95 PAs Help Make MD Anderson Cancer Center the Nation's Best

from May 30, 2003, issue of AAPA News

 

By Hillel Kuttler

(Houston) – Clutching a handbag, Franceanne Bonner sits in a spartan white room, eyes riveted to Brent Bell as he explains her cancer treatment.


“For the radiation, you’ll be on the table for 20 minutes,” says Bell, a physician assistant specializing in thoracic radiation oncology at MD Anderson Cancer Center (MDACC). “You’ll have no side effects for two weeks. You’ll have side effects after that, from the combined chemotherapy and radiation: sore throat, cough, nausea, fatigue. … You can always page me. We’ll get you through the six weeks of treatment.”


Bonner, looking the picture of health, nods. She steps over to a countertop to sign the consent forms. Bonner then follows Bell into the next room, while her husband heads elsewhere to wait. Bell and his supervising physician, Thomas Guerrero, M.D., place wires on Bonner, who lies flat on her back at the gaping mouth of a CT scan machine.


Bonner is alone. Bell and Guerrero retreat to a darkened, narrow room, where radiology technicians peer at computer screens and discuss other patients. A window looks out onto Bonner. One monitor shows an x-ray cross-section of her body, feet first. As Guerrero watches, Bell begins plotting her radiation treatment. He jiggles the mouse to pinpoint the carina, at the center of Bonner’s chest.


“There,” he says of the lymph nodes, one of the three spots where, beginning the following Monday, Bell and the technicians will direct the “external beam” radiation. There — the small tumor in her right lung, responsible for the lump on the right side of her neck. And there — the lymph nodes in the neck, where the 58-year-old schoolteacher first noticed the trouble that has a 95 percent chance of killing her.


“All the targets are identified and outlined,” Bell said afterward, completing the planning simulation by drawing on a diagram the tumor volume to be radiated and outlining the spine and heart so they can be avoided. “All we need to do now is to coordinate the chemotherapy and radiation sequence and plan the neck concomitant boost technique.


“Her prognosis is guarded, based on her 3-B staging. However, we’re confident that we’ll have a good plan of attack.”
Thus ends Bell’s day. An inpatient who also had been scheduled for a radiation planning simulation twice went out for — yes — a smoke and couldn’t be located. Just before seeing Bonner, Bell sat with John Nagle, an 82-year-old man with Stage 4 lung cancer who needs a transfusion to combat the anemia caused by his chemotherapy. Bell assured Nagle of the transfusion’s low risk, saying that MDACC takes all blood on premises and screens it. He was trying to get Nagle through his course of palliative radiation, to buy him some time.


* * *

Bell is one of six radiation PAs in the building that houses perhaps the most PAs in the country, in America’s leading cancer hospital, on the grounds of the University of Texas Medical Center — the largest such complex in the world.


Like some of the other 94 PAs at MDACC, Bell was drawn here nine years ago by the center’s reputation and stays because of its commitment to eradicating cancer, the vast opportunities for PAs, the world-class level of physicians, and the involvement of PAs in groundbreaking research.


MDACC’s organization and attention to detail set it apart, too, according to PAs and physicians who work here. The 457-bed hospital is arranged not by the services it provides, but by specialty, making it a vast collection of cancer hospitals under one roof in which everyone comes to the patient.


And the patients come, from around the world. A stroll of the carpeted corridors revealed people of all ethnicities and nationalities, women in saris, men in cowboy boots, a mother pushing a dozing, head-shaven girl in a stroller. Many arrive for treatment and stay a skyway’s walk away over Holcombe Boulevard in the Marriott-run Rotary House, available exclusively to patients. MDACC’s entrance itself resembles a hotel, beginning with a valet-parking stand out front and an airy, two-story lobby filled with puffy armchairs and featuring a grand piano often played by former patients who return to entertain. Volunteers staff the concierge desk/information booth.


“Making Cancer History” — so proclaim buttons and posters visible throughout the two-million-square-foot building. PAs say that they fully identify with the mission and that a sense of pride envelops the entire hospital. “I’ve seen the guy who takes out the medical waste stop and help a patient,” said Debra Munsell, who 13 years ago was the only PA in the head and neck surgery department and now is one of four, with two more coming. “All the employees genuinely care about the patients — not just the nurses, doctors, or PAs. That’s why I like working here.”


Munsell and other employees can be spotted carrying colorful tote bags that sport drawings of monkeys dangling from branches. The bags, as well as scarves, were designed by children who once were patients. They are marketed by employees who volunteer for the MDACC Children’s Art Project. All proceeds go toward sending the youngsters to summer camps and for scholarships for them.


MDACC places a premium on teamwork, considering it the key to realizing the slogan’s promise. Most departments hold weekly multidisciplinary meetings at which patients’ treatment options are analyzed by all the professionals involved. In Bell’s unit, for example, those sessions include surgeons, PAs, chemotherapists, radiologists, radiation oncologists, pathologists, and pharmacists.


“You have to be very driven to work here,” said Bell. “We’re not getting Stage 1 and Stage 2 cancers, we’re getting the unusual of the unusual cases, the late of the late. All cases here are complex.”


PAs’ most important contribution to the system, PAs and physicians said, is providing continuity of care to patients whose doctors often are conducting research, writing papers, or appearing at medical conferences. PAs, they added, often achieve an expertise comparable to that of MDACC doctors and exceeding that of physicians elsewhere.


“Once doctors saw how capable we are of expanding the practice, we really grew,” said Karen Gonzalez, a surgical oncology PA, who joined MDACC four years ago. “When [physicians] are so subspecialized in what they do, they need someone who can help them. One of my physicians told me, ‘You know more about surgical treatment of liver cancer than many doctors in the country.’ I’ve often gotten calls from doctors, asking me, ‘Can you treat this?’ They’ll want to send their patient here.”


The interdisciplinary, patient-centered approach to cancer treatment was a bedrock principle of the nascent M.D. Anderson Hospital and Tumor Institute that R. Lee Clark, M.D., helped found on a Houston estate in 1941. Clark was known to travel the country, recruiting new medical graduates to join his staff.


MDACC was “slow to embrace the concept” of PAs,” said Thomas Burke, M.D., a gynecologist who is the administration’s liaison to the PAs. Bob Evans, a urology PA, concurred, harking back to when he came aboard 18 years ago and a PA “had to work on a one-on-one basis to sell the concept and to sell yourself.” Just six years ago, only 30 PAs worked at MDACC.


That’s changed, said Gonzalez, and “we’ve infiltrated every facet of every … department. We’re all over the place now.”

Said Burke: “We want PAs to flourish in their areas, taking advantage of all their training. We have allowed PAs to find their own niche.”


Today’s PAs express appreciation for the encouragement they receive to further their careers at M.D. Anderson. The multitude of opportunities in cancer specialties throughout the hospital also entices PAs to move around, rather than leave for jobs elsewhere. Regular lectures, including the semimonthly PA Continuing Education (PACE) series during lunch hour, enable PAs to earn all their required CME without leaving the grounds.


Some PAs had no prior interest in oncology or in the specialty in which they now work. The hospital’s recruitment efforts and training programs in those specialties convinced them otherwise. Bell had worked in primary care and surgery at Chicago’s Cook County Hospital. Jennifer Alpard, a young head and neck surgery PA who came to M.D. Anderson just to practice her interviewing skills, got “this warm, fuzzy feeling” and accepted the job offer — and jokingly said that she plans “to retire after 28 years on this job.”


The PAs interviewed all spoke gratefully of their physicians’ confidence in them. Jeri Akins, a surgical oncology PA who focuses on breast cancer, related how her supervising physician, Kelly Hunt, M.D., prodded her to lecture, participate in research, and join a committee (Akins is the only PA on the Operating Room Committee). Asked at her first review how she’d like to expand her qualifications, Akins responded, “To be trained in central venous catheter (CVC) placement in the subclavean vein for long-term chemotherapy or medication.” At the time, only surgical oncology fellows — no PAs — were performing the procedure in the department’s infusion therapy clinic.


“It’s nice when someone encourages you to learn a new skill,” Akins said of Hunt. “The faculty in surgical oncology felt that I was a good candidate to acquire the skill because of my extensive surgical experience. I did at least 30 with the supervision of the surgeon before they let me do it on my own. A lot of time and energy were spent training me to place CVCs safely in our difficult patient population.”


The entire cohort of PAs meets monthly, usually with Burke attending. Management welcomes PAs’ input. A recent idea was to designate an M.D. Anderson PA of the Year; the first presentation will be made on October 6, National PA Day. MDACC sponsors the country’s only PA postgraduate training program in oncology, now in its second year.


“It’s a wonderful situation for the institution to have so many PAs as part of our clinical and support teams. It makes sense within the mission of the institution,” said Chief Operating Officer David Callender, M.D. “We have always operated on the philosophy that no single person has all the answers. Everyone who can contribute contributes.”


From his conference table, Callender gestured to Munsell, his colleague in the department. The two, he said, “are extensions of each other [and] play interchangeable roles.”


“We have to give credit to Debbie and others coming here when we really didn’t have a lot of PAs. It’s phenomenal to see that we’ve been successful. PAs have perfectly fit into the model. Early on, not all physicians bought into the model. I think that PAs won people over because they were so skillful. The word got around quickly, that we got more efficient because we had PAs. So we went looking for PA students.”


To Burke, flexibility is a key factor in the success of PAs at M.D. Anderson. Each specialty governs the deployment of its PAs, rather than the hospital “prescribing how PAs should function,” he said. Texas’s broadening of PAs’ prescriptive authority and changes in federal regulations that have increased PAs’ scope of practice have made PAs more valuable and cost-effective, Burke added.


“The support that you get from the institution and physicians is great. They’re interested in your needs and in your progressing,” said Evans, MDACC’s senior PA.


“There’s something special about dealing with a cancer patient. They are so appreciative of anyone who has knowledge of a particular area and who will say, ‘Yes, you have cancer, but it’s not necessarily the end of your life.’
“It also makes you deal with your own mortality — that you’re not going to live forever.”

 

Last Revised: 7/15/03