Alison C. Essary

The impact of social media and technology on professionalism in medical education.

The use of social media is the norm among the digital native generation, with 75% of the Millennial Generation connected through Facebook. For students in medical education who struggle to distinguish between personal and professional boundaries, social media provides yet another challenge. Incidents of unprofessional conduct and academic dismissal have been reported. Administration, faculty, and students would benefit from clear policies and procedures, case scenarios of social media violations, and suggestions for using social media wisely.

The risk of tramadol abuse and dependence: findings in two patients.

CASE 1 After suffering a seizure, a 38-year-old male who used tramadol frequently was still in denial about his dependence. He experienced brief, intermittent periods of abstinence, then relapsed, and 1 year later had a second seizure. This seizure prompted the man to admit his dependence on tramadol and express a desire to seek treatment. At the peak of his addiction, he was taking 27 tablets (50 mg per tablet) of tramadol daily. The patient began using tramadol for daily headaches approximately 4 years earlier. He used hydrocodone and oxycodone preparations intermittently but preferred tramadol because of the euphoria and increased energy level he experienced after taking that drug. The patient, who was a physician, obtained the medication through drug samples and Internet purchasing. He attempted to stop the medication several times but ran into difficulty when he experienced physical manifestations, such as rebound headache and mood changes. His medical history was significant for the two seizures and untreated depression. He did not use tobacco products or alcohol. His family history was positive for drug use/abuse. He had no history of physical or sexual abuse. Following completion of a 6-week inpatient detoxification and residential treatment program, the patient presented to the addiction medicine physician for follow-up care. The management plan Because the patient was employed as a physician, his management plan included a voluntary 5-year monitoring program that involved monthly office visits with an addictionist, random urine drug screens (approximately two per month), bimonthly group counseling sessions, and documented participation in 12-step meetings. Medical management included trazodone at bedtime for sleep. The patient was encouraged to seek treatment for depression and daily headaches. Outcome The patient is under the care of an internist, neurologist, and addictionists. His daily headaches are well-controlled with modifications to diet, exercise, and asneeded use of sumatriptan and NSAIDs. He has been abstinent for 25 months. He has good family support and involvement in his sobriety, has maintained employment, and is active in the recovery process, which includes 12step participation, frequent interaction with his sponsor, and bibliotherapy.

Using a Curriculum Map to Link the Competencies for the PA Profession With Assessment Tools in PA Education

&NA; The physician assistant (PA) profession has identified core competencies for practicing PAs that specifically address medical knowledge, interpersonal and communication skills, patient care, professionalism and practice‐based learning and improvement, and systems‐based practice. The American Academy of Physician Assistants (AAPA), the Accreditation Review Commission on Education for the Physician Assistant (ARC‐PA), the National Commission on Certification of Physician Assistants (NCCPA), and the Physician Assistant Education Association (PAEA) disseminated the document Competencies for the Physician Assistant Profession in the spring of 2006. Given that a significant number of the competencies are based in the educational setting, it is the responsibility of PA educators to incorporate the competencies into the curriculum in order to train students who are globally competent and prepared for clinical practice. The competencies may be integrated throughout the didactic and clinical phases of the curriculum via course syllabi, learning objectives, and assessment tools. Ideally, PA programs should conduct ongoing self‐assessment to ensure that the competencies have been successfully integrated and are being evaluated using appropriate methodology. One tool that programs may use to evaluate the integration of the competencies, and the curriculum as a whole, is a curriculum map. A curriculum map traditionally provides a comprehensive overview of the content and the respective assessment tools used to measure student outcomes. Curriculum maps also provide programs with a tool to facilitate continuous curricular evaluation and identify potential areas for improvement.

How to make the "difficult" patient encounter less difficult.

JAAPA VOL.18, NO. 5 MAY 2005 49 Clinicians label one sixth of all outpatient encounters with patients “difficult.”1 Typically, these encounters challenge both the patient and the provider.2 Common scenarios involve patients who are angry, silent, or confrontational; those who have chronic pain; those who demonstrate inappropriate seductive behavior; and those who are noncompliant. Table 1 (page 50) outlines other common patient characteristics. Difficult patient encounters can lead clinicians to feel less enthusiastic about the delivery of health care, to feel manipulated during the encounter, and to hope that the patient will not return to the office.3 Unfortunately, patients whom clinicians label as difficult are more likely to have poor outcomes and utilize the health care system more frequently.1 They also are more likely to sue.4 Labeling a patient difficult facilitates a potentially adversarial relationship between the clinician and the patient and interferes with the delivery of optimal care.5 One study showed that physicians with poor psychosocial attitudes are more likely to say that a patient is difficult.1 However, it is usually not the patient who is being difficult. Rather, it is the encounter during the office visit that is difficult, or dysfunctional, and it is the provider’s responsibility to facilitate a positive encounter.2 Continued on page 50 How to make the “difficult” patient encounter less difficult

Compensation and Production in Family Medicine by Practice Ownership

The increasing focus on high performance, patient-centered, team-based care calls for a strategy to evaluate cost-effective primary care. The trend toward physician practice consolidation further challenges the primary care health care system. Productivity measures establish provider value and help inform decision making regarding resource allocation in this evolving health care system. In this national survey of family medicine practices, physician assistant (PA) productivity, as defined by mean annual patient encounters, exceeds that of both nurse practitioners (NPs) and physicians in physician-owned practices and of NPs in hospital or integrated delivery system-owned practices. Total compensation, defined as salary, bonus, incentives, and honoraria for physicians, is significantly more compared to both PAs and NPs, regardless of practice ownership or productivity. Physician assistants and NPs earn equivalent compensation, regardless of practice ownership or productivity. Not only do these data support the value and role of PAs and NPs on the primary care team but also highlight differences in patient encounters between practice settings. Rural and underserved community practices, where physician-owned practices persist, also merit further consideration. Further research is needed to inform both organizational and policy decisions for the provision of high-quality, cost-effective, and accessible primary health care.

Ethics, equity, and economics: a primer on women in medicine.

ABSTRACTWomen account for more than 70% of physician assistant (PA) students, 62% of practicing PAs, and 57% of faculty in PA programs. About half of all US medical students, 30% of actively practicing physicians, and 37% of faculty at academic medical centers are female. However, women in medicine are paid less than men for equal work effort and achieve fewer leadership positions within academia and medicine. Neglecting the skills and talents of women may lead to a workforce that fails to represent our patient and student populations.

A Student-Centered Approach to Physician Assistant Clinical Rotations

&NA; The first day of a clinical rotation can be exciting and intimidating for the second‐year physician assistant (PA) student. Heightening this anxiety can be the clinical preceptors lack of knowledge of the students clinical skills, competence, and goals for the rotation. Preceptors should be provided with resources concerning practical approaches to teaching students in their practice. This paper outlines a proposal for a student‐centered approach to the PA clinical rotations, using family medicine as an example. This approach allows for variation in the students clinical experience, autonomy, and clinical acumen, while providing some measure of standardization regarding family medicine clinical objectives

Science of health care delivery as a first step to advance undergraduate medical education: A multi-institutional collaboration

Physicians must possess knowledge and skills to address the gaps facing the US health care system. Educators advocate for reform in undergraduate medical education (UME) to align competencies with the Triple Aim. In 2014, five medical schools and one state university began collaborating on these curricular gaps. The authors report a framework for the Science of Health Care Delivery (SHCD) using six domains and highlight curricular examples from each school. They describe three challenges and strategies for success in implementing SHCD curricula. This collaboration highlights the importance of multi-institutional partnerships to accelerate innovation and adaptation of curricula.

Incorporation of the Competencies for the Physician Assistant Profession into Physician Assistant Education

&NA; The Competencies for the Physician Assistant Profession (Competencies) were developed and disseminated in 2006 by the American Academy of Physician Assistants (AAPA), the Physician Assistant Education Association (PAEA), the Accreditation Review Commission on Education for the Physician Assistant (ARC‐PA), and the National Commission on Certification of Physician Assistants (NCCPA). They are based on the competencies endorsed by the Accreditation Council for Graduate Medical Education (ACGME). This NCCPA Foundation‐funded project describes (1) the integration of the Competencies within PA education, (2) obstacles to incorporating the Competencies, and (3) methods used to assess students based on the Competencies. A survey was developed based on a document developed by ARC‐PA: “Comparison of ARC‐PA Accreditation Standards for Physician Assistant Education, 3rd edition (2006), to the Competencies for the Physician Assistant Profession (2005).” The majority of program respondents (97.1%) reported being familiar with the Competencies and most programs (84.5%) are currently incorporating, or have successfully incorporated, the Competencies into their curricula. The two most frequent obstacles to incorporating the Competencies were reported as limited or lack of time, and difficulty identifying successful methods of assessment. Multiple‐choice testing and the clinical preceptors evaluation of the student were the two most common methods used to assess the Competencies. These baseline data may help identify common obstacles and new challenges faced by PA programs, as well as provide representative organizations with information needed to help PA programs incorporate the Competencies into their curricula.

Does the use of episiotomy protect against postpartum incontinence

A26-year-old woman presents for a routine prenatal visit. She is a primigravida, 34 weeks pregnant, and has been healthy throughout her pregnancy. She has never smoked and stopped social alcohol use before conception. The patient is currently taking prenatal vitamins. She has no known allergies. Her vital signs are within normal limits, and her physical examination findings are all normal. The patient is concerned about shortterm maternal complications associated with delivery, specifically urinary incontinence. In conversations with friends, she learned that some received episiotomies and some did not; all experienced variable impacts on their continence status. The patient is having trouble finding helpful patient education material and would like your guidance on whether an episiotomy would offer protection from urinary incontinence.