Thursday, September 29, 2016

NCCPA Wakes Up. Could somebody please shake the AAPA too?

NCCPA Responds to PA Concerns with Change to CME Requirements

At its meeting last weekend, the NCCPA Board of Directors responded to concerns from PAs and to a new analysis regarding the availability of self-assessment and PI-CME activities and reached a decision to relax the self-assessment and PI-CME requirements introduced with the new 10-year certification maintenance process.

Effective immediately, self-assessment CME and PI-CME are no longer required. However, in recognition of the value of these very interactive types of CME, NCCPA will weight those types of CME more heavily, awarding extra credit for these now optional types of CME.

Dear Colleagues:

From my perspective, this is a good adjustment and at least SOME evidence that our organizations actually listen to what we clinicians say to them.  I changed over to the 10 years cycle after my last (third) PANRE in October 2015.  In reviewing all the CME changes attached to the new cycle, I frankly couldn't discern anything that would make this a better process. The explanations of what constituted what, I found confusing.  It should like PI CME would be some collaborative process targeted to enhance the clinician's knowledge and skills in his/her practice setting, and that SA CME was simple that, self-assessment.  

Despite looking at the NCCPA site through it's changes over the past couple of years, a decent explanation of this I could not find.  That these have now been removed, serves to simplify the process for PA's who have been using a proven, flexible  and appropriate CME and re-certification process that has been in place for their entire career.  It wasn't broken, it didn't need to be "fixed" and now the failed "fix" has finally (and properly) been retired.  That's good, because it wasn't a good model to begin with.  

A major issue that I have with the NCCPA release on this subject if that the NCCPA is giving "extra credit" to the PI and SA programs it has previously approved / endorsed.  

"To encourage PAs to continue to pursue self-assessment activities, NCCPA will award 50% additional credit for all activities designated for self-assessment Category 1 CME credit (i.e., a self-assessment activity worth 10 credits will be converted to 15 credits by NCCPA). Also, the first 20 PI-CME credits logged during every two-year cycle will be doubled when logged with NCCPA."

I am not sure that the NCCPA can properly give Category I credit in excess of the number of hours for which that activity has been approved by the accrediting body.  If the AMA approves a program for 12 hours of Category I CME, then NCCPA can't simply give you six extra credits.  NCCPA is not an accrediting CME provider. It is a certifying body.  This policy might suggest that NCCPA somehow benefits from PA's purchasing these products.  Hopefully that's not the case, but certainly no stretch to see that as a real possibility.

AAPA and NCCPA need to work more cooperatively.  Ever since NCCPA stopped allowing PA's to log CME free through AAPA, there has been a running "pissing match" between the two organizations over one thing of another.  It's no wonder that may of my colleagues no longer maintain membership in the AAPA.  I am back and forth on the issue, mainly because there are few tangible benefits provided for us here in the trenches.  I have never seen a decent public service ad regarding PA's in my 20 years and people still ask me regularly about what PA's do.  The only recognition AAPA has provided is for the DFAAPA folks, mostly those involved in the politics of the profession.  You practice a couple of decades, train PA students, publish now and then, gain a specialty credential, that won't net you anything. Frankly I kinda roll my eyes at AAPA on that.  I think everyone certified PA member of the AAPA should be a FAAPA. The argument against this was that it wasn't like a "fellow" of a physician group, like FACS, FACEP, etc. Well, neither is DFAAPA.  I guess it makes some people feel special.  Certainly not the rest of us though.  

I'll give the NCCPA it's due on finally making specialty recognition happen after the AAPA turned a blind eye and deaf ear to AAPA members on the subject for years.  NCCPA used a great model that preserved the "generalist" credential along the way.  NCCPA kicking the mandatory SI and PI to the curb was another good decision.  Frankly, the "old method" allowed much more of the flexibility PA's need.  Hopefully, they won't try to further complicate the process.  PANCE - PANRE works just fine, places us at the top of chain in terms of maintaining currency and competence among health provider groups in the US.  My state doesn't require me to be NCCPA certified to maintain a license.  I like to have it, but if they muck about too much, I would NCCPA like a hot rock at then end of my current cycle.

AAPA's getting huffed up about the NCCPA and suggesting that they might seek an alternate certification model would be a disastrous move for out profession. That could lead to a fragmentation of our profession and bickering arguments about whose certification was valid or whether one was "better" that the other. I would hate to see us moving down the same road as our physician colleagues and their perpetual bickering about Board Certification. "My certification path is better than your certification path."  I can already see some of that affecting relationships among APN's.  We simply don't need that type of divisive rhetoric in our profession. PAs should always stand together.  Let the plethora of titled "doctors," argue, while we focus on providing the best possible care to our patients.

Let's try to get together on finding the most effective ways to train, certify and support some of the best and most dedicated medical care providers the U.S. has seen in the last 50 years (2017 is coming). It's either that or the possibility of letting our profession degenerate into something akin to the sad state of the 2016 Presidential Election.


R. Scott Best, PA-C

Tuesday, January 27, 2015

Injecting a Little Humor, with just a little seriousness

I'm sorry to be so sporadic in posting, but here at Bagram Air Field, there is always something to occupy my time.  My wife ran across a funny video and sent the link to me. I enjoyed it and found a second.  Both are posted for your review, and both reflect some of the frustrations we have as practitioners of emergency medicine.

Patient satisfaction.  I like people and I like practicing medicine.  However, part of the job is often to tell people things that they don't want to hear, and of course, even under the best of circumstances, you will not be able to please everyone.  Finally, doing whatever is takes to please someone, may result in a bad outcome.  Basic psychology shows us that when people are under stress, are unhappy, etc. they will often project those negative feelings towards those around them.  Our job, is not to make people happy, but to practice good medicine.  If we can make them happy at the same time, that's good, but at the core...providing good medical care always take precedence.  Administrative types and former health care personnel-turned-"suits" don't seem to get this concept.  Probably because their are dollar signs attached, which often impairs both ethics and common sense. Then again, they either never provided care, or took a desk job because they were never very good at it.

In any case, please enjoy the video (Credited of course to sure to visit the site):

My boss is CEO

Drug-seeking...have I said enough on this subject.  Probably, but these guys actually sing about it...something I would not subject you to myself.  Mo tune would be something more like, "NO!" then "I don't know how many times I can tell you No!" generally followed by a discharge, or in the case of the blatant drug-seeker for resale purposes, an introduction to a nice police officer is my approach.

Once...a patient came in with a dicey pain complaint...of course it was 10/10, but he sat cool as a cucumber requesting "PERCs" (ask for them by name), and of course an injection of dilaudid.  We wasn't from the area, but rather was staying some friends in SC (very far South of my ER) and when asked what he was doing up here, he said that he had gone up to VA to visit some other friends and his back started hurting on the way back.  He apparently was driving himself.  Oh...and of course, he listed allergies to every medication that he didn't want or couldn't sell.  Sound familiar?  I looked him up on the controlled substances registry...this was for my state only, but is showed that over the past 3-4 days, he had been visiting various facilities within a 20-30 minute drive of my ER and had received multiple prescriptions for opiates.  I guess he was taking the long way back to SC.  I placed a phone call.

About 20 minutes later, I went back to the patient's room.  I told him what I had found out, told him I wasn't going to give him any medication, either in the ER or by prescription.  I then introduced him to some nice officers, who arrested him and carried him from the ER in handcuffs right through the waiting room.  I'm sure my customer feedback would have been less than ideal.

The reality today is that more Americans die now from prescription pain medicine abuse than from heroin and cocaine combined.  Many that aren't just abusing their medications and diverting it for sale on the illegal market, and much of ER prescriptions for opiates is helping fuel these deaths and illegal diversions.  So much for serious talk...enjoy the video.  This was also on KevinMD, but I snagged it from a repost.

We are never, never, ever...

Like Reagan said...just say "NO!" to drugs.  

Tuesday, September 10, 2013

Rough Day at Work

I had a rough day at work recently.  I was in the ER doing my usual thing, seeing the routine things we see in the ER, plus a chest pain, asthma, altered mental status, etc.  Afternoon rolled around and we got a call about an EMS unit that had responded to an MVA (motor vehicle accident).  We were informed that they were on the way with a pediatric trauma code.

EMS called with a history of a child that had been hit by a truck after getting off of her school bus.  The bus was stopped, signs out, door open. The little girl bounced out of the bus and started across the street when she was struck by a large truck speeding past the stopped school bus. 

The little girl had no vital signs on the arrival of the first unit, but they instituted resuscitation attempts anyway and rushed her in to the ED.  Resuscitation and transport were futile, and the attending physician that day pronounced her dead almost as fast at she was moved to the treatment room stretcher.  The sheer force of an 18-wheeled tractor-trailer vs. the frail body of a 6-year old child obliterated any hope that she would have survived.

I saw the bus driver later.  She was, naturally, very badly shaken by the incident. I listened as she recounted, in excruciating detail, the split-second event that took the life of the little girl, and forever impacted the life of this driver, the child's grandmother who watched this tragedy occur from their yard, the child's other family members and likely some of the horrified students that watching from the bus.  I knew that she, and many others, would likely suffer from some level of PTSD.  The driver herself, returned to the ER within 48 hours with an MI.  I myself pondered how I would feel if such a thing were to happen with own little girl stepping off her bus and couldn't even imagine it.

I love you Victoria.

Saturday, January 7, 2012

Specialty CAQs

I received notification last month that I have been awarded my CAQ in Emergency Medicine from the NCCPA. The "certificate of added qualification (CAQ)" program was established by the NCCPA as a means of recognizing those certified PAs who have met certain minimum standards of achievement is a a number of specialty areas.

The CAQ program was started, and originally billed as, a specialty certification program. This eventually morphed into the CAQ as an addition to the basic PA-C credential, rather than as a stand-alone certification. I suppose the thought being that stand-alone certifications would erode the relevance of the basic PA-C credential. It was also postulated that, if specialty certifications were issued, that these credentials might be required by employers. Thus this leads to the CAQ as it exists today. I always felt, and had written to the NCCPA in the past advocating, that the NCCPA establish a series of "extended-core" examinations that could be taken with the PANCE or PANRE to provide "special recognition in" various specialties. This would have been similar to the PANCE exams taken up until 1997, when candidates were required to write both a general exam and at least one "extended core" exam for initial certification. The "extended core" exams at that time, were limited to only primary care and surgery, but the model was established and proven.

In the current CAQ process, the first step is documentation of a minimum of 150 hours of Category I CME specific to emergency medicine within the preceding six years. Fifty of these hours must be earned in the preceding two years and must include an ACLS course. The next step is certifying your work experience. For the emergency medicine CAQ, the minimum experience is 3000 hours or 18 months of full-time experience working in emergency medicine or about half the length of an emergency medicine physician residency program. The next step is certification of your patient management and procedural skills by a specialist physician with consideration to a number of specific areas. The NCCPA also recommends that applicants complete and emergency medicine review course as well as additional courses in pediatric and trauma life support (i.e. APLS/PALS and ATLS).

The final step is taking the CAQ examination. The exam contains 120 emergency medicine-specific questions based on a content blueprint develop by the NCCPA following their 2009-2010 PA practice analysis. After completing all of these requirements and passing the examination, the NCCPA awards you the CAQ in emergency medicine, which is valid for 6 years as long as the PA-C is maintained and certain specialty-specific CME requirements are maintained. Overall, I thought the exam was fairly representative of EM practice despite it's relative brevity. The CAQ program outline for emergency medicine is outline at the NCCPA link below:

The PA-C is a generalist or primary care credential at it's core. Despite this, I have been practicing for over a decade and a half with that credential and an ever-increasing base of experience. My CME since earning my PA-C in 1996 has reflectively been geared toward topics in emergency medicine, and my post PA-graduate master's degree was granted in 2000 with a concentration in emergency medicine. So now that, after over 15 years of emergency medicine practice, I have a "certificate of added qualification" in my specialty. I ponder on what that means.

After all that specialty PAs have contributed to medicine and fought for to achieve this recognition has returned to them a well-packaged "feather in their respective caps." It's nice to be recognized and to put another qualification on your CV/resume'. After all, the recognition was long overdue, and likely prompted most by the fact that some specialty PA organizations were set to bypass both the AAPA and NCCPA to get this done on their own. This less fragmented approach seems more desirable and keeps the CAQ program under the NCCPA, which has for decades now provided the profession with it's both its de-facto licensing examination and "Board certification." In short, the credential has credibility.

Will the decision to have a CAQ, as opposed to a stand-alone certification deter employers from increasingly favoring or even requiring such a credential for employment candidates? Probably not. Now that the cat is out of the bag, so to speak, the more PA's that achieve this credential will hold a definite advantage in the specialty job applicant pool. Both employers and employees will want to showcase credentials to prospective customers/patients. I anticipate that it will not be too long before there will be groups advertising the fact that their staff is comprised of all "board-certified" physicians and physician assistants. Is this a valid representation?

Since the NCCPA is the "Board certifying" body for the PA profession, the certificate of added qualification does indeed provide a specialty certification to PAs. Whether the certification is "added" or stand-alone seems irrelevant. A PA-C holding a CAQ is essentially held out to be "certified," by holding a certificate from an nationally recognized professional certification body, as holding qualifications in both general/primary care medicine and his/her respective specialty.

Friday, May 20, 2011

Emergency Ultrasound Course

If you are a serious about pursuing a career in emergency medicine, I highly recommend taking a quality course in emergency ultrasound techniques. The potential for ultrasound in the ED is vast. All EM residency programs must now provide ultrasound training for their graduates to be board-eligible.

This year, I attended both the Introductory and Advanced emergency ultrasound courses by 3rd Rock Ultrasound. The experience was excellent and by far one of the best emergency medicine CME experiences I have attended to date. My next working day, I was able to put these new skills to work as an extension of my physical examination.

The view available courses, visit:

Thursday, May 19, 2011

Gastritis gone sideways.

A woman in her early 60's came to the ER with complaints of "stomach pain" for the last six months. She localizes her discomfort to the epigastric and left upper abdomen, and a very discreet association with food. "It hurts mainly when I eat greasy foods." She reports some relief in the early weeks with Tums antacid and occasional use of OTC Omeprazole, but admits that she has taken these only sporadically. "I have a lot of burping," she tells me, "and when I do burp a lot, the pain gets a lot better." She also told me that her symptoms were worse when she was lying down at night. Though the patient had her symptoms for six month, she did not have health insurance and did not report them to her doctor "because I can't afford to have any tests done."

She denies and complaints of chest pain, weakness, diaphoresis, shortness of breath or other symptoms of concern. She also has noted no association of this illness with any physical exertion. "It's just really when I eat."

Her medical history is remarkable only for hypertension and high cholesterol. She takes medication for both, but tells me she can't take statins because they cause a lot of muscle weakness. Unfortunately, she does smoke cigarettes. She has had no surgery in the past.

On exam she is an alert, refreshingly non-obese and generally healthy-appearing lady. She is in no acute distress, but does have some complaint of her upper abdominal discomfort on exam. Her area of focal pain is mildly tender, but without peritoneal findings. Bowel sounds are normal and the aorta is not appreciated on exam. Her vitals signs are within normal limits.

I performed a bedside abdominal ultrasound and noted a normal aorta and IVC. Her liver was unremarkable, but she did have gallbladder wall thickening (5mm) with no stones, sludge, or significant edema. The common bile duct was 3-4mm. There was no sonographic Murphy's sign. I felt it likely that she had some chronic cholecystitis.

I ordered IV Zantac and Protonix and during treatment her pain subsided and she tolerated clear fluids well. Laboratory analysis showed a normal CBC and differential, essentially normal Chem 7 except for a mildly elevated glucose of 121. Liver functions showed normal bilirubin, but the AST, ALT, and Alkaline Phos. where modestly elevated. UA was normal. A cardiac profile and EKG were also ordered, the CK was normal, with a pending Troponin. I reviewed the EKG and noted inferior and lateral ST/T-wave abnormalities, Unfortunately, this was the patient's first visit to the ER, and no old EKG was available for review. Eventually, the Troponin resulted at 0.893 (MI threshold is 0.125). Chest Xray was normal.

I consulted with the hospitalist service and arranged to admit the patient for further workup. The first repeat Troponin was 0.769. I suspect that since the patient had a normal CK, this had peaked and return to normal before that patient came to the ED, and her MI was subacute. Still the extent of her coronary disease needed to be investigated and managed before a more serious event occurred.

We are taught that many MI patients will present with atypical symptoms. The higher risk groups are women and diabetics. The biggest point of liability in emergency medicine remains the missed MI. Even in a patient with clear-cut signs, symptoms, laboratory, and ultrasound findings of a compelling GI condition, you have to consider coronary disease in those with risk factors (age, HTN, hyperlipidemia, smoking). This case cannot punctuate that lesson enough.

Always consider and investigate the potential of a cardiac origin in any patient with upper abdominal complaints with coronary risk factors.

Saturday, April 2, 2011

Never trust a normal EKG

It's said that up to 20% of patients experiencing an acute MI will have a normal EKG. With over 25 years of emergency medical experience under my belt, I would dispute this statistic. I think it would be more accurate to say that a high percentage of these patients will have a "non-diagnostic" EKG. However, the totally normal EKG does occasionally happen, as in the case I am about to relate.

I recently treated a very pleasant and healthy older lady. I would say...a young eightly-year old. She came into the ER with complaints of chest pain that had been bothering her for the past 3 days. The pain was a mid-sternal pressure than radiated to her back and both axilla. She said it "cut off her wind," but didn't notice any specific provacative factors. It had been intermittant, but on the day she decided to come visit with me in the ER, she had been experiencing pain for a little over 6 hours. EMS placed her on a cardiac minitor and had started an IV.
There were no interventions because the patient had a normal EKG and told the paramedics that she had a normal stress test only 3 months ago.

When I saw this nice lady, she was still having pain and still had a normal EKG. Not a "non-disgnostic" EKG, but normal like it had been copied out of a textbook of normal EKGs. Despite this, her description of symptoms was pretty alarming, and her blood pressure was significantly elevated, she was started on typical cardiac chest pain treatment. She had already taken an aspirin at home and remained on oxygen. She was started on SL nitroglycerin and IV lopressor, which resulted in a modest reduction of her pain. Subsequently, she was started on IV nitroglycerin and titrated doses of morphine with more improvement. The EKG remained "normal," but the lab returned CK-MB and Troponin-I values well into the positive for MI ranges. Her BP and pain continued to improve with the nitrates, now in concert with Lovenox and Integrilin. Finally, now on maximal therapy, her pain was reduced to zero.

I consulted with her primary physician and cardiology and wrote orders to admit her to the ICU. The expectation was that she would undergo cardiac catheterization within 12 hours if she remained pain-free.

A few take-to-work messages:

1) The history is the most important diagnostic tool in your box
2) AMI can certainly happen, even with a stone-normal EKG
3) A negative stress test (treadmill, nuclear, or stress-echo) means nothing. These studies are only significant if they are abnormal (positive).
4) Don't delay treatment waiting on enzymatic testing

One more thing regarding cardiac catheterization reports. A normal cath may rule out CAD, but I have still seen patients die from arrhythmias and suffer MI caused by coronary vasospasm (printzmetals). In younger patients (<40) especially, screen for cocaine abuse. A cath with small (20-40%) lesions without critical stenosis does NOT reduce the risk of AMI. It is these younger and less stable lesions that will often rupture and cause an acute thrombus. Larger lesions (>50%) tend to be more stable (less likely to rupture), but may cause anginal pain and occlude with smaller thrombi.