State investigates Mercy Medical Center after deaths
BY RIDGELY OCHS
ridgely.ochs@newsday.com
10:19 PM EST, February 11, 2008

The state Health Department said it is investigating the deaths of three patients at Mercy Medical Center after a surgeon accused a physician assistant of improperly performing invasive procedures.

The investigation comes on the heels of another investigation into the death last May of a woman in her 30s at the Rockville Centre hospital who had been misdiagnosed with breast cancer. She died from complications following a double mastectomy.

Health Department spokeswoman Claudia Hutton said the hospital concluded in October that it had "taken corrective action" in the woman's death.

"The plan of correction involved ensuring that specimens are properly identified," Mercy spokesman Mel Granick said. He would not elaborate.

The state investigates hospital deaths following complaints or in unusual circumstances.

Hutton would not confirm that another part of the health department, the Office of Professional Medical Conduct, which investigates doctors and physician assistants, is also looking into three more recent cases.

But Dr. Anthony Colantonio of Garden City, the surgeon who brought the cases to the department's attention, said he had been interviewed by the OPMC and by Nassau District Attorney Kathleen Rice's office. A Rice spokesman would not confirm an investigation.

In a statement, Mercy denied that any physician assistant has performed procedures without proper supervision. The hospital would not make the physician assistant available for an interview.

"Internal reviews of all of the cases cited by Dr. Colantonio have found no instance in which the death of the patient was caused by the actions of a physician assistant," Mercy said.

The hospital said that Colantonio's "statements appear to be part of an orchestrated campaign to malign and harm Mercy Medical Center in retaliation for disciplinary action against him for disruptive behavior."

In October, Colantonio was given a leave of absence pending an investigation and hearing. The hospital said the investigation followed complaints from other doctors and that "a committee of 21 of his fellow physicians later voted to recommend that the Board of Trustees terminate Dr. Colantonio's privileges." Granick would not be more specific.

Colantonio said the hospital is punishing him for being outspoken.

"The charges brought against me have nothing to do with quality of care," he said. "My issue is with an incompetent physician assistant performing an invasive procedure unsupervised and with the hospital's disregard about the concerns ... of a senior surgeon."

Colantonio said he had complained to the hospital for more than a year about the physician assistant, whom he said lacked the skill to do invasive procedures and was acting without appropriate supervision.

According to state law, a physician assistant can perform medical services only under supervision of a doctor. But the law says the doctor does not have to be physically present.

One of the cases Colantonio cited involved a 19-year-old woman who in October had undergone surgery for a gynecological problem. According to Colantonio, the young woman's breathing tube was taken out too soon and had to be reinserted, which injured her lungs and led to her being taken to the intensive care unit.

Colantonio said the woman then died after the physician assistant punctured her lung trying to insert a central venous catheter -- used for cardiovascular monitoring, fluids and giving drugs -- in the chest. He then improperly placed a chest tube, which prevented the lung from re-expanding, Colantonio said.

The same physician assistant was responsible for the death of a 65-year-old man in July, the surgeon said. The physician assistant, without authorization, inserted a Swan-Ganz catheter, a line that goes into the heart, he said. Colantonio said it worsened an infection the patient had, causing his death.

The third case, also in July, involved that physician assistant trying to insert a catheter in the neck of a 64-year-old woman, causing multiple bruises. The woman died a month later, Colantonio said, of her underlying disease.

Copyright ? 2008, Newsday Inc.
.....

Dear Mr Ochs:

I read your article in Newsday about the surgeon and the physician assistant (PA) at Mercy Hospital and as a medical professional was shocked.?

What I was amazed at is that you allowed a physician who could actually?
have an underlying problem with PAs to twist the circumstances of what obviously were unfortunate incidents into a true attack on a profession and on an individual professional. How do we know the types of cases these were? The hardest cases are the ones with the highest mortality. Patients in the ICU/ER ?are very sick and obviously are the ones that need ?procedures with the highest risk, not the people in for a cholesterol check. This could and should have been pointed out.

I have some questions to ask of you. Please permit me to throw out a number in fairness. Did you ask the Office of Professional Medical Conduct what the track record was of PAs generally? Compare us to chiropractors? Dentists? Physicians? The answer is have a damn good track record. Did you do any research to discover that much of the emergency medicine/on the field lifesaving procedures saving our troops in Iraq and Afghanistan are being done daily by PAs? This PA has not in any way been shown to be incompetent, and if he were shown to be, is it not true that every profession has their percentage of practitioners who should not be practicing? You remember that doctor? (actually I think there were two) in Long Island that re-used needles on their patients knowing they could contract AIDS or scores of other diseases? Why single out a person who has not even been proven to have done anything wrong? Just because a physician who has obviously had problems at this medical center and possibly other centers said so? Is there not a way to already deal with poor clinicians at Mercy? Did you ask yourself why no other physicians joined this doctor in his public disclosure?  You know that most of these things are handled internally, why did he go public? These are significant questions.

Lastly, did you investigate how this physician feels about PAs in general and if he had any past incidences that needed to be, or have been investigated? As a PA who has practiced for 35 years, I find this whole story a bit strange. I'll be the first one to come down hard on any PA who is incompetent. The next patient they see could be one of my family or a close friend. But, there is something here bothering me. In the mean time, PAs are getting negative press and it is unfortunate as we are a new profession are generally not well understood by the general public. It will be hard to turn around the negative press put out by your article. I am sorry but I truly think you were "used" in this case.

I know I am reading it with a jaundiced eye but your article was slanted. It took what one physician said and painted?it to cover an entire profession. You should be ashamed of yourself.

Below is an article, one of hundreds written about PAs. This one was about Army PAs. Read what the troops think about them.

Yours for better healthcare for all Americans.
Dave Mittman, PA
 

Army short on Physician Assistants
By Kelly Kennedy - Staff writer
Posted : Monday Jan 21, 2008 8:16:00 EST
 

On the battlefield, no one earns as much respect as the physician assistants assigned to line units to ensure everybody comes home.

That respect also means many people aspire to the position; in 2007, about 1,000 troops applied for the 95 slots in the Interservice Physician Assistant Program.

We have had problems getting applicants in the past, but not now, said Capt. James Jones, Interservice Physician Assistant Program manager. We're getting the cream of the crop.

But even as their reputation grows beyond pre-war sick-call doctor? status to training medics to care for gunshot wounds, shrapnel injuries and explosion burns  as well as commanding aid stations when mass casualties come in ? the Army is still short 150 physician assistants.

?he real issue is retaining them, Jones said. Right out of school, civilians are making $85,000 to $120,000 a year for a 32-hour work week, and they do not have to leave their families.

A PA is essentially a doctor who hasn?t had the research training or in-depth training in more unusual disease processes to be a full-fledged physician, Jones said.

PAs have about half the schooling of a medical doctor, do not have to work an internship or residency, and are supervised by physicians throughout their careers. They usually work with outpatients, and earn certifications as they become adept at a skill.

The Interservice Physician Assistant Program trains PAs from all the services, which rotate management responsibilities every four years; the Army is in charge now. All services let enlisted members apply, but the only the Army accepts applicants from the other services, enlisted or officer. Two Marine officers are going through the program now to become Army PAs.

But getting in is tough. The requirements say applicants should have 60 credit hours, but in reality, they need to be close to their bachelor's degrees because of the competition.

And forget service members who have never set foot in an aid station even infantry soldiers who would like to become PAs should be volunteering with medics to show interest. Jones said 65 percent of those accepted into the program are medics, but they'll take truck drivers, too, if they outshine other applicants.

For full requirements, send an e-mail to ipap@usarec.army.mil for an automated response, which includes a list of frequently asked questions. To be competitive, applicants should have a 3.0 grade-point average and an SAT score of at least 1800, although the minimum requirement is 1500, Jones said.

Those who get into the program continue to earn a paycheck while the military pays for their schooling, and they graduate as first lieutenants with a master's from the University of Nebraska. They can make captain within 15 months of graduating.

In December, the military graduated their first four officers with a doctorate in clinical science ? the only such program in the U.S. Those doctors, training at Brook Army Medical Center in Texas, will have extra expertise in emergency room skills, Jones said, adding that officials hope to expand that 18-month program to three more Army medical facilities.

This could help the military in another way: Across the country, medical schools are short of instructors for PA programs. The troops who graduate from the new doctorate program will be able to teach at the PA program at Fort Sam Houston, Texas.

To encourage service members to remain in uniform as PAs, Jones said the Army also offers a $25,000-a-year retention bonus for a four-year commitment.

Link: February 10, 2008-- The state Health Department has launched a probe of three recent patient deaths at a Long Island hospital - and of a physician assistant accused of botching invasive procedures, The Post has learned.

The deaths - including that of a 19-year-old woman - have sparked fury at Mercy Medical Center in Rockville Centre over charges the hospital is trying to profit by having non-MDs do surgical procedures such as inserting catheters, chest tubes and pacemakers.

"We are investigating a series of deaths at Mercy Medical Center that raise questions about appropriate patient care and quality of care," said Health Department spokeswoman Claudia Hutton.

Surgeon Anthony Colantonio, who treated two of the patients who died, has complained to several health and law-enforcement agencies that the physician assistant did not get permission to insert chest and neck catheters.

Mercy has since brought up Colantonio on disciplinary charges alleging he has "problems with interpersonal relationships" in the intensive-care unit, and that his complaints are "disruptive," he said.

Colantonio has told the state Office of Professional Medical Conduct that the PA practiced "with little or no supervision," used "poor judgment" and had "substandard technical skills."

Colantonio also complained that for months he had warned top medical officials at Mercy that the assistant "was a disaster waiting to happen."
Disaster struck, he says, last October when the PA placed a central venous line in the chest of the 19-year-old woman who had been sent to the ICU for breathing problems after a gynecological surgery.

The PA punctured her lung - later telling others she had jerked in a reflex move, according to Colantonio's letter to the OPMC. The assistant then inserted a chest tube in an effort to inflate the lung.

The PA alerted the doctor in charge of the ICU, but they waited nearly 48 hours before calling a chest surgeon, Colantonio alleged. The surgeon had to operate on the woman's collapsed lung, but she died about 12 days later.

The OPMC, the Health Department's disciplinary arm, has opened an investigation, The Post learned.
In the other cases, a 65-year-old man in the hospital after falling developed an infection from a catheter and died last July, a family lawyer said.
A 64-year-old woman with cancer died in August, about two weeks after the attempted placement of a vein catheter. The PA punctured her neck, filling it with blood, Colantonio said. "In my opinion, those patients were assaulted," he said.

In a fourth case, a woman died a week ago after the PA "wrongly inserted" a pacemaker, Colantonio alleged. The Health Department said it is awaiting a possible report from the hospital.

The PA, who was licensed in 1996 and has worked at Mercy for nearly four years, declined to comment. The Post is withholding his name.
Hospital spokesman Mel Granick said: "There have been no instances in which the actions of a physician assistant have been material to the death of a patient at Mercy." Physician assistants require a bachelor's degree, including two years of intensive classroom and clinical medical training. They also must pass a national certifying exam.

They perform many of the tasks that an MD can, including taking medical histories, performing physical exams and ordering and interpreting lab or X-ray tests.
New York law requires all physician assistants - about 9,000 statewide - to have a designated physician supervisor, but the supervisor doesn't have to be in the room during a procedure.

Mercy "closely supervises" its PAs, Granick said. They "do no work outside the scope of their authority. They perform the duties assigned to them."
Colantonio contends that Mercy assigns PAs - who are hospital employees - to do procedures so it can bill insurers "and make a profit."
Physicians can bill for the procedures themselves, so the hospital gets nothing.

Other hospital sources say it's the doctors looking to collect. "Every time a PA does a procedure, a doctor doesn't," one said. "That's money out of their pocket."
susan.edelman@nypost.com

PAForum  responses:

We are aides. We are not educated enough to do the things this article said we did??This guy paints us with a brush that makes every PA out to be dangerous and incompetent. Look at the quote. Is there any doubt that there are MDs, DOs and NPs who are not practicing up to par? When docs screw up we don't get headlines saying "Legislation must be passed protecting the public against MDs". Why not? Why don't WE demand that? Because it's unfair. Because we realize that one bad apple (if this PA even is one) does not a profession make. Should we start keeping notes?
Dave

Dear Susan:
I read your article in the Sunday Post on the "MDs Aide" with shock. Not just that the name of my profession was totally wrong. I guess in this case that was a nice thing.

What I was amazed at if that you allowed a physician who may actually have a problem with PAs to twist the circumstances so that a quote was highlighted that said that legislation was needed to protect the public from PAs. Did you ask the Office of Professional Medical Conduct what the track record was of PAs generally? Compare us to chiropractors? Dentists? Physicians? Did you do a literature search on the number of mistakes by physicians being investigated by NY State versus physician assistants? Why, when a physician or nurse is incompetent do you not run a headline asking for legislation to protect people against that profession? This PA has not even been shown to be incompetent, and if he is, is it not true that every profession has their percentage of practitioners who should not be taking care of patients? We all have them. You know that doctor (actually I think there were two) in Long Island that re-used needles on their patients knowing they could contract AIDS or scores of other diseases? Why did you not allow someone to call for tighter legislation against doctors because  of that? It is patently unfair that the same standards are not held to all professions.

Your article was slanted. It took what one physician said and painted it to cover an entire profession. You should be ashamed of yourself.
Below is an article, one of hundreds written about PAs. This one was about Army PAs. Read what the troops think about them.
Yours for better healthcare for all Americans.
Dave Mittman, RPA

The solution to your question appears to be quite simple. The next time you hear of a physician error, you should contact the press for an interview, in which you call for tighter control of physicians.
Bruce

As PA's we are Physician Assistants and we demonstrate this by our allegiance to physicians, hospitals, out-patient facilities, the ME office, the military, the White House, University Health systems, Administrators and most importantly, the patient and their families. For the past forty years we have survived the scrutiny of the medical societies, quality assurance sections and the insurance industry. If anything, there are far fewer cases of poor judgement that become malpractice suits against PA's as compared to Physicians. 

As a profession, we are not engaging in a mudsling between our supervising physicians and our profession but we are however responsible for responding to allegations that are nor factual and cast an ominous shadow on our profession. The Internal Affairs department of Mercy Medical Center, a hospital within the Catholic Health System will perform due diligence to review the medical records and perform a competency on the PA. This PA can ,in every likelihood been assigned to a sick patient that had a poor prognosis and this physician was looking for a whipping boy. 

I applaud Mercy for defending their PA section as well as for reviewing these allegations. Censuring the physician for his breach of etiquette and for his remarks that can be considered slanderous , was indeed derisive. We need to be careful as to not having a knee jerk reaction and equating the MD/DO professions as the "dark side of the Force" and to remember that the Physician/PA Team has forty years of effective demonstration  and has stood the test of time throughout the United States. I look forward to a successful resolution of this situation. The PA personnel who are in administrative positions at Mercy and at other medical centers have weighed in and they are to be applauded for their excellence, their competence and their vigilance in reviewing this allegation and rendering their professional opinions.

Warmly,
Robert M. Blumm, MA, RPA-C, DFAAPA 

Susan,
 I am outraged at the lack of fair and honest reporting that has been displayed here. The fact that a media source such as the NY Post could participate in the printing of such a story as this is beyond my comprehension.

Dr. Colantonio's claims are so far from being righteous and pure than you can possibly imagine. The reporting of the unfortunate and truly tragic circumstances that surround the mastectomy pateint are only a further attempt to lend credibility to a physician who has had a history of difficulties throughout his career. This case has NOTHING to do with the attempted character assassination of the Physician Assistant at Mercy and our profession on the whole.

How you could report on the supposed "facts" involving these patients at Mercy without having having the medical knowledge nor the true circumstances and details surrounding each one of these cases, is like trying to explain a 1000 page novel after being "told" what happened in 3 pages of the story.  The point is YOU  CAN'T. 

You have a responsibility to the public, who's trust you have just violated, by not doing your homework,  and thoroughly looking at the situation which Dr. Colantonio alleges. Included in this is looking at Dr. Colantonio himself. His position as a "whistle blower" is very tactical. In this day and age, it by default has given him this "appearance" of credibility, yet at the same time is becoming a shield to which all criticism of him can be deflected as nothing but retribution or retaliation, because of his plight.

I have been a Cardiac Surgical and Critical Care Physician Assistant for the last 15 years. (My whole career) I have been a consummate educator and professional in this time, I have done as much as I could, to further the knowledge and understanding in both the medical and lay communities about PAs and the extent of our positive impact on health care.

I am familiar with Mercy hospital and the impact of this Physician Assistant there. This individual has an exemplary record and extensive experience and training. He has been the single most important addition to that ICU setting since his arrival there and in the last 15 years. His ability to forge relationships with physician in that setting, enhanced communication and the coordination and delivery of medical care to the most critically ill patients. His presence and ability to intercede in the care of a patient alone has saved countless lives. In an ICU setting, the clinical course of a patient can change in an instant. In an environment such as this, you lack the luxury of time. Hence why the ability to assess and act in a moment's notice, is what truly makes the difference in patient outcomes. Minutes count. Whether it is in placing a central venous line for the administration of emergency medication, IV fluids, or antibiotics, placing a temporary pacemaker in a patient who has little or no heartbeat, or medically assessing a rapidly deteriorating patient then communicating with the appropriate physician and initiating a new treatment plan. In many community hospitals (such a Mercy), this is not possible. Our profession as well as Nurse Practitioners represent the group of medical professionals known as physician extenders. It is our ability to communicate with our physician colleagues and the medical training that,we have that allow us to partner with physicians, nurses, and others to make up the multidisciplinary medical team of today.

I wonder if any of what I have just stated you are even aware. More importantly though, is the fact that the public largely doesn't realize this. We as professionals work painstakingly to educate the public around us. However your "Newspaper" has an instant impact with the public, who is so ready to believe any potential or alleged wrong doing that you report. The tragedy is that when exposed for what this really is I imagine there won't be any retraction on your part or restatement of the facts, because that's not nearly as interesting or shocking.

I know how this works. either nothing will be said or another story will appear minimized and buried somewhere away from visibility. You tell me what is right and what is wrong here!!!!
Bruce Hormann 
 

David,
I have written many stories on doctors and other health-care providers accused of making errors. This article dealt with accusations against one assistant, not the "entire profession."

   Many of the stories we do result in calls for new regulations or laws.

  For backround, I spoke to the president of the NY State Society of Physician Assistants, and my article explained that PAs are trained and may perform many of the same tasks that do, without their physician supervisor in the room. Patients have a right to know that.

  We do stories about misconduct by individual police officers or teachers, for example, but that does not mean we are denouncing every cop and teacher, or their professions.

   In any follow up stories, I will try my best to be fair and not give the wrong impression about your profession.
I appreciate your comments.

Susan. 
[SUSAN EDELMAN]

Susan: 
Maybe you did not write it so I could be wrong in pointing it out but there was a caption that said that said something about the public needing legislation to "protect" them from PAs. Actions by one professional do not equate to calling for new legislation. I think you would agree that that was a bit rash. There are 70,000 PAs practicing across America in every specialty. We prescribe in ALL 50 states. If we as a profession were incompetent, it would have shown up. I still say that we do not even know this PA is guilty of any wrong doing. There are hundreds of physicians who work at this institution. Why is no other physician standing next to the complaining physician in the picture? 

Thank you for your response. Please try to look at things in a bit more balanced way as PAs are a new profession and compared to physicians, generally misunderstood.
Dave
[David Mittman]

All I can say is that it seems to me they are hanging this guy out to dry in the press because a "DOCTOR" said this PA was doing procedures he really was not supposed to be doing because the hospital wanted to make a profit. 

So in her response to me, the reporter calls us "assistants" and points out that she MADE SURE that people knew we can do things without the doctor being in the same room. WOW. How about the thousands of us running clinics in towns that never will have docs in them.

I know what you guys are going to say, but I still believe that "assistants" in our society are NOT SUPPOSED TO be doing what the people they assist do. They are only assistants, how the hell can they be competent in doing complex doctor things? That to me is part of the reason why this is being sensationalized and an undercurrent in the article. Would ASSOCIATE help, in my not so humble opinion, without a doubt.

Dave
[David Mittman]
 

Once again, *assistant* is equated with aide, underling, not capable of working without supervision, not capable of making independent
decisions even within the scope of one's professional training. If you have ever read Jim Collins' classic business book, Good to Great,
you will know that he calls this: confronting the brutal facts. It's a painful but absolutely necessary step in our evolution.

The name must go. Period.

Branding is everything in the marketplace and in the minds of our consumer/patients.

Without a name change we are wasting our efforts, we cannot move forward as a profession, in fact we cannot even make a reasoned claim
to a profession in the minds of our most important stakeholders, our patients, and to the larger community. All it takes is one
mis-informed and mis-guided individual, a reporter to write a story that gets picked up by the AP wire, and the next thing you know we
could (collectively) be plastered on Larry King Live.

Best,
Ellen
Ellen Britt, PA, Ed.D.

Dave, You're right -- I did not write that caption. 
They apparently took it from a letter that Dr. Colantonio wrote, which I chose not to quote.

You're also right that the actions of one or even several professionals, even if misconduct or errors are involved, do not
alone warrant a call for legislation. If the PA broke a rule, say, of failing to get consent, he would be disciplined under a rule that
already protects from such abuse.

I see your point. Thanks for the constructive criticism.
Susan
[SUSAN EDELMAN]

Standing Together- A Collective Voice Triumphs

By Robert M. Blumm, MA, RPA-C, DFAAPA President, American College of Clinicians

People standing together for an idea that they believe is as beautiful as a budding rose on Valentine's Day. Friday, February 14, Valentines Day, the Medical staff of Mercy Medical Center, with the support of PA's, NP's, nurses, administrative PA's from other hospitals and health care systems, faculty from Hofstra University, NYSSPA and ACC and APACVS officers and other parties "met the press" on behalf of a Medical Center, a PA and a Profession.

At 1 PM, the auditorium of the Mercy Lounge was filled to capacity with cameras from all of the major news channels and the reporters from all of the major news agencies that had printed previous articles on this unfolding drama. A procession of PA's in white lab coats came down the middle aisle and took seats at the side of the auditorium and near the front. These were followed by administrative PA's from other hospitals and health care systems who were seated on the platform facing the audience. Officers from the ACC, NYSSPA and the APACVS were seated on the left front of the room along with the faculty from Hofstra University. In the center of the room was a table with five microphones that were then occupied by the executive committee of the Medical Board and the vice president of the State PA Society, NYSSPA.

Xenophon Xenophontos, M.D., president of the Executive Committee of the medical staff, a vascular surgeon, opened the conference with a statement of purpose for this unprecedented event. Dr. Xenophontos explained that the medical staff is not the administration of the hospital and added "the medical staff wanted the public to be aware of their strong feelings concerning the false information that has been disseminated about patient safety and clinical care at Mercy Medical Center." Dr. Xenophontos made it clear that their purpose was neither to respond on behalf of the hospital to allegations that had been made nor to address any particular patient. He clearly stated "we will not do any patients the disservice of commenting publically on their confidential medical information or the care they received."

Robert Curran, M.D., vice president of the Executive Committee of the medical staff, an internist, was next to comment. "In the nearly 100 years of its history of service to the Long Island community, there has never before been the need for physicians,--supported by nurses, physician assistants, and other hospital staff-to gather together for the purpose of confronting the defamation of this institution. Over the decades Mercy Medical Center has provided safe, high-quality medical care for countless people. The allegations that patients are in danger at Mercy Medical Center is simply not true! As physicians who treat our patients here, we see every day that at Mercy Medical Center, close attention is paid to patient safety and to providing the highest standard of care in a compassionate environment. Unfortunately, that fact has been swept away in a storm of sound bites, photo-ops and baseless accusations." Dr Curran continued with this closing remark which looked towards the future: "In the fullness of time, the truth will become clear. But for now, we stand behind Mercy Medical Center. We put our reputations next to its name." Pointing to those assembled around him, Dr Curran commented: "We are proud to be associated with the people in this room who come here every day for the sole purpose of helping people to get better. We are proud to be associated with the Mercy Medical Center."

The next speaker was Jan Koenig, M.D., Director of Orthopedics and a well-known total joint replacement surgeon. Dr. Koenig stated that he "works in a Mercy Medical Center that is a state of the art community hospital that believes in, and lends every effort to provide safe, quality medical care, healing, comfort and exceptional service with dignity and respect for all." In speaking concerning advanced practice clinicians, Dr. Koenig said "I believe as most of my profession does in the team approach to patient care. One man or woman cannot do it alone. Physicians rely on physician assistants, who are well trained, qualified and licensed professionals. Many hospitals rely on physician assistants to maintain the high level of quality care their patients deserve. I want to thank all of our physician assistants for the vital role they play in patient care. It is a pleasure to work with these talented and well trained professionals." In speaking of the events that have surfaced this past week, Dr Koenig commented "the false allegations that have been publicized so widely have hurt the entire staff at the Mercy Medical Center. And I am personally ashamed of the behavior of this physician who portrays himself as a 'healer' but whose unfounded allegations have hurt so many innocent patients and families." Part of his closing remarks focused on the fact that perception is not always reality. Dr. Koenig forcefully commented that "I don't practice in the same Mercy Medical Center that's been in the news this past week. I practice in a Mercy Medical Center where everyone is dedicated to patient safety and high-quality care." He commented on the skills and superior training and expertise of the physician assistant in question. As did all of the other physicians, he recognized that compared to the national average, the PA mentioned, when compared to the national average of central line insertions, has a lower rate of complications than the national average, which includes lines placed by physicians.

The next powerful advocate for the PA profession and for the institution was its Chief of the Emergency Department; Dr. Daniel Murphy, M.D. Dr. Murphy immediately commands the attention of the room of participants because of his clear, strong and dynamic message. This is a physician who depends on excellent advanced practice clinicians in order to command the "heart" of the hospital. After explaining that this is an extraordinary situation he said" not because physicians and physicians assistants have gathered to show support of the hospital where they practice, but because of the reason for all this effort and stress-and time spent away from our patients- results from the actions of a physician who has issued a series of false allegations that have raised baseless fears about patient safety at our hospital. Dr. Colantonio has in fact completely-and I pray only temporarily-corrupted the quality improvement process at Mercy Medical Center which is based upon self-reporting, surveillance and oversight, confidentiality and peer review.- just like every other hospital in the United States." Passionately Dr. Murphy explained that "the unsubstantiated claims of this man are part of a calculated effort to damage the reputation of the Mercy Medical Center by a lawyer-physician who portrays himself as a hero, but in reality has no insight about his own weaknesses and is seeking retribution for disciplinary action that came from his fellow physicians-his peers." Dr. Murphy mentioned that he was told that in the last decade only 3 have warranted the severe disciplinary action received by Dr. Colantonio. "As a lawyer as well as a physician, Dr. Colantonio understands precisely what he can allege without having to stand up to the scrutiny of facts and documentation. And he knows full well that the hospital cannot respond with details that would reveal his accusations to be false, because the hospital must abide by confidentiality laws. As important as the law, the professionals before you- who have sworn the oath of Hippocrates-would never do our patients or their loved ones the disservice or the dishonor of describing their precious, personal and private health issues in a public forum." In addition, "Dr. Colantonio has taken advantage of a lack of public understanding of the role of very valuable members of the hospital care team-physician assistants or PA's. He would have people believe that these dedicate professionals-many of whom stand behind me-are unqualified and under supervised, when the fact is, that they are highly trained and perform their tasks after an order by a physician and under the supervision of physicians-such as me." He commented that he works side by side with these professionals every day and they are very valuable team players in the care provided by this physician, allowing him to provide better care to his patients. "Indeed, Dr.Colantonio has directly insulted thousands of highly trained , credentialed and licensed PA's in this country with his self serving and false manipulations-it's exactly the same as insulting this country's firemen or policemen or military-all for his personal gain and retribution."

His final words, "So let me wish you a Happy St.Valentines Day. Look around this room." (The reporters looked carefully.) "There is a collective integrity here that is not found in Dr. Anthony Colantonio. We will not be silent in the face of this character assassination. We will not allow this hospital to suffer the actions of a single individual whose agenda has nothing to do with medicine and everything to do with inflicting pain. For the love of mercy, we stand here together as one." At this time there was a spontaneous clapping and ovation from all present, including many of the reporters. Truth is a very difficult wall to assail.

The final participant of the conference prior to the reporters themselves was John Hallowell, RPA-C, a chief PA in his institution and the vice president of NYSSPA. John was the delegated PA to speak for the 8,000 PA's in New York. Usually quiet and mild mannered, he seemed to have the mantel of authority and of righteousness as he made his remarks. "These allegations have caused quite a stir, not to mention quite a bit of public speculation about the medical training, credibility, and capability of physician assistants. Whether intended or not, many readers and viewers may have been left with less than a positive perception of physician assistants. The New York State Society of Physician Assistants represents the interests of PA's throughout New York State, a state in which more PA's work than in any other state in the country. We want to express our concern about such a misrepresentation of our profession, especially when our profession is dedicated and committed to working with physicians and providing nothing but the highest quality medical care to our patients and their families." John continued by giving the audience an overview of the Physician Assistant profession, its education, training, rotations, demonstration of competencies and re-evaluations. He delineated the role as prescribed by state law and the relationship that exists between a PA and her/his supervising physician. He described the PANCE and the PANRE. He mentioned that we are nationally certified and are the only profession that voluntarily retakes their boards every six years. John explained the total scope of practice and specialty training. For the sake of those who were not present, he summarized with these powerful words that sounded like the voice that Charleston Heston heard in The Ten Commandments. "The New York State Society of Physician Assistants and over 8,000 PA's in our great state are very proud of the care we provide. We are highly trained professionals here for our patients and their families. We care about quality healthcare. We care about positive outcomes. We care about "doing the right thing." We care about our positive role in the healthcare system and we know that many, many people are living healthier, longer and more satisfying lives because they were treated by a physician assistant." And for a second time that afternoon, the room was shook by applause from those gathered.

I'm an old salt in this profession, having been a Vietnam era combat medic who became a PA upon his return from Vietnam. It is rare that I felt the pride that I felt this Valentine's Day after hearing the remarks by these dedicated physicians and this PA leader. I only wish that the PA who was falsely accused would have been present to personally see this demonstration of support. When asked by the reporters if Mr. - was working today, Dr. Koenig said, "I hope so." Upon reading the Newsday the following morning, I saw a far more fair representation of the truth and of the meeting I attended. What also made me personally proud was the reasoning behind the presence of so many. Anne Bozzarelli, PA Program Director of Hofstra was present with her faculty because this was the least she could do for an institution who was so gracious as to allow her students the privilege of being taught by these fine physicians and PA's. The administrative PA's from the other hospitals and health care institutions mentioned that this was not an option, as when one of us is attacked we are all attacked. They also stood by the PA whom they know to be an excellent representation of our profession.

What can we all learn from this catastrophic situation that created this personal and institutional pain? Perhaps it's that not everyone with whom we work has the same integrity as ourselves. Perhaps it's the fact that regardless of our skills, our education, and our personal track record (this PA has an excellent reputation among his peers) we can still become targets and victims of selfish, unfair and corrupt individuals. Perhaps it is that the news community can report in an unethical and unsubstantiated manner, destroying confidence in a profession or an institution. Perhaps it is that if you are a PA or NP or DO or MD who earnestly is committed to quality care, your peers will stand by you, your hospital will stand with you and your patients will still be proud to receive treatment from you. Perhaps there will be a recognition and an understanding that when a profession is attacked by the press that this can initiate a "witch hunt" where another similar profession can be brought into the spotlight also. Perhaps we learn that there is strength when we stand together regardless of the initials after our name. Yes, it's the power of one that can still reconcile us to the world.

I appreciate the comments of all who were present and I hope that my readers take this situation to heart. I would like to summarize this article with a comment from another physician. "Next to the promulgation of the truth, the best thing I can conceive that a man can do is the public recantation of an error." Joseph Lister 1827-1912. Can you hear me, Dr. Colantonio? 
 
 

Copyright ©2007 by The American College of Clinicians
209 West Central Street, Suite 228, Natick, MA  01760
Telephone 1-866-338-9222
info@amcollege.org
 

ALL THESE ARE DEATHS PER YEAR: 

• 12,000 -----unnecessary surgery 8 
• 7,000 -----medication errors in hospitals 9 
• 20,000 ----other errors in hospitals 10 
• 80,000 ----infections in hospitals 10 
• 106,000 ---non-error, negative effects of drugs 2 

What does the word iatrogenic mean? This term is defined as induced in a patient by a physician's activity, manner, or therapy. Used especially of a complication of treatment.

Dr. Starfield offers several warnings in interpreting these numbers: 

• First, most of the data are derived from studies in hospitalized patients. 
• Second, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort. 
• Third, the estimates of death due to error are lower than those in the IOM report. 1 

Another analysis 11 concluded that between 4% and 18% of consecutive patients experience negative effects in outpatient settings,with: 

• 116 million extra physician visits 
• 77 million extra prescriptions 
• 17 million emergency department visits 
• 8 million hospitalizations 
• 3 million long-term admissions 
• 199,000 additional deaths 
• $77 billion in extra costs 

However, evidence from a few studies indicates that as many as 20% to 30% of patients receive inappropriate care.

An estimated 44,000 to 98,000 among them die each year as a result of medical errors.2

This might be tolerated if it resulted in better health, but does it? Of 13 countries in a recent comparison,3, 4 the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. More specifically, the ranking of the US on several indicators was: 

• 13th (last) for low-birth-weight percentages 
• 13th for neonatal mortality and infant mortality overall 14 
• 11th for postneonatal mortality 
• 13th for years of potential life lost (excluding external causes) 
• 11th for life expectancy at 1 year for females, 12th for males 
• 10th for life expectancy at 15 years for females, 12th for males 
• 10th for life expectancy at 40 years for females, 9th for males 
• 7th for life expectancy at 65 years for females, 7th for males 
• 3rd for life expectancy at 80 years for females, 3rd for males 
• 10th for age-adjusted mortality 

There is a perception that the American public "behaves badly" by smoking, drinking, and perpetrating violence." However the data does not support this assertion. 

• The proportion of females who smoke ranges from 14% in Japan to 41% in Denmark; in the United States, it is 24% (fifth best). For males, the range is from 26% in Sweden to 61% in Japan; it is 28% in the United States (third best). 
• The US ranks fifth best for alcoholic beverage consumption. 
• The US has relatively low consumption of animal fats (fifth lowest in men aged 55-64 years in 20 industrialized countries) and the third lowest mean cholesterol concentrations among men aged 50 to 70 years among 13 industrialized countries. 

Even at the lower estimate of 225,000 deaths per year, this constitutes the third leading cause of death in the US, following heart disease and cancer.

Lack of technology is certainly not a contributing factor to the US's low ranking. 

• Among 29 countries, the United States is second only to Japan in the availability of magnetic resonance imaging units and computed tomography scanners per million population. 17 
• Japan, however, ranks highest on health, whereas the US ranks among the lowest. 
• It is possible that the high use of technology in Japan is limited to diagnostic technology not matched by high rates of treatment, whereas in the US, high use of diagnostic technology may be linked to more treatment. 
• Supporting this possibility are data showing that the number of employees per bed (full-time equivalents) in the United States is highest among the countries ranked, whereas they are very low in Japan, far lower than can be accounted for by the common practice of having family members rather than hospital staff provide the amenities of hospital care. 

Author/Article Information

Author Affiliation: Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, Md. Corresponding Author and Reprints: Barbara Starfield, MD, MPH, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, 624 N Broadway, Room 452, Baltimore, MD 21205-1996 (e-mail: bstarfie@jhsph.edu).

REFERENCES

1. Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States?
Milbank Q. 1998;76:517-563.

2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

3. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.

4. World Health Report 2000. Available at: http://www.who.int/whr/2000/en/report.htm. Accessed June 28, 2000.

5. Kunst A. Cross-national Comparisons of Socioeconomic Differences in Mortality. Rotterdam, the Netherlands: Erasmus University; 1997.

6. Law M, Wald N. Why heart disease mortality is low in France: the time lag explanation. BMJ. 1999;313:1471-1480.

7. Starfield B. Evaluating the State Children's Health Insurance Program: critical considerations.
Annu Rev Public Health. 2000;21:569-585.

8. Leape L.Unecessarsary surgery. Annu Rev Public Health. 1992;13:363-383.

9. Phillips D, Christenfeld N, Glynn L. Increase in US medication-error deaths between 1983 and 1993. Lancet. 1998;351:643-644.

10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients. JAMA. 1998;279:1200-1205.

11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology and medical error.BMJ. 2000;320:774-777.

12. Wilkinson R. Unhealthy Societies: The Afflictions of Inequality. London, England: Routledge; 1996.

13. Evans R, Roos N. What is right about the Canadian health system? Milbank Q. 1999;77:393-399.

14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M, Strobino D. Annual summary of vital statistics1998. Pediatrics. 1999;104:1229-1246.

15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14:499-511.

16. Donahoe MT. Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1607.

17. Anderson G, Poullier J-P. Health Spending, Access, and Outcomes: Trends in Industrialized Countries. New York, NY: The Commonwealth Fund; 1999.

18. Mold J, Stein H. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314:512-514.

19. Shi L, Starfield B. Income inequality, primary care, and health indicators. J Fam Pract.
1999;48:275-284.

Karen Bass will be the first female African American to hold the position.
By Nancy Vogel
Los Angeles Times Staff Writer
 

February 28, 2008
 

SACRAMENTO --  Besting eight colleagues, Los Angeles Democrat Karen Bass secured enough votes Wednesday to become the next Assembly speaker, making her the first African American woman to do so.
 

Bass, 54, is expected to be formally elected today by both the 48-member Democratic caucus and the full Assembly. She will be considered "speaker designee" until she and current Speaker Fabian Nu?ez, a fellow Los Angeles Democrat, agree on a transition date, said Nu?ez spokesman Steve Maviglio.
 

Bass would become the second woman to serve as Assembly speaker. Doris Allen, a Republican, led the chamber from June to September 1995.
 

Nu?ez's term in the Assembly expires in December; if Bass is reelected this year, she may serve through 2010.
 

Bass won pledges of support from a critical mass of Democrats in the lower house Wednesday, beating a pack of contenders for the speakership. Jousting for the leadership post began after voters defeated Proposition 93 on the Feb. 5 ballot. That measure would have allowed Nu?ez and other legislators to seek reelection rather than be forced to leave their positions at the end of this year.
 

A community activist and physician's assistant whose Assembly seat is her first elected office, Bass is well regarded by her colleagues and has served as Nu?ez's majority leader. She has focused on foster care issues since her 2004 election to represent the 47th Assembly District, which includes Baldwin Hills, Culver City and parts of Koreatown, South Los Angeles and the Westside.
 

"I just spoke to Karen a few minutes ago and congratulated her and wished her well," said Assemblyman Anthony Portantino (D-La Ca?ada Flintridge), who had sought the speakership himself.?
 

"It's a historic occasion, and I look forward to continuing to work with her to benefit the state of California," he said. "I know she's going to do a great job."
 

Though Nu?ez had set a March 11 date for the Assembly's majority Democratic caucus to elect its new leader, Bass secured majority support Wednesday evening after Assemblywoman Fiona Ma (D-San Francisco) and Assemblyman Kevin De Leon (D-Los Angeles) -- both speaker candidates -- gave her their backing. Nu?ez then called members into his office one by one, and momentum behind Bass grew, Ma said.
 

"Karen and I have the same base of supporters," Ma said, "and it was very evident that she was committed to staying and being speaker."
 

Bass was not available for comment Wednesday night.
 

The post of speaker involves negotiating the budget and major public policy legislation with the governor, the Senate leader and the minority party leaders in both houses.
 

Besides Portantino, Ma and De Leon, other Democrats seeking the job had included Charles Calderon of Montebello, Hector De La Torre of South Gate, Mike Feuer of Los Angeles, Ed Hernandez of Baldwin Park and Alberto Torrico of Newark.
 

Earlier this month, senators chose Democrat Darrell Steinberg of Sacramento to replace Senate President Pro Tem Don Perata of Oakland later this year.
 

In throwing their support to Bass, members had to weigh her potential longevity in the job. Not only is she termed out in just two years, she may have the option next year of running for either a Los Angeles City Council or state Senate seat. Bass assured her colleagues that she would not depart early, according to Ma.
 

"She said she was committed to staying in the Assembly if she was elected speaker, and she really wanted to do this job," said Ma, who praised Bass' integrity and intelligence. "She is in public service for the right reasons. It was kind of her time."
 

Nu?ez was elected speaker in his second year in the Assembly and has led the 80-member house since February 2004, the longest stint of any speaker since voters imposed term limits in 1990.
 

Raised in the Venice/Fairfax area, Bass taught in USC's physician's assistant program until the crack epidemic -- which she witnessed firsthand at the USC trauma center -- spurred her to create the Community Coalition, a nonprofit group that worked to close or convert liquor stores in South Los Angeles, attract more funding to local schools and organize residents.
 

Bass' only daughter, Emilia, was a 23-year-old newlywed just months shy of graduating from Loyola Marymount University when she and her husband, Michael Wright, also 23, were killed in a car crash near Los Angeles International Airport in 2006.
 

nancy.vogel@latimes.com

2/25/2008 - SOUTHWEST ASIA (AFPN)  -- Military servicemembers wounded in combat deserve the best health care available. When it comes to providing top-notch medical support, the 379th Expeditionary Medical Group relies on a total force team of medical experts to get the job done. 
 

"When soldiers suffer injuries that have a relatively fast recovery period, they are sent here to be treated and given time to recuperate," said Lt. Col. Michele Gavin, the 379th EMDG primary care clinic element chief on her third deployment to Southwest Asia. "We have a very cohesive unit, which enables us to return them (the wounded) to the frontlines quickly." 
 

On her fourth deployment in as many years, Colonel Gavin is a seasoned veteran, having served in the Army Reserve Command and Air National Guard for more than 26 years. Whether working as a guard member or in her civilian position at the Cleveland Clinic, "my job is to practice medicine," said the physician's assistant deployed from the 180th Fighter Wing in Toledo, Ohio. 
 

"Ten to 15 percent of the group is guard or reserve," said Col. Michael Menning, the 379th EMDG commander. One of the biggest benefits to having a total force team is the fact that many of the guardsmen and reservists have deployed before, he said. It provides stability and corporate knowledge on how things work here. 
 

"Whether active duty, guard or reserve we are all medical professionals. By coming together we are able to learn from each other," said Capt. Christine Yarbrough, a pharmacist deployed from Nellis Air Force Base, Nev. "Bringing their experiences gained in the civilian sector, the guard and reserve offer a fresh set of eyes to what we do here." 
 

The learning happens not only as a result of military and civilian comparisons, but also based on the size of the hospital or clinic from which members hail. There are various resources available based on the size of the facility, said Capt. Dion Vecchio, 379th EMDG intensive care unit and ward element chief. "Different perspectives on different capabilities allow us to use our resources here wisely." 
 

A self-proclaimed "Guard bum," Staff Sgt. Trisha Myers' diverse background certainly offers a unique perspective. A Michigan native and medical technician, she has spent a total of 18 years as a member of the active duty Air Force as well as the Army and Air National Guards in mixed lengths. 
 

"I've been given a variety of opportunities to serve (my country) over the years, but my passion is patient care," Sergeant Myers said. "Working with the Wounded Warrior program here is very rewarding. I do whatever I can to make the patients more comfortable; from giving them a popsicle to telling them a joke." She says it's the simple things that brighten their days. 
 

"You never know what (type of patient) will walk through the door next. We see a lot of patients, with many different complaints," said Colonel Gavin. She says the makeup of the group helps combat that challenge. "The Air National Guard and Air Force Reserve (members) mixed with active duty Air Force gives us a wide variety, as well as many years of medical experience to care for the population here." 
 

The active duty, guard and reserve total force team that makes up the 379th EMDG helps heal the wounded and continues to make an impression on those they care for. 

"We have a small footprint in terms of personnel (numbers), but overall we make a mammoth impact," Colonel Menning said. 

By Carol Biliczky 
Beacon Journal

Published on Tuesday, Feb 12, 2008

Small Mount Union College is poised to launch a physician assistant program in May 2009, its first master's degree in almost a century.

The private, liberal arts college in Alliance chose to re-enter graduate education with a specialty in proven demand.

Ohio ranks 40th nationwide in per capita employment of physician assistants, whose ranks are expected to grow much faster than the average for all occupations through 2012, according to the U.S. Bureau of Labor Statistics.

Mount Union Dean Patricia Draves said the new program would fit in with ''who we are.'' Officials are seeking accreditation now.

''We have a strong science program and Alliance Community Hospital is right across the street,'' she said. ''We have a history of service learning and service to the community.''

In addition, now is a natural time to launch a program thanks to the state. Beginning this year, physician assistants must have graduate degrees to practice in Ohio.

Nationwide, the 137 institutions with P.A. programs include five in Ohio: at the University of Toledo; Cuyahoga Community College, in collaboration with Cleveland State; the University of Findlay; the Kettering College of Medical Arts; and Marietta College.

P.A.s provide cost-effective primary medical care under the supervision of physicians. They are employed in physician offices, public clinics, prisons and academic medical centers, the statistics bureau said.

Mount Union aims to enroll 25 to 30 students each year for its two-year program, half of which would be provided in the classroom, half in clinical settings. Admission may be rigorous, as Marietta College gets about 200 applications for its 22 seats in each year's class.

The cost of the program has not been determined, Draves said.

Mount Union's last master's programs in education and the humanities were disbanded in 1912 in favor of a stronger focus on undergraduate liberal arts.

Draves said other master's programs may be established in the future.

The college has 2,200 undergraduates and is affiliated with the United Methodist Church.
 

Kentucky Medical Association wants to keep "allied health professionals" in their place

Dr. Thomas Slabaugh, KMA president: "Opposing what doctors say are efforts by allied health professionals to practice medicine and 'supplant physicians.' "
One PA-C  in NC Replies:"INDEED!!! If they hadn't choked the flow of students through medical schools to keep"too many doctors," from going broke or starving; if they had enough primary care offices around, that their own patients didn't have to wait a week for a sore throat appointment, and looked instead to a clinic in a drugstore, then there would be no need for PAs and NPs.

PAworld.net
http://www.kentucky.com/101/story/303284.html

ROCKY HILL, Conn. - The future of medicine in Massachusetts can be found along an unremarkable patch of suburbia south of Hartford, inside a CVS pharmacy where Sheree Albino sat hunched and pale on a recent Sunday morning.

Her sinuses were killing her. She wanted relief. And she didn't have time to wait.

"So I came here," Albino, 52, said, her voice rasping like sandpaper. She'd just left the drugstore's MinuteClinic, a sliver of a medical office next to the photo processing counter and not far from the chew toys for dogs. "It's quick and easy. They should have done this a long time ago."

With CVS planning to open dozens of medical clinics in Massachusetts, Mayor Thomas M. Menino of Boston and other critics have warned of inferior care driven by an unquenchable profit motive. He and others predicted that in the name of convenience, patients would sacrifice an ongoing relationship with a doctor.

But interviews with a dozen independent researchers, insurers, and regulators in other states painted a far more positive portrait. Increasing evidence, they said, suggests that when patients are treated for sore throats and other minor illnesses at retail clinics, the care may actually be as good as - if not better than - in more traditional doctor offices. That is testament, in large measure, to an approach akin to a chef faithfully following a cookbook. Nurse-practitioners in the clinics use a computer-generated template that, for example, will not allow them to prescribe an antibiotic unless they first make sure the patient has no allergies to the drug.

"Frankly, from our perspective, there's a lot of good stuff in the MinuteClinic model," said Dr. Marcus Thygeson, vice president of HealthPartners, a major Minnesota medical plan whose patients have made 20,000 visits to the retail clinics in the past four years. "We like the convenience and ready access."

No state has more experience with retail clinics than Minnesota, the birthplace nearly eight years ago of MinuteClinic, which still dominates the field even as competitors crowd in. An independent, nonprofit coalition of doctors, insurers, consumers, and employers called MN Community Measurement annually rates health clinics' and doctors' practices statewide.

"Lo and behold," said Jim Chase, executive director of MN Community Measurement, "the MinuteClinic actually did very well."

The most recent report card from the group, based on data from 2006, awarded MinuteClinic the highest marks in Minnesota for treating children 2 to 18 years old for sore throats, giving it a score of 99 percent. The lowest grade: 26 percent for a doctors' group.

The high score reflects that nurse-practitioners were careful not to prescribe antibiotics for sore throats caused by viruses because the drugs are useless against viral infections. Incorrect use of antibiotics can spawn dangerous germs that are resistant to medication.

"This is not a prescription mill," said Michael Howe, the former Arby's chief executive who now leads MinuteClinic, which has 475 outlets, up from 466 just a week ago. The CVS subsidiary has never been sued for malpractice, executives said.

The clinics, which do not require appointments and stay open on evenings and weekends, treat a limited number of ailments: minor illnesses such as ear infections, poison ivy, and bronchitis. In its name and advertising slogan ("You're sick, we're quick!"), the chain trumpets a promise of speed and efficiency.

And much like a fast-food restaurant, they list set prices for medical care. In Connecticut, it's $59 for pink eye treatment, $69 for strep throat.

The nurse-practitioners in the stores are supposed to refer patients to primary care doctors, urgent care centers, or emergency rooms if a patient's medical condition falls outside the MinuteClinics' scope of care.

Mary Kate Scott, a California consultant who has extensively studied in-store clinics, said that by restricting the services they provide, "it's actually very easy to hit an extraordinarily high quality rate.

"Because you do the same thing again and again, you get extremely good at it," she said.

Retail clinics are proliferating across the nation, with a report by Scott estimating that between January 2006 and September 2007, the number grew eightfold. The expansion is being driven by twin epidemics: the aging of baby boomers and the declining number of primary care physicians.

And Massachusetts has emerged as a potentially lucrative market because the push for universal health insurance means that previously uninsured patients who skipped visits in the past are now likelier to seek out treatment.

It's hoped by sending patients with simple problems to in-store clinics, doctors and emergency rooms will have more time for cases that demand their expertise.

"Having their time available to do the complex work or to work with patients with chronic conditions really depends on us figuring out how to create a system that allows the easier stuff to get done as easily and cheaply as we can," said Margaret Laws, of the California HealthCare Foundation, which commissioned Scott's report.

"Retail clinics may be that - or may not," she said.

Concerns persist about the wisdom of offering episodic medical care inside retail outlets. Matthew C. Katz, executive director of the Connecticut State Medical Society, said members have expressed "grave concern about the continuum of care" for patients who go to store-based clinics.

Specifically, he said, doctors are worried that they're not always alerted when their patients are seen at retail clinics, which in turn creates a risk that tests will be duplicated or extra doses of the same medication might be prescribed. CVS executives said patients are asked if they have a primary care physician and a record of their clinic visit is sent to the physician if the patient permits it.

Some physicians are embracing the arrival of retail clinics. Claire Nadeau, a nurse-practitioner who manages the 16 MinuteClinics in Connecticut, said a physician who practices near the Rocky Hill CVS urges patients on his after-hours phone recording to consider going to the pharmacy for night and weekend treatment.

That is exactly what Sheree Albino did. "This was a Sunday," she said. "You can put a call into your doctor, and they have somebody get back to you. At a MinuteClinic, you might get relief a little bit sooner." Back to Top

Physician extenders benefit you and your patients

Many orthopaedic surgeons are using physician extenders, such as physician assistants (PAs) or nurse practitioners, in their offices. These relationships can be very beneficial to patients, physicians, and the general public in responding to the ever-increasing number of people who need orthopaedic care.

If you are considering adding a physician extender to your practice, careful thought and planning can enhance the success of this endeavor.

Patients benefit from physician extenders
Integrating a physician extender into an orthopaedic practice primarily benefits your patients because it gives them greater access to the clinic. Patients may have the opportunity to sit and talk for a longer period of time with a physician extender than with an orthopaedic surgeon. They can ask many more questions and get an educated answer based on orthopaedic science, the individual needs of the patient, and the available resources of the specific orthopaedic practice. The physician extender can elevate the level of service to every patient in the practice.

You benefit as well
Access, efficiency, improved communication, revenue generation, and enhanced services are among the ways that physician extenders benefit an orthopaedic practice. 

With the aging of the baby boomer population, the national shortage of orthopaedic surgeons, and the increasing number of orthopaedic services that can be offered to the public, the need for access to orthopaedic care far exceeds the delivery capacity. A physician extender can be a very effective and efficient way to give more people access to the orthopaedic clinic.

A PA can make your office much more efficient. Physician extenders can perform many activities that require advanced medical education. They can enable the orthopaedic surgeon to focus on more complex problems while they provide care for more routine problems.

Physician extenders also can greatly enhance patient communication. A physician extender may be able to spend more one-on-one time with the patient, explaining preoperative and postoperative care, reviewing the care of injuries, and responding to questions when the surgeon is unavailable.

A PA can be an additional provider and bill separately for certain services in most states. Their ability to use their educations and bill for their services makes them positive revenue generators in most practices.

Finally, the physician extender can greatly enhance the overall service experience provided to the patient. This service can be reflected in more accessible appointment times, more time to speak with the provider, more timely returned phone calls, and a more personal, one-on-one relationship.

Issues to consider
When adding a physician extender, orthopaedic surgeons need to be aware of several issues, including licensure, insurance, care planning, and professional education/development.

PAs and nurse practitioners must hold an active license to practice medicine in the state in which they work. Different states have different requirements; some states also have restrictions regarding what PAs can do. 

In addition to licensure, medical liability is an issue. Most states and hospitals require a minimum amount of medical liability insurance for every licensed provider. Each PA must have a separate medical liability policy, although the rates are usually a fraction of those charged to orthopaedic surgeons. 

Do not neglect to establish a supervisory agreement or collaborative care plan. This document details the working arrangements between the PA and the practice. Among the issues that should be covered are the following: lines of communication, methods of communicating with physicians, scope of practice, limitations of practice, locations of practice, and working environment. The agreement must be executed and signed by the primary supervising physician and the physician extender. 

Be sure to set aside a specific budget and time for continuing professional education for each physician extender. They are professionals, and benefits should include membership in a professional society and sponsored attendance at educational meetings.

In a similar vein, show respect for the education and professionalism of individuals who have earned Certified Physician Assistant and/or Licensed Nurse Practitioner degrees. They are colleagues in delivering health care; treating them as such fosters a healthy professional relationship. Their professional development is as important as yours.

Physician extenders can be a valuable addition to your practice. When properly integrated into the practice, they can provide greater access to patients, greater efficiency for the office, greater professional satisfaction for the orthopaedic surgeon, and a positive revenue flow.

Charles E. Rhoades, MD, is a member of the AAOS Practice Management Committee. He can be reached at crhoades@kcoi.com

Four ways to integrate PAs into your practice

Integrating a physician extender into your office isn’t a matter of “one-size-fits-all.” How you use a physician assistant (PA) depends on many factors, but PAs may be integrated into orthopaedic offices primarily in the following four ways: 

Operating room (OR) assistant only 
Independent practice without a physician present 
Independent practice with a physician in attendance 
Practicing “incident to” an attending physician 
 

Although the PA may spend extra time explaining a planned procedure to the patient, the orthopaedic surgeon should make the first postoperative visit to the patient.

Operating room assistant only
Using a physician extender only in the OR can increase turnover efficiency, provide greater continuity of care from case preparation, and free up the primary surgeon’s time at the beginning and end of each case. 

Medicare and many commercial insurance companies provide reimbursement (approximately 15 percent of the basic surgical fees) for the services of a skilled surgical first assistant on certain cases. A list of cases that are deemed appropriate for a skilled surgical first assistant is available from the Centers for Medicare and Medicaid Services (CMS) and can be found on the CMS Web site (http://www.cms.hhs.gov/).

Some physician extenders may find this role professionally satisfying. Many others, however, may desire to use their education not only as a first assistant, but in the diagnostic and treatment phases of patient care in the orthopaedic office.

Independent practice without a physician present

Many states allow physician extenders to have an independent clinical practice without a physician present. States have specific rules and regulations regarding how far away the supervising physician can be, how much time can elapse before the supervising physician responds to an emergency, and what the physician extender can do in the specific situation.

Independent practice with a physician in attendance
Many offices use this model, in which the physician extender sees patients and has an office within the practice’s offices, where an attending physician is present. The PA may have his or her own clinic and patients and is able to develop long-term patient relationships in the orthopaedic office. 

Billing for the PA’s services, using the PA’s national provider identification (NPI) number is at approximately 80 percent of the physician’s rate. Under this model, the PA might see walk-in patients, handle uncomplicated fracture work, provide emergency department follow-up, conduct low back pain and heel pain screenings, and treat other common orthopaedic problems.

“Incident to” an attending physician
Physician extenders may bill under the physician’s NPI if they are practicing in the same office at the same time under the “incident to” rules. Specific Medicare regulations apply to physician hands-on visits for new problems, first-time Medicare visits, and follow-ups after a certain number of visits. This category of service is billed under the physician’s name and at the physician’s rates. 

If the PA is practicing in this environment, one of the following methods may be used to see patients: parallel clinic with the attending’s patients, “leap-frog” method, and joint visits.

In a parallel clinic situation, the PA works independently in a room(s) next to the attending physician and sees the attending physician’s private patients.

The leap-frog method has the physician and the PA working through the clinic and alternating seeing patients as they arrive. The physician may spend a short time with patients being seen by the PA. 

Finally, the physician and the physician extender may work together in the same room 100 percent of the time, jointly visiting each patient. Although convenient for the orthopaedic surgeon, this arrangement is probably the least efficient method. From a professional viewpoint, it is also the least satisfying to the PA, because it limits his or her ability to make independent judgments, formulate treatment plans, and exercise professional education.

Charles E. Rhoades, MD, is a member of the AAOS Practice Management Committee. He can be reached at crhoades@kcoi.com

Avoiding problems
Physician extenders should be used to enhance patient care. The physician assistant (PA) should not be a substitute for the physician, but a professional extension of the physician’s expertise. To avoid misunderstandings or problems, heed the following pointers:

Tell patients in advance that they will be seeing a PA. Assure them that the orthopaedic surgeon is nearby and ready to respond if needed. 
If the patient seems uneasy about seeing a PA, be very amiable and accommodate any request to see the orthopaedic surgeon. The surgeon can then transition future visits to the PA if needed. 
The orthopaedic surgeon—not the PA—should see and follow up with any patients who have complications. 
The orthopaedic surgeon—not the PA—should make the first postoperative visit to the patient. No one can explain the surgery better than the person who performed it. 
The physician should support and back the PA in front of the patient. Statements such as “that is not what I would have done” are damaging and counterproductive.

Mar 13, 2008 07:27 PM
Keith Leslie
THE CANADIAN PRESS

Ontario residents hoping to avoid long waits at hospital emergency rooms could soon find themselves being treated by an unfamiliar type of health-care professional: the physician assistant.

Health Minister George Smitherman said Thursday that physician assistants have played a long-standing role in the Canadian Armed Forces and in the United States, and he sees opportunities for them in the provincial health-care system.

Smitherman said the province is reviewing the data from a one-year pilot project at six Ontario emergency rooms which deployed physician assistants in teams with nurse practitioners, and he is already liking what it sees.

“We’ve seen anecdotally … it does seem like where the nurse practitioners and physician assistants have been deployed together, that has been an effective model,” he said.

“We would … offer to Ontarians this as one more example of how we can utilize the skill set of health-care professionals to make sure that their access to health care is timely, effective and gives them a good degree of patient satisfaction.”

Smitherman said it’s “a little bit early” to determine the exact role physician assistants would play in Ontario’s health-care system. He said there are other two-year pilot projects underway to evaluate the role of physician assistants in other areas of hospitals in addition to emergency departments and community health centres.

“We know that there are lots and lots of places where human resources are in such scarce supply that we have to be really smart and use our health-care professionals to their broadest scope of practice,” Smitherman said.

“We think it’s also an exciting opportunity to lure some Canadians back home to be practising as physician assistants.”

Conservative health critic Elizabeth Witmer said she supports increased roles for both nurse practitioners and physician assistants, and believes they would also be a big help in long-term care facilities.

“People who have them in their hospitals have told me they do appreciate (PAs), and it has made a difference,” Witmer said in an interview.

“Whatever we can do to make sure that people have access to health care, we need to do.”

However, Witmer said more than one million Ontarians are still without a family doctor, and she warned that an increased role for physician assistants won’t solve that problem, especially when there aren’t many trained PAs in Canada.

So far, Manitoba is the only province in Canada to have legislation governing the roles and responsibilities of physician assistants.

The Ontario Medical Association said physician assistants will have the education and skills to deal with daily health-care needs as well as medical emergencies.

They will carry out their duties under the supervision of a physician, and their duties will vary depending on the doctor’s area of practice.

M. ALEXANDER OTTO; alex.otto@thenewstribune.com 
Published: January 1st, 2008 01:00 AM | Updated: January 1st, 2008 07:15 AM

Last Wednesday, an elderly woman was taken to Tacoma General Hospital after a fall. Doctors didn’t find any broken bones, and the woman was released from the hospital that day. While that was certainly good news for the woman and her family, her visit had broader significance. 

The woman was the 10,000th person treated by the Tacoma Trauma Center since the service started in June 2000. 

Since then, a team of dedicated trauma surgeons and physician assistants, with the help of neuro and orthopaedic and other specialty surgeons, has been tending to local victims of car crashes, falls, gunshot wounds and other injuries, treating patients at Tacoma General Hospital and St. Joseph Medical Center on alternating days. 

The program has saved many lives, including those who probably would have died on their way to Harborview Medical Center in Seattle, where adult trauma victims from Pierce County were treated before the local service began. 

According to statistics from the National Trauma Data Bank, the service does its job well.

While about 4.4 percent of seriously injured patients die in comparable trauma services elsewhere in the country, the mortality figure for the Tacoma trauma service is 3.2 percent. 

The service has been “a great success story. It provides a service to this community that’s been desperately needed for years,” said Dr. Mike Newcomb, senior vice-president and chief medical officer of the Franciscan Health System, which owns St. Joseph Medical Center. 
 

CRASHES AND FALLS
 

The Tacoma trauma service treats about 1,500 people a year, about 10 percent of whom are victims of gunshots or stabbings. 

“Most of what we do are car crashes and falls,” said trauma surgeon Dr. Lori Morgan, head of the service. 

“That’s not gang-bangers,” she said, a common misconception about who trauma teams most treat. “That’s mom, dad, your neighbor, you.”

Christmas, though, “is really bad for interpersonal violence and suicide attempts,” Morgan said. 

“The season is supposed to be filled with joy and family. When it’s not,” there can be problems, she said. 

Morgan’s team usually includes six surgeons and six physician assistants, though she’s currently in the process of replacing two surgeons who left recently.

The team has an established routine for dealing with trauma cases.

The emergency room handling trauma duty that day will page Morgan’s team when they learn a trauma case is coming in. 

Almost always, one of her surgeons and physician assistants – they live at the hospital while they are on duty – are in the emergency room to meet the victim when he or she arrives. A room is always ready.

Morgan said the first goal is to quickly determine how seriously the person is hurt. 

Next, they are stabilized to prevent what Morgan calls the “death triangle” – a significant drop in blood pressure coupled with hypothermia and the buildup of acid in the blood, sometimes a sign that a person isn’t breathing well enough or has very poor circulation. 

The patient’s injuries are then attended to. 

The trauma team manages the patient during their hospital stay, and afterward, at a trauma clinic at St. Joseph.

With such a system in place, only about 60 Tacoma-area patients a year are sent to Harborview these days, mostly burn patients and people who need to have limbs reattached. 

Overall, trauma care in Tacoma is “an essential service,” Morgan said. 
 

HOSPITALS, OTHERS, STEP UP

Tacoma couldn’t always provide that vital service. 

The state required that communities provide trauma care in 1990. 

To meet the requirement, general surgeons at the time were called in to Tacoma General and St. Joseph Medical Center to treat trauma patients, no matter the time of day or night, or the obligations of the surgeon’s daytime practice.

“There was no infrastructure to handle trauma,” said Tacoma surgeon Dr. James Rifenbery. “It was a lone surgeon trying to make everything happen,” including finding an available operating room, and other essentials. 

“It was just a nightmare,” he said, especially with the area’s rampant gang violence at the time. Sometimes, shooting victims were simply dumped at the hospitals’ doors.

By 1995, the local medical community had had enough. Surgeons, for one, couldn’t balance their own regular practices with trauma duties, and they weren’t always getting paid for their trauma services if patients didn’t have insurance. 

So, Pierce County trauma victims began to be airlifted to Harborview Medical Center. 

Sometimes they’d die on the way. If they made it, they’d often be far away from their families. 

By the late 1990s, Tacoma General and St. Joseph Medical Center administrators “recognized a huge unfilled need for a coordinated trauma program,” Newcomb said. 

So, Rifenbury and his physician colleagues; Tacoma General and St. Joseph Medical Center administrators; local politicians; and Madigan Army Medical Center administrators, who have their own trauma service and agreed to treat some civilian patients; all worked together to set up the Tacoma trauma system.

Morgan was hired soon after. 
 

A COMMITMENT TO CARE

Today, the service runs on about $5 million a year. 

Like trauma services elsewhere in the state, it’s funded in part by surcharges on car sales and moving violations, a system set up by the state in 1997 largely to cover trauma care for uninsured or under-insured people.

There is also some federal funding through Madigan’s Department of Defense budget.

But more than $2 million a year comes directly from Tacoma General Hospital and St. Joseph Medical Center. 

The hospitals have also boosted support staff and outfitted special trauma rooms, among other things, to help the team. 

“I think it very admirable” – and unusual – “that (two) hospitals are willing to maintain that level of service for the community,” said Kathy Schmitt of the state Office of Emergency Medical Services and Trauma Services.

Hospital administrators have “made a commitment” to trauma service, she said.