Category: Advanced Practice

Dave’s Blog: It’s Time For PA Practice In Puerto Rico

Puerto Rico is the last place that is part of the USA that does not allow PA practice. Why?

by Dave Mittman, PA, DFAAPA

I live in Florida but my soul is that of a New Yorker. It has been said that all New Yorkers are eventually a blend of each other. I believe that. That being said, NY is home to the largest population of people of Puerto Rican ancestry outside of the Commonwealth itself. When Hurricane Maria struck, I personally felt it. I know the people there. Obviously, my thoughts turned to healthcare and just who was going to provide it? Even the question of whether PAs could go down there to help? Let me explain…

If you don’t know, Puerto Rico has been experiencing a “brain drain” as physicians and nurses from there leave to make considerably more money on the mainland. Their economy has been hurting and the healthcare system had manpower shortages before the Hurricane. I can’t imagine that it will get better after. Imagine getting your degree, finishing residency and being able to make tens or even hundreds of thousands of dollars a year more for doing the same thing. It would be a challenge for any of us to stay. After Maria that challenge becomes something that can not be ignored.

Puerto Rico is the last place that is part of the USA that does not allow PA practice. Why? Most agree it is because of the pressure imposed by organized medicine. There are NPs there as they have legislation which is fairly new but they have problems also.

In a report issued January 2017 from the Health Policy Resource Center titled “Puerto Rico Healthcare Infrastructure Assessment”, this was said about PAs and NPs; “The health care provider shortage is exacerbated by a lack of midlevel providers like physician assistants (PAs) and nurse practitioners (NPs). PAs are not licensed to practice in Puerto Rico, and according to many respondents, physician groups have exerted ongoing pressure to maintain this arrangement. Some said that general practitioners worry about competition from PAs and the pressure this might create to further reduce reimbursement rates. By comparison, NPs face marginally better acceptance from the Puerto Rican medical community than PAs. Recently, Puerto Rico passed a law allowing NPs to practice, and several NP training institutions exist in the commonwealth. However, most graduates of these programs are either foreign students or Puerto Ricans intending to leave to practice elsewhere. Like physicians, bilingual nurses and NPs are in high demand on the US mainland and can earn significantly higher salaries there than in Puerto Rico”.

It’s time for PA legislation in Puerto Rico. It’s time to allow those that want to take some time and go down there to practice their profession the ability to do so. I know many of my PA friends over the years have wanted to, only to be told they were not wanted or needed. More than that let’s not settle for legislation that will tie our hands and not allow us to practice to the full extent of our education and clinical abilities. Let’s draft legislation for PA practice with OTP or as close to it as possible. We don’t need to hamper ourselves and this is a place that both needs and deserves PAs doing what we do best; providing medical care. Let’s look at what the NPs are trying to do and possibly work together and I hope all of us can team with the physicians there to provide the Island’s citizens with the healthcare they so desperately need.

It’s time for PA practice in Puerto Rico.

Dave Mittman has been a PA and later NP leader for thirty years. He co-founded the LIU PA Program student society, was President of the New York State Society of PAs from 1978-1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave was also the first USAF Reserves PA permitted to practice. Dave spent 9 years in primary care in Brooklyn, N.Y. and left to begin a career in medical publishing with Physician Assistant Journal. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice. Dave left PA Journal to co-found Clinicians Publishing Group (1990) and Clinician Reviews Journal in 1991. Dave has authored papers in publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and others. Dave¹s paper in the BMJ was the first internationally written paper written on PA practice. Dave and a few very close PA colleagues co-founded the PAs For Tomorrow”” in 2012 which is a new national professional organization representing and advocating for PAs in an different way. Dave as spoken at hundreds of NP and PA meetings and always has some interesting thoughts on the future of both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. Dave is married to his sweetheart Bonnie for 32 years and has two wonderful children.

PAs, NPs, and Physicians Deliver Comparable Patient Care

Across the outcomes studied, results suggest that NP/PA care was largely comparable to PCP care in community health centers.

A recently published study in the journal Medical Care, researching patient care outcomes in community health centers, has found that physician assistants and nurse practitioners deliver comparable care, services, and referrals to those of primary care physicians.

Using data collected between 2006 and 2010, including the analysis of 23,704 patient visits to 1139 practitioners, researchers at The George Washington University School of Nursing found seven of the nine outcomes studied showed there was no statistically significant difference between PA/NP and PCP provided care. The two remaining outcomes studied showed that visits to PAs and NPs provided patients with more health education/counseling services than visits to physicians.

These findings should serve to reassure patients who see PAs and NPs in community health centers, the numbers of which have grown significantly due to the Affordable Care Act.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Relief for Patients with Atopic Dermatitis

New immunomodulatory therapies are promising, not only for reversing skin barrier dysfunction, but in addressing the immune abnormalities associated with atopic dermatitis.

by Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP

Atopic dermatitis is characterized by abnormal skin barrier function, causing increased permeability. The filaggrin gene is a key player in maintaining the protective function of the stratum corneum. One of the roles of the filaggrin gene is to compact keratinocytes into a tight layer, creating a barrier that protects the epidermis from allergens and bacteria. Think of it as brick and mortar. When there is dysfunction of the filaggrin gene, the barrier is broken. This allows transepidermal water loss, increased skin pH, decreased resistance to bacteria, specifically S. aureus, and exposure to allergens. The cytokines interleukin-4 (IL4) and interleukin-13 (IL-13) are major components that cause itch and inflammation. Additionally, overactivity of the enzyme phosphodiesterase-4 (PDE-4) has also been shown to contribute to the inflammation of atopic dermatitis. This break in the skin barrier and resultant inflammation and exposure to allergens leads to the atopic triad of atopic dermatitis, allergic rhinitis, and asthma. Therefore, treating the abnormal skin barrier function may prevent the allergic triad.

Research during the last decade has identified these specific cytokines and enzymes that contribute to the inflammation, erythema, pruritus, and excoriations of atopic dermatitis. New treatments target IL-4 and IL-13, as well as PDE-4. Previously the management of atopic dermatitis was reliant on topical steroids. The advent of newer therapies has allowed a decrease in the length of treatment with topical steroids. Topical calcineurin inhibitors Tacrolimus (Protopic™) and Pimecrolimus (Elidel™) were approved for treatment of atopic dermatitis in patients 2 years of age and older. They inhibit calcineurin, thereby suppressing inflammation. In December, 2016, Crisaborole (Eucrisa™) was approved for treatment of mild to moderate atopic dermatitis in patients 2 years of age and older. It is a nonsteroidal PDE-4 inhibitor that suppresses proinflammatory cytokines. In March, 2017, Dupilumab (Dupixent™) was approved for treatment of adults with moderate to severe atopic dermatitis. It is a monoclonal antibody biologic injectable medication that binds to the IL-4 receptor and modulates both the IL-4 and IL-13 pathways.

There are several PDE-4 inhibitor medications currently in clinical studies which look promising in treating atopic dermatitis. These new immunomodulatory therapies are promising not only for reversing skin barrier dysfunction but addressing the immune abnormalities association with atopic dermatitis.

I will be presenting the new advances in atopic dermatitis treatments this year at Skin, Bones, Hearts, and Private Parts conferences. Register for conferences in Nashville, Pensacola, or Orlando and hear about the new and exciting treatment options for your patients and families with atopic dermatitis.

Kim’s Blog: Regeneration of the Mind and Spirit

Caring for patients, takes not only an extraordinary amount of knowledge and skill, but also caring. How can we make sure we’re mentally up for the task?

by Kimberly Spering, MSN, FNP-BC

It goes without saying that what we do, caring for patients, takes not only an extraordinary amount of knowledge, skill, but also caring. How can we make sure we’re up for the task of working in our roles? One answer: caring for ourselves… first and foremost. Doing things to “regenerate” our spirit.

It’s been a long summer and early fall season with patients. For whatever reason (full moon, superstition, eclipse, etc.), patients’ needs have seemed exorbitantly… needy lately. There were more phone calls and demands on my time than usual. I get it – in my palliative role, I may see 3 – 4 patients per day (at 40 minutes to 3 hours each), then chart later. The time I spend is nowhere near the amount that I spent working in an Internal Medicine office.

Or, do I, really?

In the office setting, I had my allotted 20 minutes (really, 10 minutes after patients were roomed) to determine the most pertinent issues that needed to be treated. Repeat by 20-plus patients daily. In my home-care palliative care world, I will spend as much time as needed to determine what is needed – whether this is new medications, family counseling, consultations with other offices, goals-of-care discussions, etc.

The numbers may be less, but the situations are often more crucial… the outcomes more perilous, and often, long visits are needed to determine patients’ needs and to coordinate care.
Can one put a time frame on these critical issues? No, we can’t. However, no matter if we see 20 – 30 patients (or more) per day, or three… caring for patients in any role takes a toll on all of us as providers.

So, what do we do to “regenerate” ourselves?

Is it taking time off (whether we travel for a fabulous vacation, have a stay-at-home vacation (also known as, in my world, doing things around the house)? Is it spending time to recoup our losses in medicine (oh, yes, we have losses – patients who die, “rules” we must follow by the so-called administration, services we could not get patients qualified for, etc.)? 

Or is it something that we make time for in our busy schedules: working out at a gym, going for a walk, getting a massage, spending quality time with a friend, etc.?

I daresay, regeneration can take place in any or all of those areas.

So why is it that many of us feel the pull to martyrdom, trying to “suck it up” without paying attention to our own needs? I’d bet that most of us have counseled patients, who were frustrated about the lack of time, lack of self-care, and we probably blithely said, “well, you have to take care of yourself first.” Or, “you need to recharge your own battery if you want to care for others.”

Well, now. That’s just great. If only we followed our own advice.

I’m guilty as anyone—putting the needs of family, home, dogs, and patients before my own self-care.

I fully believe that if we are to take care of patients – in any realm – that we must be mindful of the need for our professional & personal self to regenerate. Taking time to see out of our own world-view. Taking time to care for ourselves.

Don’t feel guilty about it. We OWE it to ourselves and our patients to practice good self-care – so we can care for others… be fully vested… and fully able to help them.

In August, I relaxed on vacation, in a private lake community in Pennsylvania, with my husband’s family. It was different from past years, as my sister-in-law died on January 31st. It was great to see how the cousins all connected, sharing in comradery, as only cousins who see each other a few times yearly can do. Our family needed that week of restoration… of healing.

I recognized that I needed time in solace and meditation. While reading eight books, including studies in the metaphysical, religion, and yes, “beach reads” with no requirement for “real” thought… I found my time to regenerate.

My taking vacation won’t adversely affect my patients. I have my co-workers to rely on to manage those issues. Purposefully, I did not log onto our hospital system to see what transpired while I was on vacation.

And you know what? The universe didn’t collapse. My patients’ needs were met by my co-workers. Life kept going on.

And when I looked out on the lake, lost in thought – or thinking nothing at all, threw a ball for one of my retrievers to fetch, spent time with my family… all was right in the world. I was regenerated to do this work for another day.

I encourage you to make time to “regenerate” in your own way. The only way we can continue to do our work is to care for ourselves first. Give it some thought. Make the time to care for YOU.

Kim Spering has been a nurse for over 25 years and worked as an NP over the past 15 years in Family Medicine, Women’s Health, Internal Medicine, and now Palliative Medicine. She serves as an editorial board member of Clinician 1 and submit blogs to the website, with a goal of highlighting both the clinician and patient experience in health care.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

The Pros and Cons of NP and PA Role Expansion

Now recognized as a “strategic necessity,” role expansion for these 2 occupations has implications for job satisfaction, burnout, and work-related stress.

from Contemporary Clinic

Role expansion is a hot topic for nurse practitioners and physician assistants as health care policymakers increasingly appreciate their value in health care. The journal Medical Care Research and Review has published a new article ahead-of-print that discusses an important issue in fields where job opportunities and responsibilities are changing: job satisfaction.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Wage Gap Between Female and Male PAs Persists

Despite 70% of PAs being female, they earn significantly less than their male counterparts, a new study has found.

A new study conducted by the AAPA and published this month in Women’s Health Issues has found that there is a glaring disparity between the salaries of male and female PAs. For every dollar a male PA earns, his female counterpart earns only 89 cents—though nearly 70% of all PAs are female.

“As a PA educator, I feel keenly the burden of student debt. One way to think about the impact of the gender pay gap is in the context of the $150,000 in student loans facing a typical PA upon graduation. A male PA earning $10,000 a year more than his female PA counterpart could use that extra money to pay off his student loan debt in 15 years. The disparate treatment of women in the PA profession is simply unacceptable,” L Gail Curtis, President and Chair of the AAPA Board of Directors, is quoted as saying.

While this 11% gap may be shocking to some, compensation disparities between males and females have persisted for decades, and despite years of progress in the fight against the gender wage gap, women continue to make less than their male counterparts for doing the same work in nearly all professions. According to the most recent data from the U.S. Bureau of Labor Statistics, on average, women’s earnings were only 82% of men’s.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

5 Things You Shouldn’t Call NPs or PAs

Use of slang like mid-level and extender contribute to a public misunderstanding of our role; they imply a need for dependence on physicians, and they obfuscate the uniqueness of our profession.

from Modern Nurse Blog

Steam comes out of my ears when someone calls me a mid-level. Or a non-physician, physician extender, allied health provider, or limited-license provider. I am a nurse practitioner (NP), which is actually fewer syllables and more meaningful than these other absurd descriptors anyway.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

States Lift More Hurdles To Physician Assistants

Like nurse practitioners, barriers to PAs are falling for a variety of reasons, including a doctor shortage and general comfort patients have with being treated by someone other than a physician.

from Forbes

An unprecedented number of regulatory hurdles are falling for physician assistants seeking more autonomy in their efforts to treat patients. In some cases, states are easing barriers that in the past led to redundant tasks or slowed the ability of patients to get the care they needed in a timely fashion. Such changes to regulations or scope of practice laws are taking effect this year as the result of state legislative sessions completed this summer.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Why Nurse Practitioners Are Fighting to Do Jobs They Were Trained For

One NP addresses physicians who say there is no substitute for the advanced education and training doctors receive.

from The Clarion-Ledger

Nurse practitioners in Mississippi have taken a lot of heat lately, after several columns were printed in The Clarion-Ledger refuting our role to treat and manage patients. Most recently, a Flowood psychiatrist was quoted as saying, “Nurse practitioners are … in it, like most people, for the money.” He continues with “if the past is any indication, access to care in rural areas will be no better than what it is now.” He also believes that “quality of care is rooted in the amount of knowledge and training that one receives” and that nurse practitioners “have important roles and can be used in a primary care setting where budgetary constraints are cost-prohibitive for physician services.”

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

APRNs Earn Highest Wages Among Nurses

CRNAs, NPs, and Midwives rank among the highest paid specialities in the field of nursing.

A new study by the Georgetown University Center on Education and the Workforce has found that APRNs, including Certified Nurse Midwives, Nurse Practitioners, Certified Registered Nurse Anesthetists, and Clinical Nurse Specialists, command the highest annual salaries in the nursing field.

While RNs make an average of $67,000 per year, APRNs rake in more than $150,000 annually, commensurate with their higher levels of education, clinical knowledge, and professional autonomy. According to the study, CRNAs earn the most among nursing specialties, with an average annual salary of $153,000, while Midwives and NPs earn, on average, the second highest annual wage ($83,000).

A co-author of the study, Nicole Smith, is quoted as saying, “For those who pursue it, nursing has well-defined career pathways.”

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.