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Impending health workforce shortages and implications for PAs

To the editor:

We read with interest the Guest Editorial by Richard Dehn, published in the December 2006 issue of JAAPA, in which he nicely summarized the pressures on and changes in the PA profession as well as the effects on the pipeline of potential PA school applicants that will affect the future health care workforce. We would like to draw attention to two pools of applicants at risk of being lost by other changes in the PA profession.

The increased demand for PAs comes at a time when the PA profession has nearly completed a transition to awarding the master's degree for PA studies. Other professions have also seen "degree creep"; pharmacists are now PharmDs, physical therapists are DPTs, and nurse practitioners are moving to the doctorate level. One can already hear talk of doctorate physician assistants.

The physician assistant profession has always appealed and been open to dedicated, intelligent, hard-working applicants who truly hear the call to provide medical care to all, including—especially including—the underserved. In a recent paper, we reported a survey of the first 32 graduating classes of MEDEX Northwest, the PA training program at the University of Washington.1 Applicants to our program must have at least 4,000 hours of prior health care experience but during these years were not required to achieve any particular academic degree level as part of their PA education. In our survey, graduates with no academic degree were significantly more likely to practice in primary care, in nonmetropolitan areas, and with the medically underserved than graduates with higher academic degrees. Many of these non-degreed PAs could not have afforded the time or expense to leave home, family, and work responsibilities to earn a master's degree in addition to their PA studies, and yet they brought a wealth of experience and dedication to their study and subsequent practice. We should look long and hard at the potential loss of similar future PA students and identify strategies to assist potential applicants with clinical experience but fewer college credits to stay in the pipeline.

Another frequently overlooked group of potential physician assistants is former military medics and corpsmen. The PA profession originated in part to take advantage of the skills and experience of military medical personnel returning from Vietnam, providing them with a civilian pathway in which to apply their skills. This has been an unqualified success, for them and for US health care. Few PA training programs continue to actively recruit military veterans, though we can expect to see many veterans with substantial clinical experience returning to civilian life from the current military forces.2 Recruited or not, many of these medics and corpsmen lack the official academic credentials that would allow them to enter PA training at the master's level. We should look for ways to assist these potential applicants to consider, qualify for, and apply to PA training programs after discharge from the military.

As Dehn has noted, part of the coming challenge in meeting the need for an expanded health care workforce will be finding qualified applicants. Potential PAs from the two applicant pools noted here should be actively encouraged, recruited, and counseled to apply for PA training. With the move to the masterÕs level, we will need to expend even more effort to find and encourage outstanding applicants from these groups if we are not to lose their potential contribution to the PA profession and US health care.

Timothy C. Evans, MD, PhD, FACP
Keren H. Wick, PhD
Douglas M. Brock, PhD

REFERENCES

1.  Evans TC, Wick KH, Brock DM, et al. Academic degrees and clinical practice characteristics: the University of Washington physician assistant program: 1969-2000. J Rural Health. 2006;22(3):212–219.

2.  APAP National Recruitment Strategies Task Force. A report of the Association of Physician Assistant PA programs National recruitment strategies task force. Available at: http://www.paeaonline.org. Accessed January 5, 2007.

Author's response:

I would like to thank Drs. Evans, Wick, and Brock for their comments in response to my editorial. Although the two points made in their comments are beyond the scope of what I wrote, they are certainly important factors in determining who is ultimately selected to become a PA and thus play a part in impacting our future.

The influence of the PA profession's move to the master's degree on the PA applicant pool is unknown and, likely, very difficult to calculate from any existing data since there are many constantly changing variables that impact the size, strength, and demographic characteristics of our applicant pool besides prior degree attained. A single-program descriptive survey of outcomes, such as the one described, can be helpful in framing these types of questions; however, one should be careful in generalizing single-program conclusions beyond the survey's sample population since admissions and curriculum variances among PA programs will likely produce substantial confounding factors. One should be careful to not interpret survey observations, particularly those of a single survey, as having implications for predicting causality. 

I agree that the return of veterans from the War in Iraq presents an opportunity for the PA profession to recruit uniquely experienced applicants, and I suspect that some programs are already in the process of determining how to attract individuals from this population.

In any case, the PA admissions pool is impacted by many factors, many of which the profession cannot control. These factors are constantly changing, some unpredictably. Some of the changes are clearly challenges, and some may present new opportunities. Research such as that cited by Drs. Evans, Wick, and Brock can provide information that may help educators react to these changes. Additionally, it is also important that the PA profession encourage other researchers, as well as our professional organizations, to collect, analyze, and report data so that we as a profession can best confront our challenges and take advantage of our opportunities.

Richard Dehn, MPA, PA-C

Exploring the complex care of the diabetic foot ulcer

To the editor:

Richard Jones writes in his article "Exploring the complex care of the diabetic foot ulcer" in the December 2006 issue that "25% of all hospital admissions are for diabetic foot ulcers." Surely what he intended to communicate was that 25% of all diabetic hospital admissions are for foot ulcers.

Jeffrey Lazar, MD, MPH

Author's response:

That is correct. It should have said 25% of all diabetes-related hospital admissions are for foot ulcers, not 25% of all admissions.

Richard Jones, MS, PA-C

Atraumatic snapping brachialis in a 37-year-old woman

To the editor:

Thank you for your recent Surgical Patient case by Bruce Rudy, MS, PA-C, and April Armstrong, MD, "Atraumatic snapping brachialis in a 37-year-old woman," published in the January 2007 issue. The article was well written and interesting. After reading the scenario, however, what came to mind was the question so often heard in the news, "Why is health care so expensive?" This woman did not have much in the way of disabling symptoms or pain, yet the workup included radiographs, MRI, CT, and dynamic ultrasound. This case also resulted in surgical exploration, which, happily, corrected this anatomic variant. I would hope that the dying art of physical examination, matched with an understanding of human anatomy, may lead to the correct diagnosis without all the fancy imaging studies. Are we, as a group, falling into the mindset of ordering expensive tests for symptoms that might be interesting from an anatomic standpoint but not necessarily a significant medical condition? We all need to do our part to help control the high cost of health care. Perhaps just an awareness of this might be a start.

Dave Brucher, PA-C

Authors' response:

We appreciate and concur with Mr. Brucher's concerns regarding the rising cost of health care and discretionary usage of diagnostic tests. However, several points should be noted. This patient had been experiencing her symptoms for nine months and was reluctant to extend her elbow beyond 20 degrees due to pain. Also, while the history in a case report is normally brief and concise, it bears mentioning that we were not the first providers to examine her. In fact, six providers were unable to render a diagnosis prior to our examination of the patient. Finally, dynamic ultrasounds are not commonly ordered within our practice but this diagnostic test provided the necessary evidence to support the diagnosis and justify the risks of surgical intervention.

Bruce S. Rudy, MS, PA-C
April Armstrong, MD

Supplement on respiratory tract infections

To the editor:

I just finished reading the JAAPA September 2006 supplement, "Primary Care Challenges in the Management of Respiratory Tract Infections." Although it is for the most part factually accurate, significant commercial bias exists throughout the entire supplement. Small print on the front cover denotes an educational grant from Aventis, but instead of a CME article, it reads more like an ad for Ketek (telithromycin). You go as far as to include a chart from the Ketek prescribing information (Figure 2), albeit from the Physicians' Desk Reference (PDR). Surely these data exist elsewhere, from a more objective source.

Without saying it directly, the supplement, in essence, pushes telithromycin as the best first-line therapy for almost any respiratory tract infection. Although significant resistance to older antibiotics obviously exists, they are still effective much of the time. Additionally, although rare, it should be pointed out more clearly that resistance to telithromycin also exists.¹ Several paragraphs explaining why telithromycin is not mentioned in older guidelines are also unnecessary and further push Aventis' agenda. More emphasis should also have been placed on the fact that in the VAST majority of respiratory tract infections, no antibiotic treatment is indicated at all.

AAPA's Standards for Commercial Support of CME Activities² state that "The activity must provide a balanced view of the clinical topic, including an unbiased discussion of therapeutic options."  This "review" is clearly pro-Ketek and in no way balanced. Indeed, as others have suggested,1 with increasing prescriptions written for Ketek, problems with telithromycin resistance will surely develop.

In summary, I have no problem with the facts presented in the article or with telithromycin itself, but only the manner in which this information was presented. JAAPA and the AAPA need to keep the supplements objective and free of commercial interests, which is something that clearly did not happen here.

Michael D. Jacobson, MSHS, PA-C
Pulmonary & Medical Associates of Northern VA
Arlington, Virginia

REFERENCES

1.  Lonks JR, Goldmann DA. Telithromycin: a ketolide antibiotic for treatment of respiratory tract infections. Clin Infect Dis. 2005;40:1657-1664.

2.  Standards for Commercial Support of CME Activities. Adapted from the 2004 Standards for Commercial Support of the Accreditation Council for Continuing Medical Education (ACCME), approved September 2004. Available at: http://www.aapa.org/cme/standards/pdf . Accessed December 30, 2006.

Response:

In response to Mr. Jacobson's claim that significant commercial bias exists regarding telithromycin throughout the JAAPA September 2006 supplement, "Primary Care Challenges in the Management of Respiratory Tract Infections," members of the Infectious Disease Leadership Council (IDLC) believe that:

• The supplement has relied on consensus guidelines and presented tables for community-acquired pneumonia (CAP), acute exacerbation of chronic bronchitis (AECB), and acute bacterial rhinosinusitis (ABS)—none of which include telithromycin, since it was not approved in North America at the time any of the guidelines were published.
• Telithromycin is mentioned as a new option that the IDLC feels is important for patients who are at risk for resistant Streptococcus pneumoniae and that the readership of JAAPA should know about. It may be a viable option, particularly for CAP, since many of us feel that telithromycin offers benefits that macrolides and quinolones do not.
• With regard to the comment that with increasing prescriptions written for telithromycin, problems with telithromycin resistance will surely develop, the supplement was clear in recommending that viral infections be treated with supportive care and not with antibiotics.
• There was no attempt with the supplement to push telithromycin or Aventis's agenda. We stand by the supplement as a fair and balanced presentation of the emerging options and recommendations to treat respiratory tract infections.

Of note, this supplement was written and published before the FDA Advisory Committee met on December 14-15, 2006, to reconsider the safety/benefit of telithromycin. The Committee made recommendations upon which the FDA must decide by March 11, 2007:

• It recommended removing the indications for AECB and ABS
• It voted 16 to 3 to indicate that the safety/benefit ratio remains favorable for telithromycin for CAP

Although many of us feel that telithromycin can still be a useful option for selected patients with AECB and ABS, we acknowledge the recommendations of the FDA Advisory Committee to remove the indications for AECB and ABS. We still recommend telithromycin as an option for CAP in patients at risk for resistant pneumococcal infection and await the decision of the FDA.

Members of the Infectious Disease Leadership Council:

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