Ruth Ballweg

A blueprint of pain curriculum across prelicensure health sciences programs: one NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) experience.

UNLABELLED To improve U.S. pain education and promote interinstitutional and interprofessional collaborations, the National Institutes of Health Pain Consortium has funded 12 sites to develop Centers of Excellence in Pain Education (CoEPEs). Each site was given the tasks of development, evaluation, integration, and promotion of pain management curriculum resources, including case studies that will be shared nationally. Collaborations among schools of medicine, dentistry, nursing, pharmacy, and others were encouraged. The John D. Loeser CoEPE is unique in that it represents extensive regionalization of health science education, in this case in the region covering the states of Washington, Wyoming, Alaska, Montana, and Idaho. This paper describes a blueprint of pain content and teaching methods across the University of Washingtons 6 health sciences schools and provides recommendations for improvement in pain education at the prelicensure level. The Schools of Dentistry and Physician Assistant provide the highest percentage of total required curriculum hours devoted to pain compared with the Schools of Medicine, Nursing, Pharmacy, and Social Work. The findings confirm the paucity of pain content in health sciences curricula, missing International Association for the Study of Pain curriculum topics, and limited use of innovative teaching methods such as problem-based and team-based learning. PERSPECTIVE Findings confirm the paucity of pain education across the health sciences curriculum in a CoEPE that serves a large region in the United States. The data provide a pain curriculum blueprint that can be used to recommend added pain content in health sciences programs across the country.

Challenges and opportunities in building a sustainable rural primary care workforce in alignment with the Affordable Care Act: the WWAMI program as a case study.

The authors examine the potential impact of the Patient Protection and Affordable Care Act (ACA) on a large medical education program in the Northwest United States that builds the primary care workforce for its largely rural region. The 42-year-old Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program, hosted by the University of Washington School of Medicine, is one of the nation’s most successful models for rural health training. The program has expanded training and retention of primary care health professionals for the region through medical school education, graduate medical education, a physician assistant training program, and support for practicing health professionals. The ACA and resulting accountable care organizations (ACOs) present potential challenges for rural settings and health training programs like WWAMI that focus on building the health workforce for rural and underserved populations. As more Americans acquire health coverage, more health professionals will be needed, especially in primary care. Rural locations may face increased competition for these professionals. Medical schools are expanding their positions to meet the need, but limits on graduate medical education expansion may result in a bottleneck, with insufficient residency positions for graduating students. The development of ACOs may further challenge building a rural workforce by limiting training opportunities for health professionals because of competing demands and concerns about cost, efficiency, and safety associated with training. Medical education programs like WWAMI will need to increase efforts to train primary care physicians and increase their advocacy for student programs and additional graduate medical education for rural constituents.

Value Added: Graduate-Level Education in Physician Assistant Programs

INTRODUCTION Statement of the Problem For many reasons, physician assistant (PA) educational programs have been moving over the past two decades toward offering exclusively the master’s degree, through a variety of curricular models and with a number of different types of master’s degrees. This movement has accelerated in recent years. At this writing, more than 90 of the 136 accredited PA programs offer a master’s degree or master’s option. But there has been little uniformity in how institutions sponsoring PA programs either transitioned existing programs to the graduate level or created new graduate-level programs, because no nationally developed standards or guidelines were available. In 2003 the membership of the Physician Assistant Education Association (then the Association of Physician Assistant Programs) charged the board of directors to commission a group to define the content and configuration of PA graduate preparation. The Graduate Education Commission (GEC), composed of senior PA educators and leaders, was charged with examining the emerging structures, content, and patterns of PA graduate education and curricula and with developing recommendations for educational institutions desiring guidance on making the transition to the graduate level. The specific charges to the group were as follows:

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:

A framework for revising preservice curriculum for nonphysician clinicians: The mozambique experience

Mozambique, with approximately 0.4 physicians and 4.1 nurses per 10,000 people, has one of the lowest ratios of health care providers to population in the world. To rapidly scale up health care coverage, the Mozambique Ministry of Health has pushed for greater investment in training nonphysician clinicians, Tιcnicos de Medicina (TM). Based on identified gaps in TM clinical performance, the Ministry of Health requested technical assistance from the International Training and Education Center for Health (I-TECH) to revise the two-and-a-half-year preservice curriculum. A six-step process was used to revise the curriculum: (i) Conducting a task analysis, (ii) defining a new curriculum approach and selecting an integrated model of subject and competency-based education, (iii) revising and restructuring the 30-month course schedule to emphasize clinical skills, (iv) developing a detailed syllabus for each course, (v) developing content for each lesson, and (vi) evaluating implementation and integrating feedback for ongoing improvement. In May 2010, the Mozambique Minister of Health approved the revised curriculum, which is currently being implemented in 10 training institutions around the country. Key lessons learned: (i) Detailed assessment of training institutions′ strengths and weaknesses should inform curriculum revision. (ii) Establishing a Technical Working Group with respected and motivated clinicians is key to promoting local buy-in and ownership. (iii) Providing ready-to-use didactic material helps to address some challenges commonly found in resource-limited settings. (iv) Comprehensive curriculum revision is an important first step toward improving the quality of training provided to health care providers in developing countries. Other aspects of implementation at training institutions and health care facilities must also be addressed to ensure that providers are adequately trained and equipped to provide quality health care services. This approach to curriculum revision and implementation teaches several key lessons, which may be applicable to preservice training programs in other less developed countries.

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.

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.

Competency Guidelines for Physician Assistants Practicing Primary Care in Low-resource Countries

A physician assistant (PA) student is beckoned by local residents in a low-resource setting to deliver a baby. The student has hadminimal experience in obstetrics, and her preceptor is unavailable to provide support, yet there are no other providers available and the delivery is imminent. In another area, a baby is delivered and is not breathing; traditional medicine dictates a cup is placed by the baby’s ear and hit with a spoon to enhance survival. No further resuscitation effort is initiated even when inquired about by a PA. An elderly local patient in a rural area presents with a potentially life-threatening condition. The visiting PA on her first global health trip disagrees with local opinion and consults the supervising PA accompanying her regarding a different health intervention. The junior US PA feels strongly compelled to send the patient to the regional emergency room, against local practice for the situation. These are just some examples of conflicts generated from the intersection of US-based PAs and their interest in working in countries with fewer resources. Since the inception of the PA profession, there has been international interest in the model from many countries to augment their own health care systems. Anecdotally, the appeal of PAs in many countries and jurisdictions is attributed to the heavy emphasis on physical examination and communication skills in PA training; the comprehensive nature of PA curricula that involves not only skills exposure but also competency in those skills; the team approach of the profession; and the ease of adapting the PA concept to a region’s needs. Although this initial competency-based education strategy has been used for decades in academic PA selection and development, the concept of competency can also be the basis for supporting PAs interested in expanding their role beyond US borders. Interest in PAs practicing globally has increased significantly as evidenced by numerous countries and jurisdictions considering the development of their own PA programs and the presence of US-trained PAs working abroad. At issue is US-based PAs transitioning to work in low-resource countries as a result of interest in themodel. Global health professionals haveoftenmaintained that the knowledge, skills, andattitudes necessary to be a successful practitioner in a low-resource country are not the same as they are in a country where diagnostic tools and treatment options are readily available to support a care plan for a patient. What skill set do graduate PAs need to have for working in a low-resource country? Many PAs are drawn to global health and serving the underserved; however, they often donot know where to start. Currently, guidelines todescribe the role of PAs in a global context do not exist. Although PAs are officially recognized as primary care providers in the United States, their role in low-resource countries is often not accepted as a strategy to deliver treatment for unmet health care needs. Primary care competencies were drafted for 3 purposes: (1) to provide PAs with a method for measuring their readiness to practice in a developing nation, (2) to establish a description of the PA profession that can be used by countries to evaluate fit of PAs for local practice, and (3) to create a combined guideline of clinical practice and global health that informs academic objectives for PA student international rotations. Primary care competencies were drafted based on those already established in the literature and reviewed by 14 PA experts in global health for clinical and practical utility. The resulting 31 competencies can be used to advance the PA profession worldwide.

Chapter 44 – The Uninsured: Challenges and Solutions

First, the good news. According to the U.S. Census Bureau, the estimated number of uninsured Americans fell to 45.7 million in 2007 as the number covered by government health insurance programs rose by 2.7 million. The proportion of Americans without health insurance declined by 0.5 percentage point to 15.3%, while the proportion with public health coverage rose by 0.8 percentage point to 27.8%. The number of uninsured children fell by 600,000 in 2007 to 8.1 million, while the proportion of uninsured children fell by 0.7 percentage point to 11%.