The document provides information about the upcoming AAPA Conference in San Antonio, including registration details, CME opportunities, keynote speakers, and a career fair. It highlights over 260 hours of AAPA Category 1 CME credits available, a 70+ employer career fair, networking events, and a 2-day exhibit hall with 250 exhibitors. The conference aims to help attendees refresh skills, recharge their careers, and power up their practices.
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3. ContentsM AY 2 0 1 6 • V O L . 8 , N O . 5
Departments
President’s Letter
The AAPA House of Delegates to debate and decide
policy that affects the PA profession
Laws+Legislation
Many states are working on PA harmonization acts
to clarify scope of practice in all laws affecting PAs
Payment Matters
A rundown on the members only reimbursement
resources on AAPA’s website
STAT
Washington State adds PAs to state’s mental health
code | Scientists confirm severe birth defects tied
to Zika virus | PA gymnast headed to Rio Olympics |
AAPA past president to serve on advisory board for
leading clinical publication
Professional Practice
How to create a references list that helps you land
your next job
First Rounds
PA students share what they’ve learned about
cultural competence and how they’re incorporating
it into their practice
6 16
8
11
34
30
Feature Story
Equipping PAs for Expanded
Opportunities in Healthcare
Multiple Pathways, Demonstrating
Competence, Flexibility
23
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 1
4. Imagine how you’ll celebrate!
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8. PRESIDENT’SLETTER
The AAPA House of Delegates:
Where the Profession’s Policy Is Debated and Decided
W
ith so much to learn, so many people to meet
and so many exciting goings-on at AAPA
Conference 2016, it can be easy to forget that
conference time is also when some of the most important
decisions impacting the PA profession are made. Your
elected representatives in the House of Delegates (HOD)
have been diligently preparing for the 2016 HOD Meeting
and this year they have much to discuss.
As an AAPA member, you are represented in the HOD
through your state or federal service chapter, your medical
specialty, your caucus or the student delegation. The HOD
Meeting is your opportunity to have your voice heard as
your representatives debate the most relevant and impact-
ful issues affecting both the profession and healthcare.
Members of the HOD will be considering 54 separate
resolutions this year.These resolutions represent a wide
range of issues, including the pain management and opioid
abuse crisis, PA licensure and the best path forward in
addressing the recent NCCPA recertification proposal, PA
license portability, guidelines for state regulation of PAs
and medical marijuana. One resolution that is particularly
important to me focuses on how we can increase the num-
ber of preceptors and clinical rotations available to PA stu-
dents so we can cultivate the next generation of PA leaders.
As a PA, you are a leader and a critical member of the
healthcare delivery team. Your voice and your opinion need
to be part of the profession’s policy discussion. So as you
finish booking your hotel and travel to San Antonio, add
an item to your to-do list. Visit the AAPA HOD Governance
page and review this year’s resolutions. If there is an item
you are passionate about, reach out to your state, federal
service, specialty, caucus or student representatives and let
them know how you feel. If you have information or data
you think is pertinent, send it along. The future of the pro-
fession belongs to all of us and your participation will
strengthen the foundation on which we will build our
future—because, as always, we are stronger together.
Jeffrey A. Katz, PA-C, DFAAPA
AAPA President and Chair of the Board
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 6
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10. LAWS+LEGISLATION
Seeking Harmony in State Laws
Many States Are Working on PA Harmonization Acts to Clarify Scope of Practice
B Y C A R S O N W A L K E R , J D
M
uch like the profession itself, PA laws and regu-
lations have come a long way in the past 50
years. States are improving patient access to
healthcare. This includes tearing down barriers standing
in the way of PAs delivering this much-needed care. How-
ever, while many are advocating for positive changes to
PA practice acts, there are still areas of law outside of PA
practice acts that are in dire need of improvements, such
as provisions on signing for handicap placards, conduct-
ing department of transportation physicals, instituting
concussion protocols for sporting events and authorizing
students to have epi-pens for self-administration at
schools. And this list is by no means exhaustive.
There are various reasons for this exclusion of PAs from
various areas of law. Generally, many of these provisions
were either drafted before the PA profession existed or it
was just assumed that by including physicians, PAs were
also included. However, PAs not being specifically
included in a list of providers who can perform certain
functions, even though these functions may be well
within a PA’s scope of practice, can lead to confusion and
unintended outcomes.
In order to address these omissions, AAPA has been
working with state chapters to introduce legislation called
“PA harmonization acts.”The purpose of these acts is to
amend those areas of law outside of the PA practice act
to accurately reflect a PA’s scope of practice and lessen
confusion around what a PA can legally do. These acts can
take a few different forms, but they generally serve to
amend the various sections of law that may only mention
physicians, or physicians and NPs, to include PAs. Numer-
ous chapters have been successful in having these harmo-
nization acts signed into law. The results not only mean
that there is no longer confusion over whether or not PAs
can perform a medical function that they are qualified to
do, but that when new sections of law and regulations are
drafted in the future, legislators and regulators will include
PAs because they are already included everywhere else.
One recent example of a state that harmonized its laws
to include PAs is Oregon. In 2014, Oregon’s governor
CARSON WALKER, JD, is an
AAPA director of constituent
outreach and advocacy. Contact
him via email or 571-319-4316.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 8
11. LAWS+LEGISLATION | continued
signed SB.1548 into law. The legislation updated 75 areas of Oregon stat-
utes to include PAs. The accomplishment was no small feat—the Oregon
Society of PAs’Government Affairs Committee spent more than 100 hours
analyzing various provisions to determine which were missing PAs.
Oregon’s example is just one way to approach harmonization of state
laws. Such a heavy lift is not always feasible. Another approach is to pick
out the most egregious or impactful omissions in a state’s laws, and draft
legislation specifically to address and amend those areas of law that will
be the most meaningful to PAs and patients in that state. One state that
took this approach was Washington, which recently had a harmonization
act (SB. 6445) signed into law that specifically amended the state’s mental
health code in 22 places to include PAs. Other states that have been suc-
cessful in harmonizing laws are Hawaii and North Dakota.
States with active legislation to harmonize laws and regulations in the
2016 legislative session include Illinois and Colorado. Other chapters,
including Rhode Island and New Hampshire, are currently in the early
stages of reviewing their state laws for the purposes of harmonization
in the future.
For more information on harmonization acts, or to find out if your state
is in the process of harmonizing its laws to include PAs, contact your desig-
nated member of AAPA’s constituent organization outreach and advocacy
team.
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13. PAYMENTSMATTER
Reimbursement Information
at Your Fingertips
A Guide to Reimbursement Resources on the AAPA Website
B Y T R E V O R S I M O N , M P P
AAPA offers numerous reimbursement
resources to its members, as well as
to employers and others interested in PA payment and
coverage information. These resources include the for-
purchase e-publication“The Essential Guide to PA
Reimbursement,”presentations at state and national PA
conferences, and the availability of the AAPA reimburse-
ment department staff. However, there’s another conve-
nient resource that contains a great deal of reimburse-
ment information that you may not be aware was readily
available: the AAPA website.
For those interested in utilizing AAPA’s website to a
greater extent, we will highlight many of the reimburse-
ment-focused resources available here. Some are available
to the general public, while others live behind the web-
site’s firewall, for the use of members only.
To begin, start at AAPA’s home page. From there, place
the cursor over the word Advocacy (top center), which will
produce a dropdown menu. To find the AAPA reimburse-
ment-related resources, scroll down the list and click on
the word Reimbursement (see picture below).
This section contains many of the reimbursement
resources available from AAPA. It includes links to:
TREVOR SIMON, MPP, is AAPA’s
assistant director of regulatory
policy. Contact him via email or
at 571-319-4405.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 11
14. PAYMENT MATTERS | continued
■ Where you can purchase “The Essential Guide to PA Reimbursement,”
an extensive explanation of PA policies across various payers and
circumstances
■ ICD-10 Preparation Resources: Various pages on the AAPA website
pertaining to ICD-10, including pages with general resources, resources
by state, resources by specialty and FAQs
■ Reimbursement Basics: An AAPA issue brief that provides an introduc-
tion to the issue of PA reimbursement
■ Medicare Reimbursement: A Medicare Resources page with issue briefs
on topics such as“incident to,”shared visit billing, use of scribes, PECOS
enrollment, Medicare qualifications and coverage of services, preventive
services, durable medical equipment, first assisting at surgery, pre-op
history and physical examination, home health, diagnostic tests and the
EHR incentive program
■ Medicaid Reimbursement: A page with background on the Medicaid
program and PA coverage
■ Private Payer Reimbursement: An issue brief on third-party payer
policy for PAs
■ Workers’Compensation: A page with background on workers’compen-
sation and PA coverage
■ Current Issues: A page containing updates, issue briefs and regulatory
comments, as well as an FAQ on the repeal of the sustainable growth
rate system
■ Calculating PA Productivity: An issue brief on the measurement of
productivity and its relationship with compensation
In addition to those resources found on the Reimbursement page, useful
reimbursement information can be found under other Advocacy subsec-
tions. By clicking on Healthcare Reform, you will be brought to a page with
information on the Affordable Care Act (ACA). From here, and using the
links now on the left side of the page, you can explore pages that provide
background on the law, information on how health reform directly affects
PAs, and resources that may be useful in learning more about the ACA.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 12
15. PAYMENT MATTERS | continued
Finally, another source of information on reimbursement policies can be
found by going to Advocacy and then clicking on Federal. Once here, click
on Regulatory Advocacy. This will bring you to the same page you were
able to access through Reimbursement under the Current Issues link. On
this page you will find a list of comment letters submitted to federal agen-
cies, such as the Centers for Medicare and Medicaid Services. These letters
respond to proposed regulations that affect PAs. In these comment letters,
AAPA summarizes relevant sections of the regulations, indicates how the
proposed policies affect PAs and makes recommendations to CMS and
other federal agencies on ways to attain optimal PA utilization and increase
patient access to care.
While this article acts as an introduction to the resources available on
AAPA’s website, it is not a comprehensive catalog of resources available.
To inquire whether AAPA possesses reimbursement-related resources
that are not mentioned here, please reach out to the Reimbursement
department.
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18. STAT | Industry News
WASHINGTON STATE ADDS PAs TO STATE’S MENTAL HEALTH CODE
PAs in Washington state are celebrating Gov. Jay
Inslee’s recent signing of SB. 6445 which adds PAs to
22 sections of the state’s mental health code.
SB. 6445 becomes effective June 8, 2016.
The bill is the product of the successful advocacy
efforts of the Washington Academy of PAs (WAPA)
and the persistence of WAPA members Suzan Dula,
PsyD, PA-C, and Dale Sanderson, PA-C, MPH, and
AAPA. Dula and Sanderson contacted their state
legislator when the omission of PAs in the state
mental health code created obstacles for PAs pro-
viding psychiatry services.
The bill’s key changes include:
• Adding PAs to the definitions of“mental health
professional”and“developmental disabilities
professional”
• Authorizing PAs to sign petitions for specified
involuntary detentions
• Authorizing PAs to make determinations
of incapacity
• Adding PAs throughout the Mental Health
Advance Directive form
Adequacy of and access to mental health ser-
vices is a leading concern across the country and
AAPA advocates for all states to ensure that PAs are
included in state mental health provisions.
For more information, contact Keisha Pitts, JD,
director of constituent organization outreach and
advocacy. Read more here.
PA GYMNAST HEADED TO THE RIO OLYMPICS!
Houry Gebeshian, PA-C, recently realized a dream deferred when
she became the first female gymnast to represent Armenia in the
Olympic Games! (She has dual American-Armenian citizenship.)
Gebeshian is a 2014 graduate of the Wake Forest University PA
program. A standout at gymnastics powerhouse the University of
Iowa, she competed as an individual all-arounder in the 2011 NCAA
Women’s Gymnastics Championship and she is the 2010 Big10
Conference champion on the balance beam. Read more here.
From left to right: state Rep. Joe Schmick; Jeb Shepard
of WSMA; state Sen. Randi Becker; Seth Dawson of
NAMI-WA; Gov. Jay Inslee; Dale Sanderson, PA-C; Ruth
Peterson, legislative assistant to Sen. John Braun, a
sponsor of the bill; Suzan Dula, PA-C; Kevin Black, staff
counsel to the Washington Senate Human Services and
Mental Health Committee; and Kate White Tudor,
WAPA’s lobbyist.
PA Houry Gebeshian on the balance beam
PHOTOBYANHVIÊTCHAU
PHOTOCOURTESYOFWAPA
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 16
19. STAT | continued
AAPA PAST PRESIDENT TO SERVE
ON ADVISORY BOARD FOR LEADING
CLINICAL PUBLICATION
Stephen H. Hanson, MPA, PA-C, DFAAPA, a former
AAPA president, has been selected to serve on the
editorial advisory board of the leading trade pub-
lication Physicians Practice. A regular contributor
to the publication, Hanson writes a
twice-monthly column on optimizing
team-based care and electronic health
record (EHR) deployment. His columns
are among some of the most widely read
and commented on blogs on the Physi-
cians Practice website.The publication—
widely read among the medical and phy-
sician leadership community—made the
decision to expand its advisory board to
providers across the healthcare landscape to reflect
the evolving landscape of today’s medical practice.
Hanson, a plastic surgery PA with experience
in emergency medicine, urgent care and public
health, is the first and only PA to serve on the edito-
rial advisory board of Physicians Practice. A PA for
more than 35 years, he currently practices medicine
in a hospital-based plastic and reconstructive sur-
gery practice, in addition to covering a burn unit
with his surgeon and business partner M. Brandon
Freeman, PhD, MD.
As part of the editorial advisory board, Hanson
joins a team of physicians and the Physicians Prac-
tice editorial staff in helping to shape the content
and strategy for the publication.
SCIENTISTS CONFIRM SEVERE BIRTH
DEFECTS TIED TO ZIKA VIRUS
Scientists from the Centers for Disease Control
and Prevention (CDC) have concluded, after care-
ful review of existing evidence, that Zika virus is a
cause of microcephaly and other severe fetal brain
defects. In an April report published in the New
England Journal of Medicine, the CDC authors
describe the rigorous weighing of evidence that
led them to their findings.
Since its first identification in Brazil in 2015, Zika
virus has spread rapidly. While prenatal Zika virus
infection was linked to adverse pregnancy and
birth outcomes, most notably microcephaly and
other serious brain anomalies, exact causation had
not yet been established before now.
Given the severity of the birth defects, the rapidly
spreading virus and the adverse effects on commu-
nities, scientists recommend a strategy focused on
education and prevention of virus transmission.
AIR FORCE PA EARNS AIR FORCE ACHIEVEMENT MEDAL
Maj. Kenneth Beadle, U.S. Air Force, DSc, PA-C, (left in photo below), recently
received the Air Force Achievement Medal from Brig. Gen. David Julazadeh, com-
mander, 455th Air Expeditionary Wing, during a ceremony at Camp Cunningham
at Bagram Airfield in Afghanistan.
Beadle was among the more than a dozen airmen who earned the recognition
for their efforts to recover the wreckage of an F-16 Fighting Falcon that crashed
during takeoff in Parwan Province on March 29. A graduate of the Interservice PA
Program, Beadle is with the 455th Expeditionary Medical Group, which provides
combat medical and combat medical support services to U.S. and coalition forces
throughout Afghanistan.
PA Stephen Hanson
COURTESYOFTHEU.S.DEPARTMENTOFDEFENSE
ADOBESTOCK.COM
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 17
20. STAT | continued
MEDICAID EXPANSIONS IMPROVE
HEALTHCARE OUTCOMES FOR LOW-
INCOME PATIENTS
States that have enacted the Affordable Care Act
(ACA) Medicaid expansions are seeing better out-
comes in many aspects of healthcare for their low-
income residents, suggests a study recently pub-
lished in the Annals of Internal Medicine.
HEALTH DISPARITIES AND LESBIAN,
GAY AND BISEXUAL PATIENTS
Lesbian, gay and bisexual patients, especially bisex-
ual women, are more likely to encounter barriers
to care than their straight counterparts, according
to two studies recently published in the American
Journal of Public Health.
A National Center for Health Statistics study
found that healthcare disparities cause gay, lesbian
and bisexual patients to suffer more health prob-
lems, including highly preventable illnesses such
as pneumonia.
NEW DIETARY GUIDELINES ISSUED
FOR 2015-2020
The U.S. Department of Health and Human Services
and the Department of Agriculture have published
their latest dietary recommendations. The guide-
lines align with previous recommendations, with
some differences. Instead of an emphasis on food
groups and pairings, the new guidelines empha-
size eating habits overall. The guidelines include
a newly recommended limit of 10 percent of daily
calorie intake coming from added sugars and state
that drinking three to five cups of coffee a day is
now considered to be part of a healthy eating pat-
tern (surely good news for many PAs!). Additionally,
the previous 300 milligram restriction on dietary
cholesterol has been lifted, in line with many stud-
ies showing that dietary cholesterol does not affect
blood cholesterol levels. The guidelines for sodium
consumption remain at 2,300 milligrams per day
for Americans ages 14 and older, but the recom-
mendation that certain groups limit their sodium
consumption has been eliminated.
These recommendations, known by their five-
year range for the first time this year, were based on
the assumption that there is a link between“poor
quality eating patterns and lack of physical activity”
and the prevalence of many preventable chronic
diseases, such as hypertension, obesity and type 2
diabetes. They were compiled based on a review of
300 studies, in addition to a review of 29,000 public
comments.
PROMOTING HERPES ZOSTER AWARENESS
Herpes zoster strikes nearly 1 million people a year in the United
States. One in three adults will get the infection in their lifetime, and
anyone who has had chickenpox is at risk of the virus reactivating
from its latent state. Yet, most patients know nothing about it or the
vaccine that can prevent it.
The National Foundation for Infectious Diseases (NFID) wants to
change that with a new campaign to raise awareness of herpes zos-
ter. Patient information materials include a public service announce-
ment about the importance of shingles prevention, an online quiz
to help individuals determine if the herpes zoster vaccine is recom-
mended for them and a factsheet on shingles myths vs. facts.
ADOBESTOCK.COM
COURTESYOFNFID
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 18
21. STAT | continued
HEALTHY EATING AND PREGNANCY
The relationship between diet and health plays a
pivotal role in the health of mother and baby dur-
ing pregnancy. The International Food Information
Council Foundation (IFIC) released a new brochure
to help providers educate patients about healthful
eating during pregnancy. The brochure covers how
to eat a balanced diet, eating a variety of foods,
healthy weight gain during pregnancy and food
safety concerns specific to pregnant women.
ESTIMATE OF PHYSICIAN SHORTAGE
INCREASED
The Association of American Medical Colleges
(AAMC) has increased its estimate of the com-
ing physician shortage, with projected shortages
reaching between 61,700 and 94,700 over the next
10 years and the primary care physician shortage
expected to range from 14,900 to 35,600 by 2025.
These projections, part of an April AAMC report, are
up slightly from recent estimates that the nation
would need an additional 46,100 to 90,400 physi-
cians by 2025. However, these estimates still fall
short of the peak 2010 projections that the United
States would be short 130,600 physicians by 2025.
This year’s report takes into account the rapid
growth of the PA profession and increasing
demand for PAs and also updated the supply and
demand data and medical school graduate data
that were used. Given the unprecedented growth
of the PA and NP professions and the projected
shortages of primary care providers, the AAMC has
recommended continued observation of these
professions as the data model evolves and more
patients enter the healthcare system.
NO DECLINE IN YOUTH TOBACCO USE
SINCE 2011
While significant decreases in overall cigarette
smoking occurred between 2011 and 2015,
tobacco use by middle and high school students
has remained unchanged since 2011, according
to new data published by the Centers for Disease
Control and Prevention and the U.S. Food and Drug
Administration’s Center for Tobacco Products.
The data from the 2015 National Youth Tobacco
Survey show that 4.7 million middle and high
school students were current users of a tobacco
product in 2015, with current use defined as using
tobacco at least once in the past 30 days. Addition-
ally, the findings show that e-cigarettes are the
most commonly used tobacco product among
middle and high school students.
NEW TESTS TO ID FOODBORNE
ILLNESSES
Changes in the tests used to diagnose foodborne
illnesses are enabling scientists to identify infec-
tions more quickly, but in the
longer term these changes could
pose challenges to scientists’abil-
ity to find outbreaks and monitor
progress in preventing foodborne
disease, according to a report pub-
lished in an April CDC Morbidity
and Mortality Weekly Report.
These new tests, known as cul-
ture-independent diagnostic tests,
help providers to quickly diagnose
infections—with results available in
hours instead of the days needed
when using traditional culture
methods that require growing bac-
teria to determine cause of illness.
However, without these bacterial cultures, scien-
tists and public health officials are unable to deter-
mine the cause of an infection—which limits their
ability to monitor outbreaks, check for antibiotic
resistance and track trends in foodborne diseases.
ADOBESTOCK.COM
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 19
22. STAT | continued
NEW SCREENING GUIDELINES FOR
COPD AND ASPIRIN USE
The U.S. Preventive Services Task Force has issued
several new recommendations, including final rec-
ommendation statements on screening for chronic
obstructive pulmonary disease (COPD) and on aspi-
rin use for the primary prevention of cardiovascular
disease and colorectal cancer.
USPSTF recommends against screening for COPD
in asymptomatic adults, a grade D recommenda-
tion. According to the Task Force, little benefit was
found in early detection, and no evidence was
found that screening for COPD in adults without
respiratory symptoms improved health outcomes.
The recommendations further state that clini-
cians should be aware of the risk factors for COPD,
including current or former exposure to tobacco
smoke, educate patients on these risk factors and
counsel them not to smoke or to quit.
The statement on aspirin use for the primary
prevention of cardiovascular disease and colorectal
cancer recommends that clinicians with patients
between 60 and 69 years old should work with
these patients to decide if aspirin use for primary
prevention is right for them. According to USPSTF,
evidence shows that low-dose aspirin use is most
beneficial for people ages 50 to 59.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 20
•
CO VISITS TO AAPA HELP BUILD RELATIONSHIPS
On February 23, 2016, AAPA hosted former Association of PAs in Cardiology (APAC) president Sondra
DePalma, MHS, PA-C, CLS, AACC, at AAPA headquarters in Alexandria, Va. DePalma participated in a full
day of strategy and planning meetings with senior leadership and staff from both AAPA and the Acad-
emy’s newly created Center for Healthcare Leadership and Management (CHLM). The meetings aimed
to identify new collaborative opportunities and ways to improve the practice environments of PAs by
leveraging the expertise and experience of PA
leaders like De Palma to create specialty-specific
approaches to demonstrating PA contributions to a
broad range of practice environments.
AAPA and CHLM are committed to working with
both current and aspiring PA leaders across the
country on the goal of increasing patient access to
care through ensuring that PAs are able to consis-
tently practice to the fullest extent of their educa-
tion and training.
Academy visits like these are an opportunity to
build seamless relationships between COs and
AAPA and for Academy staff to engage with PA
leaders. For more information on ways you can
get involved with CHLM or schedule a CO visit,
please contact Rick Christiansen, AAPA director of
employer development and constituent organiza-
tion outreach and advocacy.
PA Sondra DePalma, a past president of the
Association of PAs in Cardiology, with AAPA
staffer Rick Christiansen
25. FEATURE STORY
More than fifty resolutions have been submitted
to this year’s House of Delegates, including
several related to NCCPA’s PANRE proposal, one
relating to AAPA supporting full practice respon
sibility—the concept that PAs should have the
right to define their scope of practice and take
responsibility for their clinical decisions—and
another to the accreditation of postgraduate
clinical training programs. AAPA members can
access all the resolutions on the HOD page. The
resolutions related to the NCCPA PANRE proposal
can be found on the AAPA News Center page—
scroll down to "Submitted HOD Resolutions
Regarding the Proposed Model."
EQUIPPING PAS FOR EXPANDED
OPPORTUNITIES IN HEALTHCAREBY STEVEN LANE, MA, MPP
MANY FACTORS, INCLUDING CONSUMER EMPOWERMENT AND A HEIGHTENED FOCUS ON HEALTHCARE
QUALITY AND PATIENT SAFETY are raising the level of scrutiny on how providers develop and demonstrate
clinical competency. The PA profession itself has been changing as well, with the percentage of PAs practicing in
non–primary care specialties rising steadily over the past two decades.
Nearly three-quarters of PAs now say that their primary area of practice is in a specialty other than primary care,
which the National Commission on Certification of Physician Assistants cites as one of the reasons it has proposed
a new recertification model that would include a proctored, closed-book exam in a specialty area—a proposal that
has engendered lively debate among PAs around the country and that will be among the most discussed issues at
the upcoming House of Delegates meeting at AAPA Conference 2016 in San Antonio this month.
With the introduction of NCCPA’s voluntary certificate of added qualifications (CAQ) program several years ago,
many PAs expressed concern that a CAQ in a specialty area would eventually become mandatory, imposed by
either employers or state regulatory bodies. Many believe that the credentialing and privileging processes of
hospitals and health systems, as well as private provider practices, are sufficient to demonstrate PA competence
in a specialty.
In recent years, there has also been discussion about the appropriate role of clinical postgraduate training and
even about the creation of a PA clinical doctoral degree. An AAPA task force has just released a report on a possible
accreditation model for postgraduate training programs.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 23
26. CLINICAL DOCTORATE?
RECERTIFICATION?
RESIDENCY?
CAQ?
The issue of how to maintain multiple pathways to demonstrate PAs’
clinical competency is one of the six key issues facing the profession that is
being addressed in AAPA’s 2016-2020 Strategic Plan. (This story is the sev-
enth in PA Professional’s ongoing series of strategic plan–related articles;
you can read the other six in the PA Pro archives.)
AAPA President Jeffrey A. Katz, PA-C, DFAAPA, frames the issue like this:
“PAs have always been able to adapt to changing healthcare needs
because of the multiple pathways available to us to develop and demon-
strate our competencies. We must collectively ensure that pathways for
demonstrating our skills do not become restricted to any single require-
ment. Simultaneously, we must acknowledge the reality that demonstrat-
ing competencies is best addressed at the practice level.”
PA Professional spoke to a number of PA leaders and managers for their
perspectives on these questions.
Recertification and Maintaining Flexibility
The overriding concern of most PAs on this issue is to maintain the profes-
sion’s well-known clinical flexibility, which has allowed PAs to move quickly
to where the need is in the healthcare system or even within their current
workplace. Roughly half of all PAs change the specialty area in which they
primarily practice at least once in their careers, according to the 2015 AAPA
National Survey, and many change specialties multiple times.
The AAPA Board of Directors and HOD, and many AAPA members, are
concerned that the proposed new NCCPA recertification model threatens
this flexibility. The proposed model would require all PAs to select a spe-
cialty area in which to be examined, in a secure, proctored timed format, in
addition to the generalist portion of the recertification process, which
would assess core medical knowledge through a series of take-home
exams over the 10-year recertification cycle. NCCPA has said it expects to
offer between nine and 11 specialty area exams, including an exam in
family medicine. Under the original NCCPA proposal process, PAs
who achieve a high enough score on the specialty exam and also
elect to satisfy other requirements, including CME hours and a
minimum time spent working in the specialty, would be
eligible for a CAQ. Under the proposal, acquiring a CAQ
would be voluntary, but some PAs fear that it could even-
tually become a de facto requirement; especially in
hospitals or health systems where the PA practice
FEATURE STORY, continued
Jeffrey A. Katz
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 24
27. INTERVENTIONAL RADIOLOGY, CONTINUED
model is not well understood, administrators may be looking for easy ways
to have employees demonstrate competence, or hospital system lawyers
may want to require it in order to mitigate concerns about potential liabil-
ity in adverse outcome cases. Of equal concern is the CAQ becoming a
requirement by payers or state licensing authorities.
“Our concern is to ensure that NCCPA’s proposed specialty exam
requirements do not become a de facto requirement for specialty practice
or employment,”says Katz.
Clinical Postgraduate PA Training Programs
Another pathway for demonstration of clinical competency and advanced
training in the clinical setting is through a PA clinical postgraduate pro-
gram (sometimes called a“residency”). These have been around since the
1980s, but relatively few PAs have gone through them. Today there are
about 60 known programs, typically 12-18 months in length and graduat-
ing two to six fellows a year. The AAPA Task Force on Accreditation of Post-
graduate Training Programs recently completed its review of available
evidence on postgraduate training programs for PAs and determined that
“the development of an efficient, PA-led, national model for accreditation,
continuous quality improvement, and reporting on outcomes is needed.”
The task force described key elements and considerations for an optimal
national model.
Accreditation of postgraduate programs requires a degree of flexibility
because the programs are so different from each other, according to task
force chair Reamer Bushardt, PharmD, PA-C, DFAAPA.“The purposes of
these programs vary widely,”he says,“and we don’t really know what is
working well because we have very limited outcome data. But there is a
desire to have an accreditation or national recognition process; some insti-
tutions would like to have a way to establish their credibility.”
The task force’s paper,“Accreditation and Implications of Clinical Post-
graduate PA Training Programs,”has been submitted to the HOD for
approval as policy. If approved, the paper would replace an earlier position
paper that had cautioned against development of a postgraduate accredi-
tation process.
From the Director’s Office
PAs who oversee other PAs in large health systems are strong advocates for
maintaining the practice flexibility of their PA workforce, and for the hospi-
tal or health system’s ability to train PAs and assess their competence in
their own way. This is in accord with AAPA’s position that“competency is
best assessed at the practice level.”
FEATURE STORY, continued
Reamer Bushardt
POSTGRADUATE TRAINING
CLINICAL EXPERIENCE
TRAINING COURSES
AND CAREER RESOURCES
ADVANCED CERTIFICATIONS
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 25
28. “I think it is dangerous if we go down the path that our NP colleagues
have taken—once you have become specialized in pediatrics you cannot
treat other patients,”says Todd Pickard, PA-C, director of PA practice at MD
Anderson Center, who oversees nearly 300 PAs.“Creating pathways where
we narrowly define our competency really inhibits our ability to practice in
multiple specialties. And nobody in my institution, or others that I know of,
says that PAs are incompetent because they don’t have specialty
certification.”
Laurie Benton, PhD, MPAS, PA-C, DFAAPA, a PA administrator at Baylor,
Scott & White Health in Temple, Tex., agrees.“If you go into a new area of
practice that requires new training, let hospitals and specialty staff be the
ones to train you. We have onboarding and training procedures for that
specialty. We can take the responsibility.”
Benton, a member of the AAPA Board of Directors, also advocates for a
distinction between knowledge, which can be assessed on an exam, and
competence, which cannot.“You can have someone that is very book
smart but you put them in a life or death situation and they might not
react well,”she says.“They may not feel comfortable inserting a chest tube
or clamping a bleeding artery. I feel it should be left to the specialty team
and the physician to determine that the person is trained. I need to see it
for myself, not trust a piece of paper.”
PAs in management also make a key distinction between“a certificate”
and“certification.”
“I do advocate for recognition of PAs who have served in a specialty for
all of their careers,”says Josanne Pagel, MPAS, PA-C, Karuna®RMT, DFAAPA,
executive director of PA services at the Cleveland Clinic, and also AAPA
president-elect.“Those PAs should have that certificate, but it should not
be a certification. That was the original intent of the CAQ, to recognize the
knowledge of those PAs.”
“When I think of certification, I think of an accrediting body that has
public responsibility,”says Pickard.“Certification from NCCPA is required to
practice. But a certificate just shows that you have completed additional
training and have additional skills, like doing 25 hours of ACLS.”
‘Psychiatry Is a Bit Different’
One specialty area where the CAQ may be closest to becoming a de facto
requirement is psychiatry.“Psychiatry is a bit different,”says Tracy Keizer,
PA-C, director of the PA/NP postgraduate fellowship program in psychiatry
at Regions Hospital in St. Paul, Minn.“NPs have a specific degree that they
can get in psych. So we do have quite a bit of competition with them
because of that certification. This is a reality with employers and payers.”
“There has been a lot of push for the CAQ at our institution,”adds Keizer.
“I am not one to promote it because it does limit our flexibility, but our
administration has said it is the goal.”
“All it takes is a perception,”says Pagel.“If you have one leader at a prac-
tice who perceives that NPs are certified so PAs must be certified, that can
immediately stop the hiring of PAs. I have seen it in psychiatry; it is reality.”
James Cannon, PA-C, DHA, MBA, DFAAPA, a former chair of NCCPA and a
leader of the Association of PAs in Psychiatry, says he has seen multiple
cases of PAs being shut out of job opportunities and reimbursement in
that specialty, prior to the creation of the psychiatry CAQ. “The market-
place in mental health makes psychiatry truly the most unique specialty,”
Cannon says.“We are competing against psychologists, psychiatric NPs,
clinical counselors—all with formal qualifications in mental health. An
emphasis should be placed on first amending those state laws that cur-
rently do not define PAs as mental health providers.”Cannon, who has
earned the CAQ in psychiatry, considers the proposed CAQ program a
FEATURE STORY, continued
Todd Pickard
Laurie Benton
Josanne Pagel
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 26
29. FEATURE STORY, continued
“kind of portfolio, a way to organize one’s experience, CME, physician
attestation, and medical knowledge.”
Preserving Multiple Pathways
It remains to be seen whether other specialties will follow in the first
tentative steps toward requiring a CAQ for practice that seem to have
been taken in psychiatry. And some perspective is necessary. At present,
the number of PAs who have earned a CAQ is approximately 1,000, less
than 1 percent of the more than 108,500 PAs in clinical practice today.
“With a reported 45,000 open PA jobs, why would any prudent
employer limit their applicant pool to such a narrow universe by making
the CAQ a requirement?”asks Tricia Marriott, PA-C, MPAS, DFAAPA, MJ
Health Law, principal advisor with AAPA’s Center for Healthcare Leader-
ship and Management, who speaks regularly to health system adminis-
trators around the country.“We know that only about 100 of the 12,000
PAs in orthopaedics have obtained a CAQ, and there is no evidence that
the PA with a CAQ would be a better candidate for a sports medicine
practice than one with 15 years of experience in sports medicine and
no CAQ.”
AAPA is working proactively to ensure that CAQs, or other formal
attestations of specialty training, do not become de facto requirements
and limit the ability of PAs to switch specialties and of the profession to
move to where the demand is greatest.
“We are not against the CAQ, but we want to ensure that there are
many pathways for PAs to demonstrate competence and expertise, and
that these are well understood by employers, credentialing bodies, reg-
ulators, and payers,”says Katz.“It is well documented that provider com-
petency is best established at the practice level.”
STEVEN LANE, MA, MPP is senior
strategic writer for AAPA and an editor
of PA Professional. Contact him via
email or 571-319-4364.
Tracy Keizer
James Cannon
Tricia Marriott
NCCPA.NET
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 27
31. Our work at the AAPA Center for Healthcare Leadership and Management (CHLM) is to ensure PA
interests are represented with employers and to cultivate PA leaders. We work with employers and
you to move the PA profession forward.
WE ADVISE EMPLOYERS on best practices to maximize provider utilization and retain top talent.
Employers rely on us as the expert on PA reimbursement and billing, scope of practice, regulatory
compliance, and credentialing and privileging. When PAs are able to practice at their highest level,
patient care is at its best. And that’s something we can all support.
WE BUILD PA LEADERS with innovative training events to equip you to lead your team, your
committee, your workplace and your profession. We want to help you grow as a leader both
personally and professionally, because we know that as each PA becomes stronger, so does the
profession.
Learn more about how CHLM is working for you every day.
chlm.org
You advocate for patients. We advocate for you.
We are CHLM.
32. PROFESSIONALPRACTICE
Cultivate Your Network
Employment References: Tips and Techniques
B Y J E N N I F E R A N N E H O H M A N
C
reating your references list is an essential part of
the job search that can also help you cultivate your
professional network and prepare you for inter-
views. Your list, comprising people with whom you’ve
worked closely and who can attest to your skills, is a great
way to review your accomplishments and look at your
practice to date through the eyes of your clinical partners.
I suggest creating a reference list document that
matches the font and overall style of your CV and cover
letter and keeping it to one page. List your strongest and
most recent references first and include their contract
information and their professional relationship with you as
well as how long you’ve known each other. Choose people
with whom you’ve worked closely and can speak knowl-
edgably (and positively!) about your work, accomplish-
ments and character.
It’s key that you reach out to each reference and confirm
their willingness to be contacted. You might also review
some highlights of your work together and ask them what
they consider to be your strongest points. Share an
updated copy of your CV and some information about
your current career goals. Ask them about their preferred
method of contact by employers with whom you’ll be
putting them in touch.
JENNIFER ANNE HOHMAN is
the founder and principal of PA
Career Coach, a service dedicated
to helping PAs create rewarding,
healthy and patient-centered
careers. Contact her via email.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 30
33. PROFESSIONAL PRACTICE | continued
The assessments of physicians you partnered with are probably of
greatest interest to prospective employers, but you might also include
contact information for a few other individuals who can attest to your skills
and great qualities. For recent graduates, these people might include pro-
fessors/preceptors, established clinicians, other PAs and even a patient
you’ve treated.
To cultivate your references and keep them a thriving resource, keep
your professional network active by staying in touch with former col-
leagues and bosses. A current relationship will improve the odds of a posi-
tive and pertinent response to a referral request. It’s also a great idea to
share an updated version of your resume with them as well as information
about the job you are applying to. Help them to be advocates for you!
Be sure to express your thanks for the time and effort they share to ben-
efit your career (a thank you note is a good place to start; an invitation to
coffee, if feasible, is a nice gesture and will nurture your network) and
keep your references in the loop—let them know where your job search
landed you.
How many references to provide? Three to six is a good number for
most positions. When to share their information is also important: Rather
than sharing your reference list with an employer with your cover letter
and CV, wait until your interview to share the list. This gives you an oppor-
tunity to inform your references about the employer and some specifics
of the position.
In summary, references are an aspect of the job search that highlight the
quality of your working relationships. Everyone encounters some problem-
atic ones as part of being a PA along with the great ones—and a negative
referral need not be a career disaster. (More on that in PA Professional’s
June-July issue.) Keeping your professional network alive is a key to career
growth and this truth is never more apparent than during the job search.
Build on your relationships to help land your next position, and help
respected colleagues by doing the same for them!
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 31
34. Whether you’re in the halls of a hospital, the office or the
subway, there’s one place you can find CME to keep you
clinically current. Explore all Learning Central has to offer
– more than 400 activities, including Self-Assessment
and Performance Improvement CME (PI-CME) plus
JAAPA post-tests. Many activities are free or discounted
to members.
The Latest Featured CME like Online Orthopaedic CME
PANCE/PANRE Prep with trusted resources like AAPA
PANCE/PANRE Review
PI-CME with activities like Intralign Health’s Surgical Safety
Time Out
Self-Assessment CME with interactive eCase Challenges
LEARN HERE aapa.org/LearningCentral
Learning Central.
Connect learning with life.
36. first rounds | A special section for and by PA students
This edition of First Rounds (FR) was produced by
FR Editor Paul Gonzales, PA-S2, University of Texas
Southwestern Medical Center in Dallas, and FR Assistant
Editor Mia McDonald, PA-S1, Jefferson College of
Health Sciences in Roanoke, Va.
Tuk’s traditional Thai blessing ceremony before she was
cremated.
Sometimes the Guidelines Are Meant to Be Broken
BY STEPHANIE GOMOLKA, PA-S1
My mother-in-law, Vilavun, grew up in a small
city on the Gulf of Thailand named Chon
Buri, meaning “City of Water.” She had no running
water, slept under mosquito nets with her five
sisters and endured water snakes and roaches
invading the home during monsoon season. She
was poorly educated and attended school only
when she wasn’t tending to her father’s shop and
rice mill. In the 1960s, Tuk, as she was nicknamed,
moved to New Zealand, where she enrolled in
secretary school, met her soulmate and found
a good paying job. With $150 to their name, she
and her new partner boarded a plane for New
York to start a family. Despite being a New Yorker
for 40 years before her death, Tuk remained in
many ways a rural town Thai girl with beliefs that
matched her upbringing.
Tuk had always been apprehensive about heed-
ing the advice of American doctors. Where she
grew up people used herbal remedies and prayed
to their Buddhist ancestors for healing and
answers. She was taken aback that when she
went to doctors for a simple cold she was invari-
ably prescribed an antibiotic. This ultimately led to
her distrust in American doctors as she felt that
they did not listen to her concerns and just gave
her an antibiotic for every ailment. Tuk felt that
her perceived education level and cultural beliefs
prevented her from receiving the care that she
needed and deserved.
A turning point occurred for Tuk in the 90s when
a friend gave her a copy of “Prevention.” It was
then that she felt confirmed in her belief that
Western doctors were killing their patients with
antibiotics. She turned to supplements and herbal
remedies to take care of her own health. She
became fixated on natural medicine.
In 2005, Tuk began to feel sharp back pains,
which she treated naturally with supplements,
and in 2007, she was diagnosed with stage 4 lung
cancer. Tuk felt she was too frail to begin chemo-
therapy and decided to have the tumor removed
via cyberknife. One year later Tuk was told she
had less than a year left and began treating her-
self with natural remedies, much to her cancer
team’s disapproval. It was even difficult for our
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 34
37. first rounds | continued
Tuk and Pad with family at their traditional Thai wedding
ceremony in New York City. Left to right: Krisana Suthiwongs,
Pad Gajajiva, Vilavun“Tuk”Gajajiva,Tao Tangnavarad,
Khanitha Tangnavarad.
Tuk spending time with the author and her grandson, Kieran, in
the summer of 2011.
STEFANIE GOMOLKA, PA-S1,
attends the Shenandoah
University PA program and is a
member of the class of 2017.
family to watch her refuse treatment. No one really
took the time to understand where she was coming
from. However, the one year she was given turned
into two, and then three, before the cancer eventually
took her life. Tuk remained emotionally strong up to
her last day.
I never realized the impact Tuk had had on me until
my first job interview four years ago at Craig Hospital
in Denver. They asked about any cultural experiences
I had had in my life, and of course Tuk’s story immedi-
ately came to mind. After I told the story, the inter-
viewer asked if I believed Tuk was able to extend her
life because of culture and “alternative” beliefs about
medicine. It was the first time I had truly removed my
familial bias from the situation and thought objectively
about it. After thinking for what felt like an eternity, I
looked her straight in the eye and said, “Probably.” She
looked me in the eye and said, “Definitely.”
Now, in the midst of a rigorous PA program, I con-
stantly remind myself of Tuk and her struggle with
Western medicine. Studying guidelines, medications,
flowcharts and treatment preferences, I can’t help but
sometimes think that these will not apply to every
patient I will work with. Culturally competent medi-
cine should be tailored to the individual. Even if we
don’t completely understand a patient’s culture, it is
our job to get to know them and understand why
they make the decisions they do.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 35
38. first rounds | continued
Sheila Hautbois, PA-S1, with Rachel Carlson, director of the
Shenandoah University PA program
Outside the Box
BY SHEILA HAUTBOIS, MPH, CHES, PA-S1
When most of us consider cultural compe-
tence, we think of various ethnicities and
heritages. One culture we might not consider is
the deaf community who use American Sign Lan-
guage (ASL) to communicate. Compared to hear-
ing people, individuals who are deaf have poorer
health. In fact, patients who were deaf before age
3 are less likely to see a healthcare provider than
other adults.
Shenandoah University PA students recently
had an opportunity to interview patients of differ-
ent cultures. One such patient was deaf and had a
medical ASL interpreter with her. Although being
provided with an interpreter is a legal right, this
does not always happen in the U.S. The reality is
that both patient and provider truly need an inter-
preter to ensure that good understanding occurs
on both sides. From our interview with a deaf
patient and her feedback afterward, we learned
many things.
Properly setting up our room is vital to commu-
nication. The room should be well lit, and we
should not stand in front of a window or an area
of glare. If we stand to the side and create a tri-
angle with the patient and the interpreter, the
patient must then choose between watching the
interpreter and looking at us. This not only slows
down interpretation, but also causes the patient
to make awkward neck movements. By standing
right next to the interpreter, we can make com-
munication easier for a deaf patient.
Eye contact is very important, as is keeping our
mouth visible in case a patient reads lips to
enhance communication. If we need to wear a
surgical mask while communicating with a deaf
patient, it should be see-through when possible.
If more than one provider will be in the room, we
should explain why and gain the patient’s consent.
Even though an interpreter is present, we
should use “I” and “you,” speaking directly to our
patients. We need to be mindful of who we are
interviewing; routine questions such as “Have you
had any hoarseness?” would not apply to patients
who do not speak. Short sentences at a moderate
pace with pauses between sentences are ideal.
Providing information in a simple manner helps
with patient comprehension and also allows for
easier interpretation. Giving subject cues in
advance of details helps the patient understand
what we will discuss next. Because ASL does not
follow English syntax, many deaf high school grad-
uates only read English at a fourth- or fifth-grade
level. Patient handouts should therefore be very
easy to understand.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 36
39. first rounds | continued
SHEILA HAUTBOIS, PA-S1,
attends the Shenandoah
University PA program and is
a member of the class of 2017.
One such patient
was deaf and had a
medical ASL interpreter
with her. Although
being provided with
an interpreter is a
legal right, this does
not always happen
in the U.S. The reality
is that both patient
and provider truly
need an interpreter
to ensure that good
understanding occurs
on both sides.
Asking deaf patients open-ended questions is
vital. Yes-and-no questions will not tell us if we
have been understood. If a patient is having trou-
ble understanding something, we should explain
it differently. We can enhance communication
with gestures and facial expressions. Drawing a
picture or writing things down might also help. We
should explain what we are going to do and why,
prior to any physical contact during our exam.
Visual aids and hands-on demonstrations can be
helpful when teaching a skill or discussing how to
take medications.
All of us can continue to grow in cultural compe-
tence. In our workplace, we can offer online
appointment booking and patient communication
via email or health portals. We should never make
assumptions. Every patient is different, just as
every individual is unique. One patient at a time,
we can help make healthcare a more positive
experience for the deaf community.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 37
40. first rounds | continued
When You Can’t Speak, Listen
BY RYAN HUNTON, PA-S2
Ihumbly admit that, despite six years invested
in my Spanish language education, as of March
2016, I cannot speak conversational Spanish. This
added another layer of cultural separation in my
clinical work during our PA program’s recent med-
ical trip to Piedras Negras, Mexico. Throughout
the week, I was heavily dependent on the various
assigned interpreters. In working with interpret-
ers, I became aware of the possibility of inconsis-
tency and misinterpretation of medical words. I
inevitably vowed to reprioritize learning Spanish,
especially medical Spanish. Still, despite this in-
ability to communicate directly with the patient, I
was determined to maximize the patient-provider
relationship. And in the end, I found that speaking
the same language is not as crucial to this rela-
tionship as one might suppose.
Take, for example, the 67-year-old man who
entered our makeshift church-clinic in a town
called Nava with no particular complaint, perhaps
seeking reassurance. When I asked him the col-
loquial “What brings you in today?” he expressed
concern about his blood sugar level, which was
mildly elevated, and I could see in his eyes and
face that his concern was profound.
As I began going through the routine of asking
various questions (through the interpreter) about
recent symptoms and past medical history, he
respectfully asked me to slow down. My collabo-
rating physician had previously told me, “Many of
these people are constantly being pushed aside
by society. This is their chance to be seen and
heard.” So when this gentleman asked me to slow
down, I did. And I listened. It became clear that he,
like many who came into our clinics throughout
the week, had not primarily come for a pharma-
ceutical; rather, he came for an honest assess-
ment and care. He seemed grateful for my
For me, just as the
history and physical
exam are the
essential elements
of understanding
the patient’s medical
problem, these
nonverbal aspects of
communication became
the essential elements
of building trust and
relationship.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 38
41. first rounds | continued
attention, and I was grateful for the reminder that
sometimes patients need acknowledgement more
than anything else.
With each patient, as I explained each step in my
physical examination and treatment plan, I paid
extra attention to the nonverbal aspects of con-
versation: the introductions, the “mucho gusto,”
the eye contact despite my speaking words they
did not understand, the returned eye contact
despite my not understanding the words they
were speaking, the shaking of hands, the smile,
the farewell. These aspects of the patient encoun-
ter are often skimmed over or neglected when
one speaks the same language as the patient. For
me, just as the history and physical exam are the
essential elements of understanding the patient’s
medical problem, these nonverbal aspects of
communication became the essential elements of
building trust and relationship. And they remain
essential elements of building trust and relation-
ships as I see patients back in Kentucky.
RYAN HUNTON, PA-S2,
attends the University of
Kentucky PA program and is a
member of the class of 2017.
Ryan Hunton performs a physical exam on an infant.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 39
42. first rounds | continued
Milk, Honey and Beyond
BY BELEN LAQUI-RAMOS, PA-S2
Growing up in the Philippines, our family al-
ways valued whatever was served on the
table despite its simplicity and meagerness. My
mother always made sure my brother and I had a
cup of freshly brewed Barako coffee over steamed
rice for breakfast. A sprinkle of cane sugar made
everything magically delicious. At lunchtime, I
couldn’t wait to show off a piece of fried mack-
erel atop white rice with salty fish sauce and ka-
lamansi, a small citrus fruit something like a lime.
My mother wrapped them delicately with banana
leaves. My days were simple, yet fun-filled—I
would even say perfect.
After graduation from high school, my family
supported my decision to become a preschool
teacher, but after five years, there was a call from
far away. This call was quite hard to ignore and
led me to a teaching job in Texas. For those who
have been teachers in the U.S. public schools, you
are probably familiar with the lunch lines in the
cafeteria. The students grabbed and hastily
devoured their food with their thoughts only on
recess and enjoying 10 minutes of freedom out-
side. Some students took their food trays and
immediately swerved to dispose of their food
directly into the trash bins. I thought, “Wait, I am
missing something here?” Goodbye milk, banana,
fideo, enchiladas and broccoli! Coming from a
developing country, I was tempted to save that
good food! As a result, I talked to my students
daily about the importance of conserving food,
valuing what they have and limiting the consump-
tion of cheese- and jalapeno-smothered chips.
But I soon realized that making poor nutritional
choices and wasting food is not a trivial problem
or mere hormonal craving; it is part of their cul-
ture and tradition.
Soon there was another call, even harder to
ignore this time. Instead of the wastefulness of
preschoolers, now I saw middle school students
with lunches packed by mom or grandma full of
spicy nacho chips and 500 mL of soda. I took a
deep breath and thought, “This is an epidemic!”
These were words I would later hear from not one
but almost all of my future preceptors. While
shadowing a pediatric PA, I noticed several
patients were not only obese, but also had bor-
derline hypertriglyceridemia and diabetes mellitus
Members of the class of 2016 after performing community
service in health and patient education. Left to right: Ayana
Gates, Courtney Brice, Megan Castillo, Nathaniel Garcia, Delmer
Robinson, Cassandra Trevino, Benny Lopez, Claudia Pena, Peter
Maldonado, Lin Yang, Belen Ramos.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 40
43. first rounds | continued
BELEN LAQUI-RAMOS, PA-S2,
attends the University of Texas,
Rio Grande Valley (Pan American)
PA program and is a member of
the class of 2016.
type 2 at the young age of 14. My decision was
made. Since then, I have equipped myself with
the medical knowledge and skills to educate our
population about eating healthier, while still
enjoying the culture and tradition of being Asian
or Hispanic down in the Rio Grande Valley. I love
Mexican fajitas, menudo and carne guisada. I
always crave Filipino dishes, such as dried and
salted fish, pancit, lumpia and unripe mangoes
with salted shrimp paste. And these popular cul-
tural meals can be enjoyed, but in moderation.
Educating patients is my next calling, which I am
ready to fulfill soon as a PA.
Growing up with barely enough to eat, my fam-
ily often told stories of the U.S. being the land of
milk and honey. To me, heaps of food repre-
sented status and symbolized prosperity. Food
was celebration, family bonding and being home.
After moving to the U.S., where food scarcity is
not a day-to-day concern for most people, I have
learned that food does not hold the same mean-
ing for most Americans as it does for me. For me,
living in and enjoying the land of milk and honey
does not mean eating all you can as long as you
can, but remembering the basic premise that food
is for strength, nourishment and life.
Belen Laqui-Ramos (second from left) with her husband, Naesar,
and (left to right) daughters Pauline, Patrisha and Meleri.
Belen’s food fusion for breakfast, lunch, snacks and dinner.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 41
44. first rounds | continued
To the Border and Back
BY SUSAN M. OGDEN, PA-S2
In February, I had the opportunity to travel to the
U.S.-Mexico border for my capstone rotation.
The month I spent in the Lower Rio Grande Val-
ley provided me with firsthand knowledge of the
importance of cultural competence. Although my
journal is full of impressions and observations
there are a few key components to my experienc-
es that affect PAs.
In the Rio Grande Valley, farming and ranching
are the mainstays of life. The workweek consists
of six or seven long days for meager wages. The
more family members who can work, the better it
is for the family. Often, this means children leave
school during their middle-school years to work,
and their long-term educational goals are sacri-
ficed for family need. Formal education may end
at ages 12–14 for some young people here.
In South Texas, many of the residents only
speak Spanish. I took French as my foreign lan-
guage in high school because I grew up three
hours from Canada. Not having a background in
Spanish set up a considerable language barrier,
and I found myself initially needing a translator
for my history and physical exams during this
rotation. But over the next four weeks, my out-
look changed from dreading the next conversa-
tion to accepting the challenge of being an
effective communicator in a new language.
There is also a literacy barrier; many residents
are illiterate in both English and Spanish or have a
basic reading level in Spanish only. We learned in
didactic year that providers need to assess literacy
as part of the assessment of patients, and living
here has given me new ideas on how to address
this issue. Written instructions for medications
can lead to a high rate of noncompliance; how-
ever, pictographs can be found for almost any
medical condition and will yield better outcomes.
Although it takes time to create or copy these in
clinic, I believe it is worth it.
While here, I have seen the importance of close
family bonds in the Latino culture. Children are
raised with a commitment to care for the matri-
arch and patriarch of the family until their last
days. Decisions are made as a family unit. Now I
understand why I have walked into very crowded
hospital and exam rooms, at any time of day or
night, to take a patient history.
The living conditions for most Rio Grande Valley
residents are drastically different from those in
San Antonio. Some colonias (neighborhoods) do
not have indoor plumbing, public transportation
or paved roads; other areas lack sidewalks and
streetlights. Health challenges abound: lack of
UT Health Science Center at San Antonio PA students with
dialysis patients
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 42
45. first rounds | continued
outdoor play and exercise, greater risk of disease
and injuries, water contamination and inability to
obtain basic services. Remember Maslow’s hierar-
chy of needs? A hungry family does not make
choices about healthy food or preventive care—
the immediate goal is to feed all the mouths
around the table. In the same way, someone who
has performed manual labor for the whole week
may not have the energy to get medications
refilled or make sure well-child exams are
scheduled.
In summary, living in a different culture has
motivated me to be a better provider. I will be
examining each patient’s barriers to health and
my own treatment plan more closely. Did I com-
municate so the patient could understand? Did I
overcome language and literacy barriers? Have I
educated family members? Have I taken the
patient’s occupational, social and environmental
histories accurately? Is what I am recommending
to the patient feasible given their environment? I
hope to be able to answer “yes” to all those ques-
tions in my PA career.
SUSAN OGDEN, PA-S2, attends The University of
Texas Health Science Center at San Antonio, PA
program and is a member of the class of 2016.
Susan Ogden at Sacred Heart Church in McAllen, Texas.
Farm workers in the Rio Grande Valley. Farming is the primary
occupation of most residents.
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 43
46. first rounds | continued
Facts and Figures:
■ Program: University of Kentucky
■ Location: Lexington, KY
■ Degree: Master of Science
■ Year of Establishment: 1973
■ Program Director: Scott Black, MD
■ Number of Applicants: 340
■ Number of Applicants Interviewed: 120
■ Number of Applicants Accepted: 56; 40 in
Lexington and 16 in Morehead
■ Length of Program: 30 months; 18 didactic
and 12 clinical
■ PANCE Pass Rate (class of 2015): 94%
PA Program Spotlight: University of Kentucky
BY RYAN HUNTON, PA-S2
Inever foresaw becoming so actively involved in
PA organizations when I started my training as
a PA student at the University of Kentucky (UK)
in January 2015. In the first few days I was simply
trying to learn how to handle a scalpel without
hurting myself and how to adjust to the great tide
of information that was sweeping over me. Over
time, I learned about the various opportunities to
become involved as a PA student, and it is through
the mentorship, support and community I have
experienced firsthand at UK that I have been able
to serve in leadership roles with both AAPA and
the Physician Assistant Education Association.
I initially chose to complete my PA education at
UK because of its rich tradition in medical and
health science education. The UK PA Studies pro-
gram was established in 1973, just eight years
after the profession’s debut; it is among nine dis-
ciplines in the College of Health Sciences (CHS),
which celebrates its 50th anniversary this year.
Both UK CHS and the PA program are near UK
Chandler Hospital, and these three entities collec-
tively provide a great source of clinical, didactic
and inter-professional education for students. The
PA program also partners with Norton Healthcare
in Louisville, through which it provides a clinical
rotation scholarship. This $5,000 scholarship is
provided to 10 students who will complete most
of their rotations in Louisville through Norton
Healthcare hospitals and clinics. Other clinical
sites are provided throughout the state through
the Area Health Education Center.
In 1996, the program was extended to include a
distant learning site at Morehead State University,
designed for students who intend to work in rural
communities. One of the strengths of the UK PA
program is its focus on the history and physical
exam as the foundation of clinical medicine, which
is especially helpful in regions where certain diag-
nostic or medical imaging tools are unavailable.
The program requires students to complete rural
clinical rotations as part of its mission to “prepare
and encourage graduates to practice in rural and
underserved communities.” Through UK PA fac-
ulty member Dr. William Grimes, students also
gain clinical experience in their didactic year by
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 44
47. first rounds | continued
The University of Kentucky 2015 White Coat Ceremony for
PA students
volunteering at New Hope Clinic in Owingsville,
Ky., a free medical clinic which has served the
rural community since 2000.
Aside from its focus on rural medicine, the UK
PA program offers several international opportu-
nities, including regular clinical rotations in Kenya,
Swaziland and England, and clinical training in
Ecuador and Mexico. One of my classmates, Amy
Hehre, and her husband Robert recently pur-
chased an 11,000 square-foot building in Kenya
which will soon become a healthcare facility for
terminally ill orphans. In a recent article, she
expressed appreciation for the UK PA program’s
focus on hands-on knowledge and clinical experi-
ence even before the standard clinical year. Much
of the program’s international outreach comes
through clinical coordinators David Fahringer,
MSPH, PA-C, and Dr. Somu Chatterjee, as well as
through faculty member Sam Powdrill, PA-C, who
has served in international medical missions work
as an ophthalmology PA for more than 20 years.
Outside the classroom, UK PA students serve
the local community through organizations like
the Jordan Light Foundation, Shriners Hospital for
Children, Helping Hands and Upward Bound, and
through various schools, programs and commu-
nity events. Each year, students attend a legisla-
tive day in Kentucky’s capital, Frankfort, to
advocate for pertinent PA-related legislation. The
day is sponsored by our state PA chapter, KAPA.
Students and alumni of the UK PA program take a
leading role among the Kentucky PA community
to continue the conversation with legislators
about the PA profession and how PAs serve as
part of medical teams to address Kentucky’s
healthcare needs.
RYAN HUNTON, PA-S2,
attends the University of
Kentucky PA program and is a
member of the class of 2017.
UNIVERSITYOFKENTUCKYPAPROGRAM
PA PROFESSIONAL | MAY 2016 | AAPA.ORG | 45