Creating a Digital Front Door for Patients - Dr. Beth Smolko, President of the American Academy of PAs

DR RISHI DESAI: Hi, I'm Dr. Rishi Desai, and today on Raise the Line, I'm happy to be joined by Beth Smolko, President of the American Academy of Physician Assistants. Dr. Smolko is also a nationally recognized speaker and author on topics on telemedicine, including legislative barriers and access to care issues. Dr. Smolko's passion for accessible and compassionate patient care led her to found a nonprofit called the Heart of Medicine dedicated to delivering primary care to poor and underserved communities. Thank you so much for being with us today.

DR BETH SMOLKO: Thank you so much, Rishi for having me on the program today, thanks!

DR RISHI DESAI: I'd love to just start, it's COVID and everyone is kind of, I think, doing their best, so just how are you doing, how's your family doing right now?=

DR BETH SMOLKO: Thank you so much for asking. We are doing okay. I did have COVID last year in April. I'm, in fact, a long hauler that is slowly recovering. It was interesting to see Dr. Fauci call out post-acute sequelae for COVID the other day. A lot of people are still recovering many months afterwards.

DR RISHI DESAI: For those that may not know the phrase “long hauler,” do you mind just explaining what that is?

DR BETH SMOLKO:There's many of us, about 30% of the population who had symptomatic—whether it's mild, moderate, or severe—COVID, and have continuing symptoms. Some research has shown up to nine months or more. We're still counting because we still don't know the complexity and how long this will last.

DR RISHI DESAI: Thanks for sharing that. My heart goes out to you, and obviously I hope you have full recovery in the long scope of things. But it's interesting as we learn more and more about this disease, there are so many wrinkles and nuances and things that get missed as we kind of paint things with a single brush. I think pointing out the fact that these symptoms can last a long, long time is good for people to know.

DR BETH SMOLKO: Thank you.

DR RISHI DESAI: I'm curious, you have such an interesting background, and obviously, you're on the cutting edge, the bleeding edge of things like telemedicine, and you also have this deep, deep passion for things like how to get good care out to communities that may not be able to get that care. Can you just maybe rewind for me and get back to the part where, how did you first get excited about healthcare? What was that first initial spark for you?

DR BETH SMOLKO: Well, growing up, my family didn't have really good health insurance. So I saw firsthand how a simple trip to the doctor would put my family in a very precarious financial situation, and that's if we could actually get to the doctor. We had both cost and access issues, and it was definitely a driver for me, wanting to be a healthcare provider and specifically in underserved communities. But even as a kid, I knew I wanted to go into medicine. I'm also a first-generation college student, so I didn't always see the path to get there, nor did I have tools like medical role models, time management, financial resources, to really know how to achieve my goals. But after college graduation, I was lucky enough to get a job working in a lab at NIH, where I had great role models who fed my hunger for science and really helped me grow in confidence. I took some graduate classes, but the further I got into research, the more my desire for being around patients grew.

I left NIH to get married and start a family, and despite the challenges of motherhood and academic studies, I decided to go back to school to become a PA. My first day as a PA student was like falling in love. I was so excited to learn about medicine, and I really knew that I had found my calling.

DR RISHI DESAI: That's incredible. I'm just trying to put myself in your shoes. You said you didn't have a lot of mentors initially, and something got you excited about the NIH, that part. How did that happen? Did you see a flyer, or, how did you even learn about the NIH? How did that work for you?

DR BETH SMOLKO: That's a great question, because back in the days when we had newspapers, I literally circled this opportunity in a newspaper ad and applied to it. So I was very fortunate to get in there.

DR RISHI DESAI: Then going from the NIH—I'm just imagining, because I've never been at the NIH as an employee or anything like that, but one thinks of a very research driven place. How did you go from being in that kind of milieu to then deciding to pursue a career as a PA? How did that happen?

DR BETH SMOLKO: I think for me, I just kept noticing...there's something called Building 10 in the campus, and I was in Building 37 where we were doing research with murine models for plasmacytomas cancers, blood cancers. I always felt this urge that I wanted to be in Building 10 more so than Building 37, just really wanting to connect with people.

DR RISHI DESAI: Got it, that makes a lot of sense. You were curious about Building 10, you decided to throw your hat in the ring and pursue this career, and then you're now at what I would think of as kind of the pinnacle. I mean, you're the president of the American Academy of PAs. How did you get to that spot in your career? How did that work out?

DR BETH SMOLKO: It started as a student. I know you have a lot of students that follow you, so really it was me kind of stepping up as a leader in my class and being a student diversity rep for the Student Academy of PAs, and also then being chosen as the lead student representative for the Family Practice PAs in the country. That kind of got me into this mode of leadership and gave me a lot of opportunities. I eventually moved all the way up to president of the Family Practice PAs, and then onto the board of directors for the Academy.

DR RISHI DESAI: For those that may not know, do you mind just walking me through, what is the mission, the day-to-day? What does that organization feel like as you live and breathe it?

DR BETH SMOLKO: Sure. The American Academy of PAs represents over 150,000 PAs in the US who work in every medical specialty and setting. And our mission is really to lead the profession and empower our members to advance their careers and enhance patient health. Our vision is PAs transforming health through patient-centered, team-based medical practice.

DR RISHI DESAI: I would say the last year, at least to my knowledge, has been probably the most drastic change the healthcare industry has seen, at least in a while. How has that shaped the PA mission, and also how people are training, thinking about things like telehealth and working at distance and working across state borders and all that kind of stuff?

DR BETH SMOLKO: Speaking of telehealth, the APA surveyed our members about the use of telemedicine, and the good news is that almost two out of three PAs said that they are currently using telemedicine. But prior to COVID, our last survey before that was in February of 2020, and only one out of 10 were using it at that time. There were several challenges identified in the survey that providers, employers, and lawmakers have to work together to address. They found that from, as far as the PAs in the survey, connectivity issues for patients was a problem, comfort, familiarity, and on the provider side, reimbursement services, access to equipment and education and training were a barrier to telemedicine. But these are all things that we can overcome, which is great because we see that growth in our colleagues getting familiar with telemedicine, and our patients too.

DR RISHI DESAI: That makes a lot of sense. Do you feel like a lot of the PAs at this point that are not using telemedicine, do you think that they are folks that are likely to start using it, or are they folks that probably at this point, wouldn't want to do that for whatever reason?

DR BETH SMOLKO: I would say that everybody will have a touchpoint with telemedicine regardless of your specialty. We know even surgical PAs are doing their post-op and some pre-op visits online in telehealth. So I think that we're going to continue seeing this touch every specialty. Soon you'll see 10 out of 10 of those PAs actually doing that.

DR RISHI DESAI: Now this question is a very selfish in nature, and I'll tell you, I'm a telemedicine clinician; I do telemedicine. What are some of the things that you think most telemedicine clinicians don't know, but should know? What are some of the best practices, things that I might listen to you in a minute and be like, "Oh my gosh, I can't believe I didn't do that. That's right, I need to do that immediately." What are some of those things?

DR BETH SMOLKO: When we think about even healthcare organizations as a whole, we need to make sure everybody understands telehealth technology, at least for the sake of patient care and workflows. Having that alignment from top to bottom from the person who's kind of controlling the whole umbrella to the bottom, of that patient, that end user, really helps ensure everybody within the organization understands when and how telehealth can be deployed from one patient to the next and can proactively flag opportunities to bring a patient into the use of telehealth for their care. You can create this friendly, very patient-friendly digital front door, and I love that phrase. 

A patient shouldn't have to find telehealth within their organization; rather, routine workflows and accessing care should present telehealth as an option wherever and whenever possible. A thoughtful digital front door has multiple benefits as well—access to telehealth, of course, but also more effective channel routing can help to ensure a patient is connected to the right care, the right provider at the right time and the right place.

This can help take some of the guesswork out of patients electing to access care and ensuring that they're choosing the right entry point consistent with their care needs. Internal and ongoing system reviews should be used to identify where telehealth is functioning well, and where an opportunity exists to make it better. Organizations should really define exactly how and when telehealth is expected to play a role in clinical care. Certain medical conditions might be identified as very clear opportunities for telehealth, and an organization can seek to proactively shift care related to these conditions into a telehealth environment. So whether it's mental health or a low-complexity acute visit like a sinus infection, organizations should be really clear about where they expect a given condition to be managed under routine circumstances and track success in achieving it. So for me, it's about having a really good understanding of where that modality exists in how we practice medicine and what's appropriate and what's not, so that the patient really never has to guess.

DR RISHI DESAI: It's a really good point in terms of triaging certain conditions and certain situations. The one that jumps out right now, especially with COVID, is mental health conditions. I'm thinking of depression and anxiety. Are there data points that show that telehealth performs as well—maybe even better than a standard visit—for certain types of conditions? Maybe the ones that I mentioned, maybe other ones? Are there any examples that we have that we can already point to and be like, that proves that telehealth medicine is effective?

DR BETH SMOLKO: I'll be honest with you, I'm blanking on exact numbers right now, but certainly there's data points that aren't collected. I would say it's more important in some ways, especially when it comes to behavioral health, when we think of the stigma, especially in certain vulnerable populations, about seeking out behavioral healthcare, we've actually seen that COVID directly—not indirectly, always, but directly—creates some mental health issues. There's a lot more of it going around and less and less access. So the data that's not being collected perhaps is the stigma on certain communities, and the fact that it's a lot easier for you to perhaps express yourself when you're not worried about your neighbors seeing you go into somebody's office and you can have all of those discussions in the comfort of your home and a place that's safe to you, perhaps.

DR RISHI DESAI: That makes a lot of sense. One of the points that you brought up earlier in terms of your personal story is you mentioned, I believe, accessibility. You said that when you were growing up, accessibility was kind of a challenge. Do you mind speaking to that? Only because I think that that word sometimes means different things to different people. I often think of, like for me personally, I think of accessibility as tied into economics. Like maybe not being able to pay for a visit or not being able to take time off of work so you can go in for a visit, because you need the work money and the employment money. So what does accessibility mean outside of just money? What are the other barriers to accessibility and how does telemedicine help to resolve some of these issues?

DR BETH SMOLKO: The accessibility issues vary from geography, whether that's lack of access to care within a rural community, to what it might look like, accessibility wise, in a city where you might not have a car to get from point A to point B. We certainly see that access issue for people that want to go get a vaccine, but it's at a stadium that's outside of the city and they don't have a car to get there. But for access when it comes to telemedicine and telehealth in general, I think of the fact that 80% of the population, whether you're Black, brown, or white, typically have a cell phone with access to a provider. That percentage is so much lower for a laptop and other kinds of technologies, but that cell phone, that one access point kind of brings us together. Also it gives us this general leveling, or a “great equalizer” is what I've called it in telemedicine and the healthcare provision, because everybody has the same access point into really great healthcare.

DR RISHI DESAI: That makes a lot of sense. I think that that number would likely go up over time as more and more people use and get used to their cell phones. It kind of makes me think, going back to what you're saying with AAPA, how does AAPA or other organizations like that, that you may be working with, how do they think about cell phone usage or training clinicians to be more adept on their cell phones or to text with patients maybe? Is that part of the strategic focus for the coming years? If so, how does that roll in?

DR BETH SMOLKO: Well, we definitely have created CME content to help providers focus on both safety, security and really understanding what are the appropriate things to be addressing during a telemedicine visit. I think that really understanding the scope of telemedicine or virtual visits is so important. So we have created a lot of educational content so that they can know what that looks like. Just texting a patient might not be the most secure way to handle it, but having a secure platform that the patient and you can actually interact in is better for everybody involved.

DR RISHI DESAI: That makes a lot of sense, and I imagine that there's a lot of training around how to maintain security and balancing that against ease of use, right? It may be very convenient to—I'm just thinking out loud—to just hop on a call or to text....There are a hundred ways to send a direct message nowadays like WhatsApp and whatnot, and which ones are appropriate, which ones are not, and things like that. I guess, going back to COVID, then, what is in store for us in the coming months or years? What do we expect, especially for PAs, what do we expect their scope of practice to look like maybe two years from now that maybe is quite different from what it was two years ago? Are there certain things that have really changed and are unlikely to ever change back?

DR BETH SMOLKO: Well, I think there's definitely two parts to that, right? What is changing it more broadly is that telehealth is this broad universe of technologies and approaches to care from synchronous, video-based encounters to remote patient monitoring, asynchronous, and mHealth technology. The full suite of telehealth technologies is really just starting to scale, and mHealth and RPM, or remote patient monitoring, has enormous potential for growth in scaling to meet individual and population level patient health needs, proactively and intelligently. Telehealth is enabling the integration of multiple various data sets and is really helping drive the conversation on health care interoperability. Additionally, new and expanding reimbursement for this type of care is creating new incentives and driving additional investment in technologies in the mHealth and the RPM space as well.

I think that we also need to consider that the growth of video-based care is driving that expansion to meet needs, like whether they be a point of care at a telehealth kiosk in a grocery store or pharmacies, to remote physical exam devices, something you just press on your chest or look in your ear, through self-conducted physical exams with the use of artificial intelligence and patient-friendly guidance and technology. Also the expansion of 5G networks is shifting the conversation on data networks and data exchange, and there's been a lot more automation and clinical algorithms that have come online enabled by telehealth. That isn't to say that telehealth is replacing clinicians, but that telehealth technologies are being used to digest complicated patient information through AI and machine learning and natural language processing to support clinical workflows and strengthen diagnosis and treatment plans.

Asynchronous clinical workflows have also grown dramatically in their scope and competency, and complex diagnoses and treatment plans can be proposed based on patient data submissions paired with the intelligent, evidence-based clinical algorithms and machine learning. This creates that efficiency within a care system that enables a single clinician or clinical team to care for more patients more competently and effectively.

So COVID has really helped unshackle a lot of the constraints in the telehealth space by aligning legislators, payers and healthcare organizations relatively. That alignment is sparking additional innovation and growth in telehealth technologies that will improve on the quality of care delivered in this space, in the healthcare system more broadly, and improve patient outcomes.

If we go back to what it means to PAs, I think that it's going to be guiding a lot of the legislative changes that you and I were kind of talking about before, that we are really going to have to start naming PAs as telehealth providers in state laws and regulations. We really look to how that's going to be transforming over time. Right now, we need to focus on origination sites. How do we make compact licenses more available across the United States so that we can actually help in a crisis situation?

Like what happened in Texas just a couple of weeks ago. We had ice storms in Texas! Wouldn't it have been great if somebody in California could just as easily just said—there were executive orders; I'm giving an example—but if someone in California could just say, "Hey, I'm able to pick up and do this telemedicine. If somebody is able to do a telemedicine visit, I could pick that up." If we had less variation from state to state and telehealth laws, man, what a difference that would make to access to care.

DR RISHI DESAI: Yes, it's a really good point. Hopefully we'll see more and more of that, more flexibility across state lines. It seems logical that if you're trained as a PA in, let's say, Connecticut, you should be able to take care of someone in neighboring Rhode Island. It just seems very odd that that wouldn't be the case normally.

I'm curious, also, about international borders. You mentioned the crisis in Texas; with COVID we've seen many countries come under crisis. Is there any precedence for French clinicians to be able to help out in Italy when Italy was slammed? Or countries being able to kind of help with one another, like Canada helping to step in if the US is under crisis or vice versa, us helping Canada? Is there any precedence at all for cross-country collaborations like that, in times of crisis?

DR BETH SMOLKO: I think that's a really great question. I don't have an example for you where that has happened via telemedicine outside of the employer space, where we have seen employer-space telemedicine kind of crossing borders, but really most of the time that has been more in-person—at least what I've experienced and seen—as opposed to going via telemedicine. But I certainly would love to be able to use telemedicine in Haiti where I run clinics, because I want to be able to check on my patients throughout the year, as opposed to just when I can get there to serve them.

DR RISHI DESAI: Yes. I mean, it kind of builds this idea that you could have a clinic that's well connected and therefore it gets you access to professionals around the world. I mean, just a beautiful idea. One of the core tenants of Osmosis is that we try to see ourselves as a continually learning organization and we have a lot of students out there. I'd love to have you teach us something, maybe a knowledge gap that you've identified that a lot of people have, something that would help fill in that gap. It could be on any topic that you think makes sense.

DR BETH SMOLKO: So for any of my students that will listen, they know that I'm really passionate about our profession, but the one gap that I see pretty universally is a lack of understanding about PA, the model of PA education, whether it's a patient or a provider. Our education was actually developed by physicians, and those physicians made sure that we had the required knowledge to safely and effectively treat patients. We don't learn less about medicine than any other healthcare provider, we just do it in a different timeframe. Physicians were and still are actively involved in PA program accreditation and sit on committees for our very robust national certification exam. PA students are often in class all day long, every day without breaks in their schedules, so no winter breaks or summer breaks and this allows us to teach a hundred plus graduate credits in two to three years. It's very difficult, but the teaching model works, and PAs have over 50 years and hundreds of millions of patient encounters to prove that it works.

DR RISHI DESAI: I appreciate you making that the teaching point, I decided to better understand the PA profession myself and took it upon myself to learn about the PANCE and the PANRE. As I was doing that, I was like, "Oh my gosh, this is remarkable." It was disappointing to me that I hadn't learned earlier in my career about how the PA program is set up, because I feel like there's so much that, not just MDs, but DOs, NPs, and others could learn from how PAs have established their training, and hopefully adopt a lot of those principles, because they're obviously very effective.

DR BETH SMOLKO: Thank you.

DR RISHI DESAI: Maybe a final point then is, a lot of our students are coming out during COVID and it's such a, let's call it a wacky time, where the ground feels like it's shifting every week. Things are better, now we have variants, things are worse, now we have vaccines. It just feels like there's up and down news every day. What advice would you have for someone that's coming out? Your personal story is just so inspiring. I mean, you've worked at these profoundly well-known organizations and institutions, and the president of the AAPA. What advice would you have for someone young that's coming through and saying, "How can I have that sort of career for myself?" What would you say to that person?

DR BETH SMOLKO: Well, I would tell students, particularly that if they choose to be in pre-PA, the US News and World Report recently said that they would be choosing the very best job in the United States. I love our academic preparation. Our lateral mobility is not really emphasized enough. I think we have to train and get educated no matter where we go; it's not a, you can just slide from one position to the next. But the fact that we don't have alphabet soup after our name really allows us to be able to move from endocrinology to gastroenterology and other places. There's great opportunities for PAs, particularly in leadership in healthcare organizations, as I've seen, and the ability to provide medical care where it is needed most.

PAs are medical experts that continue to grow throughout their career. We don't stop learning when we graduate, so when challenges like the pandemic come along, as a PA, you are able to flex within the healthcare system to meet patient care needs where they arise. If you're a PA student currently, you will soon be on the front lines of a very different medical role than when you started. Make sure you get the experience in virtual visits, read a journal article every single day after graduation, and never stop learning. Your patients are depending on your medical expertise and your compassion, so bring it every single day.

DR RISHI DESAI: That's a phenomenal message. I appreciate you ending on that note; it's very, very inspiring. I want to thank you, Dr. Smolko, for being with us today.

DR BETH SMOLKO: Thank you so much, Rishi. I really appreciate the opportunity.

DR RISHI DESAI: Well, I'm Dr. 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.