Justine Strand

How do non-physician clinicians respond to advanced cancer patients’ negative expressions of emotions?

PurposePatients with advanced cancer often experience negative emotion; clinicians’ empathic responses can alleviate patient distress. Much is known about how physicians respond to patient emotion; less is known about non-physician clinicians. Given that oncology care is increasingly provided by an interdisciplinary team, it is important to know more about how patients with advanced cancer express emotions to non-physician clinicians (NPCs) and how NPCs respond to those empathic opportunities.MethodWe audio recorded conversations between non-physician clinicians and patients with advanced cancer. We analyzed 45 conversations between patients and oncology physician assistants, nurse practitioners, and nurse clinicians in which patients or their loved ones expressed at least one negative emotion to the NPC (i.e., an empathic opportunity). Empathic opportunities were coded three ways: type of emotion (anger, sadness, or fear), severity of emotion (least, moderate, or most severe), and NPC response to emotion (not empathic, on-topic medical response, and empathic response).ResultsWe identified 103 empathic opportunities presented to 25 different NPCs during 45 visits. Approximately half of the empathic opportunities contained anger (53%), followed by sadness (25%) and fear (21%). The majority of emotions expressed were moderately severe (73%), followed by most severe (16%), and least severe (12%). The severity of emotions presented was not found to be statistically different between types of NPCs. NPCs responded to empathic opportunities with empathic statements 30% of the time. Additionally, 40% of the time, NPCs responded to empathic opportunities with on-topic, medical explanations and 30% of the responses were not empathic.ConclusionPatients expressed emotional concerns to NPCs typically in the form of anger; most emotions were moderately severe, with no statistical differences among types of NPC. On average, NPCs responded to patient emotion with empathic language only 30% of the time. A better understanding of NPC–patient interactions can contribute to improved communication training for NPCs and, ultimately, to higher quality patient care in cancer.

Primary Care Training Grants Through Title VII, Section 747: The Duke Experience

Primary Care Training Grants provided by Title VII, Section 747 of the Public Health Service Act offer opportunities to enhance physician assistant (PA) education to improve access to care. Also, the Health Resources and Services Administration (HRSA) identifies crosscutting initiatives that focus on emerging issues in health care. The Duke University Physician Assistant Program was awarded a training grant for 2001–2004 to focus on increasing minority and disadvantaged enrollment, encouraging graduate selection of employment in medically underserved areas, developing curricula in oral health and the role of genetics in primary care, and expanding Duke’s existing PA teaching fellowship to a full-time position. In a larger sense, however, the Duke PA program is a microcosm of the Title VII program itself, having received funding to support program activities since its inception.

Snapshots in Time: Duke University Physician Assistant Classes, 1967-2007

INTRODUCTION The history of the physician assistant (PA) profession begins with the graduation of three former Navy corpsmen from the Duke University PA Program in 1967. The legendary medical innovator Eugene A. Stead Jr, MD, created the program and persuaded several able and dedicated medical educators to move it forward. Though the first three PA students had reason for uncertainty about their future careers in a newly minted occupation, their success and that of other early graduates garnered positive publicity — including an article in Look magazine in 1966 — and spurred the rapid expansion of the program and the profession itself. The ranks of practicing PAs now number more than 60,000, and there have been enormous changes in demographics as the profession has evolved. Once largely a male domain, the PA profession is now overwhelmingly female. PA education has maintained its focus on achievement of competencies needed to care for patients, but the credential awarded has moved from a certificate of completion, to a bachelor’s degree, to a master’s degree for the majority of programs. In many ways, the history of the Duke PA Program is emblematic of changes in the profession itself. From the first three men who made history in 1967, young women now comprise the majority of our applicant pool and admitted students. The early students were often not college graduates; now all matriculants at Duke have bachelor’s degrees and earn a master’s degree. The first four classes were referred to as “physician’s assistant” students. From 1971 to 1982 the program was called the Physician’s Associate Program and since 1983 it has been the Physician Assistant Program.

The Practicante: Puerto Rico Physician Assistant Prototype

Physician assistants (PAs) have achieved enabling legislation in all 50 states and almost all US territories, with the notable exception of Puerto Rico and American Samoa. (An attempt at passage of legislation authorizing PA practice in Puerto Rico was unsuccessful in 2000.1) Given that Puerto Rico is one of the last places in America to enact PA enabling legislation, it is surprising to learn that Puerto Rico had a PA prototype, the practicante, in the 19th and early 20th centuries. The practicante was discontinued in 1931 when the Puerto Rican legislature passed a new law regulating the practice of medicine. The Commonwealth of Puerto Rico is part of the Greater Antilles island chain in the Northwestern Caribbean. Christopher Columbus claimed the island for Spain in 1493, and it was under Spanish rule until it was ceded to the United States at the end of the Spanish American War in 1899. The island is 100 miles long and 35 miles across, and has 3,500 square miles of land and 750 miles of rugged coastline. A steep mountain range, the Cordillera Central, bisects the island from east to west.2 As recently as the second half of the 20th century, Puerto Rico had many isolated areas that were difficult to reach because of a lack of roads. Trujillo-Pagan observes that in the 19th and early 20th centuries “... physicians rarely set foot in rural areas. They saw rural, interior mountainous regions as inaccessible ... these rural areas and the people who lived within them carried contagious diseases they felt ill-equipped to control.”3 Care of the poor in rural areas thus fell to another type of health care provider, who worked under the auspices of physicians—the practicante. On May 29, 1866, the Royal Subdelegation of Medicine, which regulated the practice of medicine in Puerto Rico under the authority of the Spanish government, authorized the profession of practicante.4 The practicante is a forerunner to the modern PA. A two-volume manual for practicantes published in Spain in 1951 covers a broad range of medicine, including anatomy, physiology, diagnosis and treatment, suturing wounds, and setting fractures.5 Practicantes were typically located in rural and isolated areas, while licensed physicians usually practiced in more populous urban centers. Practicantes were classified as either minor or major, and surgical or medical, and the major practicantes had responsibility for supervision of those classified as minor. Practicantes’ duties included bloodletting (accepted medical practice in the 19th century), pulling teeth, minor surgery, and care of the acutely ill. Care of the sick was historically pluralistic in Puerto Rico, and was delivered by a variety of nonphysician and nontraditional practitioners, including comadronas and parteras (midwives), curanderos (folk healers), and curiosos (people who found medicine interesting and dabbled in it). This feature publishes articles on all aspects of PA history. Much of the material comes from the PA History Center, which is dedicated to the study of the history and legacy of the physician assistant profession. Additional information can be found on the Society for the Preservation of Physician Assistant History at http:// pahx.org. Authors desiring to contribute to PA History should forward submissions to:

Team Process Exercise: An Evaluative Admissions Tool

&NA; The individual interview has long been among the primary methods of selecting candidates for most health professional education programs. But recognizing that individual interviews are not necessarily predictive of an applicants ability to interact successfully in teams, the Duke University Physician Assistant Program developed a process for observing applicant behavior in a group setting. The Team Process Exercise (TPE) is utilized, in addition to two 20‐minute individual interviews, to more fully assess the applicants skills in interpersonal interaction. Social skills and effective personal interaction, as well as the ability to function well within a team, are critical for success in todays health care environment. While applicants with dysfunctional team skills may be quite successful in individual interviews, they may reveal problematic behavior within the dynamic of a group discussion. We describe the TPE—a 15‐minute discussion of an ethical problem among 4 or 5 candidates, followed by 15 minutes of analysis of the groups success by the members themselves. We also discuss our experience with the process and include sample scenarios and evaluation of 4 hypothetical candidates. The Team Process Exercise is one of several factors considered by the Duke University PA Program Admissions Committee in evaluating each candidate.

Health Belief Models

According to Sir William Osler, the Canadian physician and writer: “It is more important to know what sort of patient has a disease, than what sort of disease a patient has.”1 Health care professionals care for people from all walks of life, with all manner of experience and backgrounds. Patients bring alterations in health, and clinicians must listen with both their minds and hearts, attuned to the many differences in patients’ belief systems. Physician assistants (PAs) are trained in the medical model, which holds that illness is (1) deviation from normal, (2) specific and universal, (3) caused by unique biological forces, (4) analogous to the breakdown of a machine, and (5) defined and treated medically through a neutral, scientific process.2 Yet many of our patients do not see their alterations in health through the lens of the medical model. Failure to understand a patient’s perspective may result in misunderstanding, misdiagnosis, or nonadherence on the part of the patient, and can even lead to tragic consequences. The medical model teaches clinicians to listen to the voice of the medical world, while patients speak the language of their life world.3 Kleinman formulated the “explanatory model,” patient’s attributions of cause, pathophysiology, and course of an illness.4 The explanatory model includes not only causal attributions, but also the patient’s understanding of the pathophysiology and course of the illness. As the founder of the PA profession, Dr. Eugene Stead, says: “A doctor makes a mistake if he thinks he knows more about a patient than the patient does himself.”5 To illustrate this conundrum, I consider the explanatory models applied to clinical problems in several cultures.