Physician Assistants Are Showcasing Flexibility During COVID - Dr. Kevin Lohenry, Keck School of Medicine of USC

DR. RISHI DESAI: Hi, I'm Dr. Rishi Desai. Today, I'm happy to welcome Dr. Kevin Lohenry to Raise the Line. He's the Associate Dean of Graduate Student Affairs and longtime Director of the Division of Physician Assistant Studies at the Keck School of Medicine of USC. He spent many years as a PA himself before transitioning into academic roles and is a veteran of the U.S. Navy. I'm looking forward to asking him about changes in PA practice and education, and getting his assessment of the impact of COVID-19 on his students and program. Thanks, Kevin, so much for being with us today.

DR. KEVIN LOHENRY: Thank you very much, Dr. Desai. It's wonderful to be here.

DR. DESAI: I'd love to start with just learning more about you and your background in medicine. What got you started down this path to become a PA?

DR. LOHENRY: Yes, of course. So honestly, I'm probably a bit of an old-school PA in that, back in the 60s when PAs were first discovered by Dr. Eugene Stead of Duke University Medical Center, he built the model of PAs off of the medical corpsman and army medics that had combat experience in Vietnam. He had built this whole model of PA education off of the fast-tracking physicians from World War II, in which he had some experience. So many of us from the first two or three decades of our profession were often former military medics or corpsmen, or long-term paramedics or things of that nature that ended up in the profession. 

My first exposure to a PA was in the Navy. When I met my first PA, I just realized there was something unique about the way he approached patients that was really interesting and intriguing to me and caught my interest. I continued to pursue this career while in the Navy, serving as a search-and-rescue hospital corpsman. When I left the military, I sought to get into a PA training institution and then graduated and practiced as an internal medicine PA and family medicine PA for many years before moving into education. The opportunity to be part of a team is intriguing, and I think it's core to being part of the military that you're used to working as part of a team. The profession was a really good fit at that time. 

DR. DESAI: I'm curious, was that pathway pretty common with a lot of people, going from the military into healthcare?

DR. LOHENRY: It certainly was back then, yes. But it's completely flipped the script, to be honest. What we're seeing now is more undergrads who are really interested in medicine and science, but they are also cognizant of the stress of medical school and the stress on physicians. I have a lot of students who are daughters or sons of physicians who have seen their parents in that kind of environment and recognize that that might not be the best fit for them. So, they come to us seeking what they describe as a better life balance with the opportunity to still take part in people's health solutions. 

DR. DESAI: So, for you, personally, what got you interested in teaching? How did that become a part of your career?

DR. LOHENRY: I was involved in teaching in the military, and often would do sessions for our squadron of pilots and aircrew men related to health prevention issues. I also was a CPR instructor prior to going into the military. So, I think teaching was always kind of in my bones, if you will. My first real exposure to teaching as a PA was as a precept. In my internal medicine practice, we had four positions and myself, and we would bring in a student about four times a year for a month-long rotation. What I really enjoyed about it is the ability to watch them grow and develop confidence in their skills and their knowledge, while taking great care of our patients with our supervision. That led to being invited to teach a lecture or two here and there. 

Then one day I was invited to come to work one day a week at the university where I was precepting, and I caught the bug. As my kids were getting a little bit more involved in sports...the life of a practicing PA that takes call is somewhat challenging related to having some ability to coach your kids' things. I remember this one moment when my son and daughter were on a basketball team for a youth league in our community and my wife and I were co-coaching the team and I was being paged by the hospital like every five minutes and couldn't really be present. I decided at that moment in time I would consider a career in education. Honestly, I did it for a year thinking I'd be bored out of my skull, and I never really have found that boredom. So, it's been part of my career for the last 20 years.

DR. DESAI: I'm curious, and this is obviously because I enjoy education as well, what do you personally get out of education vs. what do you get out of clinical practice? Where's the overlap that you see sometimes?

DR. LOHENRY: I think clinical practice, the relationship that you have with your patients, and the opportunity to invest in their lives and have, luckily, more successes than not, is very enriching. I've been fortunate to have saved a few lives, and that's just monumental in terms of your self-worth of being able to make that kind of an impact on somebody's life. Usually, the feedback you receive from patients is pretty quick. You're either spot on and you've made them feel better about what was going on, or you're not, and you can readjust and head back down a different path. 

With students, there are similarities and differences. The similarities are, you have an opportunity to invest in somebody and watch them grow with their medical knowledge, with their medical confidence, and their skills. The feedback mechanism is usually a little bit more delayed because they're in the midst of this stress of applying to succeed in their journey to becoming a PA, and graduate on time, and things of that nature. But often when they graduate and they look back, they start to reflect and realize what that relationship meant to them. So, I think both are equally rewarding, but in a different way.

DR. DESAI: You work in a PA program and obviously the role of the PA has changed over the years. I'm curious about what you see that change evolving into, and maybe also how the PA program at Keck has adjusted over the years to set up students, so that as they become PAs, they can train and practice effectively 10–20 years from now.

DR. LOHENRY: Yes, that's a great question, Rishi. I think that the reality is, in my mind as a leader, you have to try to stay way ahead of the curve, and you have to be looking for those trends and where things are probably heading towards. That is somewhat of a magical process, and somewhat of an ensuring that you read outside of your industry,to get a sense of where business is heading, and things of that nature. 

Ultimately for us at Keck, we think there are some basic foundational skills that PA graduates need to leave with that will allow them to adapt and adjust in the future. We talk about flexibility being the hallmark of a good PA. It is the nature of our profession to be flexible because our roles can change. 

Oftentimes in medicine, you've gone through a residency and you're kind of in your realm for the rest of your career. The one thing PAs will tout is their flexibility and ability to make a movement towards a need. Probably the pandemic showed that better than anything in the last decade, when so many of these elective procedures and things were no longer important. There are a lot of PAs that were being laid off related to dermatology or orthopedics or other places where the medical necessity wasn't quite as significant at that moment in time. They were able to adjust and move into COVID-related roles, supporting ICU, supporting preventive services, vaccine efforts, things like that. 

So, to me, those basic skill sets that you need to have that flexibility are a good general education. The ability to have a strong generalist education so that you can adjust. Also, you have to have critical thinking skills to prepare yourself for those kinds of adaptive changes that are required by society.

DR. DESAI: How do you all teach critical thinking skills today, and how was it taught maybe 10, 20 years ago, if it was different then? Because I know that that's often, as you pointed out, considered to be the top, key competency that you want students to have. With that focus, I'm just curious to see if it's shifted or changed in terms of how you teach it over the years.

DR. LOHENRY: Yes, that's a great question. My sense is we are better educators now than we were a couple of decades ago. When I say that, I mean I think we're better informed by the pedagogical theories that are out there related to Bloom's taxonomy and the concepts of being mindful of our curricular construction. We have both the basic foundational components of Bloom's, but we also add in a variety of different alternative strategies on how we teach and how we deliver content and how we assess to ensure that students are able to reach the higher levels of application that you see with Bloom's.

For us, that involves, one, we do a lot of brain-based education where we're attempting to get away from the sage-on-the-stage concept and not just lecture at students for hours and hours and hours. Instead, we break it up every 15 to 20 minutes to try to do either a small group skills session, or a pair and share, or a video, or something that shifts their attention to help them stay active in their learning. 

Then we do a lot more problem-based focus cases to help them solidify information. So for example, this morning I was doing what we call our wrap-up. We have a summer bridge program for students who are starting in the fall. The goal of our summer bridge program is to help our students who are starting with a brand new graduate school experience to understand how to use learning objectives to guide their learning, and how to use the content that we're teaching and go back and use good memory retention skills to help solidify that information so that they're not playing catch up later on.

The wrap-up today was wonderful. I taught about thyroid disease and we had a pharmacy component to that, with pharmacy therapeutics and pharmacology, made a basic science prep component to that, and then I did topics in medicine component, basically covering hypothyroid, hyperthyroid, some of the thyroiditises as well. So we had two cases that they were in small groups with in a breakout room on Zoom, where they had to apply what we had taught together on a team, and then it allows the instructors in the room when they come back to see where the gaps are and fill in those gaps and hopefully solidify their understanding. 

So I think modeling that process helps them later on as self-learners—which you know, as health care providers, we have to stay in the literature. That helps them continue to use those kinds of techniques to continue to learn.

DR. DESAI: That was really nice and illustrative of how it's done today, comparing that to how you were trained when you went through the program. I'm curious. Do you feel you're going to see a different kind of graduate now than the kind of graduate you were when you started your journey in medicine?

DR. LOHENRY: Without a doubt. In my day and age, it was a lot of memorization. I still remember an 11-page document we called "the green sheet" that came to my institution from the University of Nebraska. I could probably still read it, if I had to, off the top of my head, which is great, and it did allow me to pull things from that list. When I had a patient with a headache, or a patient with low back pain, I could kind of go back into my memory on that. But the higher level of application came after graduation, when I was being mentored by the physicians that I worked with for the years following commencement. So I think our students are better prepared in many ways than I was at that time.

DR. DESAI: You mentioned COVID just briefly earlier, and I'm curious, what changes have you seen specifically in the last year, now that COVID has hit us? You mentioned critical thinking skills are important, and having a strong foundation. Are there differences in not just what you teach, but how you teach it? If so, how has that played out?

DR. LOHENRY: Yes, it's been an interesting transition. We had started using Zoom for meetings because many of our faculty members are out visiting clinical training sites to assess our students at the site. So we had already been looking at some tools and technology—that, and we use Slack for communication in the program. We had probably been using that for about a year and a half before the pandemic. 

I'm also very fortunate that we hired a digital sherpa for us about six or seven years ago, who now works for Apple. But at the time when she came in, she was a digital educational technology expert and she kind of helped our team develop the skills to move into the 21st century around delivering digital education. I felt very fortunate that we were pretty well prepared. But honestly, we went from right before spring break in March of last year, delivering our content normally, and then the week after spring break, doing everything on Zoom for the next year and a half. It was still quite an adjustment for our team despite that training.

I think that the lessons we learned are that digital delivery of content is possible. I do believe that in many instances, it's better than the classroom that we can develop here, for some of these things like critical thinking. I think critical thinking lends itself well to breakout rooms and small-group activities.

 

Clinical skills training? I may be very biased in this, but we heard loud and clear from our students and our faculty that that was well worth the risk of coming back to campus to learn from, with each other. So we were able to get permission from the Department of Public Health to do that in a very safe way. We have large classrooms that we transitioned into a small group setting of 10 students with a faculty member. Masks, shields, and physical distancing went possible, and worked a hundred percent of the time. We had zero incidents of COVID for many of our on-campus activities. 

I think there's also a mental-emotional part of COVID that all of us learn something about, related to how to adjust, as a community, to stress. I think probably the biggest lesson we saw was the absolute outcomes of racism and systemic racism across our country related to resources, and those outcomes on health disparities in the communities that we serve. Certainly here in Los Angeles, we had disproportionate numbers of LatinX communities, African-American communities, being permanently impacted by COVID as compared to some of our less disadvantaged areas. I think that was a real wake-up call for our students and our health system to see how important it is that we attend to that, moving forward.

DR. DESAI: That's a really good point. I've seen repeatedly, guidance offered at the national or state level. The fact is that richer communities do better with COVID—really better with everything— than poorer communities do. So it's really hard to give blanket guidance when your communities are dealing with this stuff so differently. I'm glad you pointed that out. 

We are, as you know, a teaching company; we love to fill knowledge gaps. I'll open this up to you. Is there any topic that you can think of where you feel like there's a common myth out there, a common misconception or misunderstanding? It can be on anything that you feel strongly about, that you could educate us on—something that you feel like everyone ought to know.

DR. LOHENRY: Well I think what I alluded to about diversity is incredibly important to our profession. I think the other health professions have struggled with this as well. So, I'll just share that from a diversity of perspective, as a nation, if we don't invest heavily in a different kind of educational process to allow for equity among all peoples, so that everybody gets a fair shot to grow, I think we're hurting ourselves. I truly believe that the cure for complex cancers is out there, but that has not come to fruition because we don't have diverse enough teams sitting around the table trying to discover this. So as an institute or as a nation, we have to invest in that equity, so that we can ensure that we get that diversity at the table in the future to solve that, in health and science as well. 

The other area I would share is one thing we've learned a lot about in the last few years is the real challenges of those experiencing chronic homelessness. Here in Los Angeles, we have over 57,000 people that live on the streets every night. It is like a movie set when you go to Skid Row and you see the living circumstances for so many of our neighbors and friends who have come across hard times for whatever reason. For some, living in an expensive area like Los Angeles, that can be one bad health problem and you are on the streets and your kids are on the streets with you. So what we started to do three years ago was, we developed a street medicine program here in the Department of Family Medicine at Keck. We recruited some international leaders in this area to help us build teams to go out and provide primary care services where those patients prefer to be seen. 

I think the biggest lesson for us is realizing that we can absolutely, positively impact the health outcomes of those colleagues of ours that are in the communities on the streets, if we meet them where they need to be met. We know that trauma impacts our ability to have good cognition, and that the more trauma we experience in life, whether it's little trauma or big trauma—you've experienced sexual assault, you've witnessed the murder of somebody through no fault of your own, you were in the wrong place at the wrong time. All those traumas add up and make it difficult for us to function in the same way that we are able to function when we don't have trauma.

For us, for example, our re-hospitalization rates for patients at LA County + USC Medical Center, which is a fantastic county hospital that cares for the most needy in our community, when we look at the re-hospitalization rates prior to street medicine, they were typically in the 60 to 70th percentile. Thirty days out from their hospitalization, those experiencing chronic homelessness who were back in the hospital, taking up resources that maybe didn't need to be used if we would do a better job of doing outreach after they're discharged. 

Those patients in our system with the street medicine teams, that number has dropped to 11 percent. That has significant quality of life for those patients, because they're getting good care in their tents, wherever they live, on the streets or in the riverbeds. But they are also not having to go back through a health system that has already, in many ways, traumatized them. So I think those two areas—diversity and taking care of the neediest of our neighbors, are probably two things that we need to continue to learn about. 

DR. DESAI: Yes, I'm glad you flag that. We have unemployment rates that are quite high and have been high for a long time. You mentioned that people can just be one health care crisis away from being on the streets. That is so true. You see now, so many people living out of their cars, living on friends' couches—really sub-optimal living situations, and a lot of kids involved in those situations as well, which is really sad. 

DR. LOHENRY. Yes.

DR. DESAI: You know we have, as you, know many students and early career healthcare professionals in our audience. What is your advice to them, as they hear your message—a lot of which, I'm sure  resonates with the folks listening—in terms of how they should approach their career in healthcare?

DR. LOHENRY: Well I have such great hope. I feel so fortunate to be in the role that I'm in, to have a job that I just love to go to almost every day of the year. It's really because of those students that are in our program, the medical students that I meet, and the pharmacy students, and all the health profession students, the research students. But I think the common denominator is, the current generation of those students—I use that term loosely because we have students from 50 down to 21—but there is a definite desire on their parts that they want to make a difference in society, and they want to be mindful of how they do it. 

I think being a healthcare provider or a healthcare researcher, you can absolutely make differences with that energy and passion that you have. I think sometimes people tend to shotgun it, and they get a little too all over the place. In my experience, at least, you can make the biggest difference by sticking to one spot. 

I remember learning in a business class many years ago about the success of 3M. One of the things that they taught us was 3M, they didn't deviate and create a bunch of subsidiary organizations at the time. They stuck with one thing and became the best at that one thing. 

So I often think students who have a passion for a population or a non-profit, if they stick with that group and contribute as much as they can to that, then when they get through medical school or PA school, they can continue to be an advocate for that organization, or that disease, or that population. So, I'd say that's number one. 

Number two is, while medicine has been incredibly stressful for the clinicians who've been on the front lines this last year, and politics of the pandemic have been particularly challenging. I think you do the right thing for the right reasons at the right time, and you benefit from it overall, and you will feel better about your career choice. So I would encourage them to continue on that journey, and not let the accessory stories that are out there about healthcare providers dissuade them from this career, because, again, there are very few careers where you can feel as happy as we do as PAs, for example. I think it's well worth the effort. 

DR. DESAI: Wow. Thank you for that. That's a very inspiring message, and thank you, more broadly, for being with us today.

DR. LOHENRY: Thank you very much. I appreciate your time.

DR. DESAI:  I'm Rishi Desai. Thank you for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.