intro us healthcare

current term for the profession

PA= Physician Assistant (term for decades) -> Physician Associate (May 2021 at AAPA meeting approved name change, but state to state processes for name change); also referred to as APP= Advanced Practice Providers

history of non-physicians to provide health care services

russian wilderness, rural china, fronteirs of the american west, alaskan villages, during times of war- provided maternity care, primary care

examples of non-physician providers

feldshers (field surgeons), loblolly boy (assistant to medical officers in Navy), highly technical surgical procedures led innovators to train technicians to assist in urology and cardiovascular surgery (the United States Public Health Service- extend the services to prison physicians- took former military corpsman to train to treat prisoners), rural north carolina physician Dr. Johnson (general practitioner) trained "doctor's assistant" (Henry Treadwell to do procedures without med school education

Dr Eugene Stead fast track

1942- developed fast track 3 year medical curriculum- this provided a model for the medical curriculum later developed to educate 'physician's assistant' at Duke University in 1965 (needed more providers because this was during wartime, so there was a physician shortage since most were men who were drafted to war)

specialization in medical practice led to a growing shortage in

primary care

Dr Stead Duke 1957 original idea for PA/doctor's assistant

1957- Dr Eugene Stead (chair of the dept of medicine at duke)- drew up a curriculum originally for nurses to train them to be doctor's assistants, but the nursing board declined and accreditation was denied twice (generally conceded that is this had been accredited, Stead would not have later initiated the Duke university PA program

effect of medicare and medicaid on healthcare system 1960

federally provided ways of providing health insurance; caused physician shortage since tons of patient who used to not be able to afford health insurance now had access to it, so more patients than doctors could care for

"mid level"provider 1961

Dr charles Hudson- addressed the AMA asking for this; movement toward the concept of the physician assistant is set in motion

Alderson-Broaddus College 1963

Dr. Hu Myers approaches the Alderson-Broaddus College Board of Trustees in Philippi, WV proposing a PA program but the board turned him down; he didn't give up, and later, AB became the 1st PA program that provided a bachelors degree

1964 Dr Stead

announces intention to develop a program for the "physician's assistant"

1965 Duke University

Duke University establishes the first program with 4 ex-Navy corpsman; the nation's first "physician assistant" educational program is inaugurated at Duke University; University of Colorado establishes the 1st Pediatric Nurse Practitioner Program

look magazine article 1966

"more than a nurse, less than a doctor" (do not use this to explain what a PA is)

primary care definition

first contact patient has with a provider

october 6, 1967

the first class of three PAs graduate from Duke University (Victor H Germino, Kenneth F Ferrell, Richard J Scheele)

when was the first certifying exam offered

1973

when did Saint Francis College begin its PA program

1977

october 6 1987

national PA day is established; this day chosen because it was the 20th anniversary to the first graduating class of 3 PAs from Duke (also happened to be Dr. Stead's birthday)

what happened as a result of majority of admitted students already having a baccalaureate degree

got rid of 2 year certificate program and added 5 year master program

mississippi in 2000

final state to have legislation for PA acceptance; physician assistant practice is finally universally accepted in all US states/territories

globalization of PA concept

2007- 40th anniversary of the graduation of the 1st formally trained PAs, Australia, Canada, England, parts of South Africa; Indiana- finally allows PAs to prescribe meds; all 50 states, DC, and Guam now allow PAs to practice and prescribe

patient protection and affordable care act 2010

need for health manpower greater than anything seen since the implementation of medicare and medicaid; tons of uninsured patients now have access to care; PAs and NPs able to assist in providing care

2017

50th anniversary of the PA program; high ranking profession in terms of job satisfaction, salary, NCCPA certified its 100,000th PA since its inception in 1975

2021

AAPA House of Delegates passes a resolution changing the name of the PA profession to Physician Associate

2024

oregon is the first state to change the title in their legislature

the Physician Assistant PA-C meaning

final passing point of professional training; can be used by PAs who have passed boards and are competent to practice; a moart of professional accomplishment indicating achievement and maintenance of established levels of knowledge and clinical skills; required certification

the structure of the PA profession

• a society of practitioners (AAPA)- represents all PAs and student members, location in DC/virginia

• a nationally recognized body charged with accreditation of the programs (ARC-PA)

• an association of educational programs training those practitioners (PAEA)

• a process of certification of graduated in the public interest (NCCPA)

American Academy of Physician Assistants (AAPA)

society of practitioners, located in DC/Virginia, established in 1968 by students and alumni of Duke PA program, recognized as the national voice for PAs in medical and surgical specialties; constituent chapters- represent the interest of PAs in 50 states and territories and federal services (Army, Air Force, Navy, Public Health Service, Department of Veteran Affairs); the AAPA annual conference- the AAPA established a House of Delegates to govern policy (where 2021 voting members approved Associate name change)

the Accreditation Review Commision on Education for the Physician Assistant (ARC-PA)

accrediting party, a nationally recognized body charged with accreditation of programs, located in Atlanta GA, currently 330 accredited programs (most located in PA and NY); role- approve and revise Accreditation Standards for Physician Assistant Education, 1st Adopted by the AMA 1971; review and grant applications for accreditation using site visitors (volunteers who look at schools wanting to accredit a program); ARC-PA- representatives from various health professional organizations

the Physician Assistant Education Association (PAEA)

an association of educational programs training those practitioners, located in DC, established in early 1970s, only national organization in the United States representing PA educational programs; mission- to pursue excellence, foster faculty development, advance the body of knowledge that defines quality education and patient centered care, and promote diversity in all aspects of physician assistant education

National Commission on Certification for Physician Assistants (NCCPA)

a process of certification of graduates in the public interest, located in Altlanta GA, established in 1974; 1971 Health Manpower Act- triples the number of programs in 1971, dedicated to assuring the public that PA-Cs meet established standards of knowledge and clinical skills upon entry into practice and throughout their careers, NCCPA is the only credentialing organization for PAs in the US, consists of a consortium of societies and agencies charged with oversight of the certification process

PANCE

Physician Assistant National Certifying Exam, national boards- 300 questions with 1 min per question; computer based multiple choice test that assesses general medical and surgical knowledge (initial certifying exam, costs $550); graduate from accredited ARC-PA program-> PANCE/NCCPA certificate-> PA-C; eligibility- graduate from accredited program and wait 7 days to take PANCE, administered almost year round and must take at approved testing center, must wait 90 days if fail

maintenance of PA-C certification

10 year cycle, CME- continuing medical education (2 year period)- 100 credits each 2 year cycle with NCCPA

PANRE

Physician Assistant National Recertification Exam- 240 multiple choise questions to assess general medical and surgical knowledge; must take every 10 years to recertify or may take PANRELA take home recert longitudinal assessment

governing boards in each state- legislative issues

PA- MD (allopathic board) and DO boards (osteopathic boards)

primary supervisor- legislative issues

supervising physician, assumes full medical and legal responsibility for PA- PAs must be regisered with state board of Medicine and work with supervising physician; the supervising physician must countersign 100% of charts within 10 days for the first 12 months postgrad and for the first 12 months of a new specialty

scope of practice- legislative issues

education and experience- as new grad, supervising MD/DO may determine amount you can perform; state law- state by state, different; supervising physician's delegatory decisions- can decide what all they want you to do; facility policy- hospital employer, private practice, may not let you do certain things alone until you've done it with supervising physician

scope of practice

prescribing, injections, casting, physical exams, suturing, order diagnostics, developmental screenings on children, document, declare a patient deceases; main things- patient history, physical exam, diagnostic tests, prescribing meds

procedures a PA can do

venipuncture, intradermal tests and injections, electrocardiogram, care and suturing of minor lacerations, wound care, casting and splinting, control of external hemorrhage, administration of medications, removal of superficial foreign bodies, CPR, ear irrigation, audiometry and vision screening, carry out aspectic/ isolation techniques, other specialty specific procedures

PAs cannot-

provide medical services outside of written agreement, independently bill- done under supervising MD/DO, independently advertise, perform accupuncture, misrepresent yourself as a physician

written agreement

document signed with state saying what you can and can't do as a PA in your specialty

limit to PAs hired to work with a supervising physician

can either hire a PA to work under other supervising physician if limit already reached, or have to hire additional supervising physicians to supervise new PAs

clinical doctorate summit 2009

AAPA and PAEA hosted in Atlanta- determined that the master's degree is the current terminal degree for a PA and doctorate degree is reserved for postgraduated education in another discipline

optimal team practice

AAPA introduced in 2017- what AAPA has been advocating for since 2017, focuses on collaboration and teamwork because PAs still not independent

PA and NP differences

• NPs are nurses first since nursing school required then additional NP school, PAs can be from any profession or straight from undergrad, just need to complete pre-reqs and graduation PA-C

• NPs can work independently in over half of the US states, PAs cannot

• NPs must choose specific specialty agreement (peds, family med, psych, etc)

• NPs do nursing model of education, PAs do medical model of education

over the counter (OTC)

can recommend to patient without a prescription; tylenol, ibubrophen, supplements, eyedrops, some allergy meds, melatonin, decongestants, asprin

behing the counter

don't need a prescription, but need to ask for it behind pharmacy counter because amounts are tracked since too much can be used to make drugs like meth; some cold/sinus meds (sudafed), migraine meds, cough syrup with codeine, birth control, oral contraceptives

prescription meds

can only be purchased with an order from MD/DO/PA/NP; oxycodone, amoxicillan, lasix, atorvastatins, blood thinners, blood pressure meds, inhalers, bronchodilators, steroids; some meds come in OTC and prescription strength- can get higher strengths with prescription

illicit drugs

illegal drugs that can be taken for non medical use

controlled substances

divided into 5 schedules based upon: whether they have a currently accepted medical use in treatment in the US, their relative abuse potential/addiction, their liklihood of causing dependence when abused; highest liklihood= schedule 1, lowest liklihood= schedule 5

schedule I controlled substances

determined at federal level (DEA); no currently accepted medical use in the united states, a lack of accepted safety for us under medical supervision, and a high potential for abuse; heroione, LSD, marijuana (even though this is legalized state by state); PAs CANNOT prescribe anything under this category

schedule II controlled substances

high potential for abuse which may lead to severe psychological or physical dependence; narcotics- morphine, codeine, hydromorphone (dilaudid), methadone, oxycodone (OxyContin, Percocet), fentanyl (Duragesic); stimulants (some can be prescribed fo ADHA: Ritalin, Adderall)- amphetamine (Dexedrine, Adderall), methylphenidate (Ritalin), methamphetamine, cocaine

schedule III controlled substance

potential for abuse is less than schedule I or II, and abue may lead to moderate or low physical dependency or high psychological dependence; combination products containing <15 mg of hydrocodone per dosage unit (vicodin), products containing no > 90 mg of codeine per dosage unit (tylenol with codeine), and buprenorphine (suboxone- for opiod dependence), stimulants for weight loss, keatmine, some testosterone supplements (prescribed as aging decreases amount, monitored because can be used in anabolic steroid)

schedule IV controlled substance

low potential for abuse relative to substances in schedule III; benzodiazepines (anxiety, seizures, before MRI)/hypnotics (sleep meds)- alprazolam (Xanax), clonazepam (klonopin), diazepam (valium), lorazepam (ativan), midazolam (versed)

schedule V controlled substance

low potentian for abuse relative to substances listed in schedule IV and consist primarily of preparations containing limited quantities of certain narcotics; cough preparations containing no > 200 mg of codeine per 100 ml or per 100 gm (robitussin AC, phenergan with codeine for chronic cough), diphenoxylate (lomotil for antidiahrrea), and pregabalin (lyrica for pain)

DEA registration

need state medical license information; applicant must still comply with state requirements, federal registration does not overrule state; also need to apply for DEA number to prescribe controlled substances, fees are non refundable- $888 for 3 years (can be payed for by employer)

prescription drug monitoring program

database which collects information on all filled prescriptions for controlled substances; monitors use and prescription of controlled substances; providers can access this by logging into program to check recent controlled substance fillings at pharmacies from all hospitals/practices; good for preventing abuse with presription drugs

prescriptive privalages

PA- the supervising physician may delegate to the PA the prescribing, dispensing, and administering of drugs and therapeutic devices; PA cannot prescribe or dispense schedule I or any drugs for a person who is not their patient; PA may only prescribe a drug for a patient who is under the care of the SP and only in accordance with the SP instructions and written agreement; PA may request/receive/sign for professional samples and may distribute samples to patients

medication errors

choosing the wrong medication (similar packaging, confusing generic listings, abbreviating units as "u"), failure to monitor side effects, prescribing a medication the patient is allergic to; common meds in drug errors- insulin, antibiotics, opioids, potassium chloride, albuterol, heparin, acetominophen, warfarin, furosemide

when prescribing…

know indications, contraindications (interaction with other meds), appropriate doses, routes of administration, and drug-drug interactions; inquire about patient's current prescirption meds, OTCs, vitamins, supplements; chronic medical conditions that affect multiple organ systems; smoking, alcohol, illicit drugs, allergies, if pregnant or breastfeeding; has patient taken this medication before? effective? side effects?; educate the patient on the potential side effects, the proper dosing schedule, and the importance of compliance (like taking medication certain number of times per day for a certain number of days); instruct the patient to call, Return to Clinic (RTC), or seek emergency medical attention of adverse reaction or worsening of condition occurs

beers list

prescribing for older adults- list of individual medications or classes to avoid in patients over 65 y/o because the risk is unnecessarily high and safer alternatives exist (ex- benzos, benedryl)

evidence based medicine

conscientous, explicit, judicious use of the current best evidence in making decisions about the care of a patient; begins when you see the patient and foreground information; background (like knowing that pt's diabetes is linked to their obesity) vs foreground questions (research or new studies); relatively new concept (popular since 1992)

steps of evidence based medicine

formulate a question -> search and retrieve the best available evidence -> critically appraise data to ascertain the validity of results

EMB integrates:

1. individual clinical expertise, 2. patient values (what is a treatment does not affect mortality but improves quality of life? reduction in symptoms, decreased rates of hospitalization, does patient want to live longer or avoid hospital stays), 3. the best external evidence

top of evidence pyramid

systematic reviews and meta analyses (both comparable, take all randomized trials and cohort studies then state conclusion)

middle of evidence pyramid

randomized controlled clinical trials (studies with a lot of people, randomized- part gets one treatment, other part gets other treatment)

bottom of evidence pyramid

cohort studies, case studies, expert opinion (small groups) (physician who has worked in field for many years, well known, considered to be an expert)

peer reviewed, reputable resources

especially used for individual studies, removes conflicts of interest, must be reliable

examples of resources

LibGuides- research databases; can be related to medicine/specific specialties, can be filtered to meta analyses and systematic reviews (PubMed, ProQuest)

Journals- The Lancet, NEJM, JAMA, JAAPA

Subscriptions- Prescriber's Letter (synopsis of all things happening in pharmacology), Up to Date (search by topic for up to date info)

Databases- PubMed, Cochrane (stored research during EMB beginning), Proquest

Textbooks- good for background information (Cecil's, Harrison's, CMDT- Current Medical Diagnosis and Treatment)

professionalism

core attribute of the PA profession, one of the most common reasons for disciplinary action

AAPA competencies for prefessional conduct. PAs should be able to:

• demonstrate compassion, integrity, and respect for others

• demonstrate responsiveness to patient needs that supersedes self-interest

• show accountability to patients, society, and the PA profession

• demonstrate cultural humility and responsiveness to a diverse patient population, including diversity in sex, gender identity, sexual orientation, age, culture, race, ethnicity, socioeconomic status, religion, and abilities

• show commitment to ethical principles pertaining to provision or withholding of care, confidentiality, patient autonomy, informed consent, business practices, and compliance with relevant laws, policies, and regulations

• demonstrate commitment to lifelong learning and education of students and other healthcare professionals

• demonstrate commitment of personal wellness an self care that supports the provision of quality care

• exercise goof judgement and fiscal responsibility when utilizing resources

• implement leadership practices and principles

  • demonstrate effective advocacy for the PA profession in the workplace and in policymaking processes

causes for program disciplinary action

• cheating, plagiarism, falsification, fabrication, unauthorized notes or references during an exam, unauthorized reuse of previous work

• providing competed assignments, graded work, answers, or other restricted materials to another student

• copying, reproducing or distributing secure examination content or discussing content for those who have not completed the exam

• forging, altering, falsifying, or misusing academic, clinical, or health documentation

• breach of confidentiality

  • disrespectful conduct/communication and failure to accept responsibility

professional appearance

• clothing not permitted- jeans, leggings, sweatpants, shorts, cut offs, sweatshirts, hoodies t-shirts, tank tops, halter tops, off the shoulder tops, strapless tops; clothing that is tight, short, low-cut, exposes trunk with movement, clothing with rips or tears, hats unless required by clinical site like surgery

• shoes- no open toed shoes, sandals, flip flops

• jewelry- no excessive bracelets or necklaces, no ear lobe stretching

• nails- trimmed

• fragrance- no excessive heavy perfumes, after shaves, or colognes

• hair- must be clean, well groomed, and a natural color, should be arranged to avoid interference with patient care

  • other prohibited- chewing gum, use of tobacco products and e-cigs, person use of electronic media in clinical setting

autonomy- ethical conduct for the PA profession

patients have the right to make autonomous decisions and choices and PAs should respect these decisions and choices; the patient is most important; ex- jehovah’s witness not accepting blood products

beneficence- ethical conduct for the PA profession

in certain cases, respecting the patient’s autonomy and acting in their best interests may be difficult to balance; act in patient’s best interest

nonmaleficence- ethical conduct for the PA profession

to impose no unnecessary or acceptable burden upon the patient; do no harm

justice- ethical conduct for the PA profession

patients in similar circumstances should receive similar care; also applies to norms for the fair distribution of resources, risks, and costs

HIPAA

the Health Insurance Portability and Accountability Act; federal law enacted in 1990s

title II of HIPAA- five rules

the privacy rule- Goal: assure that health information is properly protected while allowing the flow of information needed to provide and promote high-quality health care and to protect the public’s health and well being; set national standards to protect sensitive patient health information

protected health information (PHI) HIPAA

all “individually identifiable health information”: ex- patient names, lab tests, health insurance notes, names, addresses, photos of you in chart, medical device identifiers, phone numbers, social security number, patient ID number

covered entities- HIPAA

must follow HIPAA when using PHI- health insurers, providers, companies that help transmit electronic information, hospitals, nursing homes, pharmacies, clinics; may disclose PHI to facilitate treatment, payment, or healthcare operations without a patient’s consent or agreement; any other disclosures of PHI require signed consent/ Release of Information form; when a covered entity discloses and PHI, it must make a reasonable effort to disclose only the minimum necessary information required to achieve its purpose

penalties for HIPAA violations

fines, lawsuits, prison, fired, loss of license

breach notification rule

• if under 500 people are affected: notify affected individuals within 60 days of breach; notify HHS within 60 days of the end of the year in which the breach was identified

  • if over 500 people are affected: notify affected individuals within 60 days of the breach; notify HHS within 60 days of the breach, notify a major print or broadcast outlet in your region within 60 days of the breach

who is exempt from HIPAA

employers, life insurers, worker’s compensation carriers, state agencies (such as child protective services), law enforcement agencies, many municipal (related to a city or town) offices

mandated reporters

need to report abuse, neglect, must report to police; the lawm

minors and confidentiality

every state has laws that allow minors to give their own consent for certain kinds of healthcare- emergency, general health, contraceptive, pregnancy related, HIV or other STD, substance abuse and mental health care;
when giving own consent, state laws very regarding disclosure to parents- some do not allow without the minor’s permission, others leave the decision to the physician’s discretion, very few mandate disclosure
using parent’s insurance vs paying in cash- can request info not be sent to insurance if cash payment