care system have. Rather, I raise the issue so we can remind ourselves of the risks and ethical compromise that may emerge from engaging in questionable behavior, which may be motivated by profit-driven corporate pressure.

Remember, provided services billed to Medicare and other federal health care programs are only reimbursable if they are medically necessary for the diagnosis or treatment of illness or injury. In submitting claims to Medicare, providers must document the reasons for medical necessity and expressly certify that the services rendered were medically indicated and necessary for the health of the patient.

Submitting ineligible claims to a federal health care program constitutes a violation of the False Claim Act (FCA),¹ even if you do not know they are ineligible or do not intend to commit fraud. Simply put, the government believes it is paying for services or items that have legitimate medical value when, in fact, the services or items are essentially worthless.

Here are some strategies^2-4 for avoiding potentially fraudulent billing errors:

1. Make sure you have a Medicare provider number from the local carrier in your state. (This is required by federal law.)

2. Consult your provider relations representative to discuss regulations for reimbursement.

3. Know your codes! Ignorance of the coding system is not a defense if you are charged with fraud.

4. Check the accuracy of your coding service by having an expert periodically evaluate a few of your charts. Encourage your practice to implement a compliance program, with a focus on identification and prevention of problems with coding and billing.

5. Document the necessity of any ancillary service, and know the appropriate CPT codes.

6. Order only lab tests that are medically necessary.

7. Keep current; billing regulations change frequently and ignorance of the rules will not excuse you from liability. Encourage your state professional organization to invite a coding expert to speak to the group each year.

8. Know what is being billed in your name, particularly by a third party, since you are responsible for it even if you never receive a payment (by virtue of being on salary).

To help combat fraud and abuse, PAs and NPs must become more knowledgeable about what the billing process entails. This should be part of the curriculum in school. Although it is a complex and difficult system (especially with ICD-10 coming sooner or later), there has to be rudimentary understanding to avoid traps. 

Have I overreacted? We would love to hear additional ways to avoid fraud and/or experiences with billing that you would like to share for the benefit of our readers. You can contact me at [email protected].

REFERENCES
1. Centers for Medicare and Medicaid Services. Medicare Fraud and Abuse: Prevention, Detection, and Reporting. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud_and_Abuse.pdf. Accessed August 15, 2012.

2. Buppert C. Avoiding Medicare fraud, part 1. Nurse Pract. 2001;26(1):70, 72-75.

3. Buppert C. Avoiding Medicare fraud, part 2. Nurse Pract. 2001;26(2):34-38, 41.

4. Medicare 101 for PAs: Understanding Billing [podcast]. Available at: www.reachmd.com/xmsegment.aspx?sid=5782. Accessed August 15, 2012.

Recently, I have been dismayed to learn that some of our PA and NP colleagues have been caught up in serious federal fraudulent-billing cases. There is, of course, no precise measure of health care fraud, nor is there any doubt that the majority of PAs and NPs are honest and well intentioned.

In 1997, Congress authorized payments to NPs and PAs for Medicare-provided services; the attendant rules and regulations have become more complex over time, creating a new area of liability for both professions. Failure to follow billing rules typically results in payment denial and/or repayment of fees already paid.

However, in cases deemed egregious, the penalties can include criminal prosecution, punitive damages, and exclusion from participation in federally funded health care programs. Should you be excluded, for all practical purposes your medical career is over. Medicare forbids hospitals and health plans to employ excluded persons or contract with organizations that employ them.

Here are a couple of recent examples from the public record:

A multistate urgent care company was sued by the US Department of Justice (DoJ) and five states for implementing unethical corporate-wide initiatives aimed at generating additional income. The scheme included setting quotas for the performance of medically questionable—and often unnecessary—testing for allergy problems, regardless of the presenting condition. In addition, clinicians were required to “hard sell” immunotherapy drops not approved by the FDA, which in most cases were not effective.

This company employed many PAs and NPs, who were required to meet daily quotas or risk being fired, in order to offset the company’s struggling finances. The suit with the DoJ was settled in the multimillion-dollar range; however, the company and its principals are still at risk for lawsuits from private individuals and private health plans that were defrauded.

This significant settlement highlights the danger of putting greed before ethics and good patient care. Clinicians work very hard to attain their clinical license and should not let others put their career goals at risk.

In another case, a PA was convicted on multiple criminal counts of conspiracy, health care fraud, and aggravated identity theft in connection with a multimillion-dollar Medicare fraud scheme. The PA wrote fraudulent prescriptions  and orders for medically unnecessary durable medical equipment (DME; eg, power wheelchairs) and diagnostic tests, which were used by fraudulent DME supply companies and medical testing facilities to bill Medicare. The PA wrote the prescriptions and ordered the tests on behalf of physicians whom he had never met and who had not given their authorization. In this particular case, there was no blurring of the lines: It was a clear case of deliberate misconduct.

Now let me be clear: I am certain that these cases are rare and do not represent the high level of integrity that both PAs and NPs in our health care system have. Rather, I raise the issue so we can remind ourselves of the risks and ethical compromise that may emerge from engaging in questionable behavior, which may be motivated by profit-driven corporate pressure.

Remember, provided services billed to Medicare and other federal health care programs are only reimbursable if they are medically necessary for the diagnosis or treatment of illness or injury. In submitting claims to Medicare, providers must document the reasons for medical necessity and expressly certify that the services rendered were medically indicated and necessary for the health of the patient.

Submitting ineligible claims to a federal health care program constitutes a violation of the False Claim Act (FCA),¹ even if you do not know they are ineligible or do not intend to commit fraud. Simply put, the government believes it is paying for services or items that have legitimate medical value when, in fact, the services or items are essentially worthless.

Here are some strategies^2-4 for avoiding potentially fraudulent billing errors:

1. Make sure you have a Medicare provider number from the local carrier in your state. (This is required by federal law.)

2. Consult your provider relations representative to discuss regulations for reimbursement.

3. Know your codes! Ignorance of the coding system is not a defense if you are charged with fraud.

4. Check the accuracy of your coding service by having an expert periodically evaluate a few of your charts. Encourage your practice to implement a compliance program, with a focus on identification and prevention of problems with coding and billing.

5. Document the necessity of any ancillary service, and know the appropriate CPT codes.

6. Order only lab tests that are medically necessary.

7. Keep current; billing regulations change frequently and ignorance of the rules will not excuse you from liability. Encourage your state professional organization to invite a coding expert to speak to the group each year.

8. Know what is being billed in your name, particularly by a third party, since you are responsible for it even if you never receive a payment (by virtue of being on salary).

To help combat fraud and abuse, PAs and NPs must become more knowledgeable about what the billing process entails. This should be part of the curriculum in school. Although it is a complex and difficult system (especially with ICD-10 coming sooner or later), there has to be rudimentary understanding to avoid traps. 

Have I overreacted? We would love to hear additional ways to avoid fraud and/or experiences with billing that you would like to share for the benefit of our readers. You can contact me at [email protected].

REFERENCES
1. Centers for Medicare and Medicaid Services. Medicare Fraud and Abuse: Prevention, Detection, and Reporting. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud_and_Abuse.pdf. Accessed August 15, 2012.

2. Buppert C. Avoiding Medicare fraud, part 1. Nurse Pract. 2001;26(1):70, 72-75.

3. Buppert C. Avoiding Medicare fraud, part 2. Nurse Pract. 2001;26(2):34-38, 41.

4. Medicare 101 for PAs: Understanding Billing [podcast]. Available at: www.reachmd.com/xmsegment.aspx?sid=5782. Accessed August 15, 2012.

Recently, I have been dismayed to learn that some of our PA and NP colleagues have been caught up in serious federal fraudulent-billing cases. There is, of course, no precise measure of health care fraud, nor is there any doubt that the majority of PAs and NPs are honest and well intentioned.

In 1997, Congress authorized payments to NPs and PAs for Medicare-provided services; the attendant rules and regulations have become more complex over time, creating a new area of liability for both professions. Failure to follow billing rules typically results in payment denial and/or repayment of fees already paid.

However, in cases deemed egregious, the penalties can include criminal prosecution, punitive damages, and exclusion from participation in federally funded health care programs. Should you be excluded, for all practical purposes your medical career is over. Medicare forbids hospitals and health plans to employ excluded persons or contract with organizations that employ them.

Here are a couple of recent examples from the public record:

A multistate urgent care company was sued by the US Department of Justice (DoJ) and five states for implementing unethical corporate-wide initiatives aimed at generating additional income. The scheme included setting quotas for the performance of medically questionable—and often unnecessary—testing for allergy problems, regardless of the presenting condition. In addition, clinicians were required to “hard sell” immunotherapy drops not approved by the FDA, which in most cases were not effective.

This company employed many PAs and NPs, who were required to meet daily quotas or risk being fired, in order to offset the company’s struggling finances. The suit with the DoJ was settled in the multimillion-dollar range; however, the company and its principals are still at risk for lawsuits from private individuals and private health plans that were defrauded.

This significant settlement highlights the danger of putting greed before ethics and good patient care. Clinicians work very hard to attain their clinical license and should not let others put their career goals at risk.

In another case, a PA was convicted on multiple criminal counts of conspiracy, health care fraud, and aggravated identity theft in connection with a multimillion-dollar Medicare fraud scheme. The PA wrote fraudulent prescriptions  and orders for medically unnecessary durable medical equipment (DME; eg, power wheelchairs) and diagnostic tests, which were used by fraudulent DME supply companies and medical testing facilities to bill Medicare. The PA wrote the prescriptions and ordered the tests on behalf of physicians whom he had never met and who had not given their authorization. In this particular case, there was no blurring of the lines: It was a clear case of deliberate misconduct.

Now let me be clear: I am certain that these cases are rare and do not represent the high level of integrity that both PAs and NPs in our health care system have. Rather, I raise the issue so we can remind ourselves of the risks and ethical compromise that may emerge from engaging in questionable behavior, which may be motivated by profit-driven corporate pressure.

Remember, provided services billed to Medicare and other federal health care programs are only reimbursable if they are medically necessary for the diagnosis or treatment of illness or injury. In submitting claims to Medicare, providers must document the reasons for medical necessity and expressly certify that the services rendered were medically indicated and necessary for the health of the patient.

Submitting ineligible claims to a federal health care program constitutes a violation of the False Claim Act (FCA),¹ even if you do not know they are ineligible or do not intend to commit fraud. Simply put, the government believes it is paying for services or items that have legitimate medical value when, in fact, the services or items are essentially worthless.

Here are some strategies^2-4 for avoiding potentially fraudulent billing errors:

1. Make sure you have a Medicare provider number from the local carrier in your state. (This is required by federal law.)

2. Consult your provider relations representative to discuss regulations for reimbursement.

3. Know your codes! Ignorance of the coding system is not a defense if you are charged with fraud.

4. Check the accuracy of your coding service by having an expert periodically evaluate a few of your charts. Encourage your practice to implement a compliance program, with a focus on identification and prevention of problems with coding and billing.

5. Document the necessity of any ancillary service, and know the appropriate CPT codes.

6. Order only lab tests that are medically necessary.

7. Keep current; billing regulations change frequently and ignorance of the rules will not excuse you from liability. Encourage your state professional organization to invite a coding expert to speak to the group each year.

8. Know what is being billed in your name, particularly by a third party, since you are responsible for it even if you never receive a payment (by virtue of being on salary).

To help combat fraud and abuse, PAs and NPs must become more knowledgeable about what the billing process entails. This should be part of the curriculum in school. Although it is a complex and difficult system (especially with ICD-10 coming sooner or later), there has to be rudimentary understanding to avoid traps. 

Have I overreacted? We would love to hear additional ways to avoid fraud and/or experiences with billing that you would like to share for the benefit of our readers. You can contact me at [email protected].

REFERENCES
1. Centers for Medicare and Medicaid Services. Medicare Fraud and Abuse: Prevention, Detection, and Reporting. Available at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud_and_Abuse.pdf. Accessed August 15, 2012.

2. Buppert C. Avoiding Medicare fraud, part 1. Nurse Pract. 2001;26(1):70, 72-75.

3. Buppert C. Avoiding Medicare fraud, part 2. Nurse Pract. 2001;26(2):34-38, 41.

4. Medicare 101 for PAs: Understanding Billing [podcast]. Available at: www.reachmd.com/xmsegment.aspx?sid=5782. Accessed August 15, 2012.

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.

A number of months ago I had completed a continuing medical education conference on the East Coast and had settled myself into a window seat on the airplane, heading west and homeward. I’m not much of a talker on airplanes, so I was content to relax and sink into a semi-sleep state.

It was about 30 minutes later and probably at a cruising altitude of 35,000 feet that I heard an announcement from the flight attendant asking if there was a physician on board. This, of course, got my attention, and I sat up and turned to look toward the back of the plane. I noticed some activity around one of the passengers but sat back, thinking there was probably a physician on board who would attend to the problem.

A few minutes later, a second announcement was made, asking for any medical personnel. I rang the call button and explained to the flight attendant that I was a physician assistant. Before I could explain further, she had whisked me out of my seat and back to the passenger in distress.

Thanks to many years of work in emergency medicine, it was quite apparent to me that we had a problem. The gentleman, who was clutching at his chest, was about 60 years old and obese, with a grayish skin tone and a look of terror in his eyes. I was able to determine that he was a smoker, had an extended family history of cardiac disease, and had recently gone through a bad divorce: all the answers you don’t like to hear, especially at 35,000 feet.

Providing medical assistance in the back of a cramped airplane above the roar of the engines makes an overcrowded emergency department an ideal treatment setting by comparison. Nonetheless, we administered oxygen, loosened the man’s collar, and tried to calm him as best we could.

A blood pressure cuff and stethoscope were produced for me but, as you can imagine, getting a decent blood pressure with all the fuselage noise was near-impossible. Fortunately, I was able to get a systolic pressure of 100 mm Hg, so all was not lost. An automated external defibrillator (AED), I was told, was available if needed. I was impressed with the first aid and emergency kit that was produced for my use. According to Federal Aviation Administration regulations, all commercial airlines flying in the United States that weigh 7,500 pounds or more and have at least one flight attendant on board must carry an AED and an enhanced emergency medical kit. Flight attendants must also be certified in CPR, including the use of an AED, every two years. Pilots, too, must be trained in the use of the AED.¹

It was about that time that the first officer appeared and asked me what I needed. I responded by saying that what this gentleman needed was for this plane to land and to get him to an emergency department.

My understanding is that a diversion is the captain’s decision after consultation with his or her medical command. Nonetheless, shortly thereafter, we felt a change in the altitude of the plane and within 30 minutes, we had an expedited landing at an airport somewhere in Texas (I never did learn what city we landed in). Two paramedics entered the airplane and carted the man off for more definitive care.

After being thanked by the flight attendant and the first officer, I returned to my seat and attempted to fall back into that blissful near-sleep I had hoped for. Of course, that never happened: My experience had left me wide awake and pondering.

In-flight medical emergencies, I am told, have been occurring more frequently over the years due to the rising number of air travelers, the aging of the US and European populations, and the increasing mobility of people with acute and chronic illnesses. Clinicians may suddenly find themselves in a difficult environment, in front of many onlookers, managing conditions they do not normally treat, with unfamiliar equipment.

Apparently, there are no universal guidelines for managing in-flight medical emergencies among the nearly two billion US and overseas air travelers each year.² The precise incidence of in-flight medical emergencies is unknown because there is no uniform or required reporting system, and flight crews do not routinely report minor in-flight medical incidents that do not require ground medical support. However, a few studies have looked at the number of activations of ground-based emergency medical services for passengers arriving at any given airport. The combined data suggest an incidence of 21 to 25 emergencies per million passengers, with 0.1 to 0.3 deaths per million ­passengers.^2,3

After returning home, I found some good advice in an article in the New England Journal of Medicine. Should you find yourself in a situation similar to mine, Gendreau and DeJohn⁴ suggest that you:

1. Identify yourself to the cabin crew and explain your qualifications.

2. Ask the patient for permission before taking a complete history and performing a thorough physical exam.

3. If necessary, use an interpreter.

4. If the patient is in critical condition, request diversion to the nearest airport.

5. Cooperate with the on-ground medical staff.

6. Keep a detailed written medical record of your patient encounter.

7. Perform only treatments you are qualified to administer.^4,5

Since that time, I have wondered how many stories like this are out there and thought it would be interesting to ask Clinician Reviews’ readers to share their experiences. So, this editorial is a call to you: If you have a story like this, whether it took place on an airplane or the golf course, while you were fishing or attending an athletic event, please share it with us. Limit your story to about 1,000 words and send it to [email protected]. Perhaps we can publish some of your responses on our Web site.

Or if you just want to comment on this editorial, we would also love to hear from you.  

REFERENCES
1. Chandra A, Conry S. Be prepared for in-flight medical emergencies. ACEP [American College of Emergency Physicians] News (August 2010). www.acep.org/content.spx?id=49206. Accessed October 17, 2011.

2. Lyznicki JM, Williams MA, Deitchman SD, Howe JP 3rd; Council on Scientific Affairs, American Medical Association. Inflight medical emergencies. Aviat Space Environ Med. 2000; 71(8):832-838.

3. Delaune EF 3rd, Lucas RH, Illig P. In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med. 2003;74(1):62-68.

4. Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002;346(14):1067-1073.

5. Newson-Smith MS. Passenger doctors in civil airliners: obligations, duties and standards of care. Aviat Space Environ Med. 1997; 68(12):1134-1138.

The past year or so has seen a virtual explosion of new or renewed interest in the perennial PA name-change discussion. Last year, 100 PA leaders signed a document calling for the profession to change its name to physician associate. This year, more than 5,000 PAs signed an online petition to the American Academy of Physician Assistants (AAPA) calling for the change. Some advocates have taken up the issue on blogs and online discussion forums; even YouTube has videos about this issue!

This is not a new debate, so one must ask why it suddenly became important again. Many have referred to the lines in Shakespeare’s Romeo and Juliet in which Juliet says, “’Tis but thy name that is my enemy…. What’s in a name? That which we call a rose by any other name would smell as sweet.” In other words, a name is an artificial and meaningless convention.

Is this, in fact, analogous to the PA name-change debate? Is it less important what we are called and more important what we do? Or is it both? This certainly lies at the core of our debate. One must ask, as in this case, how a name influences a person’s character and/or profession. Is it just sound and alphabetical symbols? Or is it the intellectual embodiment of who we are? One would think the answer is obvious.

Nevertheless, for the past three or four years, I have remained on the fence regarding this debate. I have been apolitical, except for the occasional comment to close friends that I thought the debate was a colossal waste of time. As with a lot of ideas, however, timing is everything, and I have now come to the realization that the time has come. I have changed my mind. With apologies to my NP colleagues for being so PA-centric in this editorial (although I welcome your comments) and at the risk of alienating some of my close professional friends, I have decided to speak openly and share my thoughts in support of change.

Having been in the profession almost four decades, I have witnessed significant changes in the PA scope of practice, including subtle transitions in the relationship between PAs and their supervising physicians (all positive, I might add). The word assistant may have worked well in the 1970s and ’80s, as we were defining the profession and not wanting to step on the toes of organized medicine. But as PAs became integral members of the health care team, this nomenclature paled.

In fact, the debate is not really for a wholesale name change but for a name modification to provide clarity to our physician colleagues, our patients, regulators, third-party payers, and our current and future students. While many suggest the name-change debate is very egocentric, I actually think we owe it to everyone else to settle this question.

Let me review the issues as I see them, albeit editorial in nature, and share my comments. I do this while sharing what I call the four “Laws of Nature” that I have used in decision-making.

The Law of Perception: People tend to think that in the marketplace of ideas, services, or products, the best will win. However, as Ries and Trout say in their book The 22 Immutable Laws of Marketing, “Marketing is not a battle of products; it’s a battle of perceptions.”¹ It has been said that perception is reality—everything else is illusion. While this concept seems unfair, it is fundamental, and we might as well get used to it. 

If indeed, as many have suggested, the term assistant does not describe what PAs do, and the public (ie, patients) has trouble understanding the distinction between physician assistant and medical assistant, then we have a perception problem. And thus, we also have a reality problem. I’m not sure that the old solution—throwing more money at public education to redefine or further explain the term assistant—will yield much reward. In fact, it may only further confound the situation if we wind up convincing the public that their medical assistant can do what PAs do.

The Law of Focus: Again, according to Ries and Trout, the most powerful concept in marketing is owning a word or a phrase.¹ Once a word or phrase is ingrained in the mind of the public and is associated with a product (or in this case, a profession), it becomes an incredible success. Nurse practitioners have accomplished this with their name. There are few people I have met who do not understand what an NP is or does. The same is true for RNs and physicians and attorneys.

A successful marketer has to “burn” their way into the mind of the public by narrowing the focus to a single word or concept. The most effective words are simple and benefits oriented, and have a clear meaning. I am not sure that assistant in this case has a clear meaning—at least, not the one we want. Moving to associate has the potential for us to “brand” our name. It will no longer be generic, and it is clearly more descriptive of where PAs are as a profession today.

The Law of Exclusivity: Two professions cannot own the same word (or name) in the public’s mind. This is where the term assistant causes the biggest problem, since many health professions—particularly medical assistants, nursing assistants, anesthesiology assistants, and surgical assistants—share that title as well.

On the other hand, the term associate isn’t exactly unique either: There are associate deans, associate partners, and associate professors. I would argue, though, that (a) the term associate isn’t widely used in health care as a job title and (b) associate is usually used as a descriptor rather than as the name of an actual profession. Marrying physician to associate certainly clarifies the phrase and creates a new name that could be leveraged to send a powerful message about our role and our relationship to the physicians with whom we work. When thinking of that name, I refer you back to the laws of perception and focus.

The Law of Unintended Consequences: You are probably familiar with this one, the idea that actions have effects that are unanticipated or unintended. Economists, social scientists, and strategists have heeded this law for centuries. It is also true that politicians and popular opinion have largely ignored it.

This is a law that we cannot afford to ignore. One could say (and many have) that we have worked long and hard to ingrain the physician assistant name in state and federal statutes, hospital bylaws, public service announcements, the public consciousness, etc, and many wonder if changing the name now would have negative consequences for the profession.

Some have postulated that changing the name would be a huge task that would eat up millions of dollars and years of time. I think this a bit of an overstatement.  (Easy for me to say, right?) Others say that changing assistant to associate may just be a “cosmetic” or “technical” fix with state legislators, hospital administrators, and third-party payers.

As a PA who has been involved in state legislative efforts for more than three decades, I tend to favor the latter viewpoint. With the right support (and the right timing), the change could be fairly barrier-free. It is often done in legislatures when names of organizations, certification bodies, and others are changed. Getting rid of the apostrophe-s years ago is a case in point. When this happened, we changed our name in state legislatures throughout the country; it did not cost millions of dollars, and there were no significant attacks on our scope of practice.

The biggest perceived barrier, of course, is the support of physicians, particularly the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American College of Surgeons, and the rest of “organized medicine” (see law of perception). However, if we convince these groups that a name change would not alter the scope of practice nor signal a move for independent practice, then we may be able to engender their political support.

If the perception is otherwise, it could be problematic. However, PAs have become strong members of the health care team, and I think physicians and federal agencies recognize our importance in being part of the solution to caring for the 34 million new patients who will soon enter the system. 

I must also mention that without the active support of the AAPA, the Physician Assistant Education Association, and the National Commission on Certification of Physician Assistants, the name change issue will likely die on the vine. The old saying that “we should hang together or certainly we will hang separately” makes an important and serious political statement. I call on state and national PA leaders to listen to their constituents on this issue.

Many prominent PAs have spoken eloquently on the name change issue. Robert Blumm suggested, “The word assistant no longer reflects what we do or who we are as a profession.”² Vic Germino, one of the first three PAs in the country, has said: “PAs are associated with physicians in ways that enhance their ability to practice with their particular population of patients, whether that enhancement involves assisting in surgery, managing chronic illness, doing preventive and educational care, practicing in underserved areas to extend the physician’s ability to reach more patients, or doing research. We use our variety of skills and our knowledge and education to function as associates and colleagues in these and other ways. Clearly, the level of independence (with supervision) of most PAs today is far beyond the generic term assistant that has been applied to health care workers with as little as six to 12 weeks of training.”³

Even some of those who are opposed to a name-change effort have acknowledged the merits of the idea. Professor James Cawley says, “While intellectually I wholeheartedly agree with change proponents that physician assistant is an undesirable name for the profession, and agree that physician associate would be a far better and more accurate name for the profession, practically speaking, it’s just not going to happen.”⁴

If indeed we are “Here for the Long Haul” as new AAPA President Robert Wooten said in his first President’s Letter,⁵ then it is time to do what is right for our profession. If we want to continue to attract some of the best and brightest to our programs, then it is time to do what is right for our students. If indeed we are tired of sacrificing time with new patients and others to explain that our name doesn’t mean what it sounds like it means and that we are in fact qualified to provide their care, then it is time to do what is right. But as Colin Powell once said, “A dream doesn’t become reality through magic; it takes sweat, determination, and hard work.” 

Are we, as a profession, ready to invest in this yet? I hope so. As always, I welcome your comments at [email protected].

REFERENCES
1. Ries A, Trout J. The 22 Immutable Laws of Marketing: Violate Them at Your Own Risk! Harper-Collins Publishers; 1993.

2. Blumm RM. Physician associate: a name that reflects our heritage and future. PA Professional. 2011;3(5):26.

3. Germino VH. Personal communication.

4. Cawley JF. Get used to it: why the name change is impractical. PA Professional. 2011;3(5):27.

5. Wooten RL. President’s letter: here for the long haul. PA Professional. 2011;3(5):5.

The past year or so has seen a virtual explosion of new or renewed interest in the perennial PA name-change discussion. Last year, 100 PA leaders signed a document calling for the profession to change its name to physician associate. This year, more than 5,000 PAs signed an online petition to the American Academy of Physician Assistants (AAPA) calling for the change. Some advocates have taken up the issue on blogs and online discussion forums; even YouTube has videos about this issue!

This is not a new debate, so one must ask why it suddenly became important again. Many have referred to the lines in Shakespeare’s Romeo and Juliet in which Juliet says, “’Tis but thy name that is my enemy…. What’s in a name? That which we call a rose by any other name would smell as sweet.” In other words, a name is an artificial and meaningless convention.

Is this, in fact, analogous to the PA name-change debate? Is it less important what we are called and more important what we do? Or is it both? This certainly lies at the core of our debate. One must ask, as in this case, how a name influences a person’s character and/or profession. Is it just sound and alphabetical symbols? Or is it the intellectual embodiment of who we are? One would think the answer is obvious.

Nevertheless, for the past three or four years, I have remained on the fence regarding this debate. I have been apolitical, except for the occasional comment to close friends that I thought the debate was a colossal waste of time. As with a lot of ideas, however, timing is everything, and I have now come to the realization that the time has come. I have changed my mind. With apologies to my NP colleagues for being so PA-centric in this editorial (although I welcome your comments) and at the risk of alienating some of my close professional friends, I have decided to speak openly and share my thoughts in support of change.

Having been in the profession almost four decades, I have witnessed significant changes in the PA scope of practice, including subtle transitions in the relationship between PAs and their supervising physicians (all positive, I might add). The word assistant may have worked well in the 1970s and ’80s, as we were defining the profession and not wanting to step on the toes of organized medicine. But as PAs became integral members of the health care team, this nomenclature paled.

In fact, the debate is not really for a wholesale name change but for a name modification to provide clarity to our physician colleagues, our patients, regulators, third-party payers, and our current and future students. While many suggest the name-change debate is very egocentric, I actually think we owe it to everyone else to settle this question.

Let me review the issues as I see them, albeit editorial in nature, and share my comments. I do this while sharing what I call the four “Laws of Nature” that I have used in decision-making.

The Law of Perception: People tend to think that in the marketplace of ideas, services, or products, the best will win. However, as Ries and Trout say in their book The 22 Immutable Laws of Marketing, “Marketing is not a battle of products; it’s a battle of perceptions.”¹ It has been said that perception is reality—everything else is illusion. While this concept seems unfair, it is fundamental, and we might as well get used to it. 

If indeed, as many have suggested, the term assistant does not describe what PAs do, and the public (ie, patients) has trouble understanding the distinction between physician assistant and medical assistant, then we have a perception problem. And thus, we also have a reality problem. I’m not sure that the old solution—throwing more money at public education to redefine or further explain the term assistant—will yield much reward. In fact, it may only further confound the situation if we wind up convincing the public that their medical assistant can do what PAs do.

The Law of Focus: Again, according to Ries and Trout, the most powerful concept in marketing is owning a word or a phrase.¹ Once a word or phrase is ingrained in the mind of the public and is associated with a product (or in this case, a profession), it becomes an incredible success. Nurse practitioners have accomplished this with their name. There are few people I have met who do not understand what an NP is or does. The same is true for RNs and physicians and attorneys.

A successful marketer has to “burn” their way into the mind of the public by narrowing the focus to a single word or concept. The most effective words are simple and benefits oriented, and have a clear meaning. I am not sure that assistant in this case has a clear meaning—at least, not the one we want. Moving to associate has the potential for us to “brand” our name. It will no longer be generic, and it is clearly more descriptive of where PAs are as a profession today.

The Law of Exclusivity: Two professions cannot own the same word (or name) in the public’s mind. This is where the term assistant causes the biggest problem, since many health professions—particularly medical assistants, nursing assistants, anesthesiology assistants, and surgical assistants—share that title as well.

On the other hand, the term associate isn’t exactly unique either: There are associate deans, associate partners, and associate professors. I would argue, though, that (a) the term associate isn’t widely used in health care as a job title and (b) associate is usually used as a descriptor rather than as the name of an actual profession. Marrying physician to associate certainly clarifies the phrase and creates a new name that could be leveraged to send a powerful message about our role and our relationship to the physicians with whom we work. When thinking of that name, I refer you back to the laws of perception and focus.

The Law of Unintended Consequences: You are probably familiar with this one, the idea that actions have effects that are unanticipated or unintended. Economists, social scientists, and strategists have heeded this law for centuries. It is also true that politicians and popular opinion have largely ignored it.

This is a law that we cannot afford to ignore. One could say (and many have) that we have worked long and hard to ingrain the physician assistant name in state and federal statutes, hospital bylaws, public service announcements, the public consciousness, etc, and many wonder if changing the name now would have negative consequences for the profession.

Some have postulated that changing the name would be a huge task that would eat up millions of dollars and years of time. I think this a bit of an overstatement.  (Easy for me to say, right?) Others say that changing assistant to associate may just be a “cosmetic” or “technical” fix with state legislators, hospital administrators, and third-party payers.

As a PA who has been involved in state legislative efforts for more than three decades, I tend to favor the latter viewpoint. With the right support (and the right timing), the change could be fairly barrier-free. It is often done in legislatures when names of organizations, certification bodies, and others are changed. Getting rid of the apostrophe-s years ago is a case in point. When this happened, we changed our name in state legislatures throughout the country; it did not cost millions of dollars, and there were no significant attacks on our scope of practice.

The biggest perceived barrier, of course, is the support of physicians, particularly the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American College of Surgeons, and the rest of “organized medicine” (see law of perception). However, if we convince these groups that a name change would not alter the scope of practice nor signal a move for independent practice, then we may be able to engender their political support.

If the perception is otherwise, it could be problematic. However, PAs have become strong members of the health care team, and I think physicians and federal agencies recognize our importance in being part of the solution to caring for the 34 million new patients who will soon enter the system. 

I must also mention that without the active support of the AAPA, the Physician Assistant Education Association, and the National Commission on Certification of Physician Assistants, the name change issue will likely die on the vine. The old saying that “we should hang together or certainly we will hang separately” makes an important and serious political statement. I call on state and national PA leaders to listen to their constituents on this issue.

Many prominent PAs have spoken eloquently on the name change issue. Robert Blumm suggested, “The word assistant no longer reflects what we do or who we are as a profession.”² Vic Germino, one of the first three PAs in the country, has said: “PAs are associated with physicians in ways that enhance their ability to practice with their particular population of patients, whether that enhancement involves assisting in surgery, managing chronic illness, doing preventive and educational care, practicing in underserved areas to extend the physician’s ability to reach more patients, or doing research. We use our variety of skills and our knowledge and education to function as associates and colleagues in these and other ways. Clearly, the level of independence (with supervision) of most PAs today is far beyond the generic term assistant that has been applied to health care workers with as little as six to 12 weeks of training.”³

Even some of those who are opposed to a name-change effort have acknowledged the merits of the idea. Professor James Cawley says, “While intellectually I wholeheartedly agree with change proponents that physician assistant is an undesirable name for the profession, and agree that physician associate would be a far better and more accurate name for the profession, practically speaking, it’s just not going to happen.”⁴

If indeed we are “Here for the Long Haul” as new AAPA President Robert Wooten said in his first President’s Letter,⁵ then it is time to do what is right for our profession. If we want to continue to attract some of the best and brightest to our programs, then it is time to do what is right for our students. If indeed we are tired of sacrificing time with new patients and others to explain that our name doesn’t mean what it sounds like it means and that we are in fact qualified to provide their care, then it is time to do what is right. But as Colin Powell once said, “A dream doesn’t become reality through magic; it takes sweat, determination, and hard work.” 

Are we, as a profession, ready to invest in this yet? I hope so. As always, I welcome your comments at [email protected].

REFERENCES
1. Ries A, Trout J. The 22 Immutable Laws of Marketing: Violate Them at Your Own Risk! Harper-Collins Publishers; 1993.

2. Blumm RM. Physician associate: a name that reflects our heritage and future. PA Professional. 2011;3(5):26.

3. Germino VH. Personal communication.

4. Cawley JF. Get used to it: why the name change is impractical. PA Professional. 2011;3(5):27.

5. Wooten RL. President’s letter: here for the long haul. PA Professional. 2011;3(5):5.

The past year or so has seen a virtual explosion of new or renewed interest in the perennial PA name-change discussion. Last year, 100 PA leaders signed a document calling for the profession to change its name to physician associate. This year, more than 5,000 PAs signed an online petition to the American Academy of Physician Assistants (AAPA) calling for the change. Some advocates have taken up the issue on blogs and online discussion forums; even YouTube has videos about this issue!

This is not a new debate, so one must ask why it suddenly became important again. Many have referred to the lines in Shakespeare’s Romeo and Juliet in which Juliet says, “’Tis but thy name that is my enemy…. What’s in a name? That which we call a rose by any other name would smell as sweet.” In other words, a name is an artificial and meaningless convention.

Is this, in fact, analogous to the PA name-change debate? Is it less important what we are called and more important what we do? Or is it both? This certainly lies at the core of our debate. One must ask, as in this case, how a name influences a person’s character and/or profession. Is it just sound and alphabetical symbols? Or is it the intellectual embodiment of who we are? One would think the answer is obvious.

Nevertheless, for the past three or four years, I have remained on the fence regarding this debate. I have been apolitical, except for the occasional comment to close friends that I thought the debate was a colossal waste of time. As with a lot of ideas, however, timing is everything, and I have now come to the realization that the time has come. I have changed my mind. With apologies to my NP colleagues for being so PA-centric in this editorial (although I welcome your comments) and at the risk of alienating some of my close professional friends, I have decided to speak openly and share my thoughts in support of change.

Having been in the profession almost four decades, I have witnessed significant changes in the PA scope of practice, including subtle transitions in the relationship between PAs and their supervising physicians (all positive, I might add). The word assistant may have worked well in the 1970s and ’80s, as we were defining the profession and not wanting to step on the toes of organized medicine. But as PAs became integral members of the health care team, this nomenclature paled.

In fact, the debate is not really for a wholesale name change but for a name modification to provide clarity to our physician colleagues, our patients, regulators, third-party payers, and our current and future students. While many suggest the name-change debate is very egocentric, I actually think we owe it to everyone else to settle this question.

Let me review the issues as I see them, albeit editorial in nature, and share my comments. I do this while sharing what I call the four “Laws of Nature” that I have used in decision-making.

The Law of Perception: People tend to think that in the marketplace of ideas, services, or products, the best will win. However, as Ries and Trout say in their book The 22 Immutable Laws of Marketing, “Marketing is not a battle of products; it’s a battle of perceptions.”¹ It has been said that perception is reality—everything else is illusion. While this concept seems unfair, it is fundamental, and we might as well get used to it. 

If indeed, as many have suggested, the term assistant does not describe what PAs do, and the public (ie, patients) has trouble understanding the distinction between physician assistant and medical assistant, then we have a perception problem. And thus, we also have a reality problem. I’m not sure that the old solution—throwing more money at public education to redefine or further explain the term assistant—will yield much reward. In fact, it may only further confound the situation if we wind up convincing the public that their medical assistant can do what PAs do.

The Law of Focus: Again, according to Ries and Trout, the most powerful concept in marketing is owning a word or a phrase.¹ Once a word or phrase is ingrained in the mind of the public and is associated with a product (or in this case, a profession), it becomes an incredible success. Nurse practitioners have accomplished this with their name. There are few people I have met who do not understand what an NP is or does. The same is true for RNs and physicians and attorneys.

A successful marketer has to “burn” their way into the mind of the public by narrowing the focus to a single word or concept. The most effective words are simple and benefits oriented, and have a clear meaning. I am not sure that assistant in this case has a clear meaning—at least, not the one we want. Moving to associate has the potential for us to “brand” our name. It will no longer be generic, and it is clearly more descriptive of where PAs are as a profession today.

The Law of Exclusivity: Two professions cannot own the same word (or name) in the public’s mind. This is where the term assistant causes the biggest problem, since many health professions—particularly medical assistants, nursing assistants, anesthesiology assistants, and surgical assistants—share that title as well.

On the other hand, the term associate isn’t exactly unique either: There are associate deans, associate partners, and associate professors. I would argue, though, that (a) the term associate isn’t widely used in health care as a job title and (b) associate is usually used as a descriptor rather than as the name of an actual profession. Marrying physician to associate certainly clarifies the phrase and creates a new name that could be leveraged to send a powerful message about our role and our relationship to the physicians with whom we work. When thinking of that name, I refer you back to the laws of perception and focus.

The Law of Unintended Consequences: You are probably familiar with this one, the idea that actions have effects that are unanticipated or unintended. Economists, social scientists, and strategists have heeded this law for centuries. It is also true that politicians and popular opinion have largely ignored it.

This is a law that we cannot afford to ignore. One could say (and many have) that we have worked long and hard to ingrain the physician assistant name in state and federal statutes, hospital bylaws, public service announcements, the public consciousness, etc, and many wonder if changing the name now would have negative consequences for the profession.

Some have postulated that changing the name would be a huge task that would eat up millions of dollars and years of time. I think this a bit of an overstatement.  (Easy for me to say, right?) Others say that changing assistant to associate may just be a “cosmetic” or “technical” fix with state legislators, hospital administrators, and third-party payers.

As a PA who has been involved in state legislative efforts for more than three decades, I tend to favor the latter viewpoint. With the right support (and the right timing), the change could be fairly barrier-free. It is often done in legislatures when names of organizations, certification bodies, and others are changed. Getting rid of the apostrophe-s years ago is a case in point. When this happened, we changed our name in state legislatures throughout the country; it did not cost millions of dollars, and there were no significant attacks on our scope of practice.

The biggest perceived barrier, of course, is the support of physicians, particularly the American Medical Association, the American Osteopathic Association, the American Academy of Family Physicians, the American College of Surgeons, and the rest of “organized medicine” (see law of perception). However, if we convince these groups that a name change would not alter the scope of practice nor signal a move for independent practice, then we may be able to engender their political support.

If the perception is otherwise, it could be problematic. However, PAs have become strong members of the health care team, and I think physicians and federal agencies recognize our importance in being part of the solution to caring for the 34 million new patients who will soon enter the system. 

I must also mention that without the active support of the AAPA, the Physician Assistant Education Association, and the National Commission on Certification of Physician Assistants, the name change issue will likely die on the vine. The old saying that “we should hang together or certainly we will hang separately” makes an important and serious political statement. I call on state and national PA leaders to listen to their constituents on this issue.

Many prominent PAs have spoken eloquently on the name change issue. Robert Blumm suggested, “The word assistant no longer reflects what we do or who we are as a profession.”² Vic Germino, one of the first three PAs in the country, has said: “PAs are associated with physicians in ways that enhance their ability to practice with their particular population of patients, whether that enhancement involves assisting in surgery, managing chronic illness, doing preventive and educational care, practicing in underserved areas to extend the physician’s ability to reach more patients, or doing research. We use our variety of skills and our knowledge and education to function as associates and colleagues in these and other ways. Clearly, the level of independence (with supervision) of most PAs today is far beyond the generic term assistant that has been applied to health care workers with as little as six to 12 weeks of training.”³

Even some of those who are opposed to a name-change effort have acknowledged the merits of the idea. Professor James Cawley says, “While intellectually I wholeheartedly agree with change proponents that physician assistant is an undesirable name for the profession, and agree that physician associate would be a far better and more accurate name for the profession, practically speaking, it’s just not going to happen.”⁴

If indeed we are “Here for the Long Haul” as new AAPA President Robert Wooten said in his first President’s Letter,⁵ then it is time to do what is right for our profession. If we want to continue to attract some of the best and brightest to our programs, then it is time to do what is right for our students. If indeed we are tired of sacrificing time with new patients and others to explain that our name doesn’t mean what it sounds like it means and that we are in fact qualified to provide their care, then it is time to do what is right. But as Colin Powell once said, “A dream doesn’t become reality through magic; it takes sweat, determination, and hard work.” 

Are we, as a profession, ready to invest in this yet? I hope so. As always, I welcome your comments at [email protected].

REFERENCES
1. Ries A, Trout J. The 22 Immutable Laws of Marketing: Violate Them at Your Own Risk! Harper-Collins Publishers; 1993.

2. Blumm RM. Physician associate: a name that reflects our heritage and future. PA Professional. 2011;3(5):26.

3. Germino VH. Personal communication.

4. Cawley JF. Get used to it: why the name change is impractical. PA Professional. 2011;3(5):27.

5. Wooten RL. President’s letter: here for the long haul. PA Professional. 2011;3(5):5.

The past few months have been a season of graduations for new NPs and PAs across the country. Recently, I tallied all the graduation ceremonies I have attended since I began my journey in academe some 16 years ago, which came out to about 27 ceremonies—so I have watched more than 4,500 graduates walk across the stage. How exciting that has been!

Last year, I had the opportunity to be a commencement speaker, a daunting responsibility and one that I did not take lightly. I’d like to share my graduation comments with you in this editorial—dedicated to all the new PA and NP grads:

Garry Trudeau, an American cartoonist best known for the Doonesbury comic strip, said, “Commencement speeches were invented largely in the belief that outgoing college students should never be released unto the world until they have been properly sedated.” With that in mind, I will keep my remarks to a minimum. I promise. The educational process has been the subject of a great deal of comment by academics and writers over the past few decades. It has been said that education is an easy target for criticism because its stated aims are often so nobly ambitious that they have little chance of being realized. According to the poet Robert Frost, education is “hanging around until you’ve caught on.”

Your class, like most graduating classes, is unique. You come from all walks of life and all points on the map. As you are poised today on this joyous yet transitional moment, I encourage you to imagine an image of standing on the shoulders of giants. Sir Isaac Newton said, “We are like dwarfs sitting on the shoulders of giants. We see more, and things that are more distant, than they did, not because our sight is superior or because we are taller than they, but because they raise us up, and by their great stature add to ours.”

Whatever image this calls to mind for you, I want to briefly tell you about three important giants. The first is that colleague, family member, or professor who was your mentor. For me, it was Dr. Burton Brasher, a preceptor, mentor, and friend who taught me the importance of sitting with patients and allowing them to be partners in their own care. Integrity and compassion are what he brought to the table as a family doctor in the 1970s and ’80s. I recently had the opportunity to attend his 90th birthday party. Indeed, I had the opportunity to stand on the shoulders of a giant.

The second giant is well known to you. Many examples are seated behind me and perhaps seated behind you now. Who is that person who has equipped you to enter your chosen profession? Who is that person who supported you at home from grade school to grad school? Your faculty, both didactic and clinical, and your family and friends are giants who have given you the opportunity to stand on their shoulders. 

The third giant will be born in just a few minutes. That giant, ladies and gentlemen, is you. You now have the opportunity to take your knowledge and skills, your integrity and your compassion, and become a giant in your community. A giant that others can stand on, lean on, rely on, whether they be family members, friends, or students. As John F. Kennedy said, “The torch has been passed to a new generation.” I urge you to take hold of that torch.

The diversity among you has enriched your school, the university as a whole, and each of you individually. While what you brought was diverse, you will all leave with the same credential—a degree setting you apart as a clinician. The degree you will receive today is much more than a piece of paper, much more than initials behind your name.

You have been reminded many times about the expectations that society has for you. Those expectations will only increase as you go forth from today. Your profession has a calling that is devoted to health, healing, caring, and compassion. Society has entrusted its health and well-being to you, and with that trust comes a responsibility that is unmatched in other professions.

While you’ve spent long, sometimes grueling, hours mastering the skills of your new profession, what will make the difference in your success now is what comes from your heart.

Your work will be filled with challenges and opportunities, moments of disappointment, years of joy. Your patients will share their innermost thoughts and life experiences, things they won’t share with anyone else—not parents, not children, not spouses.

Despite the best educational preparation, I expect—and actually hope—you have some trepidation as you prepare to take your first real steps into your chosen profession. I encourage you to remember what that hesitation feels like and never lose sight of it. You must never become complacent. Health care is an ever-changing profession and you must forever be a student for the sake of your patients and your profession.

The uncertainty I’m describing is normal, but I assure you that you have the ability to succeed and we—the giants upon whose shoulders you stand today—are certain you will become some of the best clinicians, no matter where your career takes you. 

Today marks the beginning of your new identity. No matter what you choose to do, whether you see patients or take care of athletes, teach students, work in a research laboratory, or draft health policy, being a member of your profession will forever remain a part of your central identity. Over time, it will likely become the most important part of who you are.

And no matter how hard you try to avoid it, you will be recognized. At the grocery store, the church, the barber shop, the hair salon, football games, shopping malls, your children’s school plays, your son or daughter’s athletic event, on the beach—someone will come up to you and say, “That’s Gary Jones, he’s a PA,” or “Let me introduce you to my daughter, Nikita Wells, the nurse practitioner.” There will be no escape. So my advice is, embrace it.

It defines you not just to your patients, but to your family and friends who will consult you first for every health issue, whether it’s in your field of expertise or not. They may not always believe or accept what you tell them, but they will always consult you. Even more, it will define you to society as being someone who is quite distinct, someone who has the highest integrity and someone they can trust.

The diploma you receive today is a symbol of a deep commitment to promoting our expectations of professionalism, humanism, and compassion. From this day forward, it no longer is exclusively or even most often about you. All of your experiences to this moment have raised you up as a giant for your patients, your colleagues, your profession, and everyone you will come into contact with from this day forward. 

You must remain committed to maintaining life-long learning skills, to putting the interests of your patients above your own, to striving to treat patients with the highest possible standards, to respecting the values, culture, and dignity of every patient, and to working respectfully with other health professionals to ensure the best care for your patients.

Let me bring my remarks to a close with a few thoughts about the current challenges your professions face today.

Despite the increasing use of diagnostic technologies and advancements in therapeutic abilities, we are witnesses to increasing disparities in the delivery of health care.

Despite spending more on health care than many other developed nations, we have one of the highest percentages of uninsured citizens, leading to increased and preventable diseases. 

The threats of medical liability are ever present. Reimbursement isn’t always what we feel it should be.

These challenges lead some to become disillusioned and cynical. Be aware of those pitfalls, and always remember, whether you’re in the emergency department, the urgent care center, the orthopedic clinic, the surgical suite, or an exam room and it’s just you and your patient—yours is a profession of compassion, integrity, and service.

As Alan Kay, an American computer scientist, researcher, and visionary, once said, “The best way to predict the future is to invent it.” Therefore, I ask you to go out and face the challenges head-on and do your part to provide the best quality care to all citizens. America’s health care and that of the world is depending on each of you to make an impact. They are poised to stand on your shoulders to see further and to do more than ever before.

And now for the two words you have been waiting for: In conclusion, let me share with you a quote from my favorite professor—a giant in his own right—Dr. Seuss, who said, “You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And you are the one who’ll decide where to go.”

Best wishes and Godspeed.

Feel free to send your comments about this editorial to [email protected].

The past few months have been a season of graduations for new NPs and PAs across the country. Recently, I tallied all the graduation ceremonies I have attended since I began my journey in academe some 16 years ago, which came out to about 27 ceremonies—so I have watched more than 4,500 graduates walk across the stage. How exciting that has been!

Last year, I had the opportunity to be a commencement speaker, a daunting responsibility and one that I did not take lightly. I’d like to share my graduation comments with you in this editorial—dedicated to all the new PA and NP grads:

Garry Trudeau, an American cartoonist best known for the Doonesbury comic strip, said, “Commencement speeches were invented largely in the belief that outgoing college students should never be released unto the world until they have been properly sedated.” With that in mind, I will keep my remarks to a minimum. I promise. The educational process has been the subject of a great deal of comment by academics and writers over the past few decades. It has been said that education is an easy target for criticism because its stated aims are often so nobly ambitious that they have little chance of being realized. According to the poet Robert Frost, education is “hanging around until you’ve caught on.”

Your class, like most graduating classes, is unique. You come from all walks of life and all points on the map. As you are poised today on this joyous yet transitional moment, I encourage you to imagine an image of standing on the shoulders of giants. Sir Isaac Newton said, “We are like dwarfs sitting on the shoulders of giants. We see more, and things that are more distant, than they did, not because our sight is superior or because we are taller than they, but because they raise us up, and by their great stature add to ours.”

Whatever image this calls to mind for you, I want to briefly tell you about three important giants. The first is that colleague, family member, or professor who was your mentor. For me, it was Dr. Burton Brasher, a preceptor, mentor, and friend who taught me the importance of sitting with patients and allowing them to be partners in their own care. Integrity and compassion are what he brought to the table as a family doctor in the 1970s and ’80s. I recently had the opportunity to attend his 90th birthday party. Indeed, I had the opportunity to stand on the shoulders of a giant.

The second giant is well known to you. Many examples are seated behind me and perhaps seated behind you now. Who is that person who has equipped you to enter your chosen profession? Who is that person who supported you at home from grade school to grad school? Your faculty, both didactic and clinical, and your family and friends are giants who have given you the opportunity to stand on their shoulders. 

The third giant will be born in just a few minutes. That giant, ladies and gentlemen, is you. You now have the opportunity to take your knowledge and skills, your integrity and your compassion, and become a giant in your community. A giant that others can stand on, lean on, rely on, whether they be family members, friends, or students. As John F. Kennedy said, “The torch has been passed to a new generation.” I urge you to take hold of that torch.

The diversity among you has enriched your school, the university as a whole, and each of you individually. While what you brought was diverse, you will all leave with the same credential—a degree setting you apart as a clinician. The degree you will receive today is much more than a piece of paper, much more than initials behind your name.

You have been reminded many times about the expectations that society has for you. Those expectations will only increase as you go forth from today. Your profession has a calling that is devoted to health, healing, caring, and compassion. Society has entrusted its health and well-being to you, and with that trust comes a responsibility that is unmatched in other professions.

While you’ve spent long, sometimes grueling, hours mastering the skills of your new profession, what will make the difference in your success now is what comes from your heart.

Your work will be filled with challenges and opportunities, moments of disappointment, years of joy. Your patients will share their innermost thoughts and life experiences, things they won’t share with anyone else—not parents, not children, not spouses.

Despite the best educational preparation, I expect—and actually hope—you have some trepidation as you prepare to take your first real steps into your chosen profession. I encourage you to remember what that hesitation feels like and never lose sight of it. You must never become complacent. Health care is an ever-changing profession and you must forever be a student for the sake of your patients and your profession.

The uncertainty I’m describing is normal, but I assure you that you have the ability to succeed and we—the giants upon whose shoulders you stand today—are certain you will become some of the best clinicians, no matter where your career takes you. 

Today marks the beginning of your new identity. No matter what you choose to do, whether you see patients or take care of athletes, teach students, work in a research laboratory, or draft health policy, being a member of your profession will forever remain a part of your central identity. Over time, it will likely become the most important part of who you are.

And no matter how hard you try to avoid it, you will be recognized. At the grocery store, the church, the barber shop, the hair salon, football games, shopping malls, your children’s school plays, your son or daughter’s athletic event, on the beach—someone will come up to you and say, “That’s Gary Jones, he’s a PA,” or “Let me introduce you to my daughter, Nikita Wells, the nurse practitioner.” There will be no escape. So my advice is, embrace it.

It defines you not just to your patients, but to your family and friends who will consult you first for every health issue, whether it’s in your field of expertise or not. They may not always believe or accept what you tell them, but they will always consult you. Even more, it will define you to society as being someone who is quite distinct, someone who has the highest integrity and someone they can trust.

The diploma you receive today is a symbol of a deep commitment to promoting our expectations of professionalism, humanism, and compassion. From this day forward, it no longer is exclusively or even most often about you. All of your experiences to this moment have raised you up as a giant for your patients, your colleagues, your profession, and everyone you will come into contact with from this day forward. 

You must remain committed to maintaining life-long learning skills, to putting the interests of your patients above your own, to striving to treat patients with the highest possible standards, to respecting the values, culture, and dignity of every patient, and to working respectfully with other health professionals to ensure the best care for your patients.

Let me bring my remarks to a close with a few thoughts about the current challenges your professions face today.

Despite the increasing use of diagnostic technologies and advancements in therapeutic abilities, we are witnesses to increasing disparities in the delivery of health care.

Despite spending more on health care than many other developed nations, we have one of the highest percentages of uninsured citizens, leading to increased and preventable diseases. 

The threats of medical liability are ever present. Reimbursement isn’t always what we feel it should be.

These challenges lead some to become disillusioned and cynical. Be aware of those pitfalls, and always remember, whether you’re in the emergency department, the urgent care center, the orthopedic clinic, the surgical suite, or an exam room and it’s just you and your patient—yours is a profession of compassion, integrity, and service.

As Alan Kay, an American computer scientist, researcher, and visionary, once said, “The best way to predict the future is to invent it.” Therefore, I ask you to go out and face the challenges head-on and do your part to provide the best quality care to all citizens. America’s health care and that of the world is depending on each of you to make an impact. They are poised to stand on your shoulders to see further and to do more than ever before.

And now for the two words you have been waiting for: In conclusion, let me share with you a quote from my favorite professor—a giant in his own right—Dr. Seuss, who said, “You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And you are the one who’ll decide where to go.”

Best wishes and Godspeed.

Feel free to send your comments about this editorial to [email protected].

The past few months have been a season of graduations for new NPs and PAs across the country. Recently, I tallied all the graduation ceremonies I have attended since I began my journey in academe some 16 years ago, which came out to about 27 ceremonies—so I have watched more than 4,500 graduates walk across the stage. How exciting that has been!

Last year, I had the opportunity to be a commencement speaker, a daunting responsibility and one that I did not take lightly. I’d like to share my graduation comments with you in this editorial—dedicated to all the new PA and NP grads:

Garry Trudeau, an American cartoonist best known for the Doonesbury comic strip, said, “Commencement speeches were invented largely in the belief that outgoing college students should never be released unto the world until they have been properly sedated.” With that in mind, I will keep my remarks to a minimum. I promise. The educational process has been the subject of a great deal of comment by academics and writers over the past few decades. It has been said that education is an easy target for criticism because its stated aims are often so nobly ambitious that they have little chance of being realized. According to the poet Robert Frost, education is “hanging around until you’ve caught on.”

Your class, like most graduating classes, is unique. You come from all walks of life and all points on the map. As you are poised today on this joyous yet transitional moment, I encourage you to imagine an image of standing on the shoulders of giants. Sir Isaac Newton said, “We are like dwarfs sitting on the shoulders of giants. We see more, and things that are more distant, than they did, not because our sight is superior or because we are taller than they, but because they raise us up, and by their great stature add to ours.”

Whatever image this calls to mind for you, I want to briefly tell you about three important giants. The first is that colleague, family member, or professor who was your mentor. For me, it was Dr. Burton Brasher, a preceptor, mentor, and friend who taught me the importance of sitting with patients and allowing them to be partners in their own care. Integrity and compassion are what he brought to the table as a family doctor in the 1970s and ’80s. I recently had the opportunity to attend his 90th birthday party. Indeed, I had the opportunity to stand on the shoulders of a giant.

The second giant is well known to you. Many examples are seated behind me and perhaps seated behind you now. Who is that person who has equipped you to enter your chosen profession? Who is that person who supported you at home from grade school to grad school? Your faculty, both didactic and clinical, and your family and friends are giants who have given you the opportunity to stand on their shoulders. 

The third giant will be born in just a few minutes. That giant, ladies and gentlemen, is you. You now have the opportunity to take your knowledge and skills, your integrity and your compassion, and become a giant in your community. A giant that others can stand on, lean on, rely on, whether they be family members, friends, or students. As John F. Kennedy said, “The torch has been passed to a new generation.” I urge you to take hold of that torch.

The diversity among you has enriched your school, the university as a whole, and each of you individually. While what you brought was diverse, you will all leave with the same credential—a degree setting you apart as a clinician. The degree you will receive today is much more than a piece of paper, much more than initials behind your name.

You have been reminded many times about the expectations that society has for you. Those expectations will only increase as you go forth from today. Your profession has a calling that is devoted to health, healing, caring, and compassion. Society has entrusted its health and well-being to you, and with that trust comes a responsibility that is unmatched in other professions.

While you’ve spent long, sometimes grueling, hours mastering the skills of your new profession, what will make the difference in your success now is what comes from your heart.

Your work will be filled with challenges and opportunities, moments of disappointment, years of joy. Your patients will share their innermost thoughts and life experiences, things they won’t share with anyone else—not parents, not children, not spouses.

Despite the best educational preparation, I expect—and actually hope—you have some trepidation as you prepare to take your first real steps into your chosen profession. I encourage you to remember what that hesitation feels like and never lose sight of it. You must never become complacent. Health care is an ever-changing profession and you must forever be a student for the sake of your patients and your profession.

The uncertainty I’m describing is normal, but I assure you that you have the ability to succeed and we—the giants upon whose shoulders you stand today—are certain you will become some of the best clinicians, no matter where your career takes you. 

Today marks the beginning of your new identity. No matter what you choose to do, whether you see patients or take care of athletes, teach students, work in a research laboratory, or draft health policy, being a member of your profession will forever remain a part of your central identity. Over time, it will likely become the most important part of who you are.

And no matter how hard you try to avoid it, you will be recognized. At the grocery store, the church, the barber shop, the hair salon, football games, shopping malls, your children’s school plays, your son or daughter’s athletic event, on the beach—someone will come up to you and say, “That’s Gary Jones, he’s a PA,” or “Let me introduce you to my daughter, Nikita Wells, the nurse practitioner.” There will be no escape. So my advice is, embrace it.

It defines you not just to your patients, but to your family and friends who will consult you first for every health issue, whether it’s in your field of expertise or not. They may not always believe or accept what you tell them, but they will always consult you. Even more, it will define you to society as being someone who is quite distinct, someone who has the highest integrity and someone they can trust.

The diploma you receive today is a symbol of a deep commitment to promoting our expectations of professionalism, humanism, and compassion. From this day forward, it no longer is exclusively or even most often about you. All of your experiences to this moment have raised you up as a giant for your patients, your colleagues, your profession, and everyone you will come into contact with from this day forward. 

You must remain committed to maintaining life-long learning skills, to putting the interests of your patients above your own, to striving to treat patients with the highest possible standards, to respecting the values, culture, and dignity of every patient, and to working respectfully with other health professionals to ensure the best care for your patients.

Let me bring my remarks to a close with a few thoughts about the current challenges your professions face today.

Despite the increasing use of diagnostic technologies and advancements in therapeutic abilities, we are witnesses to increasing disparities in the delivery of health care.

Despite spending more on health care than many other developed nations, we have one of the highest percentages of uninsured citizens, leading to increased and preventable diseases. 

The threats of medical liability are ever present. Reimbursement isn’t always what we feel it should be.

These challenges lead some to become disillusioned and cynical. Be aware of those pitfalls, and always remember, whether you’re in the emergency department, the urgent care center, the orthopedic clinic, the surgical suite, or an exam room and it’s just you and your patient—yours is a profession of compassion, integrity, and service.

As Alan Kay, an American computer scientist, researcher, and visionary, once said, “The best way to predict the future is to invent it.” Therefore, I ask you to go out and face the challenges head-on and do your part to provide the best quality care to all citizens. America’s health care and that of the world is depending on each of you to make an impact. They are poised to stand on your shoulders to see further and to do more than ever before.

And now for the two words you have been waiting for: In conclusion, let me share with you a quote from my favorite professor—a giant in his own right—Dr. Seuss, who said, “You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And you are the one who’ll decide where to go.”

Best wishes and Godspeed.

Feel free to send your comments about this editorial to [email protected].

A 12-year-old boy flips his skateboard in his garage, causing a small laceration on his scalp that needs a few sutures.

An 8-year-old with established asthma has a cough with minimal wheezes and a fever.

An afebrile 32-year-old man has had a productive cough for five days, but he hasn’t been able to get in to see his primary care clinician.

What do these patients have in common? They were all seen in the local emergency department. For a plethora of reasons, our emergency departments are being filled to overcrowding with cases such as these (and many others). Is there an opportunity to create a primary care solution within our communities to care for these patients?

Many NPs and PAs—myself included—started their career in medicine either in the military as a medic/corpsman and/or in prehospital care as an EMT/paramedic. It was a great stepping-stone to the role of an NP or PA. After school, many NPs and PAs actually went back into the military or into emergency medicine. Now, some are saying, it is time for NPs and PAs to expand back into the prehospital arena.

Originally, the purpose of prehospital care was to provide patients, and the community in general, with the urgent medical care that is needed before and during transportation to a hospital. Because of the current barriers to primary care in this country, many patients are opting to go directly to the emergency department and wait anywhere from four to 14 hours to be seen for such ailments as minor lacerations, viral gastroenteritis, sore throat, minor injuries, and many other conditions that primary care clinicians traditionally handled decades ago.

Over the past decade, there have been a number of pilot programs in this country that looked at utilization of NPs and PAs in prehospital care. One such program took place in Mesa, Arizona, a little over two years ago. The Mesa Fire Department, under the auspices of Dr. Gary Smith, created a program in which NPs and/or PAs led a unit with a paramedic driver that responded immediately to medical emergencies or urgent situations in the home so that the patient did not have to seek care at the local emergency center. This program was designed to free up fire engine and ladder trucks and ambulances for more life-threatening situations.

If you have ever been at a scene after a 911 call, you would not be surprised to see a fire engine, a rescue unit, and perhaps an ambulance there. Many prehospital responders will admit that they have transported patients to local emergency departments for conditions that easily could have been cared for by a clinician visiting the home.

In this pilot program, the NPs or PAs, dressed in scrubs, were assigned to the firehouse, where they waited with their paramedic counterparts until a 911 call was dispatched. The NPs and PAs arrived at the scene equipped with a full complement of advanced life support equipment, including a 12-lead monitor, a pulse oximeter, and a box of medications.¹

This particular pilot program was instituted first and foremost to provide a community service to individuals by delivering top-notch, quality health care in a time and place that was convenient.

The second goal was to avoid unnecessary and costly transportation and care by dispensing immediate medical services to patients who otherwise would be transported to the local emergency room.

Third, it not only freed up the firefighters to be available for other emergencies, it freed up the clerical/administration people and clinicians at the emergency room to attend to more immediate problems.

Another important component of the program was the after-care. The NP or PA provided a follow-up phone call to every patient he/she saw, in order to determine whether the patient had filled the prescription, required a visit to the ED anyway, or needed follow-up care. The NP and PA had a list of local clinicians for appropriate referral, should the patient not have a primary care clinician.

This pilot project lasted 60 days, after which the results were evaluated.

As you can imagine, the numbers as well as anecdotal discussions were all positive. As with any program that does not fit into the current health care system, there were barriers. The largest barrier, of course, was compensation to cover the cost of the program. Most third-party payers were hesitant to provide coverage and, in most cases, patients are not in a position to pay. Also, developing a billing or charging system in a prehospital scenario is problematic.

Although we have heard of similar programs across the country, very little is known about them. We would like to hear your thoughts about NPs and PAs in prehospital care—especially if you have been involved in such a program. Learning what works and what doesn’t work is the hallmark of developing a future program that meets the needs of our communities. Please email me at [email protected].           

References
1. PAs with Mesa Fire Department free firefighters for the fires. AAPA News. March 15, 2008.

A 12-year-old boy flips his skateboard in his garage, causing a small laceration on his scalp that needs a few sutures.

An 8-year-old with established asthma has a cough with minimal wheezes and a fever.

An afebrile 32-year-old man has had a productive cough for five days, but he hasn’t been able to get in to see his primary care clinician.

What do these patients have in common? They were all seen in the local emergency department. For a plethora of reasons, our emergency departments are being filled to overcrowding with cases such as these (and many others). Is there an opportunity to create a primary care solution within our communities to care for these patients?

Many NPs and PAs—myself included—started their career in medicine either in the military as a medic/corpsman and/or in prehospital care as an EMT/paramedic. It was a great stepping-stone to the role of an NP or PA. After school, many NPs and PAs actually went back into the military or into emergency medicine. Now, some are saying, it is time for NPs and PAs to expand back into the prehospital arena.

Originally, the purpose of prehospital care was to provide patients, and the community in general, with the urgent medical care that is needed before and during transportation to a hospital. Because of the current barriers to primary care in this country, many patients are opting to go directly to the emergency department and wait anywhere from four to 14 hours to be seen for such ailments as minor lacerations, viral gastroenteritis, sore throat, minor injuries, and many other conditions that primary care clinicians traditionally handled decades ago.

Over the past decade, there have been a number of pilot programs in this country that looked at utilization of NPs and PAs in prehospital care. One such program took place in Mesa, Arizona, a little over two years ago. The Mesa Fire Department, under the auspices of Dr. Gary Smith, created a program in which NPs and/or PAs led a unit with a paramedic driver that responded immediately to medical emergencies or urgent situations in the home so that the patient did not have to seek care at the local emergency center. This program was designed to free up fire engine and ladder trucks and ambulances for more life-threatening situations.

If you have ever been at a scene after a 911 call, you would not be surprised to see a fire engine, a rescue unit, and perhaps an ambulance there. Many prehospital responders will admit that they have transported patients to local emergency departments for conditions that easily could have been cared for by a clinician visiting the home.

In this pilot program, the NPs or PAs, dressed in scrubs, were assigned to the firehouse, where they waited with their paramedic counterparts until a 911 call was dispatched. The NPs and PAs arrived at the scene equipped with a full complement of advanced life support equipment, including a 12-lead monitor, a pulse oximeter, and a box of medications.¹

This particular pilot program was instituted first and foremost to provide a community service to individuals by delivering top-notch, quality health care in a time and place that was convenient.

The second goal was to avoid unnecessary and costly transportation and care by dispensing immediate medical services to patients who otherwise would be transported to the local emergency room.

Third, it not only freed up the firefighters to be available for other emergencies, it freed up the clerical/administration people and clinicians at the emergency room to attend to more immediate problems.

Another important component of the program was the after-care. The NP or PA provided a follow-up phone call to every patient he/she saw, in order to determine whether the patient had filled the prescription, required a visit to the ED anyway, or needed follow-up care. The NP and PA had a list of local clinicians for appropriate referral, should the patient not have a primary care clinician.

This pilot project lasted 60 days, after which the results were evaluated.

As you can imagine, the numbers as well as anecdotal discussions were all positive. As with any program that does not fit into the current health care system, there were barriers. The largest barrier, of course, was compensation to cover the cost of the program. Most third-party payers were hesitant to provide coverage and, in most cases, patients are not in a position to pay. Also, developing a billing or charging system in a prehospital scenario is problematic.

Although we have heard of similar programs across the country, very little is known about them. We would like to hear your thoughts about NPs and PAs in prehospital care—especially if you have been involved in such a program. Learning what works and what doesn’t work is the hallmark of developing a future program that meets the needs of our communities. Please email me at [email protected].           

References
1. PAs with Mesa Fire Department free firefighters for the fires. AAPA News. March 15, 2008.

A 12-year-old boy flips his skateboard in his garage, causing a small laceration on his scalp that needs a few sutures.

An 8-year-old with established asthma has a cough with minimal wheezes and a fever.

An afebrile 32-year-old man has had a productive cough for five days, but he hasn’t been able to get in to see his primary care clinician.

What do these patients have in common? They were all seen in the local emergency department. For a plethora of reasons, our emergency departments are being filled to overcrowding with cases such as these (and many others). Is there an opportunity to create a primary care solution within our communities to care for these patients?

Many NPs and PAs—myself included—started their career in medicine either in the military as a medic/corpsman and/or in prehospital care as an EMT/paramedic. It was a great stepping-stone to the role of an NP or PA. After school, many NPs and PAs actually went back into the military or into emergency medicine. Now, some are saying, it is time for NPs and PAs to expand back into the prehospital arena.

Originally, the purpose of prehospital care was to provide patients, and the community in general, with the urgent medical care that is needed before and during transportation to a hospital. Because of the current barriers to primary care in this country, many patients are opting to go directly to the emergency department and wait anywhere from four to 14 hours to be seen for such ailments as minor lacerations, viral gastroenteritis, sore throat, minor injuries, and many other conditions that primary care clinicians traditionally handled decades ago.

Over the past decade, there have been a number of pilot programs in this country that looked at utilization of NPs and PAs in prehospital care. One such program took place in Mesa, Arizona, a little over two years ago. The Mesa Fire Department, under the auspices of Dr. Gary Smith, created a program in which NPs and/or PAs led a unit with a paramedic driver that responded immediately to medical emergencies or urgent situations in the home so that the patient did not have to seek care at the local emergency center. This program was designed to free up fire engine and ladder trucks and ambulances for more life-threatening situations.

If you have ever been at a scene after a 911 call, you would not be surprised to see a fire engine, a rescue unit, and perhaps an ambulance there. Many prehospital responders will admit that they have transported patients to local emergency departments for conditions that easily could have been cared for by a clinician visiting the home.

In this pilot program, the NPs or PAs, dressed in scrubs, were assigned to the firehouse, where they waited with their paramedic counterparts until a 911 call was dispatched. The NPs and PAs arrived at the scene equipped with a full complement of advanced life support equipment, including a 12-lead monitor, a pulse oximeter, and a box of medications.¹

This particular pilot program was instituted first and foremost to provide a community service to individuals by delivering top-notch, quality health care in a time and place that was convenient.

The second goal was to avoid unnecessary and costly transportation and care by dispensing immediate medical services to patients who otherwise would be transported to the local emergency room.

Third, it not only freed up the firefighters to be available for other emergencies, it freed up the clerical/administration people and clinicians at the emergency room to attend to more immediate problems.

Another important component of the program was the after-care. The NP or PA provided a follow-up phone call to every patient he/she saw, in order to determine whether the patient had filled the prescription, required a visit to the ED anyway, or needed follow-up care. The NP and PA had a list of local clinicians for appropriate referral, should the patient not have a primary care clinician.

This pilot project lasted 60 days, after which the results were evaluated.

As you can imagine, the numbers as well as anecdotal discussions were all positive. As with any program that does not fit into the current health care system, there were barriers. The largest barrier, of course, was compensation to cover the cost of the program. Most third-party payers were hesitant to provide coverage and, in most cases, patients are not in a position to pay. Also, developing a billing or charging system in a prehospital scenario is problematic.

Although we have heard of similar programs across the country, very little is known about them. We would like to hear your thoughts about NPs and PAs in prehospital care—especially if you have been involved in such a program. Learning what works and what doesn’t work is the hallmark of developing a future program that meets the needs of our communities. Please email me at [email protected].           

References
1. PAs with Mesa Fire Department free firefighters for the fires. AAPA News. March 15, 2008.

Shades of Peter, Paul, and Mary! I live in Arizona. As you may have noticed, over the past few years, Arizona has gained a reputation as a maverick state. In spite of the beautiful desert landscape, the inspiring sunsets, the wonderful weather, and the diversity of people, that assessment may be right.

Arizona voters, by a narrow margin, last year approved medical marijuana for use by people with chronic or debilitating diseases. This makes Arizona the 15th state to have approved a medical marijuana law (although, with 841,346 in favor and 837,005 opposed, it was not a huge mandate). California was the first in 1996, and since then 13 other states and the District of Columbia have followed. It is interesting to note that no other controlled pharmaceutical substance on the market has been made available to the public for medical purposes through an election process.

Many believed that this was an opportunity to set an example for the rest of the country on what a good medical marijuana program looks like, while others felt it was just another sign of the decline of our society. The Arizona law allows patients with conditions such as cancer, AIDS, and hepatitis C, and any other “chronic or debilitating” disease that meets guidelines, to grow plants or to buy 2.5 oz of marijuana every two weeks. Patients must obtain a recommendation from their physician and register with the department of health services. The law allows for only one dispensary per 10 pharmacies in the state, which currently equates to 124 marijuana dispensaries.¹

As you can imagine, this issue has polarized many factions both for and against legalization of medical marijuana. Former US Surgeon General Joycelyn Elders, MD, said, “The evidence is overwhelming that marijuana can relieve certain types of pain, nausea, vomiting, and other symptoms caused by such illnesses as multiple sclerosis, cancer, and AIDS—or by the harsh drugs sometimes used to treat them. And it can do so with remarkable safety. Indeed, marijuana is less toxic than many of the drugs that physicians prescribe every day.”²

Yet former US Senator Bill Frist (a physician) said, “Although I understand many believe marijuana is the most effective drug in combating their medical ailments, I would caution against this assumption due to the lack of consistent, repeatable scientific data available to prove marijuana’s medical benefits. Based on current evidence, I believe that marijuana is a dangerous drug and that there are less dangerous medicines offering the same relief from pain and other medical symptoms.”³

The American College of Physicians has supported medical marijuana and “urges an evidence-based review of marijuana’s status as a Schedule I controlled substance to determine whether it should be reclassified to a different schedule. This review should consider the scientific findings regarding marijuana’s safety and efficacy in some clinical conditions, as well as evidence on the health risks associated with marijuana consumption, particularly in its crude smoked form.”4 The ACP also says they strongly support exemption from federal criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for physicians who prescribe or dispense medical marijuana in accordance with state law.⁴

By contrast, the American Medical Association has yet to support medical marijuana as a pharmaceutical agent. The US Drug Enforcement Agency maintains that medical marijuana is an illegal substance—yet clinicians have the right to prescribe it in 15 states and are protected under state statutes.

Backers of medical marijuana have argued that thousands of patients face a terrible choice of suffering with a serious or even terminal illness or going to the illegal market for marijuana. The measure in Arizona, much like those in the other states, was opposed by all of Arizona’s sheriffs and county prosecutors, the governor, the state attorney general, and many other politicians. Yet when the people spoke, the law passed … barely.

Many feel these laws will increase crime around dispensary locations, lead to more people driving while impaired, and eventually lead to legalized marijuana for everyone—and therefore would have very dire effects on a number of levels.

In an effort to determine whether marijuana, or drugs derived from marijuana, might be effective as a glaucoma treatment, the National Eye Institute supported research studies beginning in 1978. None of these studies, however, demonstrated that marijuana could lower intraocular pressure as effectively as drugs already on the market. Some potentially serious side effects were noted, including an increased heart rate and a decrease in blood pressure in studies examining smoked marijuana.⁵

Unfortunately, clinical research trials to evaluate the effectiveness of marijuana to treat certain conditions have been restrictive and limited. Until marijuana is downgraded from a Schedule I drug of the Controlled Substances Act, widespread clinical trials are unlikely to happen.

If we really want a conclusive answer as to whether marijuana is valuable for symptom management, it should be evaluated using the same standards as other controlled medications. Is this more a scientific/medical issue or a political issue? With strong supporters on each side of the debate and a fairly new administration, the arguments for and against the legalization of marijuana are certainly hot topics.

What do you think? Email me at [email protected].

References
1.  Lee MYH. Arizona medical marijuana proposed rules released. Arizona Republic. December 16, 2010. www.azcentral.com/news/election/­azelections/articles/2010/12/16/20101216arizona-medical-marijuana-­proposed-rules.html. Accessed February 22, 2011.

2. Elders J. Myths about medical marijuana [editorial]. Providence Journal. March 26, 2004.

3. Frist B. Email correspondence to ProCon.org; October 20, 2003. Medicalmarijuana.procon.org/view.resource.php?resourceID=000141. Accessed February 22, 2011.

4. American College of Physicians. Supporting research into the therapeutic role of marijuana [position paper]. 2008. www.acponline.org/advocacy/where_we_stand/other_issues/­medmarijuana.pdf. Accessed February 22, 2011.

5. National Eye Institute. Glaucoma and marijuana use [NEI statement]. www.nei.nih.gov/news/statements/marij.asp. Accessed February 22, 2011.

Shades of Peter, Paul, and Mary! I live in Arizona. As you may have noticed, over the past few years, Arizona has gained a reputation as a maverick state. In spite of the beautiful desert landscape, the inspiring sunsets, the wonderful weather, and the diversity of people, that assessment may be right.

Arizona voters, by a narrow margin, last year approved medical marijuana for use by people with chronic or debilitating diseases. This makes Arizona the 15th state to have approved a medical marijuana law (although, with 841,346 in favor and 837,005 opposed, it was not a huge mandate). California was the first in 1996, and since then 13 other states and the District of Columbia have followed. It is interesting to note that no other controlled pharmaceutical substance on the market has been made available to the public for medical purposes through an election process.

Many believed that this was an opportunity to set an example for the rest of the country on what a good medical marijuana program looks like, while others felt it was just another sign of the decline of our society. The Arizona law allows patients with conditions such as cancer, AIDS, and hepatitis C, and any other “chronic or debilitating” disease that meets guidelines, to grow plants or to buy 2.5 oz of marijuana every two weeks. Patients must obtain a recommendation from their physician and register with the department of health services. The law allows for only one dispensary per 10 pharmacies in the state, which currently equates to 124 marijuana dispensaries.¹

As you can imagine, this issue has polarized many factions both for and against legalization of medical marijuana. Former US Surgeon General Joycelyn Elders, MD, said, “The evidence is overwhelming that marijuana can relieve certain types of pain, nausea, vomiting, and other symptoms caused by such illnesses as multiple sclerosis, cancer, and AIDS—or by the harsh drugs sometimes used to treat them. And it can do so with remarkable safety. Indeed, marijuana is less toxic than many of the drugs that physicians prescribe every day.”²

Yet former US Senator Bill Frist (a physician) said, “Although I understand many believe marijuana is the most effective drug in combating their medical ailments, I would caution against this assumption due to the lack of consistent, repeatable scientific data available to prove marijuana’s medical benefits. Based on current evidence, I believe that marijuana is a dangerous drug and that there are less dangerous medicines offering the same relief from pain and other medical symptoms.”³

The American College of Physicians has supported medical marijuana and “urges an evidence-based review of marijuana’s status as a Schedule I controlled substance to determine whether it should be reclassified to a different schedule. This review should consider the scientific findings regarding marijuana’s safety and efficacy in some clinical conditions, as well as evidence on the health risks associated with marijuana consumption, particularly in its crude smoked form.”4 The ACP also says they strongly support exemption from federal criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for physicians who prescribe or dispense medical marijuana in accordance with state law.⁴

By contrast, the American Medical Association has yet to support medical marijuana as a pharmaceutical agent. The US Drug Enforcement Agency maintains that medical marijuana is an illegal substance—yet clinicians have the right to prescribe it in 15 states and are protected under state statutes.

Backers of medical marijuana have argued that thousands of patients face a terrible choice of suffering with a serious or even terminal illness or going to the illegal market for marijuana. The measure in Arizona, much like those in the other states, was opposed by all of Arizona’s sheriffs and county prosecutors, the governor, the state attorney general, and many other politicians. Yet when the people spoke, the law passed … barely.

Many feel these laws will increase crime around dispensary locations, lead to more people driving while impaired, and eventually lead to legalized marijuana for everyone—and therefore would have very dire effects on a number of levels.

In an effort to determine whether marijuana, or drugs derived from marijuana, might be effective as a glaucoma treatment, the National Eye Institute supported research studies beginning in 1978. None of these studies, however, demonstrated that marijuana could lower intraocular pressure as effectively as drugs already on the market. Some potentially serious side effects were noted, including an increased heart rate and a decrease in blood pressure in studies examining smoked marijuana.⁵

Unfortunately, clinical research trials to evaluate the effectiveness of marijuana to treat certain conditions have been restrictive and limited. Until marijuana is downgraded from a Schedule I drug of the Controlled Substances Act, widespread clinical trials are unlikely to happen.

If we really want a conclusive answer as to whether marijuana is valuable for symptom management, it should be evaluated using the same standards as other controlled medications. Is this more a scientific/medical issue or a political issue? With strong supporters on each side of the debate and a fairly new administration, the arguments for and against the legalization of marijuana are certainly hot topics.

What do you think? Email me at [email protected].

References
1.  Lee MYH. Arizona medical marijuana proposed rules released. Arizona Republic. December 16, 2010. www.azcentral.com/news/election/­azelections/articles/2010/12/16/20101216arizona-medical-marijuana-­proposed-rules.html. Accessed February 22, 2011.

2. Elders J. Myths about medical marijuana [editorial]. Providence Journal. March 26, 2004.

3. Frist B. Email correspondence to ProCon.org; October 20, 2003. Medicalmarijuana.procon.org/view.resource.php?resourceID=000141. Accessed February 22, 2011.

4. American College of Physicians. Supporting research into the therapeutic role of marijuana [position paper]. 2008. www.acponline.org/advocacy/where_we_stand/other_issues/­medmarijuana.pdf. Accessed February 22, 2011.

5. National Eye Institute. Glaucoma and marijuana use [NEI statement]. www.nei.nih.gov/news/statements/marij.asp. Accessed February 22, 2011.

Shades of Peter, Paul, and Mary! I live in Arizona. As you may have noticed, over the past few years, Arizona has gained a reputation as a maverick state. In spite of the beautiful desert landscape, the inspiring sunsets, the wonderful weather, and the diversity of people, that assessment may be right.

Arizona voters, by a narrow margin, last year approved medical marijuana for use by people with chronic or debilitating diseases. This makes Arizona the 15th state to have approved a medical marijuana law (although, with 841,346 in favor and 837,005 opposed, it was not a huge mandate). California was the first in 1996, and since then 13 other states and the District of Columbia have followed. It is interesting to note that no other controlled pharmaceutical substance on the market has been made available to the public for medical purposes through an election process.

Many believed that this was an opportunity to set an example for the rest of the country on what a good medical marijuana program looks like, while others felt it was just another sign of the decline of our society. The Arizona law allows patients with conditions such as cancer, AIDS, and hepatitis C, and any other “chronic or debilitating” disease that meets guidelines, to grow plants or to buy 2.5 oz of marijuana every two weeks. Patients must obtain a recommendation from their physician and register with the department of health services. The law allows for only one dispensary per 10 pharmacies in the state, which currently equates to 124 marijuana dispensaries.¹

As you can imagine, this issue has polarized many factions both for and against legalization of medical marijuana. Former US Surgeon General Joycelyn Elders, MD, said, “The evidence is overwhelming that marijuana can relieve certain types of pain, nausea, vomiting, and other symptoms caused by such illnesses as multiple sclerosis, cancer, and AIDS—or by the harsh drugs sometimes used to treat them. And it can do so with remarkable safety. Indeed, marijuana is less toxic than many of the drugs that physicians prescribe every day.”²

Yet former US Senator Bill Frist (a physician) said, “Although I understand many believe marijuana is the most effective drug in combating their medical ailments, I would caution against this assumption due to the lack of consistent, repeatable scientific data available to prove marijuana’s medical benefits. Based on current evidence, I believe that marijuana is a dangerous drug and that there are less dangerous medicines offering the same relief from pain and other medical symptoms.”³

The American College of Physicians has supported medical marijuana and “urges an evidence-based review of marijuana’s status as a Schedule I controlled substance to determine whether it should be reclassified to a different schedule. This review should consider the scientific findings regarding marijuana’s safety and efficacy in some clinical conditions, as well as evidence on the health risks associated with marijuana consumption, particularly in its crude smoked form.”4 The ACP also says they strongly support exemption from federal criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for physicians who prescribe or dispense medical marijuana in accordance with state law.⁴

By contrast, the American Medical Association has yet to support medical marijuana as a pharmaceutical agent. The US Drug Enforcement Agency maintains that medical marijuana is an illegal substance—yet clinicians have the right to prescribe it in 15 states and are protected under state statutes.

Backers of medical marijuana have argued that thousands of patients face a terrible choice of suffering with a serious or even terminal illness or going to the illegal market for marijuana. The measure in Arizona, much like those in the other states, was opposed by all of Arizona’s sheriffs and county prosecutors, the governor, the state attorney general, and many other politicians. Yet when the people spoke, the law passed … barely.

Many feel these laws will increase crime around dispensary locations, lead to more people driving while impaired, and eventually lead to legalized marijuana for everyone—and therefore would have very dire effects on a number of levels.

In an effort to determine whether marijuana, or drugs derived from marijuana, might be effective as a glaucoma treatment, the National Eye Institute supported research studies beginning in 1978. None of these studies, however, demonstrated that marijuana could lower intraocular pressure as effectively as drugs already on the market. Some potentially serious side effects were noted, including an increased heart rate and a decrease in blood pressure in studies examining smoked marijuana.⁵

Unfortunately, clinical research trials to evaluate the effectiveness of marijuana to treat certain conditions have been restrictive and limited. Until marijuana is downgraded from a Schedule I drug of the Controlled Substances Act, widespread clinical trials are unlikely to happen.

If we really want a conclusive answer as to whether marijuana is valuable for symptom management, it should be evaluated using the same standards as other controlled medications. Is this more a scientific/medical issue or a political issue? With strong supporters on each side of the debate and a fairly new administration, the arguments for and against the legalization of marijuana are certainly hot topics.

What do you think? Email me at [email protected].

References
1.  Lee MYH. Arizona medical marijuana proposed rules released. Arizona Republic. December 16, 2010. www.azcentral.com/news/election/­azelections/articles/2010/12/16/20101216arizona-medical-marijuana-­proposed-rules.html. Accessed February 22, 2011.

2. Elders J. Myths about medical marijuana [editorial]. Providence Journal. March 26, 2004.

3. Frist B. Email correspondence to ProCon.org; October 20, 2003. Medicalmarijuana.procon.org/view.resource.php?resourceID=000141. Accessed February 22, 2011.

4. American College of Physicians. Supporting research into the therapeutic role of marijuana [position paper]. 2008. www.acponline.org/advocacy/where_we_stand/other_issues/­medmarijuana.pdf. Accessed February 22, 2011.

5. National Eye Institute. Glaucoma and marijuana use [NEI statement]. www.nei.nih.gov/news/statements/marij.asp. Accessed February 22, 2011.

I can rattle off and identify with the milestones of the baby boomer generation with relative ease. President Kennedy’s assassination? I was a 14-year-old high school freshman. The “Summer of Love” in 1967? I was 18 but, living in Idaho, barely knew it occurred. The assassinations of Martin Luther King Jr and Bobby Kennedy? I was in my first year of college. The Vietnam War, the first “television war,” prompted me to enlist in the military and do my part. Most boomers can relate where they were when these events happened.

The baby boom stretched over 19 years, from 1946 through 1964. My generation came of age with the likes of the Mickey Mouse Club and Leave it to Beaver. We are deeply rooted in the American experience, thanks to TV shows, advertising, politics, and race relations. Seventy-seven million strong, this generation has guided marketing and political decisions for six decades.

It should be noted that the first large cohorts of PAs and NPs—those who trained in the 1970s (you know who you are!)—are those that are about to retire. As the boomers start to hit retirement age, what of the other generations and their importance in understanding the medical workforce?

Generational gaps among colleagues present unique relationship challenges. While professional behaviors such as reliability, respect for others, and adherence to confidentiality are expected across generations, perceptions of issues such as feedback, work ethic, flexibility, and use of technology vary considerably. Although physician/PA/NP teams are bound, to some extent, by a legal collaborative relationship, the style (and details) of the relationship varies greatly, based on the generation of each individual.

Let me share why I think this “generations” idea holds some truth. Years ago, I was teamed with a new graduate of a family medicine residency at a community health center. She was an idealistic, self-sufficient woman in her late 20s, who had always planned to work in rural underserved settings. Once she got there, however, she found that it was a burden on her personal and family life.

While she had been trained in a busy family medicine residency, she had never worked with a PA. As one of her new responsibilities, she was told that she would be supervising a senior PA in his mid-40s who had a strong following of patients. I’ve rarely had issues with my supervising physicians, but this was doomed from the start. This doc seemed to have a real problem with the “teamwork” concept and felt compelled to see every patient before they left and/or review all medical charts for “errors.” When pharmaceutical reps came in, she would allow them to speak only to her. She also answered all the patient phone calls and reviewed all lab work.

Attempts by myself and the office manager to encourage her to allow the rest of us to be part of the team were unsuccessful. As one might imagine, within a few short months, the doc asked to be relieved of her duties as supervising physician and took a job in an urban clinic. As with all professional relationships, I am sure there were issues on both sides. She was replaced by another physician, 10 years my senior, who became one of my favorite supervisers because of her ability to create a team atmosphere in which the patients benefited from the relationship.

Currently, there are four different generations in the workforce: Traditionalists/Veterans (born between 1922 and 1945), Baby Boomers (1946-1964), Generation Xers (1965-1980), and Millennials/Generation Yers (1981-2000). While there is danger in generalizing, sociologists, such as Zemke, Raines, and Filipczak in Generations at Work,¹ have identified key characteristics associated with each group.

For example, Traditionalists/Veterans were impacted by their childhood experience of the Great Depression and their subsequent roles during World War II. They are thought of as hardworking, cautious, and financially conservative. Baby Boomers typically grew up in nuclear families and were encouraged to be creative and to rewrite the rules. Boomers tend to see work as defining themselves and others.

Generation X is defined by the breakdown of the nuclear family. Many of this generation grew up in divorced families or families in which both parents worked. As a result, they place major importance on spending time with their own families and seek a work/life balance. For Generation Y/Millennial workers, work-life balance is also important, but they have high expectations for themselves, including early achievements, scheduled lives, and rewards and recognition for hard work.

How the generations differ in their perspectives may come to the forefront in the workplace. Veterans like structure, discipline, and consistency; they may feel flexibility is destructive to the work environment. Boomers like structure but also feel it should be possible to negotiate for what they need. Gen Xers want both flexibility and understanding regarding their need to spend time with their families and pursue their own interests. Gen Yers may make assumptions about flexibility that is not really there—and then be unhappy with restrictions.

Technology can still become a flash point in the clinical workplace. Some Veterans would still like it to “go away,” but most see it as a “necessary evil.” Boomers see it as a useful tool—but also sometimes an interruption. Generation X grew up with technology and is adept in its use. Generation Y may quickly become the technology leaders in the clinic—but need to be inclusive and patient with others who are slower to catch on.

Facilitating growth and development in the presence of a generationally diverse workforce is difficult. Sherman makes excellent recommendations for nursing leaders who want to “enable the workforce to thrive and to meet tomorrow’s health care challenges.”² These recommendations should, in my opinion, also be used by NPs, PAs, and physicians:

• Seek to understand each generational cohort and accommodate generational differences in attitudes, values, and behaviors

• Develop generationally sensitive styles to effectively coach and motivate all members of the health care team

• Develop the ability to flex a communication style to accommodate generational differences

• Promote the resolution of generational conflict so as to build effective work teams

• Capitalize on generational differences, using the differences to enhance the work of the entire team.²

I would love to hear your thoughts. Are there differences in generational team members or are we just “stuck in time”? E-mail me at [email protected].

I can rattle off and identify with the milestones of the baby boomer generation with relative ease. President Kennedy’s assassination? I was a 14-year-old high school freshman. The “Summer of Love” in 1967? I was 18 but, living in Idaho, barely knew it occurred. The assassinations of Martin Luther King Jr and Bobby Kennedy? I was in my first year of college. The Vietnam War, the first “television war,” prompted me to enlist in the military and do my part. Most boomers can relate where they were when these events happened.

The baby boom stretched over 19 years, from 1946 through 1964. My generation came of age with the likes of the Mickey Mouse Club and Leave it to Beaver. We are deeply rooted in the American experience, thanks to TV shows, advertising, politics, and race relations. Seventy-seven million strong, this generation has guided marketing and political decisions for six decades.

It should be noted that the first large cohorts of PAs and NPs—those who trained in the 1970s (you know who you are!)—are those that are about to retire. As the boomers start to hit retirement age, what of the other generations and their importance in understanding the medical workforce?

Generational gaps among colleagues present unique relationship challenges. While professional behaviors such as reliability, respect for others, and adherence to confidentiality are expected across generations, perceptions of issues such as feedback, work ethic, flexibility, and use of technology vary considerably. Although physician/PA/NP teams are bound, to some extent, by a legal collaborative relationship, the style (and details) of the relationship varies greatly, based on the generation of each individual.

Let me share why I think this “generations” idea holds some truth. Years ago, I was teamed with a new graduate of a family medicine residency at a community health center. She was an idealistic, self-sufficient woman in her late 20s, who had always planned to work in rural underserved settings. Once she got there, however, she found that it was a burden on her personal and family life.

While she had been trained in a busy family medicine residency, she had never worked with a PA. As one of her new responsibilities, she was told that she would be supervising a senior PA in his mid-40s who had a strong following of patients. I’ve rarely had issues with my supervising physicians, but this was doomed from the start. This doc seemed to have a real problem with the “teamwork” concept and felt compelled to see every patient before they left and/or review all medical charts for “errors.” When pharmaceutical reps came in, she would allow them to speak only to her. She also answered all the patient phone calls and reviewed all lab work.

Attempts by myself and the office manager to encourage her to allow the rest of us to be part of the team were unsuccessful. As one might imagine, within a few short months, the doc asked to be relieved of her duties as supervising physician and took a job in an urban clinic. As with all professional relationships, I am sure there were issues on both sides. She was replaced by another physician, 10 years my senior, who became one of my favorite supervisers because of her ability to create a team atmosphere in which the patients benefited from the relationship.

Currently, there are four different generations in the workforce: Traditionalists/Veterans (born between 1922 and 1945), Baby Boomers (1946-1964), Generation Xers (1965-1980), and Millennials/Generation Yers (1981-2000). While there is danger in generalizing, sociologists, such as Zemke, Raines, and Filipczak in Generations at Work,¹ have identified key characteristics associated with each group.

For example, Traditionalists/Veterans were impacted by their childhood experience of the Great Depression and their subsequent roles during World War II. They are thought of as hardworking, cautious, and financially conservative. Baby Boomers typically grew up in nuclear families and were encouraged to be creative and to rewrite the rules. Boomers tend to see work as defining themselves and others.

Generation X is defined by the breakdown of the nuclear family. Many of this generation grew up in divorced families or families in which both parents worked. As a result, they place major importance on spending time with their own families and seek a work/life balance. For Generation Y/Millennial workers, work-life balance is also important, but they have high expectations for themselves, including early achievements, scheduled lives, and rewards and recognition for hard work.

How the generations differ in their perspectives may come to the forefront in the workplace. Veterans like structure, discipline, and consistency; they may feel flexibility is destructive to the work environment. Boomers like structure but also feel it should be possible to negotiate for what they need. Gen Xers want both flexibility and understanding regarding their need to spend time with their families and pursue their own interests. Gen Yers may make assumptions about flexibility that is not really there—and then be unhappy with restrictions.

Technology can still become a flash point in the clinical workplace. Some Veterans would still like it to “go away,” but most see it as a “necessary evil.” Boomers see it as a useful tool—but also sometimes an interruption. Generation X grew up with technology and is adept in its use. Generation Y may quickly become the technology leaders in the clinic—but need to be inclusive and patient with others who are slower to catch on.

Facilitating growth and development in the presence of a generationally diverse workforce is difficult. Sherman makes excellent recommendations for nursing leaders who want to “enable the workforce to thrive and to meet tomorrow’s health care challenges.”² These recommendations should, in my opinion, also be used by NPs, PAs, and physicians:

• Seek to understand each generational cohort and accommodate generational differences in attitudes, values, and behaviors

• Develop generationally sensitive styles to effectively coach and motivate all members of the health care team

• Develop the ability to flex a communication style to accommodate generational differences

• Promote the resolution of generational conflict so as to build effective work teams

• Capitalize on generational differences, using the differences to enhance the work of the entire team.²

I would love to hear your thoughts. Are there differences in generational team members or are we just “stuck in time”? E-mail me at [email protected].

I can rattle off and identify with the milestones of the baby boomer generation with relative ease. President Kennedy’s assassination? I was a 14-year-old high school freshman. The “Summer of Love” in 1967? I was 18 but, living in Idaho, barely knew it occurred. The assassinations of Martin Luther King Jr and Bobby Kennedy? I was in my first year of college. The Vietnam War, the first “television war,” prompted me to enlist in the military and do my part. Most boomers can relate where they were when these events happened.

The baby boom stretched over 19 years, from 1946 through 1964. My generation came of age with the likes of the Mickey Mouse Club and Leave it to Beaver. We are deeply rooted in the American experience, thanks to TV shows, advertising, politics, and race relations. Seventy-seven million strong, this generation has guided marketing and political decisions for six decades.

It should be noted that the first large cohorts of PAs and NPs—those who trained in the 1970s (you know who you are!)—are those that are about to retire. As the boomers start to hit retirement age, what of the other generations and their importance in understanding the medical workforce?

Generational gaps among colleagues present unique relationship challenges. While professional behaviors such as reliability, respect for others, and adherence to confidentiality are expected across generations, perceptions of issues such as feedback, work ethic, flexibility, and use of technology vary considerably. Although physician/PA/NP teams are bound, to some extent, by a legal collaborative relationship, the style (and details) of the relationship varies greatly, based on the generation of each individual.

Let me share why I think this “generations” idea holds some truth. Years ago, I was teamed with a new graduate of a family medicine residency at a community health center. She was an idealistic, self-sufficient woman in her late 20s, who had always planned to work in rural underserved settings. Once she got there, however, she found that it was a burden on her personal and family life.

While she had been trained in a busy family medicine residency, she had never worked with a PA. As one of her new responsibilities, she was told that she would be supervising a senior PA in his mid-40s who had a strong following of patients. I’ve rarely had issues with my supervising physicians, but this was doomed from the start. This doc seemed to have a real problem with the “teamwork” concept and felt compelled to see every patient before they left and/or review all medical charts for “errors.” When pharmaceutical reps came in, she would allow them to speak only to her. She also answered all the patient phone calls and reviewed all lab work.

Attempts by myself and the office manager to encourage her to allow the rest of us to be part of the team were unsuccessful. As one might imagine, within a few short months, the doc asked to be relieved of her duties as supervising physician and took a job in an urban clinic. As with all professional relationships, I am sure there were issues on both sides. She was replaced by another physician, 10 years my senior, who became one of my favorite supervisers because of her ability to create a team atmosphere in which the patients benefited from the relationship.

Currently, there are four different generations in the workforce: Traditionalists/Veterans (born between 1922 and 1945), Baby Boomers (1946-1964), Generation Xers (1965-1980), and Millennials/Generation Yers (1981-2000). While there is danger in generalizing, sociologists, such as Zemke, Raines, and Filipczak in Generations at Work,¹ have identified key characteristics associated with each group.

For example, Traditionalists/Veterans were impacted by their childhood experience of the Great Depression and their subsequent roles during World War II. They are thought of as hardworking, cautious, and financially conservative. Baby Boomers typically grew up in nuclear families and were encouraged to be creative and to rewrite the rules. Boomers tend to see work as defining themselves and others.

Generation X is defined by the breakdown of the nuclear family. Many of this generation grew up in divorced families or families in which both parents worked. As a result, they place major importance on spending time with their own families and seek a work/life balance. For Generation Y/Millennial workers, work-life balance is also important, but they have high expectations for themselves, including early achievements, scheduled lives, and rewards and recognition for hard work.

How the generations differ in their perspectives may come to the forefront in the workplace. Veterans like structure, discipline, and consistency; they may feel flexibility is destructive to the work environment. Boomers like structure but also feel it should be possible to negotiate for what they need. Gen Xers want both flexibility and understanding regarding their need to spend time with their families and pursue their own interests. Gen Yers may make assumptions about flexibility that is not really there—and then be unhappy with restrictions.

Technology can still become a flash point in the clinical workplace. Some Veterans would still like it to “go away,” but most see it as a “necessary evil.” Boomers see it as a useful tool—but also sometimes an interruption. Generation X grew up with technology and is adept in its use. Generation Y may quickly become the technology leaders in the clinic—but need to be inclusive and patient with others who are slower to catch on.

Facilitating growth and development in the presence of a generationally diverse workforce is difficult. Sherman makes excellent recommendations for nursing leaders who want to “enable the workforce to thrive and to meet tomorrow’s health care challenges.”² These recommendations should, in my opinion, also be used by NPs, PAs, and physicians:

• Seek to understand each generational cohort and accommodate generational differences in attitudes, values, and behaviors

• Develop generationally sensitive styles to effectively coach and motivate all members of the health care team

• Develop the ability to flex a communication style to accommodate generational differences

• Promote the resolution of generational conflict so as to build effective work teams

• Capitalize on generational differences, using the differences to enhance the work of the entire team.²

I would love to hear your thoughts. Are there differences in generational team members or are we just “stuck in time”? E-mail me at [email protected].

I think we all agree that patient care has been, and continues to be, a complex activity—one that commands all health care professionals to work together effectively for the sake of the patient. Yet I hear that this is far from the case.

Over the past year, I have been dismayed to read more and more editorials (predominantly by physicians) lambasting PAs and NPs for their attempts to more fully integrate themselves into the health care system. There has been a great deal of stereotyping of our professions. Words and phrases such as inadequate education, incompetence, trying to be a physician, lack of adequate supervision, as well as other criticisms, have been used. It made me wonder how many of these critics have actually worked with or around a PA or an NP for a significant period of time.

Of course, I am biased. It has been my experience over the past 30+ years that physicians who work with PAs and NPs on a regular basis actually develop an understanding of their value to the health care team. There are times, of course, when this is not true—but for me, this is more often than not the case.

Medical students, PA students, and NP students, in my estimation, identify early on with their future professions, learning from their professions’ leaders and reinforced by professional associations. While this is important, Majoor¹ noted, this “all too easily results in rigid and protective demarcations between professions who need to work closely together to respond effectively to the needs of the same patients, families, and communities.”

Should we be making a conscious effort to foster understanding and collaboration at an earlier stage, rather than waiting for it to occur (or not) once health care providers are established in practice? Maybe this is a crazy idea, and maybe there are more barriers than bridges. But according to Barr,² “Partnership has become so fashionable that it is tempting to assume that all reasonable men and women will unite in common cause. Experience teaches otherwise: best laid plans too often founder for lack of attention to differences which can bedevil relationships between professions and organizations.”

In recent years, interprofessional education (IPE) has become the new buzzword. According to the Centre for the Advancement of Interprofessional Education, IPE “occurs when two or more professions learn with, from, and about each other to improve collaboration and the quality of care.”³ (The emphasis is mine.)

Two reports issued by the Institute of Medicine in the past decade have sparked renewed interest in IPE. To Err is Human identified the magnitude of preventable medical errors, and Health Professions Education: A Bridge to Quality recommended redesigning health professionals’ training, including more interdisciplinary training. Have we, as medical educators, just given lip service to these suggestions? A search of the literature finds very little discussion of physicians, PAs, and NPs learning together, either during their entry-level education or in their practice settings.

Despite this dearth of research, in the past few years, many educational programs have attempted the development of IPE as a way to improve how professionals work together to take care of patients. The emphasis is on interdisciplinary teams, patient-centered care, and quality improvement. IPE has frequently been used with content related to prevention (primary, secondary, and tertiary), geriatric medicine, chronic disease management, and ethics.

Institutions that have utilized this model have reported significant challenges in implementing such programs, which Cashman, Meyer, and Page⁴ identified as:

• Integrating schedules across disciplinary units

• Scheduling time for all faculty members to meet and plan

• Integrating schedules between schools and community collaborators

• Coordinating activities in different geographic locations

• Obtaining course approval from participating disciplinary units

• Offering courses under multiple academic calendars

• Coordinating complex community factors in order to provide clinical experiences needed by large numbers of students

• Coordinating service activities with community-based partners

They also reported institutional-level challenges in areas such as recruitment of students, identification and engagement of faculty who have the time and interest to participate, and coordination of courses across academic programs (including which program[s] will receive credit and payment for courses). Additional issues include the need to sustain and build momentum in these programs over time, from seeking funding to expanding the concept into other fields.⁴

This is not to suggest these challenges are insurmountable. Cashman, Meyer and Page also identified factors that can improve an IPE program’s chances for success. These focus, overall, on a “team” approach: seeking student input during early planning, partnering with local Area Health Education Centers, and seeking community support for off-campus projects, among others.⁴

Growing evidence seems to support the expectation that educational programs will prepare health professions students, and current practitioners, for collaborative work. How best to support this is the question. Does the concept of “one size fits all” work? Are the professions (MD, DO, PA, NP) so different that the barriers outweigh the opportunities?

I’d love to hear your thoughts on this. E-mail me at [email protected].

I think we all agree that patient care has been, and continues to be, a complex activity—one that commands all health care professionals to work together effectively for the sake of the patient. Yet I hear that this is far from the case.

Over the past year, I have been dismayed to read more and more editorials (predominantly by physicians) lambasting PAs and NPs for their attempts to more fully integrate themselves into the health care system. There has been a great deal of stereotyping of our professions. Words and phrases such as inadequate education, incompetence, trying to be a physician, lack of adequate supervision, as well as other criticisms, have been used. It made me wonder how many of these critics have actually worked with or around a PA or an NP for a significant period of time.

Of course, I am biased. It has been my experience over the past 30+ years that physicians who work with PAs and NPs on a regular basis actually develop an understanding of their value to the health care team. There are times, of course, when this is not true—but for me, this is more often than not the case.

Medical students, PA students, and NP students, in my estimation, identify early on with their future professions, learning from their professions’ leaders and reinforced by professional associations. While this is important, Majoor¹ noted, this “all too easily results in rigid and protective demarcations between professions who need to work closely together to respond effectively to the needs of the same patients, families, and communities.”

Should we be making a conscious effort to foster understanding and collaboration at an earlier stage, rather than waiting for it to occur (or not) once health care providers are established in practice? Maybe this is a crazy idea, and maybe there are more barriers than bridges. But according to Barr,² “Partnership has become so fashionable that it is tempting to assume that all reasonable men and women will unite in common cause. Experience teaches otherwise: best laid plans too often founder for lack of attention to differences which can bedevil relationships between professions and organizations.”

In recent years, interprofessional education (IPE) has become the new buzzword. According to the Centre for the Advancement of Interprofessional Education, IPE “occurs when two or more professions learn with, from, and about each other to improve collaboration and the quality of care.”³ (The emphasis is mine.)

Two reports issued by the Institute of Medicine in the past decade have sparked renewed interest in IPE. To Err is Human identified the magnitude of preventable medical errors, and Health Professions Education: A Bridge to Quality recommended redesigning health professionals’ training, including more interdisciplinary training. Have we, as medical educators, just given lip service to these suggestions? A search of the literature finds very little discussion of physicians, PAs, and NPs learning together, either during their entry-level education or in their practice settings.

Despite this dearth of research, in the past few years, many educational programs have attempted the development of IPE as a way to improve how professionals work together to take care of patients. The emphasis is on interdisciplinary teams, patient-centered care, and quality improvement. IPE has frequently been used with content related to prevention (primary, secondary, and tertiary), geriatric medicine, chronic disease management, and ethics.

Institutions that have utilized this model have reported significant challenges in implementing such programs, which Cashman, Meyer, and Page⁴ identified as:

• Integrating schedules across disciplinary units

• Scheduling time for all faculty members to meet and plan

• Integrating schedules between schools and community collaborators

• Coordinating activities in different geographic locations

• Obtaining course approval from participating disciplinary units

• Offering courses under multiple academic calendars

• Coordinating complex community factors in order to provide clinical experiences needed by large numbers of students

• Coordinating service activities with community-based partners

They also reported institutional-level challenges in areas such as recruitment of students, identification and engagement of faculty who have the time and interest to participate, and coordination of courses across academic programs (including which program[s] will receive credit and payment for courses). Additional issues include the need to sustain and build momentum in these programs over time, from seeking funding to expanding the concept into other fields.⁴

This is not to suggest these challenges are insurmountable. Cashman, Meyer and Page also identified factors that can improve an IPE program’s chances for success. These focus, overall, on a “team” approach: seeking student input during early planning, partnering with local Area Health Education Centers, and seeking community support for off-campus projects, among others.⁴

Growing evidence seems to support the expectation that educational programs will prepare health professions students, and current practitioners, for collaborative work. How best to support this is the question. Does the concept of “one size fits all” work? Are the professions (MD, DO, PA, NP) so different that the barriers outweigh the opportunities?

I’d love to hear your thoughts on this. E-mail me at [email protected].

I think we all agree that patient care has been, and continues to be, a complex activity—one that commands all health care professionals to work together effectively for the sake of the patient. Yet I hear that this is far from the case.

Over the past year, I have been dismayed to read more and more editorials (predominantly by physicians) lambasting PAs and NPs for their attempts to more fully integrate themselves into the health care system. There has been a great deal of stereotyping of our professions. Words and phrases such as inadequate education, incompetence, trying to be a physician, lack of adequate supervision, as well as other criticisms, have been used. It made me wonder how many of these critics have actually worked with or around a PA or an NP for a significant period of time.

Of course, I am biased. It has been my experience over the past 30+ years that physicians who work with PAs and NPs on a regular basis actually develop an understanding of their value to the health care team. There are times, of course, when this is not true—but for me, this is more often than not the case.

Medical students, PA students, and NP students, in my estimation, identify early on with their future professions, learning from their professions’ leaders and reinforced by professional associations. While this is important, Majoor¹ noted, this “all too easily results in rigid and protective demarcations between professions who need to work closely together to respond effectively to the needs of the same patients, families, and communities.”

Should we be making a conscious effort to foster understanding and collaboration at an earlier stage, rather than waiting for it to occur (or not) once health care providers are established in practice? Maybe this is a crazy idea, and maybe there are more barriers than bridges. But according to Barr,² “Partnership has become so fashionable that it is tempting to assume that all reasonable men and women will unite in common cause. Experience teaches otherwise: best laid plans too often founder for lack of attention to differences which can bedevil relationships between professions and organizations.”

In recent years, interprofessional education (IPE) has become the new buzzword. According to the Centre for the Advancement of Interprofessional Education, IPE “occurs when two or more professions learn with, from, and about each other to improve collaboration and the quality of care.”³ (The emphasis is mine.)

Two reports issued by the Institute of Medicine in the past decade have sparked renewed interest in IPE. To Err is Human identified the magnitude of preventable medical errors, and Health Professions Education: A Bridge to Quality recommended redesigning health professionals’ training, including more interdisciplinary training. Have we, as medical educators, just given lip service to these suggestions? A search of the literature finds very little discussion of physicians, PAs, and NPs learning together, either during their entry-level education or in their practice settings.

Despite this dearth of research, in the past few years, many educational programs have attempted the development of IPE as a way to improve how professionals work together to take care of patients. The emphasis is on interdisciplinary teams, patient-centered care, and quality improvement. IPE has frequently been used with content related to prevention (primary, secondary, and tertiary), geriatric medicine, chronic disease management, and ethics.

Institutions that have utilized this model have reported significant challenges in implementing such programs, which Cashman, Meyer, and Page⁴ identified as:

• Integrating schedules across disciplinary units

• Scheduling time for all faculty members to meet and plan

• Integrating schedules between schools and community collaborators

• Coordinating activities in different geographic locations

• Obtaining course approval from participating disciplinary units

• Offering courses under multiple academic calendars

• Coordinating complex community factors in order to provide clinical experiences needed by large numbers of students

• Coordinating service activities with community-based partners

They also reported institutional-level challenges in areas such as recruitment of students, identification and engagement of faculty who have the time and interest to participate, and coordination of courses across academic programs (including which program[s] will receive credit and payment for courses). Additional issues include the need to sustain and build momentum in these programs over time, from seeking funding to expanding the concept into other fields.⁴

This is not to suggest these challenges are insurmountable. Cashman, Meyer and Page also identified factors that can improve an IPE program’s chances for success. These focus, overall, on a “team” approach: seeking student input during early planning, partnering with local Area Health Education Centers, and seeking community support for off-campus projects, among others.⁴

Growing evidence seems to support the expectation that educational programs will prepare health professions students, and current practitioners, for collaborative work. How best to support this is the question. Does the concept of “one size fits all” work? Are the professions (MD, DO, PA, NP) so different that the barriers outweigh the opportunities?

I’d love to hear your thoughts on this. E-mail me at [email protected].