Randy Danielsen, PhD, PA-C, DFAAPA

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

I was speaking with a nurse friend the other day about an experience she had while attending a NASCAR event with friends. She had a syncopal event, which prompted a call to 911 and an evaluation by paramedics.

Although she did not have any seizure activity (nor was it reported), the concern of the first responders was a grand mal seizure. She was subsequently evaluated in the emergency center with that "diagnosis" and discharged with recommendations for additional (and expensive) testing.

It didn't seem—although one shouldn't criticize if one wasn't there—that the common causes of syncope in that particular environment were considered in the rush to find the not-so-common (and yes, perhaps more serious) etiology. No IV was started nor was an ECG obtained. Ultimately, it was decided that the syncopal episode was likely secondary to volume depletion.

Now, I realize syncope is a transient abrupt loss of consciousness with complete return to preexisting neurologic function. Population-based studies have indicated that approximately 40% of adults have experienced syncope, with women being more likely than men to report an event. Neurally mediated syncope is the most common type, with cardiac syncope being the second.

I also realize that seizures and syncope are often confused. Features most suggestive of a seizure are tongue laceration, head turning, and witnessed abnormal posturing—none of which my friend had. Factors strongly predictive against seizure are presyncopal spells before loss of consciousness, diaphoresis before a spell, and loss of consciousness with prolonged standing or sitting.¹ Perhaps orthostatic syncope, in this case secondary to volume depletion, could have been explored (or at least treated) early on.  No doubt syncope in older persons generally has more than one etiology, making the diagnosis difficult and requiring additional information on medications, past history, level of cognitive impairment, and physical frailty.

REFERENCE
1. Gauer RL. Evaluation of syncope. Am Fam Physician. 2011;84(6):640-650.

As I get older and more experienced, with continued efforts to keep up to date on medical knowledge, I worry about the increase in medical errors and the possibility that some are caused by rushing to judgment on a diagnosis. Errors in clinical judgment, miscommunication, and technical mistakes are the three top reasons cited for medical liability cases.

During my clinical rotations as a PA student, it wasn't long before I became quite good at briefly presenting cases to the preceptors. I would describe my patients' presenting complaints and clinical findings for their consideration—just as I was taught in the didactic portion of school—and report them in an order that I thought was concise and relevant, building to an obvious diagnosis and, ultimately, to my brilliant life-saving treatment. Oh, how smart I felt at that moment! 

One preceptor, Dr. M., would dutifully listen, then call me out for my lack of knowledge and naiveté and dispatch me back to the library and reference books (remember those?). Of course, preceptors were seldom wrong, so I'd study hard, learn some minutia that would clutter my confused and overwhelmed mind, and find I had rushed through the history and physical examination (H&P) without really knowing the patient—only his/her presenting symptoms. Back then, I focused more on identifying a condition or disease than on being my patient's health care provider.

Then another preceptor, Dr. T., would begin his shift and inevitably disagree with the previous guru. Dr. T.'s mantra was "What's the story?" followed by "Tell me the etiology and differential." That was usually followed by "You are being way too esoteric; REMEMBER, COMMON CONDITIONS ARE COMMON!" Oh my, what a catch-22. When is the first guy due back? 

Now, four decades after my entry into the PA profession, I understand that our initial H&P might not elicit the "truth." After all, is not this information mostly judgmental, subjective—affected by trust, environment, communication skills, keen sense, and timing? Clinicians, patients, and students are all dealing with imprecise information.

We also know that the sheer amount of new scientific knowledge, understanding, change, and rebuttal makes it impossible for practicing clinicians to remain the repositories of standard of care. Why else do we have all these guidelines written by dozens of academicians with hundreds of references every year or two? It is just too much to stay on top of and remember.

So we have those in academe/research with their evidence-based medicine and those in the exam room, with their H&P information—which is better for making the diagnosis and treatment plan? And just in case you think this is a diatribe against academicians, you should know I believe we need those academic folks around to pay attention to the research and advances so they can tell us the "truth"—at least statistically speaking. (OK, OK, I know: Guidelines are developed by panels of researchers, academics, and clinicians, not just those in academe.)

Sometimes, though, the true issues, diseases, and illnesses that our patients have and need treatment for are not always evidence-based. Sometimes, they are vignettes or capsules in a person's life (see "A Hasty Diagnosis").

Those who champion evidence-based health care have controlled statistics to guide and direct us to treatment, diagnosis, and cost-effectiveness (maybe not in that order). But—and this is huge—our practicing clinician colleagues have patient stories and experiences that are perhaps just as credible.

After all, what is more evidence-based than real patients, taken care of by real clinicians, with real outcomes? This is not a subtle put-down of evidence-based medicine. Being evidence-based is certainly a framework for refining the information gained in the H&P.

But maybe we need to combine methods: to review the available literature (paying attention to the esoteric) while remaining focused on the patient's story and keeping that story simple.

Were Dr. M. and Dr. T., those two very different preceptors, "in cahoots"? Come to think of it, they were pretty smart. Maybe I should look them up, to say thanks and let them know that I'm still looking for answers and finding truth along the way. 

I would love to hear your response to this. Please contact me at [email protected].

As I get older and more experienced, with continued efforts to keep up to date on medical knowledge, I worry about the increase in medical errors and the possibility that some are caused by rushing to judgment on a diagnosis. Errors in clinical judgment, miscommunication, and technical mistakes are the three top reasons cited for medical liability cases.

During my clinical rotations as a PA student, it wasn't long before I became quite good at briefly presenting cases to the preceptors. I would describe my patients' presenting complaints and clinical findings for their consideration—just as I was taught in the didactic portion of school—and report them in an order that I thought was concise and relevant, building to an obvious diagnosis and, ultimately, to my brilliant life-saving treatment. Oh, how smart I felt at that moment! 

One preceptor, Dr. M., would dutifully listen, then call me out for my lack of knowledge and naiveté and dispatch me back to the library and reference books (remember those?). Of course, preceptors were seldom wrong, so I'd study hard, learn some minutia that would clutter my confused and overwhelmed mind, and find I had rushed through the history and physical examination (H&P) without really knowing the patient—only his/her presenting symptoms. Back then, I focused more on identifying a condition or disease than on being my patient's health care provider.

Then another preceptor, Dr. T., would begin his shift and inevitably disagree with the previous guru. Dr. T.'s mantra was "What's the story?" followed by "Tell me the etiology and differential." That was usually followed by "You are being way too esoteric; REMEMBER, COMMON CONDITIONS ARE COMMON!" Oh my, what a catch-22. When is the first guy due back? 

Now, four decades after my entry into the PA profession, I understand that our initial H&P might not elicit the "truth." After all, is not this information mostly judgmental, subjective—affected by trust, environment, communication skills, keen sense, and timing? Clinicians, patients, and students are all dealing with imprecise information.

We also know that the sheer amount of new scientific knowledge, understanding, change, and rebuttal makes it impossible for practicing clinicians to remain the repositories of standard of care. Why else do we have all these guidelines written by dozens of academicians with hundreds of references every year or two? It is just too much to stay on top of and remember.

So we have those in academe/research with their evidence-based medicine and those in the exam room, with their H&P information—which is better for making the diagnosis and treatment plan? And just in case you think this is a diatribe against academicians, you should know I believe we need those academic folks around to pay attention to the research and advances so they can tell us the "truth"—at least statistically speaking. (OK, OK, I know: Guidelines are developed by panels of researchers, academics, and clinicians, not just those in academe.)

Sometimes, though, the true issues, diseases, and illnesses that our patients have and need treatment for are not always evidence-based. Sometimes, they are vignettes or capsules in a person's life (see "A Hasty Diagnosis").

Those who champion evidence-based health care have controlled statistics to guide and direct us to treatment, diagnosis, and cost-effectiveness (maybe not in that order). But—and this is huge—our practicing clinician colleagues have patient stories and experiences that are perhaps just as credible.

After all, what is more evidence-based than real patients, taken care of by real clinicians, with real outcomes? This is not a subtle put-down of evidence-based medicine. Being evidence-based is certainly a framework for refining the information gained in the H&P.

But maybe we need to combine methods: to review the available literature (paying attention to the esoteric) while remaining focused on the patient's story and keeping that story simple.

Were Dr. M. and Dr. T., those two very different preceptors, "in cahoots"? Come to think of it, they were pretty smart. Maybe I should look them up, to say thanks and let them know that I'm still looking for answers and finding truth along the way. 

I would love to hear your response to this. Please contact me at [email protected].

As I get older and more experienced, with continued efforts to keep up to date on medical knowledge, I worry about the increase in medical errors and the possibility that some are caused by rushing to judgment on a diagnosis. Errors in clinical judgment, miscommunication, and technical mistakes are the three top reasons cited for medical liability cases.

During my clinical rotations as a PA student, it wasn't long before I became quite good at briefly presenting cases to the preceptors. I would describe my patients' presenting complaints and clinical findings for their consideration—just as I was taught in the didactic portion of school—and report them in an order that I thought was concise and relevant, building to an obvious diagnosis and, ultimately, to my brilliant life-saving treatment. Oh, how smart I felt at that moment! 

One preceptor, Dr. M., would dutifully listen, then call me out for my lack of knowledge and naiveté and dispatch me back to the library and reference books (remember those?). Of course, preceptors were seldom wrong, so I'd study hard, learn some minutia that would clutter my confused and overwhelmed mind, and find I had rushed through the history and physical examination (H&P) without really knowing the patient—only his/her presenting symptoms. Back then, I focused more on identifying a condition or disease than on being my patient's health care provider.

Then another preceptor, Dr. T., would begin his shift and inevitably disagree with the previous guru. Dr. T.'s mantra was "What's the story?" followed by "Tell me the etiology and differential." That was usually followed by "You are being way too esoteric; REMEMBER, COMMON CONDITIONS ARE COMMON!" Oh my, what a catch-22. When is the first guy due back? 

Now, four decades after my entry into the PA profession, I understand that our initial H&P might not elicit the "truth." After all, is not this information mostly judgmental, subjective—affected by trust, environment, communication skills, keen sense, and timing? Clinicians, patients, and students are all dealing with imprecise information.

We also know that the sheer amount of new scientific knowledge, understanding, change, and rebuttal makes it impossible for practicing clinicians to remain the repositories of standard of care. Why else do we have all these guidelines written by dozens of academicians with hundreds of references every year or two? It is just too much to stay on top of and remember.

So we have those in academe/research with their evidence-based medicine and those in the exam room, with their H&P information—which is better for making the diagnosis and treatment plan? And just in case you think this is a diatribe against academicians, you should know I believe we need those academic folks around to pay attention to the research and advances so they can tell us the "truth"—at least statistically speaking. (OK, OK, I know: Guidelines are developed by panels of researchers, academics, and clinicians, not just those in academe.)

Sometimes, though, the true issues, diseases, and illnesses that our patients have and need treatment for are not always evidence-based. Sometimes, they are vignettes or capsules in a person's life (see "A Hasty Diagnosis").

Those who champion evidence-based health care have controlled statistics to guide and direct us to treatment, diagnosis, and cost-effectiveness (maybe not in that order). But—and this is huge—our practicing clinician colleagues have patient stories and experiences that are perhaps just as credible.

After all, what is more evidence-based than real patients, taken care of by real clinicians, with real outcomes? This is not a subtle put-down of evidence-based medicine. Being evidence-based is certainly a framework for refining the information gained in the H&P.

But maybe we need to combine methods: to review the available literature (paying attention to the esoteric) while remaining focused on the patient's story and keeping that story simple.

Were Dr. M. and Dr. T., those two very different preceptors, "in cahoots"? Come to think of it, they were pretty smart. Maybe I should look them up, to say thanks and let them know that I'm still looking for answers and finding truth along the way. 

I would love to hear your response to this. Please contact me at [email protected].

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at [email protected] or [email protected].                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/[email protected]@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at [email protected] or [email protected].                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/[email protected]@.2a35001c!comment=1. Accessed October 12, 2012.

Over the past year, we’ve seen ongoing relentless rhetoric, in the medical and lay press, besmirching the competence of PAs and NPs. The motives behind this unsettling trend can be viewed either as a veiled attempt to diminish our standing in patients’ eyes or even constrain our scope of practice. For years, we have tried to stay above the fray and avoid weighing in. However, we now feel compelled to address this rising negative tide.

Recently, Louis J. Goodman, PhD, President of the Physicians Foundation and CEO of the Texas Medical Association, stated, “The idea that nurse practitioners or physician assistants can fill the vacuum [in primary care] is not accurate.” He continued, “They can do some things, but someone needs to make the unequivocal diagnosis, and the person who is best qualified to do that is a physician.”¹

According to a recent white paper from the American Academy of Family Physicians (AAFP),² “Physicians offer an unmatched service to patients and without their skills, patients would receive second-tier care.” This report also recommended the establishment of more patient-centered medical homes in which a physician leads a team of “allied health professionals,” particularly PAs and NPs, as the way to provide optimal care. It is interesting to consider that the AAFP statement flies in the face of evidence to the contrary from credible and powerful organizations, including the Institute of Medicine and the National Institutes of Health.

Even a well-meaning 2011 article in American Medical News, entitled “Bringing PAs and NPs on Board: What to Do if You’re Hiring,”³ had inaccurate assertions about PA and NP practice—for example, that PAs tend to carry out more procedures, while NPs are better suited to provide evaluation and management.

So the question has to be asked: Who is the enemy here? There are plenty of fingers to go around if we are pointing—physicians, administrators, regulators—even ourselves! Truth be told, the enemy is, of course, ignorance. Why, in this world of evidence-based practice, do we so often write, post, and verbalize inaccurate information about each other? Even in light of the fact that in 2009, 49.1% of office-based US physicians worked alongside NPs and PAs, the misconceptions persist.⁴

The concept of patient satisfaction with health care has only recently received the attention it deserves in the medical literature; concurrently, there has been increased interest in patient satisfaction measurements among hospitals and health plans as they compete to attract and retain members. Analysis based on data from an adaptation of the “Art of Medicine” survey (an eight-item, patient-reported measure of clinician style of encounter) supports the finding that patients are indeed satisfied with their care, regardless of the type of practitioner who delivers it. The study found no statistically significant differences between scores for physicians and PAs or NPs, whether provider practice was differentiated by specialty or data were combined for statistical purposes. In addition, it was reported that some patients perceive PAs and NPs as somewhat indistinguishable from physicians.⁵

Regarding the quality-of-care issue, a number of studies—generated by nonbiased authors and entities and available online—have concluded that the quality of care provided by NPs and PAs is comparable to that given by physicians, in terms of functions that all these clinicians usually perform. Case in point: A seminal 1986 policy analysis from the congressional Office of Technology Assessment documented that NPs and PAs provide care of quality equivalent to that provided by physicians.⁶ The researchers found that NPs are more adept than physicians at providing services that depend on communicating with patients and taking preventive action. The evidence also indicated that PAs perform better than many physicians do in supportive care and health promotion activities. 

In addition to communicating more effectively, PAs and NPs have been found to be more proficient than many physicians at managing patients who require long-term and continuous care. Extending early studies, researchers have repeatedly demonstrated the high-quality care delivered by these professionals. 

Since the 1960s, the priority of health policy initiatives has been to make health care accessible to all Americans. As a means to this end, programs were developed to educate future clinicians (maybe even potential patients!) about the NP and PA professions, with the purpose to improve access to care. That, we have done. We have made important contributions to meeting the nation’s health care needs, especially by improving the geographic distribution of care, because we have been willing to practice in underserved rural and inner-city areas. And we will continue to do so, as meeting the health care needs of the nation has always been our priority—more important than disabusing those with misconceptions about our value and competence. 

Bottom line? Health care reform will bring numerous challenges for stakeholders over the next few years. It is imperative that we all focus on what matters most: a collaborative model of care that delivers improved patient outcomes through qualified providers, with access to health care for all Americans. And just as it “takes a village” to raise a child, it will take all of us, working collegially and cooperatively, to meet those challenges.

Our professions have been studied to death. If we continue to focus on the wrong problems, notes health analyst Brian Klepper, PhD, “primary care will continue to flail.”⁷ Let’s get on with the work of providing that care and researching better methods of preventing and treating diseases. Our discussions should be about the patient!

Are we overreacting? Are you tired of the inaccuracies perpetuated about both of our professions? Tell us what you think at [email protected] or [email protected].                  

REFERENCES
1. Hertz BT. Primary care and the keys to its success: newer revenue and practice models to gain in popularity as primary care skills increase in value. Modern Medicine. Aug 25 2012. www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Primary-care-and-the-keys-to-its-success/ArticleStandard/Article/detail/785800?contextCategoryId=40158. Accessed October 11, 2012.

2. American Academy of Family Physicians. Primary care for the 21st century: ensuring a quality, physician-led team for every patient (2012). www.aafp.org/online/etc/medialib/aafp_org/documents/membership/nps/primary-care-21st-century/whitepaper.Par.0001.File.dat/AAFP-PCMHWhitePaper.pdf. Accessed October 12, 2012.

3. Elliott VS. Bringing PAs and NPs on board: what to do if you’re hiring. Am Med News. January 10, 2011. www.ama-assn.org/amednews/2011/01/10/bisa0110.htm. Accessed October 12, 2012.

4. Park M, Cherry D, Decker SL. Nurse practitioners, certified nurse midwives, and physician assistants in physician offices. NCHS Data Brief. 2011:69. www.cdc.gov/nchs/data/databriefs/db69.htm. Accessed October 11, 2012.

5. Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. Permanente Journal. 1997;1(1). http://xnet.kp.org/permanentejournal/sum97pj/ptsat.html. Accessed October 11, 2012.

6. US Congress, Office of Technology Assessment. Nurse Practitioners, Physician Assistants, and Certified Nurse-Midwives: A Policy Analysis (1986). www.fas.org/ota/reports/8615.pdf. Accessed October 12, 2012.

7. Klepper B. Care and cost: the wrong battles. http://boards.medscape.com/[email protected]@.2a35001c!comment=1. Accessed October 12, 2012.

Recently, Christy Wilson, PA-C, and I presented a workshop on “Balancing Your Life After PA School.” The program discussed everything that was not taught in PA school that the practicing clinician should know.

To prepare, we asked our peers what they wished they had known in their early years of practice. The response was over­whelming. Herewith, the top 20 items that emerged:

20. Learn to manage your time. No, really. Find ways to build downtime in your schedule. There is no doubt that the first years after school are not unlike a “residency,” as you learn how to practice medicine effectively. You should develop a ritual of good habits. Refocus and drop activities that sap your time.

19. Enhance your professional relationships. Be sure to know the ins and outs of a professional contract. Be nice to everyone—not only the other clinicians, but also the office staff and the cleaning personnel. It is a small world even if you live in a big city.

18. Enhance your relationships with your patients. Remind yourself why you do what you do. Continue to look at your patient as an individual—not a disease, condition, or room number. Be honest and empathetic, and prepare for the times when you will have to give bad news or when a bad outcome occurs. It is important to remember that patient satisfaction may not be compatible with just good medicine.

17. Understand your medical liability. When it comes to medical malpractice insurance, should you have your own? Should you have tail coverage? Learn ways to reduce liability. The better care you take of yourself in a legal sense results in less time you may have to spend with an attorney.

16. Understand the business of medicine. Who knew how important this would be? There is just as much politics in medicine as there is in Washington, DC. Learn to lobby for what you want. Electronic medical records (EMR) and CPT coding have become extremely important in the practice of medicine. Get involved in the know-how of these items.

15. Care for your body, mind, and spirit. Your physical and mental well-being depend on nourishment. Don’t skip meals, and find regular time for exercise, even if that just means taking a short walk or using the stairs instead of the elevator. Get enough sleep. Surround yourself with positive people. You may find it equally healthy to give something back by volunteering in your church, hospital, civic club, and alumni association, by being a clinical preceptor, or by doing some pro bono work.

14. Deal with fear. Cut yourself some slack. You don’t have to do everything—just the right things. It is not uncommon for us to worry all the time about our patients or other issues. It is important that we find time to compartmentalize. Find an outlet to vent when you have a bad day.

13. Take care of your finances. Financial planning is important. What does your practice/company offer you in regard to retirement and/or disability insurance? Don’t delay getting those student loans paid off.

12. Stay up to date with your professional requirements. Keep on top of hospital credentialing, state licensure, and national certification. Don’t let them lapse.

11. Understand when to order the appropriate diagnostic tests. Know when to order an MRI versus a CT or ultrasound. Don’t be afraid to ask if you don’t know.

10. Always remember the five Ds of prescribing: the right diagnosis, the right drug, the right dose, the right duration, and the right time for discontinuation or withdrawal.

9. Be involved in your profession. Get and stay involved in your state and national professional associations. It is always better to work from within an organization, even if you are unhappy with some of the things they do, than try to make changes from the outside.

8. Don’t forget your family. Don’t let your career take the place of your family. Set both career and family goals.

7. Be professional at all times. You never know who your next patient will be. Dress, act, and speak in a professional manner.

6. Find some quiet time. It is OK to turn off your smartphone and enjoy some peace and quiet (unless you are on call, of course). Ignore the idea that everyone takes precedence over you. If you are able to, outsource any of your time-consuming household chores or errands. Do something you enjoy; it will reenergize you.

5. Be “interested,” not “interesting.” Sit down with your patients and find out about them. Place follow-up phone calls to make sure your patients are doing better. 

4. Learn how to handle mistakes. Honesty is important. If you make a mistake, own up to it. Everyone will appreciate you for it.

3. Develop a referral base. Establish professional relationships with colleagues in specialties to whom you may refer patients. Also, it is important to develop relationships with the ancillary services for the same reason (eg, physical therapists, occupational therapists, audiologists). Support interprofessional collaboration.

2. Show your appreciation. A written note to a patient or a colleague goes a long way. Take the time to thank someone for the referral or for something nice they did for you.

1. Hugs! Yes, it is OK to give and receive appropriate hugs from patients, colleagues, and family members. A hug is just as healing as medicine.

I am sure there are many more “pearls” to share with our colleagues. If you have one that wasn’t mentioned here, please send it to [email protected]. Thanks for listening.

Recently, Christy Wilson, PA-C, and I presented a workshop on “Balancing Your Life After PA School.” The program discussed everything that was not taught in PA school that the practicing clinician should know.

To prepare, we asked our peers what they wished they had known in their early years of practice. The response was over­whelming. Herewith, the top 20 items that emerged:

20. Learn to manage your time. No, really. Find ways to build downtime in your schedule. There is no doubt that the first years after school are not unlike a “residency,” as you learn how to practice medicine effectively. You should develop a ritual of good habits. Refocus and drop activities that sap your time.

19. Enhance your professional relationships. Be sure to know the ins and outs of a professional contract. Be nice to everyone—not only the other clinicians, but also the office staff and the cleaning personnel. It is a small world even if you live in a big city.

18. Enhance your relationships with your patients. Remind yourself why you do what you do. Continue to look at your patient as an individual—not a disease, condition, or room number. Be honest and empathetic, and prepare for the times when you will have to give bad news or when a bad outcome occurs. It is important to remember that patient satisfaction may not be compatible with just good medicine.

17. Understand your medical liability. When it comes to medical malpractice insurance, should you have your own? Should you have tail coverage? Learn ways to reduce liability. The better care you take of yourself in a legal sense results in less time you may have to spend with an attorney.

16. Understand the business of medicine. Who knew how important this would be? There is just as much politics in medicine as there is in Washington, DC. Learn to lobby for what you want. Electronic medical records (EMR) and CPT coding have become extremely important in the practice of medicine. Get involved in the know-how of these items.

15. Care for your body, mind, and spirit. Your physical and mental well-being depend on nourishment. Don’t skip meals, and find regular time for exercise, even if that just means taking a short walk or using the stairs instead of the elevator. Get enough sleep. Surround yourself with positive people. You may find it equally healthy to give something back by volunteering in your church, hospital, civic club, and alumni association, by being a clinical preceptor, or by doing some pro bono work.

14. Deal with fear. Cut yourself some slack. You don’t have to do everything—just the right things. It is not uncommon for us to worry all the time about our patients or other issues. It is important that we find time to compartmentalize. Find an outlet to vent when you have a bad day.

13. Take care of your finances. Financial planning is important. What does your practice/company offer you in regard to retirement and/or disability insurance? Don’t delay getting those student loans paid off.

12. Stay up to date with your professional requirements. Keep on top of hospital credentialing, state licensure, and national certification. Don’t let them lapse.

11. Understand when to order the appropriate diagnostic tests. Know when to order an MRI versus a CT or ultrasound. Don’t be afraid to ask if you don’t know.

10. Always remember the five Ds of prescribing: the right diagnosis, the right drug, the right dose, the right duration, and the right time for discontinuation or withdrawal.

9. Be involved in your profession. Get and stay involved in your state and national professional associations. It is always better to work from within an organization, even if you are unhappy with some of the things they do, than try to make changes from the outside.

8. Don’t forget your family. Don’t let your career take the place of your family. Set both career and family goals.

7. Be professional at all times. You never know who your next patient will be. Dress, act, and speak in a professional manner.

6. Find some quiet time. It is OK to turn off your smartphone and enjoy some peace and quiet (unless you are on call, of course). Ignore the idea that everyone takes precedence over you. If you are able to, outsource any of your time-consuming household chores or errands. Do something you enjoy; it will reenergize you.

5. Be “interested,” not “interesting.” Sit down with your patients and find out about them. Place follow-up phone calls to make sure your patients are doing better. 

4. Learn how to handle mistakes. Honesty is important. If you make a mistake, own up to it. Everyone will appreciate you for it.

3. Develop a referral base. Establish professional relationships with colleagues in specialties to whom you may refer patients. Also, it is important to develop relationships with the ancillary services for the same reason (eg, physical therapists, occupational therapists, audiologists). Support interprofessional collaboration.

2. Show your appreciation. A written note to a patient or a colleague goes a long way. Take the time to thank someone for the referral or for something nice they did for you.

1. Hugs! Yes, it is OK to give and receive appropriate hugs from patients, colleagues, and family members. A hug is just as healing as medicine.

I am sure there are many more “pearls” to share with our colleagues. If you have one that wasn’t mentioned here, please send it to [email protected]. Thanks for listening.

Recently, Christy Wilson, PA-C, and I presented a workshop on “Balancing Your Life After PA School.” The program discussed everything that was not taught in PA school that the practicing clinician should know.

To prepare, we asked our peers what they wished they had known in their early years of practice. The response was over­whelming. Herewith, the top 20 items that emerged:

20. Learn to manage your time. No, really. Find ways to build downtime in your schedule. There is no doubt that the first years after school are not unlike a “residency,” as you learn how to practice medicine effectively. You should develop a ritual of good habits. Refocus and drop activities that sap your time.

19. Enhance your professional relationships. Be sure to know the ins and outs of a professional contract. Be nice to everyone—not only the other clinicians, but also the office staff and the cleaning personnel. It is a small world even if you live in a big city.

18. Enhance your relationships with your patients. Remind yourself why you do what you do. Continue to look at your patient as an individual—not a disease, condition, or room number. Be honest and empathetic, and prepare for the times when you will have to give bad news or when a bad outcome occurs. It is important to remember that patient satisfaction may not be compatible with just good medicine.

17. Understand your medical liability. When it comes to medical malpractice insurance, should you have your own? Should you have tail coverage? Learn ways to reduce liability. The better care you take of yourself in a legal sense results in less time you may have to spend with an attorney.

16. Understand the business of medicine. Who knew how important this would be? There is just as much politics in medicine as there is in Washington, DC. Learn to lobby for what you want. Electronic medical records (EMR) and CPT coding have become extremely important in the practice of medicine. Get involved in the know-how of these items.

15. Care for your body, mind, and spirit. Your physical and mental well-being depend on nourishment. Don’t skip meals, and find regular time for exercise, even if that just means taking a short walk or using the stairs instead of the elevator. Get enough sleep. Surround yourself with positive people. You may find it equally healthy to give something back by volunteering in your church, hospital, civic club, and alumni association, by being a clinical preceptor, or by doing some pro bono work.

14. Deal with fear. Cut yourself some slack. You don’t have to do everything—just the right things. It is not uncommon for us to worry all the time about our patients or other issues. It is important that we find time to compartmentalize. Find an outlet to vent when you have a bad day.

13. Take care of your finances. Financial planning is important. What does your practice/company offer you in regard to retirement and/or disability insurance? Don’t delay getting those student loans paid off.

12. Stay up to date with your professional requirements. Keep on top of hospital credentialing, state licensure, and national certification. Don’t let them lapse.

11. Understand when to order the appropriate diagnostic tests. Know when to order an MRI versus a CT or ultrasound. Don’t be afraid to ask if you don’t know.

10. Always remember the five Ds of prescribing: the right diagnosis, the right drug, the right dose, the right duration, and the right time for discontinuation or withdrawal.

9. Be involved in your profession. Get and stay involved in your state and national professional associations. It is always better to work from within an organization, even if you are unhappy with some of the things they do, than try to make changes from the outside.

8. Don’t forget your family. Don’t let your career take the place of your family. Set both career and family goals.

7. Be professional at all times. You never know who your next patient will be. Dress, act, and speak in a professional manner.

6. Find some quiet time. It is OK to turn off your smartphone and enjoy some peace and quiet (unless you are on call, of course). Ignore the idea that everyone takes precedence over you. If you are able to, outsource any of your time-consuming household chores or errands. Do something you enjoy; it will reenergize you.

5. Be “interested,” not “interesting.” Sit down with your patients and find out about them. Place follow-up phone calls to make sure your patients are doing better. 

4. Learn how to handle mistakes. Honesty is important. If you make a mistake, own up to it. Everyone will appreciate you for it.

3. Develop a referral base. Establish professional relationships with colleagues in specialties to whom you may refer patients. Also, it is important to develop relationships with the ancillary services for the same reason (eg, physical therapists, occupational therapists, audiologists). Support interprofessional collaboration.

2. Show your appreciation. A written note to a patient or a colleague goes a long way. Take the time to thank someone for the referral or for something nice they did for you.

1. Hugs! Yes, it is OK to give and receive appropriate hugs from patients, colleagues, and family members. A hug is just as healing as medicine.

I am sure there are many more “pearls” to share with our colleagues. If you have one that wasn’t mentioned here, please send it to [email protected]. Thanks for listening.

The other day, a good friend of mine took his wife to the cardiologist for complaints of dizziness and palpitations. The physician took a short history and said he wanted to order an ECG, an echocardiogram, and some blood work, then started to walk out of the room. At the door, he spun around, walked back, and said, with a chuckle, “I guess I should also listen to your heart,” whereby he did so, through her blouse in two places. (Yes, I know you can hear heart sounds through clothing.) 

The director of a PA program recently shared with me her concerns that PA students are losing their physical examination skills in their clinical year, because preceptors are teaching students to use short cuts and rely more on laboratory studies than their hands-on examination skills. 

I guess I am old-fashioned. When I went to school—and throughout many years of practice—I relied heavily on my history-taking and physical exam skills to lead me toward an accurate diagnosis. Are we losing those skills? Are we passing them on to the new generation of clinicians? Is technology replacing the need for good examination skills? 

Recently National Public Radio (NPR) published an audio report called “The Fading Art of the Physical Exam.” This very poignant report discussed a number of stories in which physicians omitted part or all of a physical examination in favor of an expensive technological test. There are some fears that the trend is likely to get worse. Nesli Basgoz, MD, of the Massachusetts General Hospital, is quoted in the report as saying, “I’m definitely worried that the physical exam is dying a slow death.”¹

As a practicing PA for more than 35 years, who has also done his share of both didactic and clinical teaching, I am familiar with this age-old topic and would like to bring forward a couple of points. First, I have learned that a thorough patient history yields about 80% of the information needed to arrive at an accurate diagnosis. That leaves the physical examination to a somewhat, albeit perceived, lesser role. 

Secondly, I am convinced that a relevant “laying on of hands” is not only therapeutic but may lead the clinician to a final key to a diagnosis or to further appropriate testing. It never feels complete for me to leave a patient without an appropriate physical exam, whether complete or focused. It is a crucial part of the relationship with our patients that cannot, in my opinion, be underestimated. Now, I’m not saying diagnostic tests are unimportant; they are important. But they should be adjuncts to a proper examination. 

On the other hand, Danielle Ofri, MD, suggests “There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history.”² It is true that research has shown patients expect a physical exam. So, are we doing it for the patient’s sake or to elicit more data to assist us with the diagnosis—or both? What about the importance of checking for previously missed findings or monitoring chronic disease progression?

There is also evidence that a complete annual physical exam is not cost-effective (assuming that is one of the goals of medicine). Has the focus of medical schools turned from teaching diagnosis using the tried-and-true history and physical examination to using increasingly sophisticated and expensive technologies? If this is true, the skill sets of new physicians in practice may not include listening and physical examination. 

The medical profession, and the business element of today’s health care practice, must accept responsibility for the dying art of physical examination. It should be noted, this process of collecting data also includes teaching patients and their community the nature of their problem, what to monitor, and when to call the clinician to intervene. The physical exam encompasses both data gathering and patient education. Touching and listening with documentation will avoid lawsuits, provide cost-effective care, and enhance the clinician-patient rapport.

Since the widespread discussion initiated by the NPR report, a number of respected physicians around the country have called for a renewed emphasis on the physical examination. Abraham Verghese, MD, MACP, has joined with colleagues at Stanford University to publicize a 25-item list of physical-exam maneuvers³ that they feel should be required of internal medicine residents—and perhaps all clinicians. These include everything from funduscopy to knee and shoulder exams to palpation of the spleen. (See medicine.stanford.edu/education/stanford_25.html for the full list.)

In a profile of Verghese in the New York Times, science and health reporter Denise Grady stated, “In an era where lab tests and MRI, CT, and ultrasound machines are the ultimate diagnosticians, old-fashioned physical exams that include careful touching, looking, and listening are at risk of extinction. While some doctors consider physical exams obsolete in light of modern technology, others like Dr. Verghese believe they are a lost art in need of revival.”⁴

Maybe there is hope that we will not altogether lose the importance of an effective physical examination as part of the toolkit of medicine. Is this an issue for anyone else? Or should we bow to technology? 

There are many questions left unanswered. I would love to hear your thoughts; email me at [email protected].

The other day, a good friend of mine took his wife to the cardiologist for complaints of dizziness and palpitations. The physician took a short history and said he wanted to order an ECG, an echocardiogram, and some blood work, then started to walk out of the room. At the door, he spun around, walked back, and said, with a chuckle, “I guess I should also listen to your heart,” whereby he did so, through her blouse in two places. (Yes, I know you can hear heart sounds through clothing.) 

The director of a PA program recently shared with me her concerns that PA students are losing their physical examination skills in their clinical year, because preceptors are teaching students to use short cuts and rely more on laboratory studies than their hands-on examination skills. 

I guess I am old-fashioned. When I went to school—and throughout many years of practice—I relied heavily on my history-taking and physical exam skills to lead me toward an accurate diagnosis. Are we losing those skills? Are we passing them on to the new generation of clinicians? Is technology replacing the need for good examination skills? 

Recently National Public Radio (NPR) published an audio report called “The Fading Art of the Physical Exam.” This very poignant report discussed a number of stories in which physicians omitted part or all of a physical examination in favor of an expensive technological test. There are some fears that the trend is likely to get worse. Nesli Basgoz, MD, of the Massachusetts General Hospital, is quoted in the report as saying, “I’m definitely worried that the physical exam is dying a slow death.”¹

As a practicing PA for more than 35 years, who has also done his share of both didactic and clinical teaching, I am familiar with this age-old topic and would like to bring forward a couple of points. First, I have learned that a thorough patient history yields about 80% of the information needed to arrive at an accurate diagnosis. That leaves the physical examination to a somewhat, albeit perceived, lesser role. 

Secondly, I am convinced that a relevant “laying on of hands” is not only therapeutic but may lead the clinician to a final key to a diagnosis or to further appropriate testing. It never feels complete for me to leave a patient without an appropriate physical exam, whether complete or focused. It is a crucial part of the relationship with our patients that cannot, in my opinion, be underestimated. Now, I’m not saying diagnostic tests are unimportant; they are important. But they should be adjuncts to a proper examination. 

On the other hand, Danielle Ofri, MD, suggests “There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history.”² It is true that research has shown patients expect a physical exam. So, are we doing it for the patient’s sake or to elicit more data to assist us with the diagnosis—or both? What about the importance of checking for previously missed findings or monitoring chronic disease progression?

There is also evidence that a complete annual physical exam is not cost-effective (assuming that is one of the goals of medicine). Has the focus of medical schools turned from teaching diagnosis using the tried-and-true history and physical examination to using increasingly sophisticated and expensive technologies? If this is true, the skill sets of new physicians in practice may not include listening and physical examination. 

The medical profession, and the business element of today’s health care practice, must accept responsibility for the dying art of physical examination. It should be noted, this process of collecting data also includes teaching patients and their community the nature of their problem, what to monitor, and when to call the clinician to intervene. The physical exam encompasses both data gathering and patient education. Touching and listening with documentation will avoid lawsuits, provide cost-effective care, and enhance the clinician-patient rapport.

Since the widespread discussion initiated by the NPR report, a number of respected physicians around the country have called for a renewed emphasis on the physical examination. Abraham Verghese, MD, MACP, has joined with colleagues at Stanford University to publicize a 25-item list of physical-exam maneuvers³ that they feel should be required of internal medicine residents—and perhaps all clinicians. These include everything from funduscopy to knee and shoulder exams to palpation of the spleen. (See medicine.stanford.edu/education/stanford_25.html for the full list.)

In a profile of Verghese in the New York Times, science and health reporter Denise Grady stated, “In an era where lab tests and MRI, CT, and ultrasound machines are the ultimate diagnosticians, old-fashioned physical exams that include careful touching, looking, and listening are at risk of extinction. While some doctors consider physical exams obsolete in light of modern technology, others like Dr. Verghese believe they are a lost art in need of revival.”⁴

Maybe there is hope that we will not altogether lose the importance of an effective physical examination as part of the toolkit of medicine. Is this an issue for anyone else? Or should we bow to technology? 

There are many questions left unanswered. I would love to hear your thoughts; email me at [email protected].

The other day, a good friend of mine took his wife to the cardiologist for complaints of dizziness and palpitations. The physician took a short history and said he wanted to order an ECG, an echocardiogram, and some blood work, then started to walk out of the room. At the door, he spun around, walked back, and said, with a chuckle, “I guess I should also listen to your heart,” whereby he did so, through her blouse in two places. (Yes, I know you can hear heart sounds through clothing.) 

The director of a PA program recently shared with me her concerns that PA students are losing their physical examination skills in their clinical year, because preceptors are teaching students to use short cuts and rely more on laboratory studies than their hands-on examination skills. 

I guess I am old-fashioned. When I went to school—and throughout many years of practice—I relied heavily on my history-taking and physical exam skills to lead me toward an accurate diagnosis. Are we losing those skills? Are we passing them on to the new generation of clinicians? Is technology replacing the need for good examination skills? 

Recently National Public Radio (NPR) published an audio report called “The Fading Art of the Physical Exam.” This very poignant report discussed a number of stories in which physicians omitted part or all of a physical examination in favor of an expensive technological test. There are some fears that the trend is likely to get worse. Nesli Basgoz, MD, of the Massachusetts General Hospital, is quoted in the report as saying, “I’m definitely worried that the physical exam is dying a slow death.”¹

As a practicing PA for more than 35 years, who has also done his share of both didactic and clinical teaching, I am familiar with this age-old topic and would like to bring forward a couple of points. First, I have learned that a thorough patient history yields about 80% of the information needed to arrive at an accurate diagnosis. That leaves the physical examination to a somewhat, albeit perceived, lesser role. 

Secondly, I am convinced that a relevant “laying on of hands” is not only therapeutic but may lead the clinician to a final key to a diagnosis or to further appropriate testing. It never feels complete for me to leave a patient without an appropriate physical exam, whether complete or focused. It is a crucial part of the relationship with our patients that cannot, in my opinion, be underestimated. Now, I’m not saying diagnostic tests are unimportant; they are important. But they should be adjuncts to a proper examination. 

On the other hand, Danielle Ofri, MD, suggests “There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history.”² It is true that research has shown patients expect a physical exam. So, are we doing it for the patient’s sake or to elicit more data to assist us with the diagnosis—or both? What about the importance of checking for previously missed findings or monitoring chronic disease progression?

There is also evidence that a complete annual physical exam is not cost-effective (assuming that is one of the goals of medicine). Has the focus of medical schools turned from teaching diagnosis using the tried-and-true history and physical examination to using increasingly sophisticated and expensive technologies? If this is true, the skill sets of new physicians in practice may not include listening and physical examination. 

The medical profession, and the business element of today’s health care practice, must accept responsibility for the dying art of physical examination. It should be noted, this process of collecting data also includes teaching patients and their community the nature of their problem, what to monitor, and when to call the clinician to intervene. The physical exam encompasses both data gathering and patient education. Touching and listening with documentation will avoid lawsuits, provide cost-effective care, and enhance the clinician-patient rapport.

Since the widespread discussion initiated by the NPR report, a number of respected physicians around the country have called for a renewed emphasis on the physical examination. Abraham Verghese, MD, MACP, has joined with colleagues at Stanford University to publicize a 25-item list of physical-exam maneuvers³ that they feel should be required of internal medicine residents—and perhaps all clinicians. These include everything from funduscopy to knee and shoulder exams to palpation of the spleen. (See medicine.stanford.edu/education/stanford_25.html for the full list.)

In a profile of Verghese in the New York Times, science and health reporter Denise Grady stated, “In an era where lab tests and MRI, CT, and ultrasound machines are the ultimate diagnosticians, old-fashioned physical exams that include careful touching, looking, and listening are at risk of extinction. While some doctors consider physical exams obsolete in light of modern technology, others like Dr. Verghese believe they are a lost art in need of revival.”⁴

Maybe there is hope that we will not altogether lose the importance of an effective physical examination as part of the toolkit of medicine. Is this an issue for anyone else? Or should we bow to technology? 

There are many questions left unanswered. I would love to hear your thoughts; email me at [email protected].

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at [email protected].            CR

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at [email protected].            CR

Many of us remember the 1961 satirical novel (which later became a movie) by Joseph Heller, Catch-22. The term catch-22 has become a (forgive the pun) catchphrase describing an ineffective bureaucratic process and reasoning that results in a “no-win” state of affairs. Increasingly in the past few years, I have heard patient stories that demonstrate a medical catch-22. Let me relay one such story. The patient’s name has been changed to protect the innocent and to adhere to HIPAA standards. The guilty are obvious. 

Stacey, now 30, is the middle child of five children. She manifested bipolar symptoms when she was 12, with dramatic and unpredictable mood swings.¹ At that time, despite counseling and treatment, she experienced significant symptoms of mania: irritability, restlessness, increased energy, little need for sleep, racing thoughts, hypersexuality, and a tendency to make grand and unattainable plans. She became a two-pack-a-day smoker. 

During this time, she would run away from home, on a number of occasions actually taking the family car. She spent a great deal of time in juvenile detention. Her depression symptoms included sadness, anxiety, irritability, loss of energy, uncontrollable crying, weight gain, increased need for sleep, difficulty making decisions, and thoughts of death. These symptoms worsened over time, and Stacey refused to use prescribed medication or to attend individual and family counseling. 

Often, she would run away for weeks at a time, then show up in the middle of the night. It was during this period that she became pregnant with her first child. Shortly after the birth of her son, and due to safety concerns, Stacey’s parents were granted temporary custody of the child. It took two years for her parents to obtain legal guardianship of the child, because of Stacey’s recurrent inability to attend court proceedings and give permission for the necessary court action.

During her young adulthood, Stacey’s condition became even more difficult to manage—due in part to her legal right to make her own decisions and to the fact that she would “escape” for weeks at a time. During these years, her parents would find that she had been incarcerated or had lived on the street or with total strangers. 

She was diagnosed with schizophrenia² and was able to receive Social Security money each month for her disability. Her symptoms now included recurring episodes of elevated or depressed mood, with significant distortions in perception. Her symptoms affected cognition and emotion. She demonstrated auditory hallucinations, paranoia, bizarre delusions, disorganized speech, and social and occupational dysfunction. 

Stacey gave birth to a second son. Again, due to her disability, she was unable to care for this child, and Stacey’s parents gained legal guardianship. Over the next few years, Stacey would give birth to two other children, who were subsequently adopted, and an additional pregnancy was terminated by abortion.  

Once, Stacey showed up at her parents’ house and in front of two of her children attempted to cut her wrists. She was taken to the urgent psychiatric care center and hospitalized. She checked herself out 72 hours later. This became a recurring pattern. She would have outbursts, be hospitalized, then check herself out—back to the streets. 

Unable to manage her Social Security checks, Stacey frequently went to casinos to spend her money rapidly; she would then have no money for food, clothing, or transportation. She has been banned from most casinos because of outbursts and inappropriate behavior. 

Her parents believe Stacey has become a danger not only to herself, but also to the lives of her children and siblings. Her behaviors have escalated to include threats to harm others. 

Recently, Stacey was found wandering around town and talking to herself. She was again admitted to the local psychiatric facility. Her intake examination revealed she was undernourished, with poor hygiene. Her drug screen was positive for cocaine, and a pregnancy test was positive. A hearing took place, and she was committed for 30 days for evaluation and treatment. An assigned caseworker explained to her parents that, due to financial constraints, they would not be able to hold Stacey past the 30 days, despite her pregnancy.  

There is no doubt that Stacey is suffering from a serious mental illness that has severely impaired her functioning. Caseworkers, counselors, and physicians all agree that Stacey’s health and well-being, particularly now that she is pregnant, can only be maintained by the most restrictive psychiatric setting. Unfortunately, the long-term psychiatric hospital has denied a request for admission. Stacey will be returned to outpatient treatment where she will, undoubtedly, be lost to follow-up and treatment. The risks to the fetus and to Stacey are extreme.

It has become commonplace to see and hear media reports about police interactions with mentally ill people. Yet it is not uncommon for correctional officers and officials to voice concerns that our jails have become de facto mental health hospitals, with more people than ever before incarcerated with—and sometimes because of—mental health problems. Correctional personnel continuously remind us they are neither trained nor funded for these types of responsibilities.

Mental health funding has faced the budgeting sword in many states over the past couple of years. While the social implications are tragic, there is also a significant cost. Law enforcement and emergency services are not designed to provide mental health services to patients on a prolonged basis. The needs of the chronically mentally ill quickly overwhelm those systems and become very expensive to address.     

Releasing patients from the psychiatric wing of a jail, a crisis center, or a psychiatric hospital without ensuring that treatment is continuously maintained is a profound medical error, with risk to patient and community—not to mention a waste of taxpayer’s money. There is an astonishing recidivism rate among repeat offenders with serious mental illness, even though parole or probation conditions usually mandate follow-up treatment. Even when effective medications are dispensed, many patients suffer from anosognosia (impaired awareness of illness) and subsequently do not continue their medications or follow-up care.  

According to the Treatment Advocacy Center, anosognosia is the single largest reason that individuals with schizophrenia and bipolar disorder do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere, and affects approximately 50% of individuals with schizophrenia and 40% of individuals with bipolar disorder.³ 

Another major factor in noncompliance is alcohol and substance abuse; this further complicates treatment of the seriously ill. Commonly, such patients revert back to abusing drugs or alcohol. It is clear that abuse of these substances mars one’s ability to appreciate symptoms, to make proper judgments, and to have the insight necessary to recognize one’s dysfunctional behavior.

The National Alliance on Mental Illness estimates the cost of untreated mental illness to be more than $100 million annually. Ignoring the needs of the mentally ill contributes to and fosters:

• An inability to maintain employment

• An increased burden on law enforcement

• Overcrowding of cases in an already strained legal system

• Stressed jail facilities

 • Overburdening of local crisis centers 

• An increase of the homeless population in our communities.⁴

The plight of mentally ill patients in this country is heartbreaking. Of course, no single answer or approach will fix this problem. It will take multiple funded agencies working together with clinicians and caseworkers to provide the necessary continuation of care for the chronically mentally ill to correct this catch-22. 

I’d love to hear from you if you have comments about this editorial. E-mail me at [email protected].            CR