EpiPens, Election Health, and the Plight of Bagpipes

If you’re outside, you can’t escape the heat. If you’re online, you can’t escape election coverage. If you’re following me on Twitter you can’t escape opioid articles. And if you play the bagpipes, you can’t escape ridicule and fungus.

These are leftover thoughts, reheated and served just for you. Enjoy!

 

– The opioid epidemic has weighed on my mind lately. I wrote an editorial for JAAPA that attempts a fair and balanced look at the issue and a blog for NEJM group that takes a more pointed tone.

For a street-level look at a different angle, NPR’s Embedded podcast did a fantastic job covering a town in Indiana that has become ground zero for a new HIV outbreak. The occupants of a single house have taken to injecting Opana, an opioid pain medication. The drug’s manufacturer employed a “safety mechanism” to stop abusers from crushing and snorting the pills. This drove users to melt and inject the drug instead and—in a town of just 5,000 people– has produced 190 new HIV infections.

 

– We are once again outraged by the hyperinflation of a drug price, this time Mylan’s EpiPen. People imagine a child’s preventable death at the hands of greedy pharmaceutical companies and their anger is well-deserved and well-placed. But I can’t help but wonder if the magnitude of rage is dependent on the perceived victim.

There are some things, like self-injecting epinephrine, that one should not be denied because of cost. But a patient recently told me he stopped taking his HIV antiretrovirals because he lost insurance coverage. I wonder if we could ever find similar outrage for that.

 

– The wackiest election ever has finally intersected medicine as media outlets focus on the health of each candidate.

Examining the now-famous letter from Donald Trump’s personal physician, the Washington Post’s Aaron Blake shared some of reporter Philip Bump’s criticism of the letter’s peculiar word choices. Among other more bizarre phrases, they take issue with the use of the term “no history” of substance use. Maybe that letter was the first medical document either had read. The article also laments the exclusion of important medical details like “heart rate, respiratory rate.” Apparently voters should know if their candidate was tachypneic that one time. Or they could just watch a speech and count.

Celebrity doc Drew Pinksy (aka “Dr. Drew”) stepped into the line of fire by offering his take on Hillary Clinton’s publicized health information. In a radio interview he blasted “not just her health but her health care.” He pointed to a “1950-level” of medical care declaring, “Coumadin really isn’t used anymore.” Coumadin commanded 60% of the blood thinner market in 2015, more than all other anticoagulants combined.

 

–  USA Today’s Liz Szabo recently wrote the story of a musician who contracted pneumonitis from a fungus growing in his bagpipes. The case was first published in the journal Thorax. I have to hand it to Ms. Szabo for culling her information from proper peer-reviewed sources. But since she literally asked for it, I am happy to also give her some flack: that opening line was a brutal shot at the bagpiping community, Liz.

SUCKIT: PAs Best in Universe

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Move over firefighter, astronaut, and princess; the Best Job in the Universe is now physician assistant (PA).

According to recent reports published in Forbes, Business Insider, Glamour, and Exotic Pets Quarterly, experts in other people’s jobs now regard PAs as the most desirable profession.

The Bureau of Labor Statistics describes PAs as making “well above the poverty line” and “often getting those swanky bennies we all want.”

But there’s more to being a PA than just fat stacks of money and great benefits. Fantasy occupation expert Ted Benjamin says the job has plenty of perks.

“I often see my neighbor, a PA, running errands in the middle of the week,” Benjamin said. “I mean, does this guy ever work?”

Most PAs obtain a Bachelor’s degree and then attend professional school, a two to three year intensive program that generally awards a Master’s degree. PAs can then practice in nearly every medical specialty.

“The fast pace and limited breaks mean you can graduate from PA school and still look young enough to be disrespected by your colleagues and patients,” said Diana Newman, someone who read about PAs online the other day. “It’s really a win-win.”

The Best Job in the Universe was calculated by a complex algorithm that weighs the daily stress factor against the average annual income to produce a score called the BHF, or Buying Happiness Factor. A guy with a calculator then multiplies the BHF by the estimated number of jobs available over the next 10 years. All of these factors produce a final Success Utility Composite Kinetic Index Total (SUCKIT) score.

“The potential job outlook was one thing that determined the success of PAs in our formula,” Benjamin said. “A single PA could potentially hold 100 or 200 jobs at once. The earning potential in that scenario really skyrockets.”

Other jobs ranking highly in SUCKIT score are technology or finance-based, with high earning potential and little contact with the general public. While these jobs tend to have lower exposure to bodily fluids than PAs, they lack some of the glitz of the clinical setting.

“Just look at how many of these PAs are showing up to work in matching pajamas,” Benjamin said. “You really can’t put a dollar value on that kind of freedom.”

Editor’s Note: The above post is satirical and not intended to represent any actual individuals, organizations, or scientific data. Don’t take things too seriously.

Sometimes

This is my latest article to appear in the September 2015 issue of JAAPA’s Art of Medicine section. You can read it on JAAPA’s website and download the free PDF (formatted for our print issue) here. Please remember to check in each month for new publications in the Art of Medicine section and continue to support humanities in medicine.

Sometimes your job feels like a job.

Sometimes you feel under the gun, underappreciated and underpaid.

And sometimes money just seems cold and hard.

Sometimes you’re so exhausted at the end of the day you don’t look at your own feet and end up on a treadmill in your work shoes.

And sometimes you don’t even make it to the gym.

Sometimes you wonder how medical training can make you a hypochondriac

and still syphon your empathy, drop by drop.

Sometimes your job feels like a burden.

Sometimes your allies and your enemies crisscross and trade places like a barnyard dance.

And sometimes it feels like you are the only one who hears the music.

Sometimes they scream your failures

Sometimes they whisper your praises.

Sometimes the small, quiet acts—the ones you can’t quantify or itemize or bill—are the most valuable.

And sometimes they go unnoticed.

Sometimes the best parts of your job are the ones that hurt you the most.

And sometimes you avoid them.

Sometimes your friends think you work at a hospital like the ones on TV.

Sometimes you think those TV people must wait for the commercials before they cry.

Sometimes you forget the words you recited with all of your classmates when you took that oath.

But sometimes, when you remember those words, you realize they answer all of your uncertainties.

Sometimes your patients require patience.

Sometimes, despite your passion, they curse your name.

Sometimes you deserve it. And sometimes you don’t.

Sometimes they push through a tiny gap in their pain and kiss your gloved hand and thank you.

Sometimes you don’t deserve it. But sometimes you do.

Sometimes their faces blur together into one unfamiliar mask.

And sometimes they all look just like your nephew or your mom.

Sometimes your job feels like your duty.

Sometimes your calling eclipses your occupation.

Sometimes your passion shakes the branches of the tree that shades you.

Sometimes doing what’s right puts you in the wrong.

Sometimes your convictions have you convicted.

Sometimes those who once pledged support speak against you.

And sometimes those seem like the only voices.

But sometimes that’s because the grateful ones have no voice.

Sometimes you remember the most important person is not the most powerful.

Sometimes you remember the weak, sick person is the reason you exist.

Sometimes they make it in the end.

And sometimes they don’t.

And sometimes it doesn’t matter, as long as you were there.

A Foreign Concept: The latest from JAAPA

My latest blog to appear in the Journal of the American Academy of Physician Assistants explores the concept of social responsibility. Read it below and visit the Musings blog on the JAAPA website to explore more from the JAAPA editorial board.

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“I returned from a trip to another hemisphere, but it could have been another planet. It was the type of place where you could hear a half-dozen languages spoken at a single restaurant and, from the color of someone’s skin, you couldn’t guess which continent they were from, much less the neighborhood. And although my foreign language skills need work, I was much more embarrassed by how foreign a different concept felt: social responsibility.

You’ll see it in other countries. It’s the kind of thing that makes a baker set extra bread on the outside stoop at night or the reason stray dogs still somehow stay plump and alive. It’s not charity. It doesn’t come from pity. It comes from understanding what separates the prosperous from the impoverished. 

From knowing the only difference between a pet and a stray is a piece of fabric around the neck. 

“Every success, and every mistake, only happens as the result of 500 successes or mistakes before it,” the Chilean bartender says as he slides me an India Pale Ale—the beer itself is the happy result of a shipping mistake hundreds of years ago. “There are infinite opportunities along the way to prevent something. And many people have the power to do so. Even if they choose not to.”

The bartender has never heard of Atul Gawande or read Complications or seen the inside of a modern OR. At least not that he remembers.

But a sniper’s bullet tore through his chest in Kosovo, so I imagine he understands the concept of mistakes and millimeters.

Right here, he points to a scar just south of his clavicle. I remember enough from anatomy class to know he is lucky to have the use of that arm, much less his life.

I asked him why a man would leave the tranquility of his native harbor town to learn English and fight for peace in a bomb-riddled country he had never heard of. He shrugged.

“Because no one else would do it.”

I wondered in that moment how many in modern medicine would take a metaphorical bullet because it was the right thing to do, because no one else would.

I’ve certainly seen that kind of steel resolve when it comes to fighting for reimbursement. When it comes to government officials and corporate administrators justifying their jobs. When it comes to hospital mergers and buyouts. When it comes to performance measures or legislation or loopholes.

But I’ve spent enough time on conferences and meetings and media outlets to know that the conversation usually focuses more on what’s efficient and effective than what is just and right.

My grandfather moved his wife and seven children to rural Virginia because the people there needed him. Because he felt a social responsibility. Now his grandson works in an industry that has more in common with Walmart than well-being.

Of course, commercial success is nothing to disparage. But I wonder if those at the top of the healthcare mountain remember the 500 prior successes that led to each of theirs. And the people who made it happen. I wonder how they would treat those same people if they were in one their hospital beds right now. When the ledger is balanced at the end of the day, I wonder if there is enough change left over to invest in some social responsibility.

Or if that is merely a foreign concept.

Here’s a response from Twitter:

Leave your response as a comment here and on JAAPA’s page.

Rebirth

The lines of my face are deeper now. There are a few more scars, inside and out, and callouses earned from contact with rough things.

You would still recognize me, though, from when we met three years ago. Back then I started my first blog, “PA-Ssed Out,” to keep myself writing during my final year of PA school and because, for the most part, I couldn’t find anyone who wanted to publish me. But now, things are different.

A lot has changed since my last post on this blog. I stopped writing here and I owe you some explanation. The truth is: life happened.

I graduated from school and got my first job offer. I began practicing critical care medicine at a giant hospital, a zoo full of every type of human and disease.

I spent my first year blogging for ADVANCE for NPs and PAs before I joined the editorial board at JAAPA. I shared with you my Letter and discovered the value of A Few Gray Hairs.

I helped put together a research abstract and won this award:

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I treated many patients and I watched a lot of them die.

And all the while, this blog sat untouched. At least by me.

Over the last few years, I have still heard from more people about this defunct little blog than nearly anything else I have written. It is no longer the only place to publish what I write. But it has taken on a new importance.

One of the lessons I have learned is the importance of owning your voice. And the obligation to use it to say what is right, even when that is difficult. This blog brings us together unfiltered. And you deserve that.

I’m not the same person I was three years ago and this isn’t the same blog. It’s a rebirth. And a chance to prove you can still be an individual, even if you have a PA-C Mentality.

Perpetuating My Nonsense

Harrison Yale PA AlumnusA disclaimer: All of my views are based on my experience completing one PA program, Yale University, and my limited understanding of Yale’s medical school education gleaned by working, socializing, and discussing these issues with medical students and faculty over the last 2.5 years. My views and opinions do not reflect situations at other institutions because, frankly, I have no idea what happens at those programs. My blog posts never asserted anything beyond a reflection of my own personal experiences.

 

My first blog on ADVANCE for NPs and PAs launched in January and I received a great response from readers. I really appreciate those who took the time to read and comment, even those who disagree with me.

One comment caught my attention as an opportunity to open further discussion. Since it touches on a primarily PA school topic, I figured it was a great opportunity to address it on PA-Ssed Out (my PA school blog) rather than my new professional PA-centered blog.

The commenter Dan identifies himself as an ICU PA and quoted a specific portion of my blog before offering his comment. He writes:

“‘[…] Was told to learn a medical school curriculum in half the time.’ Please don’t perpetuate this nonsense.”

Any comment is a good comment. Except spam. I hate spam.
Any comment is a good comment. Except spam. I hate spam.

First, I want to thank Dan for taking the time to read and comment. Not everyone cares enough to offer feedback. Second, while I appreciate concise writing, I wish Dan had elaborated a bit more on his point, since now I have to speculate to try and cover all of my bases in responding. For now, I assume that Dan contends that I was not expected to cover a medical school curriculum during my time in PA school.

The sentence that Dan quoted in my blog refers to the didactic portion of medical education (1st year of PA school and 1st and 2nd years of medical school). Clinical rotations were mentioned a bit later.

Let’s start with the easy and obvious. In some cases there is a literal doubling of the pace of education when comparing Yale’s PA and Medical programs. For example, our anatomy lessons are taught and evaluated by the same professors in the same facilities with the same curriculum. We just do two labs each week while the medical students do one. Anyone with a syllabus and a calendar can confirm this.

Now you might say, “But Harrison, the medical school education covers courses, like basic science and embryology, which PA programs simply don’t have time to.” And you would be right. Logic and simple math dictate that in the 12 months of PA school and 18 months of medical school didactics (24 months minus the 6 months of two summers in which students typically work on projects outside of the classroom), there are more lectures in the medical school portion that cover more topics.

However, when clinical year begins (2nd year of PA school, 3rd year of medical school), our PA students are expected to have the same patient care skills and pull from the same fund of knowledge as our medical school colleagues. My preceptors and patients did not stop to examine my didactic-year syllabus and their disease processes certainly didn’t care that it said PA-S after my name.

The clinical knowledge that makes me proficient on the wards (and led to successful evaluations and eventually graduation) requires the same background science and other topics taught in medical school, even if they were not explicitly given a course title. If I wasn’t handed the information on a PowerPoint slide, I was still expected to learn it on my own and be ready for evaluation, whether it’s a multiple choice test or a dying child in the ICU.

The PA students and medical students at Yale are all amazingly talented and intelligent individuals. It is a testament to both groups that they so homogenously blend as colleagues on the wards. Don’t believe me? Go to Yale-New Haven Hospital and ask the students on an internal medicine rotation to remove their name badges. At the end of the week, see if you can separate the PA and medical students. In my two years at Yale, I didn’t meet anyone who could.

 

I want to again thank Dan and everyone else for the comments. Please keep reading and commenting, especially if you disagree. And catch my ADVANCE blog twice a month here.

The ADVANCE of Progress

ADVANCE logoOne of the most rewarding things I did during PA school was create this blog. It hasn’t just served as an outlet to share my trying experiences and occasional rants. It has been an opportunity to connect to students, clinicians and readers from every corner of medicine and the globe. The feedback and support I received was truly remarkable, but the most incredible outcome has been the comradery I formed with complete strangers who, I now know, were going through the exact same experiences. I have cherished the ability to share my uncensored thoughts with you and I hope you all have also.

If you have a sneaking suspicion that I am stalling here, you have good intuition. I have a bittersweet pill to deliver and I hoped the preceding sugar would make it easier to swallow.

You can also subscribe to a FREE print version of ADVANCE (sans Harrison Reed's blog)
You can also subscribe to a FREE print version of ADVANCE (sans Harrison Reed’s blog)

First the good news: Late last year the Editor-in-Chief of the magazine ADVANCE for NPs and PAs approached me and offered a great opportunity. She wanted me to revive a popular blog that the ADVANCE website used to feature, “Adventures of a First Year PA.” This is a great opportunity to do what I love, share my experiences with all of you, for an even larger audience and on a bigger stage than my humble blog. I accepted this offer and my first blog will run later this week on Jan 10th (and every two weeks after that).

Of course, there is a drawback for the loyal readers of this blog. While my agreement with ADVANCE allows me to maintain a personal blog, it would not be right for me to simultaneously try to maintain two blogs with the same perspective and similar material. It is just not realistic to expect this blog to maintain the same fresh material that I was able to provide it over my last year of PA school.

I will keep this blog online as a student blog as I think some of the previous posts will continue to be helpful for students. I will attempt to update it as I can, but I can in no way have it overlap or interfere with my other blogging endeavors. The good news is that you can continue to follow my adventures over on the ADVANCE website (and I highly encourage you to).

A year from now, this blog may be resurrected or it may have already evolved into something else. I am leaving it open to many possibilities and, as always, I appreciate your ideas and feedback.

This is certainly not goodbye, but I want to thank you all for the amazing support that PA-Ssed Out has received over the last year. The next time you hear from me it will be on a different venue but I hope you will enjoy it all the same.

 

Sincerely grateful,

Harrison