Keren H. Wick

The military veteran to physician assistant pathway: building the primary care workforce.

The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans’ entrance into civilian PA careers and leveraging their skills. More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans’ health care experience and maturity make them ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training. The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans’ potential as PAs. Both strategies are described, and early outcomes are presented.

MEDEX Northwest: Workforce Innovations

A NEW HEALTH PROFESSION MEDEX was never simply about the development of a new health profession. Instead, MEDEX was conceived as a strategy to transform health care. The MEDEX concept was developed by Richard A. Smith, MD, a brigadier general in the US Public Health Service and a former medical director for the Peace Corps. Educated as an epidemiologist and experienced in policy development, international health, and human rights issues, Dr. Smith was interested in the idea of “multiplying my hands” through the training and deployment of health workers. The MEDEX principles, developed at the University of Washington, were subsequently applied to training health workers internationally through 21 years of MEDEX International, which was based at the University of Hawaii. A 1971 evaluation of the MEDEX Demonstration Project for its federal contract described the program, as follows:

Online Collaborative Exercises: The Implications of Anonymous Participation

Introduction: This article describes differences in the rates of student participation resulting from changes to the structure of online discussion forums. In one cohort, students posted and replied anonymously to assigned discussion topics, but in the second, students were required to use their actual names. The use of names was required, in part, to increase participation rates by generating an increased sense of accountability. Method: Two cohorts (2002 and 2003) of first‐year students in the MEDEX Northwest Physician Assistant Program participated in online discussions of six topics relevant to their profession. Students in the 2002 cohort participated anonymously, using pseudonyms. Students in the 2003 cohort were required to use their real names. Rates of participation were determined by counts of student original posts and replies to existing messages. In both years, participation was required to earn part of a course grade. The discussion topics and participation requirements were identical for both cohorts. Results: Participation rates were generally equivalent across the two cohorts for the posting of original messages. However, when required to use their actual names, the number and length of student replies to existing messages decreased significantly. Gender differences were noted; women generally exhibited more consistent numbers and lengths of replies across cohorts than did men. Conclusion: Online discussions provide an important training tool and foster collaborative and flexible group learning. However, our efforts to enhance accountability diminished levels of participation rather than increasing it. The implications of these findings and limitations of the study are discussed.

Student Use of Handheld Computers in Clinical Settings: A Survey

Purpose: This article describes usage patterns of personal digital assistants (PDAs) by students completing the clinical phase of training at the MEDEX Northwest Physician Assistant Program. Methods: Seventy‐one students from MEDEX were surveyed to assess PDA usage patterns and their perceptions of the impact of this technology on clinical and educational performance. Results: Fifty‐two students (73%) responded, with 35 (67%) of these reporting using PDAs. All PDA owners used their PDAs for clinical work; 20 (57%) also used them for educational purposes. Students averaged 8.0 clinical uses and 3.9 educational uses per day. Students mentioned some concerns but generally expressed satisfaction with PDA clinical applications. Overall, students who used these devices reported that PDAs improved the quality of their clinical performance, facilitated access to information, and that patients perceived their use positively. Discussion: As a result of these findings, the program has decided to implement a policy requiring incoming students to purchase and use a PDA during training.

Physician assistant program outreach to military service members as potential applicants

Abstract Recent efforts to facilitate the career pathway for military veterans into the physician assistant profession include outreach to current service members that will make information about physician assistant education more readily accessible. This research article reviews several topics that physician assistant programs would need to consider before conducting outreach to this population and discusses methods for outreach activities. Physician assistant programs may choose to apply similar approaches as appropriate for their individual circumstances. Outcomes will be evaluated separately.

Web-based Collaborative Exercises: Lessons Learned in Conducting On-line Discussion Forums

Purpose: This article describes a Web‐based collaborative learning experience implemented by the MEDEX Northwest Physician Assistant Program at the University of Washington. Methods: Seventy‐three students and 8 faculty moderators across 3 geographically separated sites were assigned to small groups. Each group participated in 5 on‐line discussions of ethical concerns pertinent to the PA profession. Results: Student contributions were generally positive, and ranged from brief comments to longer, well‐considered arguments. A few individuals new to the chat format experienced minor difficulties with the unfamiliar Web‐based structure. Overall, the level (quantity) of student participation was high. Discussion: Web‐based discussions are a useful tool to integrate students and faculty from geographically diverse training sites into virtual communities. In future applications, consideration should be given to group composition, training for students unfamiliar with on‐line chat protocol, and moderator training.

International medical graduates as physician assistants.

This study describes the MEDEX physician assistant (PA) programs experience with screening, educating, and graduating PA students who were international medical graduates (IMGs). Methods:The study reviewed IMG-PA demographics including country of origin; prior primary care practice; and current practice location, specialty, and medically underserved designation. Descriptive statistics and chi-square analysis or Fisher exact test summarize outcomes. Results:Thirty-nine IMG-PAs were graduated from 1991 through 2013. IMGs came from central and eastern Europe (48.7%), Asia (33.3%), and other regions. Most (69.2%) are women. Almost all (91.7%) practice in urban settings, 55.6% are in primary care, and 30.6% work in medically underserved areas. IMG-PAs in primary care were more likely to practice in underserved areas (P=0.009). Conclusion:MEDEX has graduated IMG-PAs who possess appropriate clinical and professional PA skills.

Morality, Professionalism, and Clinical Ethics: Part II

INTRODUCTION When Just Ethics made its appearance in 2004, the first column noted a question from a colleague: “Are we as PAs held to a higher moral standard than the general public?”1 The response was “yes,” followed by a rationale. This same colleague recently asked: “Can we really teach morality, professionalism, and clinical ethics?” A related question is: how do we as educators, physician assistant (PA) professionals, and PA colleagues assess our behaviors? More importantly, how do we teach appropriate behaviors to and assess them in our students? Just Ethics provides a forum for discussion of these and similar questions. The name of this feature, Just Ethics, refers not to a narrow ideal, but rather to a broad concept that embraces integrity, moral reasoning, and professional behavior. A variety of factors may contribute to what we summarize as professionalism and medical ethics, and we welcome discussion of the unique details, the wider context, and everything in between. The literature addressing these concerns in medical education has been growing;2 it is a knowledge base to which PA faculty can and should contribute. Following is a brief review of recent literature on morality, professionalism, ethics, and the need to teach these concepts to our students. This overview will provide both a contextual framework and a starting point for PA educators to add their perspectives to this important discussion.

Tradition and treatment: The impact of cultural beliefs on medical decision making

Ms. X, a G2P1 23-year-old pregnant Navajo woman, came with her mother to an Indian Health Service clinic on the Navajo reservation. Her complaint was a bloody discharge for 1 week, and Ms. X and her mother were very concerned. The patient had been receiving regular prenatal care but had missed her last appointment. There was a slight language barrier, as her primary language was Navajo. Ms. X grew up on the Navajo reservation, and like the rest of her family, she utilized Navajo traditional medicine. She participated in Navajo traditional ceremonies and consulted medicine men and women, but she also sought medical care from providers of Western medicine. A fetal gestational age of 23 weeks had been determined from Ms. X’s last menstrual period. An ultrasound was performed, which showed no fetal activity and no cardiac activity. Further examination of the fetus revealed a gestational age of 17 weeks, according to femur length. The patient and her mother were informed of the ultrasound results and told that the fetus should be removed. They immediately requested a second opinion. The patient received a second opinion from a medicine woman, who told her, “The doctor is lying, and the baby is alive. The baby had a hard time breathing but is fine now.” The medicine woman told the patient to wait 2 days and then return to the hospital, at which time the doctors would realize they were wrong. The patient returned to the clinic and reported the second opinion to the doctor. The provider proceeded to explain the findings of the ultrasound. Ms X. and her mother informed the doctor that they were very traditional people and did not appreciate the provider delivering such a negative statement. Based on the consultation with their traditional healer, they believed the baby was very much alive and well.

Full Circle: A New Classroom Site to Facilitate the Veteran to Physician Assistant Pathway

INTRODUCTION Former military medics and corpsmen face challenges entering a civilian health care system that underutilizes their training and experience. The MEDEX Northwest physician assistant (PA) program launched a new classroom site in Tacoma, Washington, near local military bases, to ease entry into the PA profession for those in the local military and civilian communities. METHODS To fill the new classroom, the program conducted outreach to prospective applicants at community colleges, on-base transition and education centers, and education and career events near local installations. RESULTS Half of the first Tacoma class members are military veterans, half are female, 71% are from disadvantaged backgrounds, and the average age is 33. The Tacoma class demographics are equivalent to the overall 2013 MEDEX entering class with the exception of a higher veteran population (p < 0.001) and a higher rate of educational or economic disadvantage (p = 0.001). DISCUSSION The MEDEX PA program has met its mission with the new Tacoma site in terms of access for former military, disadvantaged, and local enrollees. Offering a pathway to the PA profession for those with prior military medical experience recognizes the training and skills attained while in uniform and allows entry into a meaningful civilian career.