Thank you for this opportunity to talk about the Preventive Services Task Force recommendations in our curriculum at WSU. I’d like to do this brief, descriptive presentation in a funnel format, that is, I would like to speak briefly about the Physician Assistant profession because there may be some in the audience who aren’t familiar with the critical contributions that Pas make in the health care workforce. Then I will review our national association’s policies and practices regarding preventive services. And finally I will speak about our experience at WSU using the Preventive Service Task Force Guidelines.
How did the Physician Assistant profession begin? A. In the mid-1960s, physicians and educators recognized there was a shortage and uneven distribution of primary care physicians. To expand the delivery of quality medical care, Dr. Eugene Stead of the Duke University Medical Center in North Carolina put together the first class of PAs in 1965. He selected Navy corpsmen who received considerable medical training during their military service and during the war in Vietnam but who had no comparable civilian employment. He based the curriculum of the PA program in part on his knowledge of the fast-track training of doctors during World War II. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and write prescriptions. Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. A PA's practice may also include education, research, and administrative services. Because of the close working relationship the PAs have with physicians, PAs are educated in the medical model designed to complement physician training. Education consists of classroom and laboratory instruction in the basic medical and behavioral sciences (such as anatomy, pharmacology, pathophysiology, clinical medicine, and physical diagnosis), followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine.
Physician assistant-certified. It means that the person who holds the title has met the defined course of study and has undergone testing by the National Commission on Certification of Physician Assistants (NCCPA) . The NCCPA is an independent organization, and the commissioners represent a number of different medical professions as well as PAs. The NCCPA is not a part of the PA professional organization, the American Academy of Physician Assistants (AAPA). To maintain that &quot;C&quot; after &quot;PA&quot;, a physician assistant must log 100 hours of continuing medical education every two years and take the recertification exam every six years. The Board exam and the re-certification exam cover the scope of medical practice such as Cardiology, Pediatrics, Neurology, Reproductive Medicine and Infectious Diseases. It also covers the essential Task Areas that include Diagnosis and Therapy, Pharmacology and Physical Examination. The Task Area of Health Maintenance is 10% of the Board exam and includes all the preventive services listed here. The 140 accredited PA programs in this country are now clearly mandated to teach and test knowledge and skills in clinical preventive services.
In addition to the weight on prevention that was demonstrated by the Board Exam content, our national association has long-standing policy recommendations on the imperative of PA delivery of science-based, clinical preventive services consistent with the recommendations of authorities such as the USPSTF.
Even when I was in PA training in the early 1970’s, there was a great emphasis on the delivery of preventive services especially in the primary care setting. This was one area where we felt PAs excelled compared to their clinical counterparts. This environment of valuing preventive services has been fostered by our national association, the AAPA, through their many years of clinical partnership with AHRQ and the USPSTF. In fact our vice president, Bob McNellis, is attending this conference today as he has for many years. Over the summer just past the AAPA helped distribute 15,000 copies of Guide to Clinical Preventive Services to PAs practicing in: Family Medicine General Internal Medicine General Pediatrics Obstetrics and Gynecology
We have one of the oldest (and I believe one of the best respected) PA programs in the country at Wichita STate. Our first class graduated in 1975 and many of them are still practicing clinical colleagues of mine. Since then we have educated over 1,200 certified and practicing Physician Assistants. The program has always had a mission of providing excellent clinicians to address the shortage of rural primary care providers in Kansas. As you can probably imagine, Kansas is a very big state and most of it qualifies as Medically Underserved Health Manpower Shortage Areas. It is always difficult to recruit physicians, Pas and NPs to practice in sometimes isolated and impoverished agricultural areas.
This graph demonstrates how our graduates compare to the national PA population. You will notice that we have a much higher rate of graduates practicing in underserved, primary care and rural practice settings.
I started teaching Clinical Preventive Services recommendations when I joined the faculty in 1995, 8 years after the first guidelines were published and just before the 2 nd edition of the Guide to Clinical Preventive Services was published. Now that the Guide is produced every year I require my students to get a copy (free) from AHRQ, but we still use the online resources regularly for drilling deeper into the Evidence Review etc. The course is heavily dependent on the online course platform “Blackboard” where all readings, handouts, articles and weblinks are posted. So for each section of the Preventive Medicine course (e.g Cancer or Infectious Disease) there are hyperlinks taking the student directly to the USPSTF webpage on that topic. My hope is that also helps them as future clinicians when they want to research the recommendations on a particular subject. The students are basically expected to know all the A (strongly recommended) and B (recommended) services, and to be able to discuss the recommendations and rationale with patients and other clinicians. That information is well covered in the Clinical Considerations section of each topic in the Guide. Finally, when the students enter their clinical rotations they are required to carry PDAs to log their clinical encounters and to access drug and prescribing information. We send each student the link to AHRQ’a Electronic Preventive Servides Selector so they can easily identify the appropriate screeening, counseling and chemoprophylaxis recommendations for the patient sitting in front of them.
The students also study the Methods of the Task Force and the rigorous process that is used to evaluate the scientific literature, the impartiality of the experts that issue the Recommendations and Rationale.
I grade the students in the classroom portion of their training, but I do see a lot of opportunities to research how well the clinical students are utilizing the Recommendations, and how well graduate, practicing Pas are using the recommendations in their practice. Are they using other AHRQ resources in their practice? i.e. the Consumer Guides for Prevention and Wellness……. With competing recommendatiosn from the American Cancer Society and the American Heart Association and the American Diabetes Association, how do practicing Pas make decisions with their patients.
USPSTF CLINICAL GUIDELINES IN A PHYSICIAN ASSISTANT CURRICULUM Timothy Quigley, MPH, PA-C Associate Professor Wichita State University
Physician Assistants <ul><li>History </li></ul><ul><ul><li>First class of Navy corpsmen started in 1965 </li></ul></ul><ul><li>Function </li></ul><ul><ul><li>PAs practice medicine under physician supervision </li></ul></ul><ul><li>Numbers </li></ul><ul><ul><li>68,000 in clinical practice in 2008 </li></ul></ul><ul><li>Education </li></ul><ul><ul><li>141 accredited programs </li></ul></ul><ul><ul><li>Typical 24-32 months long Masters degree </li></ul></ul><ul><li>National Organization: </li></ul><ul><ul><li>American Academy of Physician Assistants (AAPA) </li></ul></ul><ul><ul><ul><li>40,000 dues paying members </li></ul></ul></ul><ul><li>Legal </li></ul><ul><ul><li>All states authorize PA practice including prescribing </li></ul></ul><ul><ul><li>Certification after PA education and board exam </li></ul></ul>
Board Exam Content: Health Maintenance (10%) <ul><li>Knowledge of: </li></ul><ul><li>Epidemiology of selected medical conditions </li></ul><ul><li>Early detection and prevention of selected medical conditions </li></ul><ul><li>Relative value of common screening tests </li></ul><ul><li>Appropriate patient education regarding preventable conditions or lifestyle modifications </li></ul><ul><li>Prevention of communicable diseases </li></ul><ul><li>Immunization schedules and recommendations for infants, children, adults and foreign travelers </li></ul><ul><li>Risks and benefits of immunization </li></ul><ul><li>Cognitive Skills in: </li></ul><ul><li>Using counseling and patient education techniques </li></ul><ul><li>Communicating effectively with patients to enhance health maintenance </li></ul><ul><li>Adapting health maintenance to the patient’s context </li></ul><ul><li>Using informational databases </li></ul>
AAPA Policy <ul><li>… Physician assistants should routinely implement recommended clinical preventive services appropriate to the patient’s age, gender, race and individual risk profile. </li></ul><ul><li>… Preventive services offered to patients should be supported by scientific criteria that demonstrate clinical effectiveness . </li></ul><ul><li>… To offer effective clinical preventive services to their patients, it is important that PAs become familiar and stay current with authoritative clinical preventive services guidelines and recommendations . </li></ul>
USPSTF and AAPA <ul><li>Long AAPA clinical partnership with USPSTF </li></ul><ul><ul><li>Also HP 2010, Partnership for Prevention and Task Force on Community Preventive Services </li></ul></ul><ul><li>Recently (Summer 2008) AAPA helped distribute 15,000 copies of Guide to Clinical Preventive Services to PAs practicing in: </li></ul><ul><ul><li>Family Medicine </li></ul></ul><ul><ul><li>General Internal Medicine </li></ul></ul><ul><ul><li>General Pediatrics </li></ul></ul><ul><ul><li>Obstetrics and Gynecology </li></ul></ul>
Wichita State University PA Program <ul><li>History </li></ul><ul><ul><li>First class started in 1973 </li></ul></ul><ul><ul><li>Focus on rural primary care </li></ul></ul><ul><li>Students </li></ul><ul><ul><li>84 students </li></ul></ul><ul><ul><ul><li>42 in didactic training </li></ul></ul></ul><ul><ul><ul><li>42 in clinical training </li></ul></ul></ul><ul><li>Graduates </li></ul><ul><ul><li>1,200 graduates </li></ul></ul><ul><ul><ul><li>45% in primary care </li></ul></ul></ul><ul><ul><ul><li>30% rural </li></ul></ul></ul><ul><ul><ul><li>25% medically underserved. </li></ul></ul></ul>
WSU PA Graduate Practice Settings, 1975-2006 (%) Source: AAPA, 2007; n=1117
USPSTF in the WSU PA Curriculum <ul><li>History </li></ul><ul><ul><li>USPSTF formally incorporated into curriculum in 1995 </li></ul></ul><ul><ul><li>Now about 500 students skilled in it’s utilization </li></ul></ul><ul><li>Texts </li></ul><ul><ul><li>Guide to Clinical Preventive Services required </li></ul></ul><ul><li>Online </li></ul><ul><ul><li>Especially for Rationale, Recommendation Statements and Evidence Review </li></ul></ul><ul><li>Homework </li></ul><ul><ul><li>Required searches in Guide and website </li></ul></ul><ul><li>Competency </li></ul><ul><ul><li>Working familiarity with Recommendations in Guide </li></ul></ul><ul><li>Personal Digital Assistants (PDAs) </li></ul><ul><ul><li>Required for clinical rotations </li></ul></ul><ul><ul><li>Linked to Electronic Preventive Services Selector through USPSTF </li></ul></ul>
Why We Value USPSTF Guidelines <ul><li>Independence of members </li></ul><ul><li>Experts in prevention and primary care </li></ul><ul><li>Rigorous evaluations of the literature </li></ul><ul><li>Transparency of the scientific evidence </li></ul><ul><li>Impartiality of panel and recommendations </li></ul><ul><li>Broad spectrum of recommendations for primary care (Screening, Counseling, Chemoprophylaxis) </li></ul><ul><li>Clarity of Recommendations and Rationale </li></ul><ul><li>User-friendly website and guide </li></ul>
Unanswered Questions <ul><li>Use in Clinical Practice </li></ul><ul><ul><li>How frequently do PA students and PA grads utilize the Guide or EPS </li></ul></ul><ul><li>Use in Patient Education </li></ul><ul><ul><li>Resources to discuss/explain recommendations </li></ul></ul><ul><li>How do PA clinicians decide on which preventive service to offer (and when) </li></ul>
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