Tuesday, April 27, 2010


Once again, Physician Assistants are raising the issue of changing the name of the profession. I suppose it's appropriate to consider adopting a professional title that accurately reflects the job that we do. As the PA concept is being eagerly adopted internationally, more appropriate titles for the PA role (Medical Care Practitioner, Assistant Physician, etc.) are being utilized. In the US, the term Physician Associate seems the preferred title amongst our profession. The title accomplishes two important goals; it more accurately reflects the role that PAs provide as part of the health care team and preserves the "PA" acronym.

A professional name change does present challenges, namely the revision of the practice codes in every state and the federal government that makes reference to Physician Assistants. Despite the advances and inroads the profession has made in it's 43 year history, every revision attempt opens the opportunity to lose something in return. A name change would likely raise the ire of some of the more insecure physicians organizations, who would undoubtedly take the opportunity to try and curtail PA practice in some way. Take for example the idiots in NJ right now up in arms to keep PAs from performing EMG studies. Perhaps the way to go is simply to alter state and federal licensing codes to recognize the two titles as interchangeable. Thus you might be licensed as a "physician assistant/associate." This would allow you legally to use the title "associate," without affecting insurance and other regulatory codes that recognize the "assistant."

I like the term Physician Associate. I am an associate of the physician, a colleague. In no way do I "assist" physicians, other that to assist them in increasing their revenue and occasionally provide input on patient care questions. In professional school, I studied the theory and application of clinical medicine, not how to assist physicians. In practice, I evaluate patients with acute and potentially life-threatening complaints, order diagnostics, interpret tests, order treatments, perform invasive procedures, evaluate the effectiveness of said treatments, consult specialists, and make diagnoses and patient dispositions. Somewhere at the end, somebody signs off on the chart. Nope...not alot of assisting going on here, but rather a lot of practicing medicine. Been doing it for 14 years. Yes, personally I would like the title change, since it more accurately reflects the work I am doing.

So the change would be appropriate, but is it worth the risks? What are the negative consequences? How will the change benefit the profession down the road? These are all questions that need to be addressed before moving forward on the issue.

Tuesday, April 6, 2010

Just Say No: Drug-Seekers in the ED

One of the daily frustrations of working in the ED is dealing with drug-seeking patients. Presentations of these patients will vary, but with some time and experience most providers will generally be able to differentiate the "seekers" from patients presenting with legitimate pain. Regardless, it is important to always provide care appropriate to the patients immediate needs and to facilitate appropriate follow-up care. When these patients continue to repeatedly visit the ED for on-going chronic pain control, it is appropriate to just say "No."

The EMTALA definition of an "emergency" in the prudent layperson standard specifies "acute" complaints (which includes pain). When a complaint is not "acute," then the prudent layperson definition (and therefore EMTALA itself) does not apply to that patient encounter. However, it is still important to perform a history and examination sufficient to reasonably exclude any potentially serious problems.

In my experience, the "seekers" will generally present with a limited number of complaints. Most often, there and on-going complaints of back or other musculo-skeletal pain, toothaches, headaches, etc. A few may present with a myriad of minor complaints and then address their medication-seeking with an "oh-bye-the-way" type of request. Unlike most patients with actual acute pain, these patients tend to either be fairly nonchalant with their 10/10 pain, or overly dramatic. The vital sign abnormalities generally associated with acute pain (i.e. mild tachycardia, elevated BP, etc.) are often absent. Medication allergies are typically extensive and usually include all analgesics that the patient doesn't want. Toradol is almost always listed. Historical inaccuracies with these patients are common. Some may weave a story based on a thread of truth, while others will outright lie. Several could easily qualify for an Oscar-winning performance. One recent example that comes to mind was a patient that came to my ED for pain complaints stemming from being "injured by an IED in a Humvee in Iraq in July of 2002." Having been in Baghdad myself and knowing that the US didn't invade Iraq until March of 2003, I was able to get a handle on this one pretty quickly and had him bounced from the ED PDQ.

In less blatent cases, it is important to deal with the apparent acute need for pain management and reasonably attempt to facilitate appropriate follow-up care. Observing my own persoanl "three-strikes" rule, I will order appropriate analagesia for the complaint, and refer the patient back to the primary care provider (or refer to a primary care practice if the patient has no PCP) for continued outpatient management of the pain. I will give a short-term prescription for analgesics, generally a 4-5 days supply and tell the patient that the emergency department will not be able to provide ongoing care for his/her pain control needs. All of this is documented in the patient's record and spelled out in the discharge instructions that the patient signs.

On a second visit, I will do the same thing. Administer analgesia, refer again, but provide only a 2-day prescription for analgesics. Again, the encounter is documented and spelled out in the discharge instructions, with the statement that additional prescriptions for controlled medication will not be issued from the ED.

On a third visit, I will adminsiter only a single dose of oral analgesic medication and provide no prescription. I will tell the patient in no uncertain terms that there will be no prescriptions issued for his/her chronic pain on this or any subsequent visit to the ED and remind him/her of my prior referrals and instructions.

On subsequent visits for the same complaint, I will perform the H&P, document that the patient has no acute issues or emergency medical conditions, and will offer or provide only an oral dose or a non-controlled analgesic and discharge the patient without a prescription. If the "give them what they want" mentality hospital administrators disagree with my approach, I would invite them to head back to school to become qualified and licensed to do what I do. Otherwise, they can feel free to stay behind their desks.

With limited resources, the emergency department cannot be "all things to all people." EMPs cannot assume the role of both the acute and chronic care provider for the community, much less the prescription drug supplier. Trying to do so results in a disservice to all of our acute patients.