PAEA Forum Keynote and Plenary Speakers

Dr. Krugman’s Presentation | Dr. Collins’s Presentation

Attendees at the 2007 PAEA Education Forum were treated to not one but two thought-provoking presentations from leading physicians. Keynote speaker Dr. Dick Krugman, dean of medicine at the University of Colorado and chair of the Association of American Medical Colleges, shared his thoughts on 40 years of PA education by asking the question: “Are you on the leading or bleeding edge of the future of medicine?” And Dr. Francis Collins, director of the National Human Genome Research Institute (NHGRI) at the National Institutes of Health, presented his views on the important role that PAs can play in applying genomics to clinical medicine in his presentation, “Physician Assistants and Personalized Medicine.”

Shortly after attending the Education Forum, on November 5, Dr. Collins received the Presidential Medal of Freedom from President Bush for his services to science and the nation. The Medal of Freedom is the highest civilian honor the president can bestow.

The Leading or Bleeding Edge of Medicine?

Dr. Krugman began his address by noting that the pending shortages of physicians and other providers now being forecast are “déjà vu all over again” — these same shortages were being predicted in the 1960s, when the PA profession was founded. The problems with access to care, Krugman said, stem from the increasing specialization of medicine that was hastened by the establishment of Medicare in 1965 — “the beginning of a 42-year inexorable pressure for physicians to specialize into lucrative procedural areas of medicine.” Dr. Krugman summarized this by the first of several “maxims” with which he punctuated his address: “Faculty and directors of training programs are fiscalophiles — they grow toward the money.”

In the 1960s, Krugman said, medical students were “stem cell students.” They were selected for their ability to become any kind of physician and were not supposed to have any preference when applying to medical school. By contrast, he said, the Child Health Associate Program at the University of Colorado in the 1960s, founded by Dr. Henry Silver, showed that providing a competency-based curriculum that prepared students for particular roles and selecting students with a particular interest in filling those roles, meant that students could be trained much more quickly than the 7–10 years required for medical school. “This,” he said, “is the gift of PA education to medical education.” He expressed this in a maxim, as well: “If you need to know something to practice medicine, it should not be elective.”

Looking to the future, Krugman said that he believes that health care reform will be difficult because the “pressure of degree creep and the need for higher salaries will conflict with the need of the federal government to keep costs down.” What will be needed in the coming years, he said, is “balance,” to ensure that all health professions can accomplish their goals; that health care is accessible and affordable to the patients who ultimately pay the bills; and finally, to ensure that “an incredibly complex and heterogeneous health care system can meet the challenges that loom ahead in a resource strained environment and provide quality health care.”

But if the 45 million people currently without health insurance do get insurance? “Who better to care for them than PAs?”

Krugman capped his presentation with Dr. Silver’s list of the stages of reaction to a new idea:

• Indignant rejection
• Reasoned objection
• Qualified opposition
• Tentative acceptance
• Qualified endorsement
• Judicious modification
• Cautious adoption
• Impassioned espousal
• Proud parenthood
• Dogmatic propagation

Physician Assistants and Personalized Medicine

Physician assistants, Dr. Collins said in his special plenary session address, “are nimble and fearless.” PAs’ shorter training period and the adaptability of their curriculum, he said, make the PA profession a prime candidate to lead the incorporation of genomic research into clinical practice in the next few years. He even made a prediction in writing: “Physician assistants will play a lead role in the personalized medicine revolution.”

These facts have led to a rapidly burgeoning relationship between the PA profession and NHGRI. Collins’s presence at the Education Forum grew out of a special meeting at NIH in March, that brought together leaders from the four national PA organizations, NHGRI, and the U. S. Surgeon General’s office. Genomics was heavily featured at the Tucson Education Forum, with several other sessions on this topic. PAEA also displayed a series of posters around the meeting venue that highlighted ordinary people who would benefit from their providers’ taking time to solicit family history information. Each poster introduced a patient by name and asked the question: “Do YOU know (name of patient) …?”

Collins provided a brief update on the progress of genomic research. The pace of discovery is now so rapid, he said, that the number of confirmed specific genetic contributors to human disease has increased from a handful a year, as recently as two years ago, to now dozens each month. “I’m going to give up making this slide,” he said, referring to one that he could not longer keep up with, given the explosion of identified disease genes. But despite these successes in isolating genes that contribute to specific diseases, it is important to remember, Collins said, that “all diseases have a genetic component.” Another factor that is changing rapidly is the cost of sequencing an individual genome, which may soon be as little as $1,000, making it a viable option for nearly all patients.

Collins noted that NHGRI had paid particular attention from the beginning to the ethical, legal, and social implications of genomics — the so-called “ELSI” components — and had put considerable energy into pushing for federal legislation that will protect patients from discrimination based on genetic information. He reported that the Genetic Information Nondiscrimination Act (GINA) has been stalled in Congress, but opined that in the very near future legislation would be passed.

To bring home the importance of steering the right course on genomic medicine and its implications, Collins compared two rhetorical situations involving a patient named “Betty.” In one scenario, Betty learns early of her family history of heart disease, consults her PA (who works for a practice that is well informed about genomic medicine), and receives treatment and recommended lifestyle modifications that keep her alive and well into the 22nd century. She does not have to worry about discrimination because strong federal legislation has been passed. In another scenario, Betty never learns of her family history, her PA knows little about genomics, and in any case the threat of genetic discrimination keep her from the appropriate testing. She dies in the ER at 50. Collins’s charge to all health care providers is obvious: Save Betty!