News
Official Publication of the California Academy of Physician Assistants
March/April 2013
\The Magazine
CAPA Is Front and Center In Sacramento – Working For California PAs by Teresa Anderson, MPH, Public Policy Director
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Proudly representing California PAs at a Joint Informational Hearing of the Senate Committee on Health and the Senate Committee on Business, Professions and Economic Development
here has been and will continue to be a lot of press about legislation to expand the scope of practice of several health professions in California. We want to assure you that the California Academy of PAs is diligent and focused on our legislative agenda and advocacy. Due to CAPA’s consistent work, the law governing PA practice in California is excellent and it improves each year. Working with our lobbyist and Public Policy team, CAPA is front and center in Sacramento. The next several months will be turbulent as all stakeholders bring their respective solutions to the impending influx of patients to the table. “Never Let a Crisis Go To Waste”… a popular saying in politics coined by Rahm Emanuel. Whether you agree
with the politician or not is not the issue. However, some wisdom can be gleaned from the intent of his comment in that he meant it is an opportunity to do something you could not do before. The health care crisis, as many have referred to it, is no exception and several professions are taking the “opportunity” in the form of scope expansion. CAPA is also taking the opportunity to advance the PA profession in ways that adhere to and embrace our core values of delivering high quality team-based care as part of a physician-led team and expanding access to care. Access to care is the crux of the conversation as the health care community and legislators seeks solutions to providing high-quality, cost-effective care to millions of additional people who will obtain coverage in 2014. CAPA has an ambitious legislative agenda this session that gets right to the heart of access through care coordination and utilizing the profession more efficiently to increase
the number of patient encounters. Senator Pavley (SB 352) has introduced a bill sponsored by CAPA that would remove the archaic barrier that prohibits PAs from supervising MAs across all medical office settings. Senator Monning (SB 494) has introduced a bill sponsored by CAPA that will allow health plans to significantly increase the number of lives (patients) that can be assigned to a practice/physician based on the use of a PA. It is incumbent upon CAPA to promote regulatory and legislative changes that will ENHANCE the ability of physician assistants to provide high-quality, safe, cost-effective medical care to all Californians. As we work together toward advancing the PA profession in California we will call upon you, the members of CAPA, for help with action alerts, letters, emails and phone calls to your legislators. Ultimately it is your voice they need to hear!
Spend Just A Few Minutes To Take A Quick On-line Survey For A Chance To Win A 32 GB iPad + More!* Prizes: 32 GB, 3rd Generation iPad • Conference registration at the 2013 CAPA Conference in Palm Springs, Conference registration at the 2014 CAPA at Napa Conference • One Year CAPA Membership *Complete details on back cover.
News
Editor Gaye Breyman, CAE Managing Editor Denise Werner
At The Table CAPA was part of the Host Committee for a fundraiser on March 7, 2013 in La Jolla. CAPA Vice President, Jeremy Adler, PA-C and CAPA COO, Gaye Breyman attended.
Proofreaders Kimberly Dickerson Coryn Kulesza
Editorial Board Jeremy A. Adler, MS, PA-C Adam Marks, MPA, PA-C Bob Miller, PA Larry Rosen, PA-C Michael Scarano, Jr., Esq.
CAPA Board Of Directors President Adam Marks, MPA, PA-C presidentelect@capanet.org
(L-R) Speaker of the Assembly, John A. Perez, Jeremy Adler, PA-C and Assembly Majority Leader, Toni Atkins.
(L-R) Toni Atkins, Jeremy Adler, PA-C, San Diego Mayor, Bob Filner and Gaye Breyman, CAE
Vice President Jeremy A. Adler, MS, PA-C vicepresident@capanet.org
On March 13, 2013, several PAs joined CAPA’s Public Policy Director, Teresa Anderson and Lobbyist, Kathryn Scott in visits to key legislators. Later that day, CAPA Vice President Jeremy Adler, PA-C presented testimony before a Senate Hearing. Pictured here (L-R) Judi Price, PA-C; Atul Sharma, PA-C; Senator Monning; Jeremy Adler, PA-C and Tracy DelNero, PA-C.
Secretary Joy Dugan, PA-C, MSPH secretary@capanet.org Treasurer Bob Miller, PA treasurer@capanet.org Directors-At-Large Anthony Gauthier, PA-C, ATC diranthony@capanet.org Roy Guizado, MS, PA-C dirroy@capanet.org Matthew Keane, PA-C dirmatthew@capanet.org Greg Mennie, PA-C, MSed dirgreg@capanet.org Larry Rosen, PA-C dirlarry@capanet.org Student Representative Saloni Swarup, PA-S studentrep@capanet.org
The CAPA News is the official publication of the California Academy of Physician Assistants. This publication is devoted to informing physician assistants to enable them to better serve the public health and welfare. The publisher assumes no responsibility for unsolicited material. Letters to the editor are encouraged; the publisher reserves the right to publish, in whole or in part, all letters received. Byline articles express the opinion of the author and do not necessarily reflect the views or policies of the California Academy of Physician Assistants.
The CAPA office is located at: 2318 S. Fairview St. Santa Ana, CA 92704-4938 Office: (714) 427-0321 Fax: (714) 427-0324 Email: CAPA@capanet.org Internet: www.capanet.org ©2013 California Academy of Physician Assistants
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CAPA NEWS
We are mutually committed to continuing to improve safe access to health care by providing patient-centered, quality care within integrated, coordinated, physician-led teams.
VOTE IN THE CAPA ELECTION – YOUR VOTE COUNTS
VOTE IN THE CAPA ELECTION
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n Assista of Physicia Academy California view St. 2318 S. Fair 92704-4938 , CA Santa Ana
r Membe CAPA ain St., #3 0 M 00 1234 CA 90 here, Anyw
OT LL ED BA LOS C EN
– YOUR VOTE COUNTS – BALLOTS MUST BE RECEIVED BY CAPA BY MAY 2, 2013
Please, Please, Read… by Bob Miller, PA, Professional Practice Chair
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nly eight pages! (only six if you use smaller font!)
Over the years, I have had the opportunity to enjoy hundreds of interactions with PAs – both students and PAs in practice – regarding professional practice issues of all variety. Many of the same questions, concerns and discussions arise about the day-to-day practice of PAs. Just recently, at the CAPA at Napa conference, I had several PAs join me after a presentation to clarify which parts of the law and regulations (which I had recommended) are most important to their every day practice as a PA. The laws and regulations which focus on PA practice can be found on the Physician Assistant Board (PAB) website www.pac.ca.gov. (Watch for a possible website name change now that they have become a “Board.”) You are encouraged to look through the 75+ page “Complete Booklet on the Laws and Regulations Relating to the Practice of Physician Assistants” but the most important eight pages
are the four included in Article 1 of the PA Practice Act (the law) and the four in Article 4 of the CCR (the regs). You will find the regs by scrolling about halfway through the booklet. Physician Assistant Practice Act CHAPTER 7.7. PHYSICIAN ASSISTANTS Article 1. General Provisions Beginning with Section 3500 and
California Code of Regulations Article 4. Practice of Physician Assistants Beginning with Section 1399.540 Before studying these two articles, give the online 10-question quiz a try. Answers are provided in real time to give you immediate feedback and information sources are supplied. Find the quiz under Test Your Knowledge of PA Laws and Regulations. Good luck on the test – I passed – whew!
CAPAsNotes We have made it easy for you to be well-informed about the PA Practice Act. We have taken some of the most important sections of the PA Regulations and put them in a quick reference guide. This guide can be found, in its entirety, on pages 16-19 of this publication. We encourage you to take a few moments to read all 4 pages. You may be surprised at what you don’t know.
Inside This Issue At the Table................................................................ 2
The Flying Sams Need PAs!....................................... 12
Transitions From PA-S to PA-C.................................... 26
Please, Please, Read….............................................. 3
CME Clarification...................................................... 14
NHSC Grants............................................................... 4
CAPA at Napa........................................................... 15
Financial Preparation of PA Education Starts Before the First Day of PA School.............................. 28
Scope of Practice: One Does Not Fit All......................... 5
Controlled Substances Education Course..................... 15
Life 2.0...................................................................... 6
CAPA Notes............................................................... 16
Medical and Pharmacy Boards’ Promote Controlled Substance Education … CAPA Delivers!....... 8
Touro University Hosts “Mental Health Through the Life Span” at CAPA at Napa.................... 20
Maintaining a Good Foundation................................. 10
Specialty Care for the Uninsured: Building a Bridge to Better Access - Part 3................. 22
California Changes Regulations to Allow PA Preceptors.................................................. 11
Oops!! You’ve Done It Again!.................................... 29 Creating an Accurate Patient Record.......................... 30 Welcome New Members............................................ 31 Local Groups............................................................ 31
The Secrets of Pregnancy.......................................... 24 MARCH/APRIL 2013
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NHSC Grants by Adam Marks, MPA, PA-C, President
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very year the National Health Service Corps (NHSC) grants funds to PA students and practicing PAs through scholarships and loan repayment. In return, PAs from across the nation go out into underserved areas and provide primary care services. I have been lucky enough to be a part of this program and this article is being written on my two year anniversary with the NHSC; an anniversary which marks the end of “The opportunity to work my contractual obligation but also with the NHSC has helped marks the beginning of a different phase of my service with the me in my early career as NHSC.
a PA and has helped pave
In 2010 I was a “green” PA graduate the way for my future as with the desire to provide primary a primary care provider in care in rural central California. I had rural medicine.” structured my education, clinical rotations and first job based on this desire. I was hopeful that I would not only be able to serve my community, but also help pay for my education by becoming a NHSC loan repayment recipient. My application was submitted four months after graduating from PA school and starting work. At that time, the NHSC had started their first electronic application. The process was simple and it took me more time to compile the paperwork needed for the application than it actually took to apply. One month later I was notified that I had been granted loan repayment and that my term of service would start 4
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immediately. Within six months from my initial application, my loans had been paid off and I was working as a NHSC loan repayment recipient. It has been 24 months since my initial application and I have just completed my final service verification, officially completing my service commitment. As alumni of the NHSC’s loan repayment program, I realize that this process not only benefitted me by paying for my education, but it also exposed me to various elements which I have found to be very impactful on my professional education. I have met many fellow NHSC scholars and loan repayment recipients and have found extraordinary diversity in the participants and an undying commitment to serve the underserved. As a native to rural central California, which has many NHSC sites and rural health centers, I have found that the NHSC’s program is instrumental in bringing dedicated providers from around the country to provide primary care services in underserved areas. With this diverse pool of providers there are more primary care services being provided to residents in the area. These providers are putting roots down in this community and staying to provide services even after their obligation has ended. As we look to the horizon and the emergence of the Patient Protection Affordable Care Act (PPACA), I think the demand for these services will be stretched to their maximum, along with the dedicated providers who are already providing services in these areas. It will be important to continue to support the NHSC’s efforts to bring in new providers and even increase the number of scholars
and loan repayment recipients to meet the needs of an expanding patient population. The NHSC is not only about bringing in providers to underserved areas, but the NHSC made it a point to provide educational material to its current scholars and loan repayment recipients. The NHSC routinely provides webinars which are aimed at expanding their clinical knowledge, education on the underserved patient population and tools which they can use to help balance their personal life with their professional life. These types of services not only are important to the providers working with the NHSC, but the patient population as a whole. I have found them useful in my day to-day activities as a primary care PA. The opportunity to work with the NHSC has helped me in my early career as a PA and has helped pave the way for my future as a primary care provider in rural medicine. As I look back and reflect on my time as a loan repayment recipient, I can’t help but think of how great the experience was and how quickly two years can fly by. I look forward to seeing how I can continue to be involved with NHSC as an NHSC ambassador, working to encourage more medical providers to serve the underserved by providing primary care services.
Scope of Practice: One Does Not Fit All by Anthony Gauthier, PA-C, ATC, Public Policy Committee Chair
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n early February, the Wall Street Journal published an interesting article highlighting the importance of the PA profession and some of the legal ramifications States may need to revise in an effort to strengthen the future of the PA profession. The article gained the attention of the AAPA and was included in one of the email blasts the AAPA sends out to its members. Entitled: “Battles Erupt Over Filling Doctors’ Shoes,” Wall Street Journal health writer Melinda Beck reported specifically on Kentucky and a state law which dictates for the first 18 months after certification, physician assistants are allowed to treat patients only when a supervising physician is physically on-site. A representative of the Kentucky Academy of Physician Assistants (KAPA) interviewed, reported that with this rule in place about half of the recent graduates from Kentucky’s PA programs are fleeing the state in search of employment in other states. He went on to mention this regulation not only hinders the PA profession in Kentucky, but also the availability of health care to Kentucky’s medically underserved population. Kentucky is the only state to have such a law. The author concluded that, with the passage of the Affordable Care Act, the demand for more health care professionals is clear. Mid-level clinicians will need to step up and help provide compassionate and quality care to patients. After reading the article, I went to www.kentuckypa.org, the website for the Kentucky Academy of Physician Assistants in hopes of gaining a better understanding about this issue. The first item on the home page was a link to support Kentucky Senate Bill 43 which would eliminate the 18 month on-site supervision
requirement for recent graduates. KAPA is passionate in getting this new legislation passed and has been lobbying to gain support. Reading the article and reviewing KAPA’s website reaffirmed the importance of being cognizant of state regulations regarding licensure and PA practice. There may be occasions where a PA can possibly be asked to perform duties or activities without a complete understanding of the regulations. Doing so can place one at risk of practicing beyond their scope or outside of current state regulations. Recent graduates should strive to educate themselves of their state’s rules and regulations regarding PA practice. Ignorance is no excuse for practicing outside of your scope or outside of state regulations. CAPA and its Professional Practice Committee go to great lengths to provide our members the
information necessary to become knowledgeable about current regulations. Future legislation which can impact California PAs is always on CAPA’s radar. Members are encouraged to review resources available online at www. capanet.org. Members can also contact the CAPA office with any questions regarding practicing under current state rules and regulations. References Beck, Melinda,(2013, February 4). “Battles Erupt Over Filling Doctors’ Shoes” Wall Street Journal. Retrieved February 8, 2013 from http://online.wsj. com/article/SB10001424127887323644 904578271872578661246.html. Kentucky Legislative Research Commission. “KRS 311.860 Services performed in location separate from supervising physician -- Non-separate location -- Definition and exceptions.” Retrieved February 8, 2013 from www. lrc.state.ky.us/krs/311-00/860.pdf.
Robert Miller, PA CAPA Professional Practice Committee Chair … your host on an enlightening series of videos depicting the history of physician assistant practice in California and the evolution of the Physician Assistant Practice Act.
• • • • • •
PA Scope of Practice Prescriptive Authority and Protocols Laws and Regulations The Surgical PA Reimbursement Issues The New PA and the New Job
CAPA Members Can View the Videos On-line at www.capanet.org MARCH/APRIL 2013
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Life 2.0 by Greg Mennie, PA-C, MSed, Director-At-Large
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he rumors of my demise have been greatly exaggerated. It’s not supposed to occur until August 12, 2045 … at least that’s what the all powerful and ever knowing Internet tells me.1
Neanderthals v2.0 “In the beginning, there was no retirement. There were no old people. In the Stone Age, everyone was fully employed until age 20, by which time nearly everyone was dead, usually of unnatural causes. Any early man who lived long enough to develop crow’s-feet was either worshiped or eaten as a sign of respect.” 2 When I first began in the PA profession, I can’t recall ever hearing of a retired PA. Our profession was still a bit young at that time, and now 18 years later I know quite a few retired PAs. Over the last few years, I’ve been quite diligent in looking forward and asking what’s in store for me and the younger generation of PAs. Certainly, the workforce environment has changed, and the 2008-2009 economic crisis has created a quite different set of concerns and issues for many people working toward the idea of not working someday. In the last installment of CAPA News I wrote an article that discussed potential ages we, as health care providers, should counsel patients to stop certain screening exams. After completing that article, I was struck by the uncertainty of the recommendations. Most of the recommendations had caveats of “if > 10 years of life expectancy.” Even as a provider, how would I know other than just make an “educated guess?” It was that small notion that led me to think at what point one stops other important things in their life. For example, when’s the right time to leave practice, change focus, or 6
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just ... stop? As with the scientific recommendations in my last article, the answers to these other questions will be individualized, but more importantly, am I really doing all I need to do now to make sure I have everything needed for a good “Life 2.0?” The Oracle of Omaha Balance - An even distribution of weight enabling someone or something to remain upright and steady. 3 A number of years ago I saw Warren Buffet speak in Omaha. A young man in the audience stood up and asked “I’m a young investor and I was wondering if you had any advice for me.” Warren quickly responded [“Everyone should save money, there’s no dispute in that but, if you were told when you turned 16 that you could pick one vehicle that you would have to drive for the rest of your life, I bet you’d take really good care of that vehicle. You’re your vehicle. Invest in you”.] I frequently have students rotate with me during Family Medicine clerkships. I used to spend a great deal of time talking about educational goals and objectives, the importance of integrating a good foundation of the basic sciences in their clinical acumen, etc. It was all very heady and important, but was that what they needed? Was it the most important information? At the time, I always thought it was. To a good extent, I still believe it to be. But with both of my daughters off to college, I have first hand knowledge of other important objectives necessary for success. Student debt for the U.S. exceeds a trillion dollars. The potential debt accumulated by the new generation of PAs can be quite daunting. According to the AAPA, the average PA student
debt is approximately $100,000 by the end of their training. That is quite a sum to manage. I now find myself talking to my students about school loans and interest rates, debt accumulation and security, 401Ks, 403bs, IRAs and equities. I also talk about the importance of taking care of themselves. I stress how equally important it is to have health in both finance and body as it is in studying hard to get through the didactic and clinical training years in school. It not only sets the stage for Life 2.0, exposing the need for balance between longevity and quality, but it also opens up the idea to have balance in the early part of a career. According to a CDC National Institute for Occupational Safety and Health publication on work stress, 25% of people say their job is the number one stressor in their lives and problems at work are more associated with health complaints than are any other life stressor. The U.S. has some of the worst statistics when it comes to balance, family, life and work. We are the only industrialized country without a national paid parental leave benefit. The average around the planet is 12 weeks and as much as 20 weeks in certain countries. Approximately 70% of children live in a household where both parents are working, certainly some of that percentage is by choice, but I would suspect the majority is out of necessity.4,5 Currently, 134 countries have laws that set a maximum work week, the U.S. has no such laws. According to the Economic Policy Institute, workers in the U.S. work more hours than any other western nation. Well over 75% of male employees and over half of all female employees work more than 40 hours per week. According to the International Labour Organization (ILO),
“Americans work 137 more hours per year than Japanese workers, 260 more hours per year than British workers, and 499 more hours per year than French workers.” The U.S. Bureau of Labor and Statistics (BLS) have data showing that the American Worker’s productivity has increased 400% since 1950. If our productivity really has increased that much our standard of living should be four times higher than that of a worker in 1950. Unfortunately all current data says our standard of living has decreased, thus we are working longer and harder for less.4,5 Right Thing - Wrong Reason German Chancellor Otto Von Bismarck does the right thing for the wrong reason. In 1883 the controlling powers in Europe felt threatened by the push of Marxism. Bismarck decided to bribe his fellow Germans by offering a pension to anyone over the age of 65 who was no longer working. Bismarck not only started the idea of pensions from the government but arbitrarily established old age.2 Currently, the U.S. has the third highest retirement age of 66, the median age for men and women being 62 and the expected age to retire for men and women 70 and 65 respectively. Turkey has the lowest, as they set a 25 year pension contribution rule, thus if you began working and contributing to the pension at age 25 you could retire at age 50.6 I have always felt that health care providers work much longer before retiring compared to other workers. According to the AMA, 20% of active licensed MDs are over the age of 65. The 2010 AAPA Census noted 2,340 PA respondents were age 60 to 74 years and approximately 16%
of PAs are over the age of 55. Survey results looking at retirement patterns of PAs presented at the 2012 AAPA Impact meeting noted 13% of the respondents were already retired and others expect to retire at age 70 for men and 65 for women.7 The current expected or actual retirement age for PAs, according to the AAPA census, is 65. When’s the last time you stopped to consider that idea, or better yet, the idea of age 60 … or 55? Perspective A new report just out in January 2013 from the National Research Council and Institute of Medicine states the average life expectancy in the U.S. is retreating. “Not only do Americans live shorter lives than people in other wealthy nations, but they suffer more violent deaths compared to their peer countries.” Lest you think this is because of socioeconomics or education, the report also noted “that even advantaged Americans -- those who have health insurance, college educations, higher incomes, and healthy behaviors -appear to be sicker than their peers in other rich nations”.8 Recently, a few of the older physicians who work in my hospital have passed away. I always perceived them as diligent and hard working. One was always in early and usually seen leaving the hospital quite late. Stories of enormous amounts of work accomplished and a high volume of patients seen were the norm for both. But to what end? One day they’re at work and the next day, gone. Lately, I’ve caught myself wondering, what’s the point in spending the preponderance of time enmeshed in your profession to only leave secondary to illness or incapacity? Why limit yourself through circumstances of poor planning only to be stuck in your employment? Why not enjoy the fruits of your labor
when you’re still capable? Perhaps there are a number of people who are tied to the joy of their work, certainly the healing profession offers no better chance for real personal satisfaction, but is that all there is? Where’s the balance? More is not the answer and working harder for less to get more seems like a losing proposition. With a little planning and sacrifice on the front end, you can develop a good Life 2.0 strategy. More importantly take some time to mentor a younger generation of PAs, slow down and lead by example, take the time to discuss the balance of life, family, and finances. Perhaps that provides them more value than the cost of their training. When I first began in the PA profession I can’t recall ever hearing of a retired PA. I’m really happy to know quite a few now. References
1. Life expectancy calculator. (n.d.). Retrieved from http ://gosset.wharton.upenn.edu/ mortality/form.html 2. Weisman, M. (1999, 03 21). The history of retirement, from early man to AARP. New York Times. Retrieved from http://www.nytimes. com/1999/03/21/jobs/the-history-of-retirementfrom-early-man-to-aarp.html 3. Oxford Dictionary 4. Miller, G. (2010, 10 12). The u.s. is the most overworked developed nation in the world: When do we draw the line . Retrieved from http://20somethingfinance.com/american-hoursworked-productivity-vacation/ 5. World legal rights database. (n.d.). Retrieved from http://raisingtheglobalfloor.org/ 6. Brandon, E. (2010, 11 15). Why the retirement age is increasing. Retrieved from http://money.usnews.com/money/retirement/ articles/2010/11/15/why-the-retirement-ageis-increasing 7. Coombs, J., & Sparrell, M. (2012, 05 26). Retirement patterns of pa’s. Retrieved from http://media.jaapa.com/documents/37/ research_day_abstracts_9224.pdf 8. National Research Council. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: The National Academies Press, 2013.
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Medical and Pharmacy Boards’ Promote Controlled Substance b: Jeremy A. Adler, MS, PA-C, Vice President
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he Medical Board of California and the California Board of Pharmacy recently, on February 21 – 22, 2013, convened the first Joint Forum to Promote Appropriate Prescribing and Dispensing. The focus was on controlled substance use in California. In addition to the Boards’, also present was the Drug Enforcement Agency (DEA), the White House Office of National Drug Control Policy (ONDCP), California Department of Justice, the CAPA Controlled Substance California State Education Course: and Consumer http://www.capanet.org/Conferences/ Services Agency, Controlled-Substances-Education-Course/ a number of Deputy Medical Board of California Guidelines Attorney for Controlled Substances for Pain: Generals, http://www.mbc.ca.gov/pain_guidelines.html specialists in workers’ comCalifornia Board of Pharmacy: pensation inveshttp://www.pharmacy.ca.gov/ tigations/fraud, CURES Program: and physicians http://oag.ca.gov/cures-pdmp specializing in addiction mediDrug Enforcement Agency: cine, emergency http://www.justice.gov/dea/index.shtml medicine and pain medicine. White House Office of National Drug A common take Control Policy away message http://www.whitehouse.gov/ondcp from this historic meeting included the need to provide additional education involving controlled substances. (CAPA) shares this desperate need to educate our PA workforce, and two days after the Boards’ Forum, provided the 25th Controlled Substances Education Course for PAs since beginning in 2008. CAPA has now provided the latest evidence-based scientific information regarding the pharmacology of controlled substances and guidelines for their appropriate use to over 4000 PAs in the State of California (that is more 8
CAPA NEWS
that 50% of the entire California PA workforce). Many providers in California may not realize how significant the problem of prescription drug abuse has become. Michael Botticelli, the Deputy Director of the White House ONDCP reported that prescription drug abuse is the “biggest public health issue facing our times.” The United States represents 4.5% of the world’s population, but reportedly uses 80% of the world’s opioid. In fact, the U.S. consumes 99% of the world’s hydrocodone. Of the 4.5 billion annual controlled substances prescriptions written nationally, California writes about 650 million of them, or around 12% in total. Given the perceived safety of prescription drugs, the non-medical use has likewise escalated. In fact in 2011, one out of five people using drugs non-medically for the first time chose a prescription controlled substance. The younger population in the 18-24 years of age appears to be the most susceptible to prescription drug addictions and, by virtue of economics, have now been seeking heroin because of its less expensive cost. The Centers for Disease Control has reported that as the use of opioids rises, the opioid related morbidity and mortality have risen as well (Figure 1). The death rate from opioid involved deaths has surpassed motor vehicle accidents and no part of the country has been spared (Figure 2). The White House recommends education, use of prescription drug monitoring programs (CURES in California), proper disposal of unneeded medications and enforcement. The payer mix of those affected by opioid abuse and overdose may surprise some. It was reported that 74% of all opioids prescribed in California are for work-related injuries and 3%
of prescribing physicians in workers’ compensation accounted for prescribing 62% of all morphine equivalents. Increasing workers’ compensation fraud has been identified both to support drug addiction and drug diversion. The opioid abuse in workers’ compensation affects all of California. With higher costs of treatment, insurance premiums rise, businesses suffer, unemployment increases and California is hurt. Adverse outcomes have been associated with payer mix as well. Patients insured by Medicaid (California’s MediCal) were twice as likely to be prescribed an opioid and 6 times as likely to have an opioid overdose. In Washington State, 45% of those who died on an opioid were insured by Medicaid. The source of these medications generally start with a prescription, but those who overdose or misuse opioids typically obtained them in some illegal manner (Figure 3). The distribution of non-medical use of opioids is also not equally distributed throughout California (Figure 4). A key message from the Forum included the role of pharmacists. Pharmacists have a “corresponding responsibility” in the legitimate dispensing of controlled substances. A message from the pharmacists to prescribers is that they will need to contact the prescriber at times and urge prescribers to take their calls. Also suggested was, opioid pain agreements should be sent to the patient’s designated pharmacy when a patient is managed with chronic opioid therapy. The DEA was present, and Joseph Rannazzisi, Deputy Assistant Administrator, Office of Diversion Control, DEA presented that the prescription drugs sought in our communities have changed. He identified carisoprodol (Soma®) as
Education … CAPA Delivers! a “potentiator” of opioids, and with restricted access to Soma®, people are now seeking cyclobenzabrine (Flexeril®). He called the “trinity” the combination of Vicodin®, Soma® and Xanax®, and the “holy trinity” as Oxycodone, Soma® and Xanax®.” Former San Diego Prescription Pharmaceutical Task Force Member, Kevin Barnard, also mapped out the trend in non-medical opioids. Previously OxyContin® was the sought after drug at 7200mg per month (80mg TID). In 2010 the formulation changed and rapidly the use and street price for OxyContin® dropped, and the use of Roxicodone® 30mg increased. Now Roxicodone® 30mg at the same 7200mg is sought after (30mg at 8/day). Also present was the one, sole person currently running California’s prescription drug monitoring program (CURES), Mike Small. He reviewed how California has the longest running monitoring program in the United States and currently the database contains over 100 million entries of controlled substances. The database indexes Schedule II-IV controlled substances dispensed in California and is an important tool to “identify, intervene and deter abuse and diversion” of these medications. All prescribers and pharmacists are entitled to have access to the Internet-based database which totals 212,631 eligible professionals in California. Sadly, only 12, 967 are registered, representing 6.09% of eligible workforce. CAPA has strongly encouraged PAs to register and at the 2012 Annual Conference in Palm Spring, had notaries present to sign up over 200 PAs to access the CURES database. The future for CURES became uncertain when the California legislature defunded CURES last year. CAPA is working as a key stakeholder in securing funding for this vital resource. Mr. Small would like to see
the system expanded to be intraoperative with other states and integrated with electronic health records. Since the passing of Assembly Bill 3 in 2008, CAPA has been providing Controlled Substances Education Courses to PAs all across California. This course removed the required “prior approval” component for PAs when they take the course, pass an exam and have the authority delegated to them by their supervising physicians. The course only needs to be taken once in the career of a licensed Figure 1. Opioid Deaths, Treatment Admissions and Sales, 1999-2010
http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6o43a4.htm?s_cid=mm6o43a4_w
Figure 3. People who abuse prescription painkillers get drugs froma variety of sources
PA. This course provides the latest education about controlled substance pharmacology and appropriate use of controlled substances for patients. I am not aware of any other widespread dissemination of such vital, content controlled, information to a diverse health care workforce. CAPA is very proud to contribute positively to the educational component our workforce needs to improve pain control for those who legitimately need it, and at the same time reduce the abuse, misuse and diversion of controlled substances that is epidemic. Figure 2. Opioid Overdose Rate per 100,000 by State 2008
http://www.cdc.gov/homeandrecreationalsafety/rxbrief
Figure 4. Nonmedical Use of Pain Relievers in Past Year, age >12 (Avg 2004-6)
http://www.cdc.gov/homeandrecreationalsafety/rxbrief
http://www.samhsa.gov/data/substate2k8/statefiles/CA.htm
MARCH/APRIL 2013
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California Changes Regulations to Allow PA Preceptors by Michael J. De Rosa, MPH, Ph.D., PA-C, PA Program Relations Chair
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n 2009, I accepted Miguel Medina’s offer to serve as Chair of the Program Relations Committee (PRC). At my first CAPA Conference as PRC Chair, I met with education leaders from California’s PA training programs and asked what CAPA could do to help. The unanimous answer was to work on regulations in the Business and Practices Code (BPC) of the State of California which mandated that PA students on clinical rotation be supervised by a physician. A little history here is probably instructive. Regulations in the BPC regarding the training of PA students appear under the heading of “Program Approval.” That is, when a physician assistant applies for
PHYSICIAN ASSISTANT COMMITTEE § 1399.536. Requirements for Preceptors. (a) Preceptors participating in the preceptorship of an approved program shall: (1) Be a licensed health care provider physicians who is are engaged in the practice of the profession for which he or she is validly licensed and whose medicine which practice is sufficient to adequately expose preceptees to a full range of experience. The practice need not be restricted to an office setting but may take place in licensed facilities, such as hospitals, clinics, etc. (A) For the purposes of this section, a “licensed health care provider” means a physician and surgeon, a physician assistant, a registered nurse who has been certified in advanced practices, a certified nurse midwife, a licensed clinical social worker, a marriage and family therapist, a licensed educational psychologist, a licensed psychologist. (2) Not have had the privilege to practice the profession for which he or she is licensed medicine terminated, suspended, or otherwise restricted as a result of a final disciplinary action (excluding judicial review of that action) by any state healing arts licensing medical board or any agency of the federal government, including the military, within 5 years immediately preceding his or her participation in a preceptorship.
licensure in the State of California, the Physician Assistant Committee (now PA “Board” (PAB) – not to be confused with the PA job website of the same name) reserves the right to “approve” or “disapprove” of the program from which that PA was graduated, i.e. they can deny the request for licensure if your program doesn’t measure up. The standards for programs which will meet with Board approval are delineated in the BPC. These standards go way back. In fact, most, if not all, of them predate national accreditation of PA training programs. So it was important in the 70s to provide some form of consistency and expectation around the training of this new health care provider called a “Physician Assistant.” Currently, the Board recognizes
(3) By reason of his or her professional medical education, specialty and nature of practice be sufficiently qualified to teach and supervise preceptees within the scope of his or her license. (4) Not be assigned to supervise more than one preceptee at a time. (4) (5) Teach and supervise the preceptee in accordance with the provisions and limitations of sections 1399.540 and 1399.541. (6) Shall in conjunction with his or her use of a preceptee, charge a fee for only those personal and identifiable services which he or she, the preceptor, renders. The services of the preceptee shall be considered as part of the global services provided and there shall be no separate billing for the services rendered by the preceptee. (5) (7) Obtain the necessary patient consent as required in section 1399.538. (b) It shall be the responsibility of the approved program to assure that preceptors comply with the foregoing requirements. Note: Authority cited: Section 3510, Business and Professions Code. Reference: Sections 3509 and 3513, Business and Professions Code.
accreditation by a third party organization (such as the Accreditation Review Commission on Education for the Physician Assistant or ARCPA) for the purposes of program approval. But the regulations have been maintained in the BPC, including the regulation dictating that only a physician could precept a student. Fast forward 30 plus years to my meeting with PA faculty in Palm Springs: While the PAB had long since recognized third party accreditation for program approval, programs were still concerned that if a student were involved in a situation with a bad outcome, the student and/ or the program may be held liable for violating this regulation if it could be demonstrated that a non-physician was acting as a preceptor. It took some time, but last year CAPA was finally able to convince the PAB that it was in the public interest to change this regulation. We were able to make an effective argument that physicians are not always the best provider to supervise a PA student or train physician assistants to work within certain practice settings. We reasoned that if we are to accept as fact a dramatic reduction in primary care physicians, particularly in underserved areas over the last several decades, then we must also accept that it would be no easier to find a physician to supervise a student in underserved areas than it is for a patient in an underserved area to be seen by a physician. And, if it is the physician assistant and our nurse practitioner colleagues stepping in to fill that void, then it also stands to reason that the best person to train a PA student to practice in that setting may well be a PA or an NP. Additionally, as we expand the role of physician assistants practicing in underserved and rural areas and move further in the direction of remote Continued on page 25
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CAPA NEWS
Maintaining a Good Foundation by Sonny Cline, PA-C, MA, M.Div, Political Action Committee Chair
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nyone who has ever owned a home for any length of time will proudly tell you about one or more remodels that they have done since owning the home. We spend an extreme amount of money on kitchen and bathroom remodels like nowhere else in the world. Some of our bathrooms contain more square footage than an entire home for a family of four in the Third World. Homeowners will log countless hours going to Home Depot, Lowes and a laundry list of other specialty stores in search of the right faucet or the perfect toilet. We develop ulcers over the ideal surface for counter-tops in the kitchen and bite our nails over whether we need a double oven or not. We will spend a thousand dollars extra for a Sub-Zero refrigerator or a Wolf stove, neither of which we actually need, but it looks and feels so good. I have been on countless tours over the years of friends’ homes, hearing their stories of which walls they took out, the headaches they endured and oh how much they have loved it since finishing. I must confess I have given my share of these same tours. However, in all these years, I have yet to have anyone take me on a tour of the foundation of their home. No one I know goes on and on about the type of concrete, whether they used rebar and where it was placed. No exciting stories about looking at other foundations to get “great ideas.” I can’t remember anyone comparing a raised foundation to a conventional one. There are no exciting paint schemes in foundations and they are certainly not part of the ultimate entertaining epicenter of the home.
The truth is that the decor of the home is the appealing allure of the home - the fun stuff. The cool kitchen, the gathering place, the parties, the food and all the good times are all connected to the part of the house we see, but without the foundation, none of the fun stuff would exist. And, so it is with our profession... suturing up wounds, delivering babies, having great meaningful discussions with patients and caring for a newborn are all the fun things in our profession. These are the reasons that we get up in the morning and put on the white coat, waving goodbye to our families. These patient encounters are the entertainment epicenter of our profession that we all love, and that’s why the CAPA PAC exists. The CAPA PAC is a major part of the foundation that supports your ability to do the work you do every day. We educate legislators, monitor attitudes regarding our profession, and do our very best to
ensure you have every opportunity to freely care for your patients and enjoy the work you have trained for and love. It is of upmost importance for the CAPA PAC to stand guard over a profession that has established itself as a major patch in the quilt of health care. That is why we need your ongoing support. Just like a house is uninhabitable without a strong foundation, so is your profession without the CAPA PAC. The money you give to the CAPA PAC goes directly to the foundation under your feet that is holding you up. I know we all love to redo the kitchen, but I will always be here to remind you that your foundation is crucial for your survival as a profession and it is reasonable and wise to support your CAPA PAC. As Tom Cruise said in Jerry Maguire, “Help me...help you”. As always, thanks for all that you do every day. I am proud to be a colleague with you in the profession.
MARCH/APRIL 2013
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The Flying Sams Need PAs! by Larry Rosen, PA-C, Director-At-Large
T
he flight down is beautiful. The medical team is compassionate, diverse and great fun to hang out with. The people you will serve are a hardy lot, but in desperate need of medical care as most of these impoverished, grateful residents have little or no access to it. The Flying Samaritans began in 1961 to help fill the medical void in El Rosario, Baja California. Today, their membership numbers more than 1500. They service 7 drive-in clinics and 11 fly-in clinics in Baja, from Playas Rosarito to Lopez Mateos.
Physicians, physician assistants, nurse practitioners, dentists, pharmacists, audiologists, and optometrists account for most of the medical team members. Lay personnel, interpreters and administrative aids fill out the weekend troupes. The Flying Sams also have recruited a cadre of experienced, expert pilots who bring us safely there and back without incident. Every trip I’ve made to Baja is memorable for the professionals I served with and the patients I cared for; the 9 year old boy whose foot we saved from an untreated infection; the 34 year old, obese 12
CAPA NEWS
Skilled pilots, volunteers and medical professionals from all across California gather every month to reaffirm the message of service and selfless care to the grateful people of Bahia De Los Angeles.
mother of five who finally learned the importance of treating her diabetes and resolved to do so; the cranky, 71 year old fisherman who was fitted for a prosthetic leg and danced for us at the clinic. The need for medical care grows all over the world, specifically for the underserved and indigent. But Baja is close and donating a weekend of your time is a small sacrifice when the stakes are high and the rewards of service plentiful.
Usually, the trips involve a weekend; leave early Saturday morning and returning by dinnertime on Sunday. Check the links below for locations and dates. The Flying Sams need PAs to help service the people of Baja. Please consider this unique, humanitarian opportunity that will fill you with pride and bring joy to our needy southern neighbors.
For a schedule of the planned trips in 2013, access the following link: https://www.flyingsamaritans.net/MbrPgm/Events/EventsFuture.asp? For more information, please contact the following people: Cheung (“TC”) Tung Ping, PA-C Larry Rosen, PA-C Tung.p.cheung@gmail.com CAPA Board of Directors doklite3@gmail.com Victor Jones President, So. California Chapter The Flying Samaritans Victorjones@earthlink.net www.flyingsamaritans.net
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CME Clarification by Eric Glassman, MHS, PA-C, CME Committee Chair
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ll of you know that we need CME hours to keep up with our certification with the NCCPA. We all have logged the hours on their website and we know that logging Category I and Category II CME is part of the process. We know we are required to get a minimum of 50 hours of Category I CME during the two-year cycle. But, many of us are still confused about Category II CME, what it entails, and when we can use it. As your CAPA CME Committee We hope to see you in Chair, I wanted to clear up some of Palm Springs for the the confusion that comes with claiming CAPA Conference CME hours, more specifically, Category on October 3-6, 2013. II CME hours. I hope by now, all of you have attended at least one of the wonderful CME opportunities that CAPA offers each year, whether in October in Palm Springs or in February in the beautiful Napa Valley. If so, if not, or even if you have just attended local pharmaceutical dinner lectures then you have undoubtedly heard the phrase: “This program is not eligible for CME. In reality, this is not a
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correct statement. Pharmaceutical companies are under close scrutiny by the government for violations that can result in huge fines for those companies. With these potential fines, pharmaceutical companies must state that CME credit may not be earned. But as PAs, we have two different ways of earning CME credit. The NCCPA defines Category II CME credit as: Any medically related activity that enhances the role of a PA (including journal reading). Category II credits are earned on an hour-by-hour basis. There is no minimum requirement for Category II activities. That said, a PA may claim these sponsored learning opportunities as Category II CME credit without a problem. Peter Aronson, PA-C, a CAPA Past President, long-time CAPA member and supporter has touched on this issue in the past and has reached out to the NCCPA for a response: “If the CME activities you participated in during the CAPA Annual Conference are not eligible for Category I CME, but enhance your medical knowledge and/or role as a PA, you can log the hours toward Category II CME hours…earned on an hour-per-hour basis.” Peter has also reached out to Adrienne Harris, Past AAPA Director
of Continuing Medical Education Services who said this about the “Not eligible for CME” phrase: “When a pharmaceutical sponsored program states, “This session is not eligible for CME,” what they should be saying is, “This session is not eligible for Category I CME credit.” Hopefully this clarifies a potentially confusing issue for everyone. So, let’s do some math, if this year’s Annual CAPA Conference in Palm Springs offers 23 hours of Category I CME hours plus offers seven meal lectures, what is the maximum number of CME hours the PA can earn? That answer would be 30 hours: 23 hours of Category I CME and 7 hours of Category II CME. This scenario has always been available for PAs attending conferences and I hope everyone is taking advantage of all of the CME hours earned from your conference experience. At the conference, you will always still hear “This program is not eligible for CME, but now you know Category II CME credit is available to you. I want to make sure PAs are getting the most benefit from every conference. Category II CME exists for a reason and not taking advantage of these hours is missing a great opportunity to earn the hours toward your certification.
Third Edition of the California Physician Assistant’s and Supervising Physician’s Legal Handbook*
M
ichael Scarano, Jr., Esq. authored the California Physician Assistant’s and Supervising Physician’s Legal Handbook. Newly updated, it answers scores of questions in a concise, clear fashion, with citations and appendices that will permit practitioners to read the operative statutes and regulations for themselves. A must have for all California practices employing PAs. Visit the CAPA website at www.capanet.org for more information or to order the book online. *CAPA Member Price - $34.95
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CAPA NEWS
Non Member Price - $54.95
CAPA at Napa by Eric Glassman, MHS, PA-C, CME Committee Chair
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his year’s CAPA at Napa was another great conference and I think all who attended on February 23, 2013 would agree. Our host hotel, the Napa Valley Marriott, is a perfect place to hold this one-day event. And, who could ask for a better time of year to be in the beautiful Napa Valley. This is always a coveted conference that sells out every year. This year was no exception! We had six great lectures from start to finish. The first lecture was on EKGs by Jennifer
Carlquist, PA-C who is rapidly becoming one of the most popular speakers at our CAPA’s Conferences. We also had one of CAPA’s longtime favorite speakers, Dr. Robin Dore, speak about the work up and treatment of Rheumatoid Arthritis. Many attendees had great interest in and questions for our Legal Issues Update lecture speakers, CAPA’s Professional Practice Committee Chair, Bob Miller, PC and Mike Scarano, CAPA’s Legal Counsel. Another well received addition this year was the CAPA PAC “Wine Pull” offered by the CAPA Political Action Committee. Congratulations to all
who supported the CAPA PAC and went home with a great bottle of wine and other great prizes. We hope you will join us in Napa next year on February 22, 2014 to experience this great conference. In addition, you won’t want to miss the 37th Annual Conference in Palm Springs October 3-6, 2013. Mark your calendar now as this will be here before we know it. We have already started the planning process, it is almost a year around task now, but it will certainly not disappoint and we would love to see you there!
Registe r Today
s 6 Hour Cat. I CME
Controlled Substances Education Course A Course Which Upon Successful Completion Will Allow You To Write For Controlled Substances Without Patient Specific Approval* Saturday, April 20, 2013 Scripps Green Hospital Timken Amphitheater 10666 N Torrey Pines Rd La Jolla, CA 92037
Saturday, August 17, 2013 UC Davis Education Building 4610 X Street, Ste 2128 Lecture Hall 1222 Sacramento, CA 95817
Wednesday, October 2, 2013 Renaissance Palm Springs (preceding the CAPA Conference) 888 E Tahquitz Canyon Way Palm Springs, CA 92262
*California Code of Regulations Sections: 1399.541(h), 1399.610 and 1399.612. A PA may administer, provide, or issue a drug order for Schedule II through V controlled substances without patient specific approval if the PA completes specified educational requirements and if his/ her Supervising Physician delegates the authority to them. Courses will be canceled if minimum number of registrants is not met.
MARCH/APRIL 2013
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CAPAsNotes
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n a perfect world every PA would be able to recite the PA Practice Act, chapter and verse. We know the reality is that most of you have never read the entire book of PA laws and regulations. We have excerpted here the Prescription Transmittal Authority Section from Article 1 of the PA Practice Act and all of Article 4 of the California Code of Regulations pertaining to PAs. These two articles are the “meat” of the PA laws and regulations. Both have had substantial changes recently. We sincerely hope that you will thoroughly read and learn these sections. Share them with your supervising physicians and keep this information close at hand. We have taken editorial privilege here. Please keep in mind that in some cases we have added emphasis and/or text, highlighted certain sections, made notes in others. We have deleted the cited authority and history footnotes in the interest of space. You may download the complete 79 page document from the Physician Assistant Committee’s website. We encourage you to do so.
For complete PA laws & regulations http://www.pac.ca.gov/about_us/ lawsregs/law-booklet.pdf
Excerpted from The Physician Assistant Practice Act Business and Professions Code CHAPTER 7.7. PHYSICIAN ASSISTANTS
(Title amended by Stats. 1992, Ch. 427.)
Article 1. General Provisions Section 3502.1 Prescription Transmittal Authority Prescription Transmittal Authority 3502.1. (a) In addition to the services authorized in the regulations adopted by the board, and except as prohibited by Section 3502, while under the supervision of a licensed physician and surgeon or physicians and surgeons authorized by law to supervise a physician assistant, a physician assistant may administer or provide medication to a patient, or transmit orally, or in writing on a patient’s record or in a drug order, an order to a person who may lawfully furnish the medication or medical device pursuant to subdivisions (c) and (d). (1) A supervising physician and surgeon who delegates authority to issue a drug order to a physician assistant may limit this authority by specifying the manner in which the physician assistant may issue delegated prescriptions. (2) Each supervising physician and surgeon who delegates the authority to issue a drug order to a physician assistant shall first prepare and adopt, or adopt, a written, practice specific, formulary and protocols that specify all criteria for the use of a particular drug or device, and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued.
Visit www.capanet.org for sample protocols and formulary The drugs listed in the protocols shall constitute the formulary and shall include only drugs that are appropriate for use in the type of practice engaged in by the supervising physician and surgeon. When issuing a drug order, the physician assistant is acting on behalf of and as an agent for a supervising physician and surgeon. (b) ‘‘Drug order’’ for purposes of this section means an order for medication that is dispensed to or for a patient, issued and signed by a physician assistant acting as an individual practitioner within the meaning of Section 1306.02 of Title 21 of the Code of Federal Regulations. Notwithstanding any other provision of law, (1) a drug order issued pursuant to this section shall be treated in the same manner as a prescription or order of the supervising physician, (2) all references to ‘‘prescription’’ in this code and the Health and Safety Code shall include drug orders issued by physician assistants pursuant to authority granted by their supervising physicians and surgeons, and (3) the signature of a physician assistant on a drug order shall be deemed to be the signature of a prescriber for purposes of this code and the Health and Safety Code. (c) A drug order for any patient cared for by the physician assistant that is issued by the physician assistant shall either be based on the protocols described in subdivision (a) or shall be approved by the supervising physician and surgeon before it is filled or carried out. (1) A physician assistant shall not administer or provide a drug or issue a drug order for a drug other than for a drug listed in the formulary without
CAPAsNotes advance approval from a supervising physician and surgeon for the particular patient. At the direction and under the supervision of a physician and surgeon, a physician assistant may hand to a patient of the supervising physician and surgeon a properly labeled prescription drug prepackaged by a physician and surgeon, manufacturer as defined in the Pharmacy Law, or a pharmacist. (2) A physician assistant may not administer, provide or issue a drug order for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets standards, including pharmacological content, approved by the committee. The education course shall be provided either by an accredited continuing education provider or by an approved physician assistant training program. If the physician assistant will administer, provide, or issue a drug order for Schedule II controlled substances, the course shall contain a minimum of three hours exclusively on Schedule II controlled substances. Completion of the requirements set forth in this paragraph shall be verified and documented in the manner established by the committee prior to the physician assistant’s use of a registration number issued by the United States Drug Enforcement Administration to the physician assistant to administer, provide, or issue a drug order to a patient for a controlled substance without advance approval by a supervising physician and surgeon for that particular patient.
To learn more about CAPA’s Controlled Substances Education Course visit www.capanet.org
(3) Any drug order issued by a physician assistant shall be subject to a reasonable quantitative limitation consistent with customary medical practice in the supervising physician and surgeon’s practice. (d) A written drug order issued pursuant to subdivision (a), except a written drug order in a patient’s medical record in a health facility or medical practice, shall contain the printed name, address, and phone number of the supervising physician and surgeon, the printed or stamped name and license number of the physician assistant, and the signature of the physician assistant. Further, a written drug order for a controlled substance, except a written drug order in a patient’s medical record in a health facility or a medical practice, shall include the federal controlled substances registration number of the physician assistant and shall otherwise comply with the provisions of Section 11162.1 of the Health and Safety Code. Except as otherwise required for written drug orders for controlled substances under Section 11162.1 of the Health and Safety Code, the requirements of this subdivision may be met through stamping or otherwise imprinting on the supervising physician and surgeon’s prescription blank to show the name, license number, and if applicable, the federal controlled substances number of the physician assistant, and shall be signed by the physician assistant. When using a drug order, the physician assistant is acting on behalf of and as the agent of a supervising physician and surgeon. (e) The medical record of any patient cared for by a physician assistant for whom the physician assistant’s Schedule II drug order has been issued or carried out shall be reviewed and countersigned and dated by a supervising physician and surgeon within seven days.
All Schedule II drug orders must be countersigned within 7 days (f ) All physician assistants who are authorized by their supervising physicians to issue drug orders for controlled substances shall register with the United States Drug Enforcement Administration (DEA).
If you are writing drug orders for Schedule II-V medications you must have your own DEA number. (g) The committee shall consult with the Medical Board of California and report during its sunset review required by Division 1.2 (commencing with Section 473) the impacts of exempting Schedule III and Schedule IV drug orders from the requirement for a physician and surgeon to review and countersign the affected medical record of a patient. (Amended by Stats. 2007, Ch. 376.) Excerpted from The California Code of Regulations Article 4. Practice of Physician Assistants Section § 1399.540. Limitation on Medical Services. § 1399.541. Medical Services Performable. § 1399.542. Delegated Procedures. § 1399.543. Training to Perform Additional Medical Services. § 1399.545. Supervision Required. § 1399.546. Reporting of Physician Assistant Supervision.
CAPAsNotes 1399.540. Limitation on Medical Services. (a) A physician assistant may only provide those medical services which he or she is competent to perform and which are consistent with the physician assistant’s education, training, and experience, and which are delegated in writing by a supervising physician who is responsible for the patients cared for by that physician assistant. (b) The writing which delegates the medical services shall be known as a delegation of services agreement. A delegation of services agreement may be signed by more than one supervising physician only if the same medical services have been delegated by each supervising physician. A physician assistant may provide medical services pursuant to more than one delegation of services agreement.
A Delegation of Services Agreement is required in every practice (c) The committee or division or their representative may require proof or demonstration of competence from any physician assistant for any tasks, procedures or management he or she is performing. (d) A physician assistant shall consult with a physician regarding any task, procedure or diagnostic problem which the physician assistant determines exceeds his or her level of competence or shall refer such cases to a physician. 1399.541. Medical Services Performable. Because physician assistant practice is directed by a supervising physician, and a physician assistant acts as an agent for that physician, the orders given and tasks
performed by a physician assistant shall be considered the same as if they had been given and performed by the supervising physician. Unless otherwise specified in these regulations or in the delegation or protocols, these orders may be initiated without the prior patient specific order of the supervising physician. In any setting, including for example, any licensed health facility, out-patient settings, patients’ residences, residential facilities, and hospices, as applicable, a physician assistant may, pursuant to a delegation and protocols where present: (a) Take a patient history; perform a physical examination and make an assessment and diagnosis therefrom; initiate, review and revise treatment and therapy plans including plans for those services described in Section 1399.541(b) through Section 1399.541(i) inclusive; and record and present pertinent data in a manner meaningful to the physician. (b) Order or transmit an order for x-ray, other studies, therapeutic diets, physical therapy, occupational therapy, respiratory therapy, and nursing services. (c) Order, transmit an order for, perform, or assist in the performance of laboratory procedures, screening procedures and therapeutic procedures. (d) Recognize and evaluate situations which call for immediate attention of a physician and institute, when necessary, treatment procedures essential for the life of the patient. (e) Instruct and counsel patients regarding matters pertaining to their physical and mental health. Counseling may include topics such as medications, diets, social habits, family planning, normal growth and development, aging, and understanding of and long-term management of their diseases. (f ) Initiate arrangements for admissions, complete forms and charts pertinent to the patient’s medical record,
and provide services to patients requiring continuing care, including patients at home. (g) Initiate and facilitate the referral of patients to the appropriate health facilities, agencies, and resources of the community. (h) Administer or provide medication to a patient, or issue or transmit drug orders orally or in writing in accordance with the provisions of subdivisions (a)-(f ), inclusive, of Section 3502.1 of the Code.
Reference to protocol again. (i) (1) Perform surgical procedures without the personal presence of the supervising physician which are customarily performed under local anesthesia. Prior to delegating any such surgical procedures, the supervising physician shall review documentation which indicates that the physician assistant is trained to perform the surgical procedures. All other surgical procedures requiring other forms of anesthesia may be performed by a physician assistant only in the personal presence of an approved supervising physician. (2) A physician assistant may also act as first or second assistant in surgery under the supervision of supervising physician. 1399.542. Delegated Procedures. The delegation of procedures to a physician assistant under Section 1399.541, subsections (b) and (c) shall not relieve the supervising physician of primary continued responsibility for the welfare of the patient. 1399.543. Training to Perform Additional Medical Services. A physician assistant may be trained
CAPAsNotes to perform medical services which augment his or her current areas of competency in the following settings: (a) In the physical presence of a supervising physician who is directly in attendance and assisting the physician assistant in the performance of the procedure; (b) In an approved program; (c) In a medical school approved by the Division of Licensing under Section 1314; (d) In a residency or fellowship program approved by the Division of Licensing under Section 1321; (e) In a facility or clinic operated by the Federal government; (f ) In a training program which leads to licensure in a healing arts profession or is approved as Category I continuing medical education or continuing nursing education by the Board of Registered Nursing.
such times when a supervising physician is not on the premises. (e) A physician assistant and his or her supervising physician shall establish in writing guidelines for the adequate supervision of the physician assistant which shall include one or more of the following mechanisms: (1) Examination of the patient by a supervising physician the same day as care is given by the physician assistant; and/or (2) Countersignature and dating of all medical records written by the physician assistant within thirty (30) days that the care was given by the physician assistant; and/or
1399.545. Supervision Required. (a) A supervising physician shall be available in person or by electronic communication at all times when the physician assistant is caring for patients. (b) A supervising physician shall delegate to a physician assistant only those tasks and procedures consistent with the supervising physician’s specialty or usual and customary practice and with the patient’s health and condition. (c) A supervising physician shall observe or review evidence of the physician assistant’s performance of all tasks and procedures to be delegated to the physician assistant until assured of competency. (d) The physician assistant and the supervising physician shall establish in writing transport and back-up procedures for the immediate care of patients who are in need of emergency care beyond the physician assistant’s scope of practice for
(3) The supervising physician may adopt protocols to govern the performance of a physician assistant for some or all tasks. The minimum content for a protocol governing diagnosis and management as referred to in this section shall include the presence or absence of symptoms, signs, and other data necessary to establish a diagnosis or assessment, any appropriate tests or studies to order, drugs to recommend to the patient, and education to be given the patient. For protocols governing procedures, the protocol shall state the information to be given the patient, the nature of the consent to be obtained from the patient, the preparation and technique of the procedure, and the follow-up care. Protocols shall be developed by the physician, adopted from, or referenced to, texts or other sources. Protocols shall be signed and dated by the supervising physician and the physician assistant.
Most PAs practice using this third option: by adopting protocols.
The supervising physician shall review, countersign, and date a minimum of 5% sample of medical records of patients treated by the physician assistant functioning under these protocols within thirty (30) days. The physician shall select for review those cases which by diagnosis, problem, treatment or procedure represent, in his or her judgment, the most significant risk to the patient; (4) Other mechanisms approved in advance by the committee. (f ) In the case of a physician assistant operating under interim approval, the supervising physician shall review, sign and date the medical record of all patients cared for by that physician assistant within seven (7) days if the physician was on the premises when the physician assistant diagnosed or treated the patient. If the physician was not on the premises at that time, he or she shall review, sign and date such medical records within 48 hours of the time the medical services were provided. (g) The supervising physician has continuing responsibility to follow the progress of the patient and to make sure that the physician assistant does not function autonomously. The supervising physician shall be responsible for all medical services provided by a physician assistant under his or her supervision. 1399.546. Reporting of Physician Assistant Supervision. Each time a physician assistant provides care for a patient and enters his or her name, signature, initials, or computer code on a patient’s record, chart or written order, the physician assistant shall also enter the name of his or her supervising physician who is responsible for the patient. When a physician assistant transmits an oral order, he or she shall also state the name of the supervising physician responsible for the patient.
Touro University Hosts “Mental Health Through the Life Span” at by Joy Dugan, MPH, PA-C, Secretary
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or the first time during the with multiple diagnoses. Dr. Alenkin provide this type of care. According CAPA at Napa conference recommends that our offices become to Dr. Neal Adams, “The number weekend, on February 24, 2013, of newly-trained psychiatrists both “patient and family centered, while Touro University hosted a mental community and population oriented. nationally and in California has health training conference especially Interprofessional teams bring togethremained stable in recent years, and for physician assistants. The training er complementary skill sets for more shows little prospect of increasing. was made available through a grant patient-centered care. If this is not an PAs may be positioned to fill this gap from the State of California’s Office option at your practice, I urge you “with additional education, training of Statewide Health Planning and to become familiar with resources in and practice supports. As providers Development. Veteran mental health your county. skilled in psychopharmacology, PAs care was a central focus, with gencan close the gap in the ability and eral topics of homelessness, mental 3. You’ll never know if you don’t ask. distribution of providers able to care health policy, women and substance for mental health patients. abuse and post-traumatic stress disPatients with chronic mental health order (PTSD) were also discussed. conditions are likely to initially presIf you work in mental health, proLecturers included associate profesgrams are very much in need of train- ent in primary care. PAs, for many of sor of Touro University California these patients, will be the first step in ing sites. Please contact any of the PA Program, Ana Maldonado, California PA programs or the CAPA seeking help. This is why screening MPH, DHSc, PA-C; Neal Adams, for mental health is so important in office if you would be interested in MD, MPH of California Institute primary care. However, screening is precepting PA students, especially of Mental Health; Nikola Alenkin, not an assessment, but serves as a way within the mental health setting. PhD, LCS ; Shaili Jain, MD and to help identify patients who are at Training more PAs to become comElizabeth Manning, PhD all from higher risk for mental health disease. petent mental health care providers the Department of Veteran’s Affairs. is one of the steps we, as a profession, Having a positive screen for depression does not mean we should just can take to meet the need for mental In the last edition of the CAPA News, health providers. identify the ICD-9 code for the diagI introduced the topic of mental nosis of depression. That is where we health access and barriers to receiving 2. Interprofessional management of begin an open dialogue regarding the care. The article included statistics patient’s current mental health. mental health patients needs to and epidemiological data on mental become the norm in primary care. 4. Become educated on veteran healthhealth with the recommendation of care needs. utilizing screening tools to identify According to the United States patients suffering from a mental Department of Health and Human As of 2012, in California there are health disorder. After attending Services, as of January 9, 2013, 91.7 1.8 million veterans from all conTouro’s mental health training conmillion people live in a Mental flicts since World War II through ference, I wanted to share five major Health Professional Shortage Area1. Unfortunately these 91.7 million the current military operations in points for PAs to consider in relation people do not simply have the Afghanistan and Iraq4. Identifying to mental health care: diagnosis of depression or generalveterans in your practice is important since one-fifth of suicides are 1. Health reform makes it more impor- ized anxiety – they also suffer from chronic illnesses including diabetes, veterans, at a rate of approximately tant than ever to precept. hypertension, heart disease and can18 deaths from suicide per day by cer. It is well established that chronic veterans5. The Patient Protection and Affordable diseases can intensify the symptoms Care Act (PPACA) includes insurance of mental health disorder, and vice The Department of Veteran’s Affairs reform that will require an essential versa, having a cyclic impact on dishas numerous free programs for health benefits package that provides ease burden2,3. This creates an overall patients with suicidal or depressive comprehensive services including poorer prognosis in health outcomes. symptoms: mental health. However, access to · Veterans Crisis Line (1-800mental health care will only truly be Ideally, interprofessional collabora273-TALK, press 1): a toll-free, met if there are enough adequately tion occurs to care for these patients confidential resource that trained health care providers to 20
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connects Veterans and Service Members in crisis and their families with qualified VA responders. Veterans Chat (http://www. veterancrisisline.net, http:// www.miliarycrisisline.net): an anonymous online chat service with crisis counselors. Veterans Text (text VETTALK): a free option to text about mental health with crisis counselors.
As a quick reference, you may want to access: http://www.va.gov/ oaa/pocketcard/Military-HealthHistory-Card-for-print.pdf. This pocket reference was designed by the Department of Veteran’s Affairs and includes history questions to develop rapport with military service members and veterans. 5. Become educated on FEMALE veteran healthcare needs The demographics of the military population are changing. More women are serving than ever before. Women compromise 15% of active duty military, 20% of new recruits to military, 18% of reservists and National Guard, and 12% of Operation Enduring Freedom/ Operation Iraqi Freedom veterans. Compared to their civilian counterparts, women veterans are three times more likely to commit suicide6 and suffer significantly higher rates of sexual trauma and intimate partner violence (IPV)7. As health care providers, we need to ask questions about exposure to combat stressors, sexual trauma, substance abuse, and IPV. In writing these two articles, it is my hope that we all devote some of our CME or journal reading to mental health topics. I urge you to assess your current practices around
screening and discussing mental health. Please feel free to contact me with any questions or comments: joy.dugan@tu.edu. References
1 U.S. Department of Health and Human Services. Shortage Designation: Health Professional shortage Areas & Medically Underserved Areas/Populations. http://bhpr. hrsa.gov/shortage/index.html. Accessed 25 February 2013. 2Division of Adult and Community Health, Centers for Disease Control and Prevention. Public Health Action Plan To Integrate Mental Health Promotion and Mental Illness Prevention with Chronic Disease Prevention, 2011–2015. (20011). Available from http://www.cdc. gov/mentalhealth/docs/11_220990_Sturgis_ MHMIActionPlan_FINAL-Web_tag508.pdf [PDF - 829KB] 3Chapman DP, Perry GS, Strine TW. (2005). The vital link between chronic disease and depressive disorders. Preventing Chronic Disease.
Atlanta, GA: Centers for Disease Control and Prevention. Available from: http://www.cdc. gov/pcd/issues/2005/jan/04_0066.htm 4 National Center for Veterans Analysis and Statistics. Department of Veteran’s Affairs. (2010). http://www.va.gov/vetdata/Quick_ Facts.asp Accessed 27 February 2013. 5 Karch, DL, Logan J, McDaniel D, Parks S, Patel N. (2009). Center for Disease Control. National Violent Death Reporting System. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6106a1.htm?s_cid=ss6106a1_w. Accessed 27 February 2013. 6 Dichter ME, Cerulli C, Bssarte RM. (2011). Intimate partner violence victimization among women veterans and associated heart health risks. Women’s Health Issues. S190-S194. 7 McFarland BH, Kaplan MS, Huguet N. (2010). Self-Inflicted Deaths Among Women With U.S. Military Service: A Hidden Epidemic? Psychiatric Services. Vol. 61, No. 12: 1777.
Heard Any Great Speakers Lately?
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very year at the CAPA Conference in Palm Springs we hear it said: “You guys have the best speakers. How do you do it?” The answer is we hand pick them based on referrals, feedback and firsthand experiences. The CAPA Conference Planning Committee comprised of CAPA members who help us identify gaps in medical knowledge of PAs working in various practices/specialties. Once we identify the needs of our potential audience, we will come up with lecture topics. We will then need to find exceptional speakers to address those topics. We are very discerning in our speaker selection which makes for an excellent program and ensures a quality conference for those who attend. This is no easy task, but with the help of every CAPA member, it is manageable. If you know of an exceptional speaker; one who is knowledgeable, entertaining and engaging, please let us know. We will add them and their lecture topic to our list. Once our conference program topic “wish list” is developed, we can start to match speakers with topics. Your help is invaluable. We hope you will take a moment, throughout the year as you hear speakers to let us know the names of the ones you enjoyed and learned the most from.
Please give us a call or send us an e-mail! Email: capa@capanet.org Phone: (714) 427-0321 Fax: (714) 427-0324
Thank you and we hope to see you at the CAPA Conference on October 3-6, 2013
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Specialty Care for the Uninsured: Building a Bridge to Better Access - Part 3 by Matthew Keane MSPA, PA-C, Director-at-Large
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n Part 2 of “Specialty Care for the Uninsured: Building a Bridge to Better Access” we focused on embedding referral guidelines into the referral process between primary care providers and specialists. Referral guidelines can help clarify what specialists are looking for in a referral; anything from required physical findings, diagnostic testing, laboratory tests and prior treatments can be included to form guidelines for referrals for any given specialty. In Part 3, we will focus on building and expanding specialty care networks. Working to increase access and capacity to a network of specialty care can take many forms such as: volunteer models, persuading specific partners (such as hospitals) to hire more specialists by documenting demand, expanding the use of mid-level providers and telemedicine. Focusing on one or multiples of these strategies can help create more capacity and better access to specialty care. Within my association of clinics we have focused on increasing the number of
community volunteers willing to see uninsured or undocumented patients either in their own private office or at one of our association’s member clinics. We have begun a pilot project with three of our clinics that offer different specialty care within their clinics by volunteer specialists. The pilot project focuses on 3 of our 14 clinics’ members who offer specialty services on site. In order to make access efficient, we are developing a referral sheet, specialist calendar and referral guidelines. We are also working with a group of specialists that have begun to develop their own specialty care network of community volunteer specialists that will see patients in their own private offices. This twopronged approach has allowed maximizing access and capacity of our volunteer network. There are several factors that influence the sustainability and spread of this strategy: 1. Formalizing and institutionalizing individual relationships with
physician “champions” is critical for both sustainability and spread. 2. Opportunities and the most effective approaches differ depending on available resources in the health care system (e.g., number of specialists, existence of a public hospital). 3. Developing referral processes and communication systems between specialty and primary care is essential for supporting these activities. The most important aspect of developing an expanded volunteer network is identifying a “champion” that can be a leader and role model for other specialty providers. With a “champion” you have a provider that can relate and communicate with other specialists on your behalf. Other specialty providers will see this person as an equal and hopefully begin to see “if he/she can volunteer their time, then I can too” type attitude.
CAPA’s 37th Annual Conference October 3-6, 2013
Optional Workshops, October 3 and 5
Controlled Substances Education Course
October 2, 2013 – Prior to the CAPA Conference 22
CAPA NEWS
American Society of Hypertension, Inc.
Clinical Hypertension Review Course
The ASH Clinical Review Course at Cedars-Sinai Medical Center Join us forHypertension The ASH Clinical Hypertension Review Course scheduled for April 27-28,Course, 2013 will be rescheduled later April this year in anticipation a Full Two (2) Day Saturday–Sunday, 27–28, 2013, of the publication of the new National Hypertension Guidelines. at Cedars Sinai Medical Center, Los Angeles, CA CME Credits: 18.5 AMA PRA Category 1 Credits
To be determined Course Dates: Saturday–Sunday, April 27–28, 2013 Location: Harvey Morse Auditorium, Cedars Sinai Medical Center, Los Angeles, CA Purpose: The ASH Clinical Hypertension Review Course is a comprehensive immersion in evidence-based treatment strategies for hypertension and related diseases. The ASH Review Course will help current ASH Hypertension Specialists achieve the Core Competencies of a Clinical Hypertension Specialist, and may help those preparing to take the Qualifying Examination for Specialists in Clinical Hypertension. Format: Didactic Lectures and In-Depth Patient Case Review/Discussions Including information from the new hypertension guideline (JNC 8), pending its release Course Highlights: Session I: Session II: Session III: Session IV: Session V: Session VI: Session VII: Session VIII:
A Refined Definition of Hypertension Pathophysiologic Mechanisms in Hypertension Diagnostic Evaluation of Hypertension Identifiable Causes of Hypertension The Hypertension Syndrome & Target Organ Involvement Therapy of Hypertension: Evolving Concepts Evolving Therapeutic Strategies Challenges and Insights
Accreditation: The American Society of Hypertension, Inc. (ASH) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Designation: The American Society of Hypertension, Inc. (ASH) designates this live activity for a maximum of 18.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Visit the ASH Website for more information www.ash-us.org
The Secrets of Pregnancy by Tana Summers, MS, PA-C, CAPA Member
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otherhood is sort of like a secret society – there are all these details you don’t know until you enter the inner circle. As a clinician, a primary care provider no less, I spent much of my pregnancy wondering why I didn’t already know these secrets. There are some things women just don’t talk about, even to each other. I have friends who told “I vowed that, should I me (after the fact) they “didn’t want to survive labor and delivery, scare me,” and others who said that “every I would dispel the myths pregnancy is different and break open the hidden so they wanted to let me have my own experience.” What underworld of pregnancy.” I really wanted to know was why I hadn’t learned some of this stuff in PA school! I vowed that, should I survive labor and delivery, I would dispel the myths and break open the hidden underworld of pregnancy. It’s not always pretty, but here are some of the dark secret truths about pregnancy.
my pregnancy. I did not expect “morning sickness” to last all day long and be associated with dizziness and the deepest fatigue I have ever experienced. I did not expect my breast tenderness to be so uncomfortable that it hurt to take a shower (by the way, that gets worse the first few weeks of breast feeding). I was lamenting to a girlfriend who has three kids that I couldn’t believe how tender my breasts were, that I couldn’t even sleep. She was so nonchalant about it, “Oh, yeah, that happens. Try a sleeping bra.” A what? Turns out there are bras in the maternity store specifically to provide comfort to the girls while you sleep. Amazing! And the nipple itching, I thought I would go insane due to the itching of my breasts and nipples. A colleague (another PA who had a 15 month old baby at the time) asked me about nipple itching, because it drove her crazy and she had never heard of it before becoming pregnant. Yep, it’s super common but nobody talks about it. Other common but little known discomforts of early pregnancy: increased vaginal discharge, weird smell aversions (I could not stand the smell of coffee, something I love dearly), and increased flatulence.
I should start by admitting that I had a wonderful pregnancy. I loved being pregnant, I had a very easy pregnancy. I was one of those people you hate that didn’t gain a lot of The Second Trimester weight or retain fluid and didn’t This is supposed to be the “golden” look pregnant from the back. I also trimester; some refer to it as the had an uncomplicated home birth, “horny” trimester. I spent much of which means no drugs, no epidural, my pregnancy trying to eat enough just the midwives and my husband. protein (seriously, who can eat 80 So when I mention that parts of grams of protein in a 24 hours pregnancy were uncomfortable, I’m period? It’s just not possible) and saying that from the other side of a drinking the “pregnancy tea” that the completely natural delivery. midwives were very serious about, but I have nothing against the second The First Trimester trimester. The baby starts to move I expected some nausea and breast and you look pregnant but don’t yet tenderness in the early weeks of feel like a whale. It was great. 24
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The Third Trimester Everyone knows that the end of pregnancy can get uncomfortable. It was interesting to me to feel BraxtonHicks contractions, which felt like a tightening in my abdomen but didn’t ever hurt. I was not bothered by the mild dependent edema and cankles I developed at the end of the day, especially if I had been on my feet for several hours. I was prepared to give up wearing heels and was secretly excited to buy new shoes (my husband was not convinced I needed 6 new pairs of flats, but he wasn’t pregnant so it was not an argument he took on). I did not know that the average pregnant woman increases her shoe size – permanently! – by a half size during pregnancy. That meant my 60 pairs of shoes in their own closet could potentially not fit me anymore (gulp). Luckily, that was a tragedy I did not have to face. I expected some gastroesophageal reflux, and by the third trimester we had more pillows in our bed than living creatures (counting the fetus and two cats). The head of the bed was propped up by bricks and I had the Costco size bottle of Tums on my nightstand. And still, I could not sleep. I was a belly sleeper before I got pregnant, so between the tender breasts, the growing belly and the rules about sleeping on your left side, sleep was a challenge throughout my pregnancy. But nothing compared to the misery of reflux. Thankfully it vanished the moment my baby was born. My baby dropped pretty early, about 34 weeks, so the last 6 weeks of my pregnancy I felt like her head was in my vagina, which it practically was! That meant I could not sit comfortably in any hard chair and I spent the end of my pregnant days on an exercise ball. The term pelvic pressure took on a whole new meaning. Other common but little discussed woes of late pregnancy:
hemorrhoids, anemia and shortness of breath from the uterus squeezing the diaphragm up and the lungs into your throat. Breast Feeding Just a few words on the joys of breast feeding…I remember learning, and have taught my students for the past six years, that mild nipple soreness is common when breast feeding, especially in the first few weeks. What a ridiculous understatement! When my daughter was five days old, I had blisters on my nipples from her feeding every one to two hours, even though her latch was perfect and she was changing positions at every feed. I would cry from the pain every time she started to suckle, it was horrible. And engorgement! OMG! When my milk came in I got shaking chills and rock hard breasts up to the clavicle and the sensation of knives stabbing my breasts when the milk letdown reflex occurred. I actually had projectile milk shooting out of my nipples once! Painful milk leakage could even happen by going down the wrong isle at Target and finding someone else’s screaming baby. Breast feeding is hard work, but I have come to cherish this time with my daughter. All of these discomforts, I am convinced, help prepare women for the discomforts of labor and
breast feeding and the utter exhaustion of having a newborn. If your breasts have hurt since the first trimester, breast feeding will be more tolerable. If you haven’t slept well since the second trimester, the newborn period will be much less overwhelming. If you’ve been waddling and unable to sit comfortably since the third trimester, the perineal discomfort that only lasts a few days to a week won’t seem like such a big deal. I mean, there has to be some reason for all of this, right?! Now that I am nine months postpartum, I understand better why these secrets remain hidden, why these details remain unspoken
outside the mother circle. It’s because you forget! As a new mom you are sleep deprived and overwhelmed, and by the time you re-emerge into the world all those things that seemed so important when you were pregnant are forgotten – or normal. It’s difficult to remember what was so traumatizing in the midst of pregnancy because in hindsight it was just part of being pregnant. Some of the secrets of pregnancy must be experienced to be fully understood and appreciated, but if I can enlighten other women not yet in the motherhood ranks and help them have a better pregnancy experience, I have done my job as a PA and an educator. Besides, it’s not like the secret society can kick me out; I’ve earned my mom credentials!
California Changes Regulations to Allow PA Preceptors Continued from page 10
access and telemedicine, the provider interacting with the patient is less and less likely to be a physician and more and more likely to be a PA or NP. It stands to reason, therefore, that the PA or NP would be best suited to train a PA student in those practice settings. And, ultimately, the interests of the health care consumer are served by physician assistants who are trained by the mentors and preceptors best able to train them for their ultimate career, whether or not those trainers are physicians. For more than a year, I have represented CAPA in meetings with the State’s attorney, representatives of the PAB, the AAPA and PA educators. I would like to offer my sincere thanks to Roy Guizado of Western University and Tracey Del Nero of Touro University for their participation and input into this process.
Together we were able to draft a regulation revision that brings California regulations into line with our ARC accreditation standards and allows for non-physician supervision (preceptors) of PA students while still acknowledging the primary role of physicians in the training of PA students. Recently, we received word that our regulatory change has met with its final approval and will be effective April 1, 2013. It has been a long, slow and occasionally painful journey to make one small change that will benefit PA training programs, PA students and the patients we treat. Now it is incumbent upon all of you PAs in CAPAland. Call a local training program and volunteer to precept a PA student!
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Students Students Students Students Students Students Transitions From PA-S to PA-C by Saloni A. Swarup, PA-S, Student Representative
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ugust 8th, 2011… my first day of PA school. I remember walking into class anxious and excited at the same time. I am finally walking down the path that will grant me an opportunity to help my community and make a difference… in at least one person’s life. And, here I stand today, with only 5 more rotations to finish before I embark upon my journey into my life as a PA-C. This journey has been the best experience of my “Even though you may entire life. Many of you stand at the know in what field you same spot as I and would like to practice, treat I’m sure you glance into the future with every rotation with utmost that same anxiety and excitement as the first day of PA importance.” school! So what should we do to make this transition process a smooth operation? I have a few pointers that have been handed down to me by my professors and my preceptors. From here on, treat your rotation like a real job. You never know, this might turn into your future job! Even though you may know in what field you would like to practice, treat every rotation with utmost importance. For example, during your pediatrics rotation, convince yourself, your preceptor and everyone around you that you are in love with pediatrics. By placing yourself in this mind-set, you will not only gain the most out of your 26
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rotation, but you will also give yourself a chance to discard your preconceived notions about the rotation and experience it for what it really is.
will you gain a plethora of knowledge from a preceptor who likes you, but you will gain a work skill set that will set up your career as a PA.
Start looking for jobs that would interest you NOW! I completely understand if you think it is too early to do this. However, the idea behind this exercise is to practice your job seeking skills and to also see what is out there. We are exposed to the core rotations during our rotations and may not even realize the variety of fields where PAs work. For example., I was introduced to PAs who work within the mental health specialty. They provide therapy along with medication for their patients. Given this information and my background in Psychology, working as a PA in the mental health field is a new option for me. Take a minute to take a look at the Fabric of the Profession Videos on YouTube. You will be amazed, enlightened and inspired by the variety of practices in which PAs practice.
Take a practice PANCE-style exam to see where you stand We have worked through our text book medical knowledge at least once by this stage of our careers. What’s more, we have learned how to apply this information in the clinical setting too. This is a perfect time for you to take a practice PANCE exam to see where you stand in your knowledge level per organ system. Start studying the organ system that you are weakest at and build your knowledge set. This will ensure that you have a well-rounded knowledge set that increases your chances of scoring higher on the PANCE. In addition, keep re-studying topics you think you are weak in to maximize your prep time. The best way to assess your knowledge set, in the midst of your studying, is to answer as many questions as you possibly can. After you feel better prepared, take another PANCE practice test to assess how much better you are prepared. If you are not satisfied yet, repeat this cycle until you’re performing at a level that makes you comfortable. Then … CONQUER THE PANCE!
Repeat a rotation that is a job prospect If your preceptor is pleased with your knowledge and your work ethic and offers you a job, please consider this seriously. This job might be or might not be in the field that you thought you wanted to practice. However, you are good at it! It might be a great job for you to start at and to build your foundation working as a PA. Not only
Enjoy your graduation with your loved ones, YOU’VE EARNED THIS! I want to take this opportunity to congratulate you on the
Students Students Students Students Students Students success you have earned by simply making it to this point in your PA education. This program is not for the fainthearted and you have “almost” conquered it. Your graduation is a testament to this fact. And finally, your family and loved ones can have you back in their lives. I know that graduation is the end of school but the beginning of your PANCE study time. But, please take some time out and lavish it on your family and friends. They have been our support system throughout this time period and we must thank them on this glorious occasion. I think your graduation marks a time for your family and loved ones to look at you and marvel at what a wonderful human being and professional you are. Enjoy this attention and love because it is once in a lifetime! ESCAPE … between graduation and taking the PANCE Once you have finished your rotations and exams, please take some time for you. Plan a mini vacation with family or friends and RELAX! I know that you will be preoccupied with PANCE prep work. But your mind, body and soul need some time to heal. I believe this vacation can be that perfect interruption to your journey that will rev you up for the next phase. After you return to your books refreshed after your break, you will notice that you are less frustrated and able to concentrate on the task at hand. Then what’s left you ask: the PANCE! That’s all!
I believe if we all keep these pointers in mind for the rest of our student tenure, we will be able to perform to the best of our capabilities. We will not only graduate as PAs but we will also achieve the goal of becoming excellent diagnosticians and clinicians who give our patients the best care possible. I know you are tired at this point, but in the words of my mother; “You have already dealt with the elephant. All that remains is its tail.” It is close to the end of my term as your Student Representative. I would like to take this opportunity to thank you for electing me into this position and giving me a chance to help you. Even though this year has been crazy with rotations, taking time out to write these articles has been a learning experience for me too. I would sit down in front of my computer and think about what I have done to better my learning experience. By penning it and sharing it with you, it reminded me of what worked and what didn’t. I went to work the next day with my own pointers in my mind and did a much better job at my rotation. You have been the reason I have done well and I want to take this opportunity to thank you my fellow classmates. You made me a better student. Please let me know if you have any questions or concerns regarding this topic or anything else. I would be more than happy to help.
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Students Students Students Students Students Students Financial Preparation of PA Education Starts Before the First Day of PA School by Roy Guizado, MS, PA-C, Director-At-Large and Student Affairs Committee Chair
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he financial stress that education places on students can be very concerning. The costs of graduate school are even more overwhelming when combined with the debt of undergraduate education. This article is geared for students going to a PA school that awards a graduate degree.
which means interest starts accruing on the first day of the loan and continues to accumulate while the student is taking courses. Unfortunately, subsidized loans became extinct on July 1, 2012, so the only federal loan option available at this time is the unsubsidized loan.
PA school education financing is a different beast than undergrad. State or federal based scholarships and grants that can help finance undergraduate education are almost nonexistent “Get to know what the for graduate school students. Loans financial aid office can are the mainstay of graduate school fioffer, beginning with a nancing. In the case of PA students, it is thorough Internet review, reported that 92% are receiving financial and then schedule an aid, according to the Annual Reports on appointment with a Physician Assistant Educational Programs counselor to help you find in the United the best options available.” States published by the Physician Assistant Education Association.
Students are able to defer the interest payments of unsubsidized loans until program completion, but the interest accrues from the first day the loan was accepted by the student. If possible, students should try to pay back some or all of the interest that has accrued while in school. Otherwise, the accrued interest is added onto the original principal and this new amount becomes the new principal.
There are several different paths PA students can take to procure financial aid. One popular method is to obtain a direct education loan granted by the Department of Education. At one time, students could choose between a subsidized loan, which is a loan based on student need as determined from the Free Application for Federal Student Aid (FAFSA) and tax returns, and unsubsidized loans, 28
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The mainstay federal loan is the Stafford Loan, which currently carries a 6.8% annual interest rate. Typically the Stafford Loan is not enough to cover all expenses so many students will supplement their needs with private education loans such as the Grad Plus loan, which currently carries a 7.9% annual interest rate. The private education loan companies do review the student’s credit history. Applicants for these loans cannot have an adverse credit history, which includes 60, 90 days or more delinquency on any debt or having a credit report that shows default, discharge, foreclosure, repossession, tax lien, wage garnishment or writeoff. If you are not approved for a private loan you will need to obtain a co-signer who must be a U.S. citizen or permanent resident and credit worthy.
Another possibility for obtaining financial assistance is by checking with your school’s financial aid office. Some programs or departments will offer scholarships in various amounts to students. Sometimes the loans are based upon a certain condition, such as being the first in a family to attend graduate school. Get to know what the financial aid office can offer, beginning with a thorough Internet review, and then schedule an appointment with a counselor to help you find the best options available. Another consideration for PA school finances is the National Health Services Corp (NHSC). The NHSC does provide scholarships and stipends for selected individuals. There is an obligation to practice in underserved communities for a specific amount of time after graduation. The NHSC also offer loan repayment programs after you graduate. Selected individuals for this program must agree to work in an underserved community for a specified amount of time and will be provided with stipends to pay back loans. There are other financial aid possibilities available. Various military branches offer scholarships, which can be researched through their representatives and recruiters. Many service organizations, churches, and philanthropic organizations offer scholarships, generally in amount less than $1000. An Internet search is a good starting point to determine which option is the most promising. Each option requires your time and energy to explore the details of the
Students Students Students Students Students Students Oops!! You’ve Done It Again! by Gaye Breyman, CAE, Chief Operating Officer application process to see if you qualify. While this can be time consuming, a little effort could pay off. Financial Aid Representatives offer these tips to assist in procuring financial aid: 1. Apply for the FASFA early. It is okay to use estimated taxes. 2. Apply for financial aid early – you do not need to be accepted to a program. 3. Apply for the Stafford and Grad Plus loans early. 4. If you can afford to, pay back interest on any loans accumulating interest while in school. 5. Start saving money in undergraduate school to use for graduate school. 6. Develop and follow an affordable monthly budget. 7. Minimize credit card debt prior to school. 8. Live like a student when you are a student. 9. Get roommates while in school to share costs. 10. Don’t forget to see if the Bank of Mom and Dad can contribute.
E
very year we hear of an unfortunate new graduate or seven who have not followed the Golden Rule and because of that, their career starts off on a very bad foot. Please, please read the article below and please, please don’t think that you are an exception to the rule. You worked hard to get into PA school. You studied hard and passed your NCCPA exam. And then you apply for your license to practice as a PA and suddenly all common sense leaves you. You decide that no one will ever find out about that little (or big) violation that happened when you were just a young guy or gal so you lie/omit information when filling out your license application. Do you remember giving the Physician Assistant Committee (PAC) your fingerprints? Do you remember when you were arrested and booked for whatever all those years ago, you gave them your fingerprints? Computer matching is an amazing thing! Each year many new graduate PAs (and practicing PAs who are moving here from another state) fail to honestly answer question 19a. on the California Physician Assistant License Application. The question reads: Have you ever been convicted of or pled nolo contendere to any violation (including misdemeanor or felony) of any local, state, or federal law of any state, territory, country, or U.S. federal jurisdiction? The application states: You are required to list any conviction that has been set aside and dismissed or expunged, or where a stay of execution has been issued. Please know and please heed the warning: The Physician Assistant Committee investigates each applicant (they have your fingerprints!) and subsequently finds out when applicants have been less than totally honest. In most cases, the truth will cause you little to no problem. In all cases, lying on your PA license application will cause you a tremendous amount of grief. I so hate getting those calls and you can’t go back. You can’t unbreak the egg!
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Creating an Accurate Patient Record
A
n accurate patient record not only promotes optimal patient outcomes; it’s essential to protect yourself from lawsuits. If litigation occurs, an accurate patient record is an invaluable resource for your defense attorney. Here are steps you can take to ensure your records meet the needs of patients and your organization.
of practice.
Step 1: Follow your organization’s documentation policy Follow your organization’s documentation policy. A patient’s record must be highly detailed. Without sufficient detail, an attorney will be unable to provide an adequate defense should you be sued. Your documentation policy should also reflect national standards for your industry. Also consider rules and regulations in the state where the facility is located and your scope
An accurate patient record contains information for each patient visit, including your observations and recommendations, actions you took, and future plans. In addition to helping the patient, an accurate record protects you in case of legal action.
Step 2: Good documentation counts Practice your documentation skills. For instance, provide a patient situation and ask a peer to document it or to do the same for you. Then hold a discussion about what the best entry would be.
Protect yourself and your organization By following your organization’s policy and educating yourself you can ensure you have a patient record that protects you and your
organization from legal action and serves as the front line of defense in court. This risk management information was provided by Healthcare Providers Service Organization (HPSO), the #1 provider of professional liability insurance for over 1 million healthcare professionals, and is now offering the same quality coverage, financial strength and level of service to Physician Assistants. The professional liability insurance policy is administered through HPSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an email to service@hpso.com or call 1-800982-9491. www.hpso.com.
CAPA0112_Layout 1 11/29/11 4:08 PM Page 1
You’re “on-call” 24/7. Make sure your malpractice coverage is too.
Individual professional liability coverage at competitive rates.
Physician Assistants Professional Liability Insurance 888.273.4686 | www.hpso.com/oncall This program is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company, and is offered through the Healthcare Providers Service Organization Purchasing Group. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. This material is for illustrative purposes only and is not a contract. It is intended to provide a general overview of the products and services offered. Only the policy can provide the actual terms, coverages, amounts, conditions and exclusions. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2012 CNA. All rights reserved. Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc.; (AR 244489); in CA, MN & OK, AIS Affinity Insurance Agency, Inc. (CA 0795465); in CA, Aon Affinity Insurance Services, Inc., (0G94493), Aon Direct Insurance Administrator and Berkely Insurance Agency and in NY and NH, AIS Affinity Insurance Agency. ©2012 Affinity Insurance Services, Inc. CAPA112
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CAPA NEWS
Welcome New Members
Local Groups
January 14, 2013 through March 21, 2013 Abraham Abraamyan Jeremy Akers, EMT, CPT, PA-S Lindsay Allen, PA-C Kyle Allred, PA-C Lupita Alvarez, PA-S Shellie Babich, PA-C Rhonda Blankenheim, PA-S Annette Boatswain, PA-C Christopher Bradshaw Tamar Broussard, PA-S Elizabeth Buenrostro, MSPA Heidi Burgi, PA-C Demetrio Cardenas, PA-S Christopher Ceriale JC Chavez, PA Reena Cherry, PA-C David Chong, PA-C Matt Clark, PA-C Donald Cobbler, PA-C Elisabeth Cooper, PA-C Frederick Curtis, PA-C Robin Danks, RT, ATC River Dansing, NP Hilla Davidi Rigoberto Del Toro, PA-S Andrew Denevan, PA-C Laura Duffy, PA-C Shawn Edelstein, PA-S Chris Faldmo Deborah Fredell, PA-C Jennifer Frontela, PA-S Ronald Ganzon, PA-S Julie Geimer, PA-C Richard Gilgut, PA-C Philip Gosvener, PA-C Nicole Groux, PA-C, MPAS Benjamin Haber, PA-S Maria Hanna Sandra Hansen, PA-C Natalie Hardie William Hardwick, PA-C Netaneil Haronian Kristin Harris Jennifer Henshaw- LeFever, PA Erika Horner, PA-C Christina Horvath, PA-C Kellie Hoy
Charlotte Hunt Ryan Hussman, PA-S Rich Huynh Bernadette Hystad, PA-S Janice Iglesias Joei Johns, PA-S Stephanie Johnson, PA-S Caylie Kachinski, PA-C Kara Karalis, PA-S Shashanna Kenan Dena Keyhaninejad Thanh Khong, PA-S Lino Kim, PA-C Eric Kinsey, PA-S Darin Kleinsmith, EMT Shing-Hwa Lai, NP Kirsten Landes, PA-C Dahlia Lavi, PA-C Heather LeSieur, PA Casey Lieb, PA-S Monique Lopez Haley Lowe, PA-S Cindy Luo, MA Todd Lythgoe, PA-C Lindsay McClurg, PA-C Jacqueline McNeely, PA Anna Lissa Millett, PA-C Jarred Minefee, PA-C Tiffany Mock, EMT Joseph Murillo, PA-C Annie Neuman, PA-S Dina Newman, PA-C Kimberly Nguyen, PA-C Minh Nguyen, PA-S Tara Oliveri, PA-C Lorelei Opene, PA-C Heather Orosco, PA-C Marina Ortega, PA-S Susie Paik, PA-C Robert Pandolfe, PA Mary Parker, PA-C Dion Parks, PA Riddhi Patel, PA Terry Pelayo, PA-S Thanh Pham, PA-C Tonya Pinkerton, PA-C Donald Plong, PA-C, MS
Randall Poblete, PA-S Hilary Powell, PA-C David Reich, PA-C Jaclyn Rentz Jennifer Reynolds, PA-S Andrew Rives, MA Lori Romeo, PA-C Tamar Rosner, PA-S Shira Roth, PA-S Leticia Rubalcava, PA-S Lisa Ryavec, PA-C Amita Saggi, MS, PA-C Eva Schmitt, PA-C Katelyn Schuck, PA-C Kiran Semelsberger, PA-S Yael Shull, PA-S Kylie Smith, PA-S Sarah Spear, PA-C Joanne Suarez, PA-S Maria Teresa Suarez, PA Brittany Sumerel, PA-S Heather Tews, PA-S Tamara Trzcinski, PA April Umek, PA-C Tammy Ung Jackie Upton, PA-C Stephanie Ventrella, PA Natalie Vizcarra, PA-S Brianne Wagenman, PA-S Katherina Ward, PA-S Suniti Warey, PA-C Tamra Warner, PA-C Scotty West, PA-S Amanda Weston, PA-C Crystal Whitlow, PA-S Douglas Wong, PA-C Veda Wong Sing, PA Moudy Youssef, PA-C
1. Redding Area PA/NP Alliance Summer Ross, PA-C; (530) 275-5747 summerross@hughes.net 2. Physician Assistant Society of Sacramento (PASS) Carlos De Villa, PA-C, PASS President; (916) 973-6185, pasocietyofsac@yahoo.com Atul Sharma, PA-C, MMS, MPH, CHES; (916) 397-6035, pasocietyofsac@yahoo.com 3. Contra Costa Clinicians Association Brian Costello, PA-C; (925) 204-5406, contracostapas.com 4. San Francisco Bay Area Physician Assistants (SFBAPA) www.sfbapa.com, Martin Kramer, PA-C; (415) 433-5359 220 Lombard St., Apt. 118, San Fransisco, CA 94111-1155 mkramersf@hotmail.com 5. Bay Area Mid-Level Practitioners Rose Abendroth, PA-C; (650) 697-3583, Fax: (650) 692-6251, rosepard@aol.com Matt Dillon, PA-C; (650) 591-6601, mattdillon42@hotmail.com 6. Bay Area Non-Docs Linda O’Keeffe, PA-C; (650) 366-2050, lindapac@aol.com 7. Northcoast Association of Advanced Practice Clinicians John Coleman, PA-C; (707) 845-6008, streetdrag49@sbcglobal.net 8. Stanislaus County NP/PA Network Brian Cormier, PA-C; (209) 605-4966, briancor@verizon.net, www.nppanetwork.org 9. Stockton Midlevels Emma Calvert, PA-C; stocktonmidlevels@gmail.com 10. Journal Club for PAs and NPs (Fresno area) Cristina Lopez, PA-C; (559) 875-4060; Fax: (559) 875-3434, clopez875@aol.com; 2134 10th St, Sanger, CA 93657 11. Central Coast Nurse Practitioners & Physician Assistants Kris Dillworth, NP; ccnppa@yahoo.com Sharon Girard, PA-C; (305) 803-1560; ccnppa@yahoo.com 12. So Cal PAs Linda Aghakhanian, PA-C; want2heal@hotmail.com 13. Orange County Hung Nguyen, PA-C; (714) 846-8178; nhy52@yahoo.com 14. San Gabriel Valley Local Group M. Rachel DuBria, PA-C; (818) 744-6159, racheldca@aol.com 15. San Fernando/Santa Clarita Valley Group Jonah Tan, MPT, PA-C; (818) 634-0007, jotptpa@yahoo.com 16. Coachella Valley Physician Assistant Group Matthew Keane, MS, PA-C; mkeanepas@gmail.com 17. San Diego Area Jeremy Adler, MS, PA-C; (619) 829-1430, jadler@simplyweb.net
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California Academy of Physician Assistants 2318 S. Fairview St. Santa Ana, CA 92704-4938
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Spend Just A Few Minutes To Take A Quick On-line Survey For A Chance To Win A 32 GB iPad + More! CAPA is PArtnering with the Office of Statewide Health Planning and Development (OSHPD) to gather workforce data on PA practice in California. An OSHPD report will be published in 2013 using the data collected. Your response is imperative to make the report valid and meaningful. Take a short survey (4-6 minutes to answer 22 important multiple choice questions) and you will be entered into a drawing for one of the following: 1) 32 GB, 3rd Generation iPad 2) Conference registration at the 2014 CAPA at Napa Conference
3) Conference registration at the 2013 CAPA Conference in Palm Springs 4) One Year CAPA Membership