2 Medical Ethics & Professional Practice (Week 2)

What degree is required for new PA graduates?

MS degree

What is the Degree Qualifying Profile (DQP)?

A framework for assessing the qualifications of graduates

In what settings do new PAs apply their practical skills?

Various patient care settings

What exam must new PAs pass to enter the profession?

PANCE

What is required to maintain PA certification?

Continuing Medical Education (CME) and periodic recertification

What defines competency for PAs?

A specific skill, knowledge, or ability that is observable and measurable

What are task force core competencies?

Essential skills and knowledge required for PAs

What are the essential skills for patient-centered practice knowledge?

- information and history taking

- physical exam

- important vs. extraneous information

- prioritization of actions and clinical care decisions based on available data and information and the patient's beliefs about care

- empathetic listening

- relationship building

- evidence-based decision-making

What are the six Core Healthcare Competency Domains for a new PA graduate?

- Patient-Centered Practice Knowledge

- Society and Population Health

- Health Literacy and Communication

- Interprofessional Collaborative Practice and Leadership

- Professional and Legal Aspects of Health Care

- Health Care Finance and Systems

What are the 7 competencies for the physician assistant/associate profession?

- Knowledge for practice

- Interpersonal and communication skills

- Person-centered care

- Interpersonal collaboration

- Professionalism and ethics

- Practice-based learning and quality improvement

- Society and population health

What does the code of conduct for certified PAs and PAs with PA-C Emeritus Designation provide?

guidelines for the standards of professional practice and conduct expected

What does the code of conduct for certified PAs and PAs with the PA-C Emeritus Designation include?

- professional boundaries and interactions with patients and others

- behave in a manner that is lawful and ethical during and outside of the practice of medicine, and adhere to accepted evidence-based standards of care and practice guidelines

- shall not disclose confidential information

- practice without impairment that would adversely affect their practice (i.e., substance abuse)

- recognize and understand their professional and personal limitations

- report to NCCPA within 30 days of convictions, guilty pleas, or no contest pleas to felonies and certain misdemeanors

What will happen if one fails to follow the code of conduct standards by the NCCPA?

disciplinary action

What organization reassures the public?

NCCPA

Who must disciplinary actions be reported to?

- Federation of State Medical Boards

- State licensing authority

- Federal government

- PA's employer

What is considered in the laws and regulations regarding professional practice and conduct?

standard of care

What is patient advocacy?

- support and promote the interest of your patients

- individual, community, or group

- provide patients' needs throughout their care and treatment

Where should you go to apply and maintain a license?

DPH of your state (initial fees $190)

What do all states require to apply and maintain a license?

- Graduate accredited PA school

- Pass the PANCE (NCCPA)

- Every 2 years CME 100 hrs NCCPA

- 60 hrs of didactic pharmacology*

- Controlled substance Registration

What does the PA temporary permit allow (or NOT allow)?

Does NOT authorize the holder to prescribe or dispense drugs and shall be valid only until the issuance of the results of the first examination scheduled by the NCCPA following the applicant's graduation from an accredited physician assistant program

When does the temporary license expire?

30 days after receipt of the NCCPA examination scores

Who regulated your license?

your state (it is important to support your local state chapter)

What does the PA Licensure Compact allow for?

An interstate licensure compact that will streamline the process for PAs to obtain authorization to practice in more than one state.

Describe the history of PA prescriptive privileges.

- long battle with state legislature over 5 decades

- first state Colorado, 1969 (could prescribe without immediate consultation)

- 1972 - New York

- Maine, New Mexico, North Caroline, Oklahoma, Kansas

- 1979 - 11 states

What are the current AAPA guidelines about PA prescriptive privileges?

PAs are licensed to practice in all 50 states, the District of Columbia, all US territories with the exception of Puerto Rico, and the uniformed services. PAs are authorized to prescribe medications in all jurisdictions where they are licensed.

What are the PA license requirements?

- graduated from an accredited PA program (ARC-PA)

- eligible for a temporary permit (does NOT authorize prescriptive privileges)

- pass the PANCE issued by NCCPA

- completed 60 hours of pharmacology

- official transcript sent to the Department of Public Health

- $190 fee in CT

True or False: A temporary permit authorizes prescriptive privileges.

FALSE; a temporary permit does NOT authorize prescriptive privileges

What does the Prescription Monitoring Program (PMP) collect?

prescription data for Schedule II through Schedule V drugs into a centralized database, the Connecticut Prescription Monitoring and Reporting System (CPMRS), which can be used by healthcare providers and pharmacists in the active treatment of their patients

Under Connecticut law, what must be reported to the CPMRS?

- information about all transactions for controlled substances (Schedule II-V) dispensed in CT

*pharmacies (both in and out-of-state) and dispensing practitioners must submit data daily*

Whenever a prescribing practitioner prescribes ______________________________ controlled substance for the treatment of any patient, such prescriber, or such prescriber's authorized agent, shall review, not less than annually, the patient's records in the CPMRS.

greater than a 72-hour supply of any Schedule V

What is the federal law enforcement agency that governs DEA licenses?

Drug Enforcement Administration (DEA)

What are the requirements for DEA licensure?

- 3 years, $888

- need state license

- background check

What is the Connecticut Controlled Substance Registration for Practitioners?

- A state registration that allows the prescriber to order, administer and dispense controlled substances to patients. - - The number is practitioner specific and is required regardless of practice location

What is the Federal DEA registration?

DEA registration number is a Federal identification number.

In the State of Connecticut, the DEA requires the practitioner to obtain the Controlled Substance for Practitioner Registration prior to obtaining a new DEA number with a Connecticut address or changing the address of a current DEA to a Connecticut address.

How are controlled drugs categorized?

in order of their abuse risk and placed in "Schedules" by the federal Drug Enforcement Administration (DEA)

What are Schedule I drugs?

drugs with a high abuse risk; these drugs are NOT accepted medical use and have a high potential for abuse

Examples of Schedule I drugs

heroin, LSD, Marijuana (cannabis), Ecstasy, and mescaline

What are Schedule II drugs?

Drugs with a high abuse risk, but also have safe and accepted medical uses in the United States.

What can Schedule II drugs cause?

Severe psychological and/or physical dependence

What types of drugs are Schedule II?

certain narcotic, stimulant and depressant drugs

Examples of Schedule II drugs

morphine, cocaine, oxycodone, hydrocodone with acetaminophen, methylphenidate, and dextroamphetamine

Describe the refills of Schedule II drugs

No refills of Schedule II medications are permitted

What are Schedule III, IV, or V drugs?

drugs with an abuse risk less than Schedule II; these drugs also have safe and accepted medical uses in the United States

What types of drugs are Schedule III, IV, and V?

those containing smaller amounts of certain narcotic and non-narcotic drugs, anti-anxiety drugs, tranquilizers, sedatives, stimulants, and non-narcotic analgesics

Examples of Schedule III, IV, and V drugs

acetaminophen with codeine, diazepam, alprazolam and zolpidem

Describe the refills of Schedule III, IV, and V drugs

maximum of five refills are permitted

What is credentialing?

formal process following guidelines to ensure a healthcare professional who is verified and properly trained to practice medicine or a procedure

What can we do to make the credentialing process easier?

- practice logging cases and procedures

- students in the clinical year at UB use Typhon

- request privileges to perform certain procedures

What is privileging?

the process of authorizing a health care practitioner's specific scope and content of patient care services

What does scope vary with?

each institution (hospital & urgent care settings)

What is included in PA scope of practice?

- Obtain patient history

- Perform physical examinations

- Formulate a differential diagnosis

- Order and interpret tests

- Formulate and implement a therapeutic plan, including the prescribing of medications

- Assist in surgery

- Perform therapeutic & diagnostic procedures

- Counsel in preventive care

- Rounds in hospitals and nursing homes

- In some states open clinics (under MD supervision)

What is the definition of burnout?

- emotional exhaustion

- depersonalization

- lack of personal accomplishment

What conditions does burnout occur under?

- poor workplace environment

- increased workloads, multitasking, and projects

What are the consequences of burnout?

- medical errors

- decreased efficiency

- provider turnover

- increased medical costs (~$76k/physician/year)

What area has the highest burnout? What area has the lowest burnout?

Highest = emergency medicine

Lowest = dermatology

What are the five risk factors for provider burnout?

- sense of failure and self-doubt

- feeling helpless, detached, and defeated

- loss of motivation

- increasingly cynical and negative outlook

- decreased satisfaction and sense of accomplishment

Risks of impairment and burnout to clinicians and PAs (just read through the statistics)

- 10% of physicians use alcohol with adverse effects to their health and well-being and medical practice

- 10-15% had addiction at one point in their career

- 6% of US population have AUD and 13% of male surgeons and 26% of female surgeons

- Among ED physicians 50% in HAVEN like treatment for alcohol, 38% for opioids and 10% for stimulants......

- 60% of ED physicians report burnout

- Behavioral health issues: anxiety, depression, imposter syndrome

- 78% remain drug-free, and 71% maintain their license utilizing the HAVEN programs

What is included on the wellness wheel?

- emotional

- physical

- occupational

- financial

- spiritual

- social

- intellectual

What is wellness affected by?

eating, stressors, financial, environmental, emotional, spiritual, weight loss, respond to stressful situations

What contributes to wellness?

- positive attitude

- invest time for yourself

Why is it difficult to identify an impaired provider?

providers excel at concealing their symptoms

True or False: Any acute change in behavior is concerning.

True

What are examples of acute changes in behavior?

- Unexplained lateness or absence

- Absence from professional functions

- Careless medical decisions, increased errors

- Sudden isolation, not responding to pages or calls

- Citing unexplained "personal problems" to mask deficits in concentration

What is the AMA's definition of the impaired practitioner?

psychiatric, cognitive, behavioral, or general medical problems with potential to adversely affect the physician's ability to perform specific duties

What are three areas a practitioner may be impaired in?

- physical

- mental

- substance-related*

Examples of impaired per CT law

- Physical illness or loss of motor skill, including, but not limited to, deterioration through the aging process

- Abuse or excessive use of drugs, including alcohol, narcotics or chemicals

- Illegal, incompetent or negligent conduct in the practice of the profession of the health care professional

- Possession, use, prescription for use or distribution of controlled substances or legend drugs, except for therapeutic or other medically proper purposes

- Misrepresentation or concealment of a material fact in the obtaining or reinstatement of a license to practice the profession of the health care professional

- Violation of any provision of the chapter of the general statutes under which the health care professional is licensed or any regulation established under such chapter

What percentage of the US population experiences substance use disorders?

~8-13%

- Retrospective study 3604 MDs monitored 1980s to 2002

- 2012: (7197 surgeons) American surgeons (28.7 percent response rate) 15.4% had a score on the Alcohol Use Disorders Identification Test with the presence of an alcohol use disorder

- 2015: (7206 MDs) 26.7% response - 21.4% substance use disorder (alcohol and/or other drugs)

Contributing risk factors for impaired practitioners/substance use disorders

- Greater access to drugs

- High work stress

- Co-occurring mental disorder

- Denial of personal problems

- Self-medicating

What specialties have the highest rate of addiction?

- Anesthesiology (opioids, IV form)

- Emergency medicine (cocaine abuse)

- Psychiatry (benzodiazepines)

- Family practice

What % of substance abuse is alcohol?

25%

What % of substance abuse is opioids?

25%

What % of substance abuse is marijuana?

12%

What % of substance abuse is cocaine?

11%

What % of substance abuse is sedatives?

10%

What does mandatory reporting of impaired healthcare providers include?

Effective October 1, 2015, hospitals and certain healthcare providers are required by law to report information when another healthcare provider is, or may be, unable to practice his or her profession with reasonable skill or safety.

Where must mandated reporters report?

to State Medical Board

What is a good impairment resource?

Health Assistance InterVention Education Network (HAVEN) Program

What is the HAVEN Program?

- voluntary referral

- confidential program meets state law issues

What additional organization has resources about burnout, moral distress, well-being, and mental health

AAPA

What do diversity, equity, and inclusion include?

Fair treatment and full participation of all people who have historically been underrepresented or subject to discrimination on the basis of identity or disability

What is diversity?

identity (gender, culture, ethnicity, religion, disability, class, age, or opinion)

What is equity?

- fairness and justice

- societal disparities

- allocating resources

What is inclusion?

creating a culture for a sense of belonging or togetherness

How many PAs across the US does AAPA represent?

> 150 K

What is the AAPA committed to?

enhancing the diversity of the PA profession, addressing health inequities among patients, and fostering a staff culture to DEI

What does the AAPA embrace?

the values of DEI to improve collaboration and morale, as well as greater innovation, productivity, and representation within our communities

Other notes about DEI and the AAPA

- research shows positive benefits

- encourage and attract more underrepresented minorities

True or False: Black women are three times more likely to die from a pregnancy-related cause than White women.

True

What are the obstacles that affect the PA practice?

- why scope of practice matters

- title change

- variability in states with autonomy

- transitioning to collaborative work

- expanding medical access needs to the public and community

- high-quality training and education

When does optimal team practice (OTP) occur?

When PAs, physicians, and other healthcare professionals work together to provide quality care without burdensome administrative constraints

What does optimal team practice (OTP) allow for?

PAs to practice to the full extent of their education, training, and experience

What does optimal team practice (OTP) authorize?

PAs to be eligible for direct payment by all public and private insurers

What are the PROs of OTP?

- Greater access to high-quality healthcare

- Increase flexibility for healthcare teams

- Increase access and lower Medicaid costs in their States

- Unnecessary administrative and legal burdens

What are the CONs of OTP?

PAs will be fully responsible for the care they provide

Compare and contrast supervision vs. collaborative practice

- Change over time from Physician Supervisors (proven high quality and cost-effective)

- Team-based healthcare is the new norm

How are PAs now treated?

- as competent and skilled professionals

- collaborative and collegial

A supervising physician shall establish the terms of a Written Delegation Agreement (WDA), including....

- Description of professional relationship between supervising physician and PA

- Identify medical services that PA can perform

- PA documentation of prescribed controlled substances

- Describe the process of PA evaluation by supervising physician

•Annual review and renewal of WDA and adherence to hospital policies

What must the process of PA evaluation by the supervising physician include?

- Frequency of evaluation

- Review of prescriptive practice of CS Schedule II & III

- Adherence to hospital policies/procedures

What does collaboration include?

- direct communication (in person, radio, telephone, or video)

- active/continuous overview of PA's activities

- personal review of PA's performance, in accordance with the WDA, on a "regular basis"

- review of charts/records on a "regular basis"

- delineation of a predetermined plan for emergency situations

- designation of alternate licensed physician in absence of supervising physician

What are the 6 key elements of modern PA practice art?

- "Licensure"

- Full prescriptive authority

- Scope of practice determined at the practice level

- Adaptable collaboration requirements

- Co-signature requirements determined at the practice level

- Number of PAs a physician may collaborate