Hot Topics: A Mix of Weighty Issues and Light Moments

By Eileen Evans

APAP’s Hot Topics session drew a large number of PA program directors, faculty, and staff, who assembled to share concerns affecting their programs and PA education. There was no shortage of humor to lighten the discussions to which many of the attendees contributed. Jim Cawley, then president elect, served as moderator.

Program Rankings

The first topic to generate discussion was the suggestion of a boycott by programs in response to ranking forms disseminated by U.S. News and World Report, the basis for the news magazine’s national publication of program rankings. J. Dennis Blessing, from the University of Texas Health Science Center at San Antonio, said that while the idea of a boycott evoked emotion, before he as a chairman voted not to complete his program’s rankings form, he would ask his dean or vice president of academic affairs for advice. Blessing, with Rod Hooker, Gene Jones, and Richard Rahr, undertook a survey on criteria for ranking PA programs and published the outcomes in a 2001 issue of Perspective. Blessing explained to session attendees that many administrators are opposed to not having the ratings survey completed, and people have lost their positions for failing to comply. Even if the programs voted to boycott it, Blessing asked how binding this would be on the membership. His conclusion was that, while it may be something we talk about, in reality, it’s moot.

Other suggestions were raised to address the more troubling aspects of the rankings. It was acknowledged, however, that despite flaws that might exist in the publication’s data gathering process, students and their advisors pay attention to these rankings, and rankings sell magazines.

Michael Rackover, from the Philadelphia University PA Program, saw the issue in a different light. He said the profession should be proud to have a national magazine that goes out to every student in the country and publicizes the programs. For years, Rackover said, we’ve wanted that kind of advertising. We need to accept the negative, as well as the positive. As the profession grows, a better evaluation process may evolve. “Let’s not boycott,” Rackover advised; “the publishers may eliminate the survey. And who would lose?”

Effect of Limitations on Graduate Residency Hours for PA Education

Cawley listed a number of questions facing PA educators and the programs in light of the new restrictions on physician residency hours that have made medical news for the last year. Will these result in an increased demand for PAs? Should PA programs gear up the configuration of clinical training in the second year to allow for inpatient specializations in internal medicine or surgery? Should there be extended training for PAs to fill hospitalist roles, as substitutes for residents, in graduate medical education?

Nicole Gara, AAPA vice president, government and professional affairs, said that the Academy has received an increased number of inquiries from hospitals wishing to hire PAs and is preparing materials to send in response. She asked for audience feedback on whether the demand would be primarily in surgery, or if other hospital departments would be affected as well.

Norman Rose spoke of the situtation at his program, Miami-Dade Community College in Florida. He reported an upsurge in hiring his program’s graduates due to the decrease in residents’ hours, a positive change as far as making new positions available. Mid-level providers were needed and training was provided, particularly for PAs in cardiovascular surgery and in emergency departments.

Mark Zellmer, from the PA program at the University of Wisconsin-La Crosse - Gundersen Lutheran - Mayo, said that in Rochester, Minnesota, and in LaCrosse, Wisconsin, internal medicine and other residencies have severely cut residents’ time. Zellmer added, “We’ve seen institutions develop inpatient services staffed entirely by an attending physician and PAs. This is the greatest employment demand for our new graduates, and we project an increased demand in these areas for next year when the residency restrictions are fully implemented. For us this is a new phenomenon that we’ve not seen in previous years.”

Blessing speculated that if residents’ hours were limited, and students work resident hours, we may see limits in students’ clinical hours.

“Several changes to program curricula have come out of increased demands for clinical productivity across the board,” said Paul Lombardo, from the Stony Brook University PA Program in New York. “Whether it’s supervising PAs, residents, attending physicians, or fellows, they no longer have the time they previously did to help refine fundamental skills such as oral presentation. They come to us and say, ‘Your students need to come to us prepared to present cases in five or 15 minute formats.’ And that requires more faculty time and adjustments to the curriculum. Similar issues arise in training for most technical skills. Residents no longer have the time to teach students some of the more complex procedures from scratch. Consequently we’ve had to enhance technical skill training, push more of this training into the first year of our program and more carefully monitor student proficiency with these skills during clinical rotations.”

Walter Eisenhauer, from the PA Program at Lock Haven University in Pennsylvania, commented that, although we are always tweaking the curriculum to better prepare students for the market, ten years from now it will be primary care again, and students will be best served by the generalization of their education. He spoke of the residency programs versus other models, such as on the job training and hospital internship models. If the profession goes to a model in which residency training, specialized training, or postgraduate training become the norm, Eisenhauer asked whether we need to fear that those students who choose not to undertake these are going to face limitations as they go into the job market. Traditionally we’ve done well in getting students up to speed very quickly in a number of specialties without their having to take on residencies, and Eisenhauer advised paying attention to this issue as we proceed.

Reggie Carter, from the Duke University PA Program in North Carolina, pointed out the flip side of the current direction of the market that will open up jobs in hospitals and specialty areas: we’re going to take another hit in primary care. While this movement may be just temporary, it might conflict with the goals of the federal government and its emphasis in funding primary care.

Ellie Grant, PA program specialist at HRSA, was on hand and emphasized that primary care is still very important and getting primary care PAs into underserved areas is HRSA’s number one goal. The second, she said, is getting minorities into the work force. Although it’s still unclear what will develop in the way of funding, Grant said that HRSA is still promoting PA applications.

Cawley said that the programs realize that the thrust of HRSA is driven primarily by Title VII and its emphasis on primary care initiatives. Over the decades that these have been in place, he said, they have promoted diversity in the workforce and acted as a necessary counterbalance to market forces.

Don Pedersen of the PA Program at the University of Utah mentioned that PAs were specifically referenced in recent federal legislation regarding graduate medical education (GME) funding. He said that Utah is pursuing the inclusion of PAs in this funding stream on the state level. Gara noted that Congress had encouraged the Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) to reform GME funding and include other providers. Expanding GME to include providers other than residents, as well as outpatient settings, presents so many problems that CMS has made no progress. In states that financially support graduate medical education, such as Utah, including PA students still remains a possibility.

With regard to the development of future residency training programs, Glen Combs of theWake Forest PA Program in North Carolina indicated that he felt postgrad residency programs would come about because of workforce issues, and that if this is simply allowed to happen, it will be very difficult for the profession to get control of this issue. He encouraged APAP to take a proactive stance and urged Cawley, as the Association’s future president, to consider launching a task force to examine the graduate medical education aspect of postgraduate training from political, legislative, and reimbursement perspectives. Our first priority, Combs maintained, is our graduates.

PA Students As Consumers

Lastly, the topic of students as consumers drew many responses from those present. A comment by Hank Lemke of the University of North Texas PA Program was representative. “This is a complicated issue,” he said. “Students are consumers not so much in the knowledge that is conveyed, but in the methods and means of delivery. I listen to concerns that students have about how courses are delivered, but the quality of the knowlege-content is for faculty to measure. Still, we shouldn’t be closed-minded to criticisms that the students have to offer.”

“We are in an era of aggressive consumerism,” said Matt Dane Baker of Philadelphia University PA Program. He repeated what he tells his students. “Students are customers, but we have a lot of customers, I tell them. It’s not a passive consumerism; you’re not buying a shirt. It’s not about the best education money can buy. You can’t buy an education, just the resources we give you. And it’s a partnership. At the end of the day, no matter how much you spend, if you don’t earn it, you don’t get the grade.”