A Profession As Versatile As You Want It To Be - Sonia Otte and Brianna Cardenas, Keck Graduate Institute PA Programs

Dr. Rishi Desai: Hi, I'm Dr. Rishi Desai. Today on Raise the Line, I'm happy to be joined by Sonia Otte and Brianna Cardenas of Keck Graduate Institute. Sonia is the Founding Program Director for the Master of Science Program in Physician Assistant Studies at KGI. She has led PA program directors and new PA faculty through curriculum development at numerous PA programs across the U.S. 

Brianna is the Director of Clinical Education and Professor of Practice in the MSPA program at KGI. She currently serves on the Physician Assistant Education Association (PAEA) CASPA student committee, to help diversify the PA profession. She's also an award-winning faculty reviewer for us here at Osmosis: Knowledge Diffusion. Thank you both for being with us today. So, maybe, I'll start with you, Sonia. Can you start by telling us briefly your background and what led you to your interest in healthcare? And, Brianna, I'd love to hear the same from you as well afterward. 

Sonia Otte: In college I was in pre-med until I went on a study abroad trip to Italy. I don't know if it was the beautiful Roman architecture, or if it was the stracciatella gelato, but my perspective on things kind of changed. I realized that there was really this world out there that I wanted to explore that I hadn't gotten the opportunity to do so. And so, when I came back, I decided to continue the pre-med curriculum, but I didn't take the MCAT and I didn't apply to medical school. I ended up going into corporate America and, eventually, landed at a job at the American Cancer Society headquarters in corporate communications. I love writing so I really thought this was going to be the perfect blend for me where I was writing about health and patients. 

But the longer I was there, the more I realized that that was not the way that I wanted to be integrated in. I really wanted to have these connections with patients. And so, around that same time was when I met a newly graduated physician assistant, and she was so excited about her career and told me all about it. After I did my own research, I realized that that was really where I fit into medicine. It would allow me this flexibility that I had always wanted, to kind of switch between specialties, but to also still get that critical thinking and that problem solving that I really liked about medicine...things that you are deciding can help really change someone's life, but also, the relationship and the connections that I could build with patients were really important to me. Once I found that out, becoming a PA was really the right track for me and, again, those connections were what really drew me to healthcare in the first place. 

Dr. Rishi Desai: That's awesome. Brianna, what's your backstory? I'd love to hear that as well.

Brianna Cardenas: Awesome, thanks. So, I am the first person in my family to pursue any type of graduate education or any type of career in the Health Sciences. In high school, I was an athlete and had a really strong interest in injury rehab. I actually hurt my shoulder and my knee several times, so I got exposed to a variety of different health care providers at an early age. And so, in college, my undergraduate major was athletic training. I graduated from college and became a certified athletic trainer. And in my very last rotation, I was just chatting with one of my preceptors in undergrad and he was like, "Why don't you consider going into med school or advancing your education because I really think that you have the capacity to be able to serve in a broader scope of practice and to help the community." That sounded really appealing to me but I think because I didn't have family members or a lot of people in the medical field that I was close with, the idea of pursuing graduate education was a little bit intimidating to me. I really didn't feel like I could afford, for my family's sake, to go to school for another several six, seven, eight, or nine years. 

And so, one of my preceptors told me about the PA profession and I felt like I was a little bit late to the game. I was like, "I've never even heard of a PA. I'm about to graduate from college. Can I do this?" He was like, "Yes, it's amazing. You have a big scope of practice and it's only another two to three years." I was like, "Wow. I think that I could do that." So, I went ahead and applied to one school because that was all I could afford to apply to, and I knew that I needed to stay close to home. I actually ended up going to a PA school five minutes from home. I've lived in the same community my whole life, and then, became a PA. I worked in pain management for the better part of my career. Because I have a chronic illness, I actually had to take time off of clinical practice when I had back surgery. And then, got my toe in the water in PA education once my back started to recover and I fell in love with education a couple of years ago. So, I'm really excited to be here at KGI. 

Dr. Rishi Desai: So, a common theme then between both of your stories is that it wasn't on your radar. Sonia in your case, you had something different on your radar. But then, it was on your radar and when it was, that's when, for lack of a better word, the love began. You kind of fell in love with this profession and you really enjoy the profession. Is that a theme that's common as you reflect on students at KGI? Is that a common story? Did they often not know about it, and then, they came to know about it through, like in your case Brianna, a mentor and then, kind of through word of mouth or through knowing that person, sort of explored it. Is that a common theme? 

Sonia Otte: Honestly, I think it is. I think it's becoming less because I think there is more publicity around our profession, and I hope it continues to go in that direction. Now, we've been speaking to pre-PA clubs at school. It's not just pre-med clubs. So, I think there is broader knowledge about it among college students. So, they get it but I think it took several decades to kind of get there. Our profession's been around since the 60s, but I think a lot of people don't really understand it. I know Brianna knows a lot about this...there are so many misconceptions about our title, and I think that also has contributed to people not really knowing, "Oh, this is really this type of scope of practice? Oh, I didn't know that. I didn't know I could do all of that as a PA." I think the more that people do learn about it, the more this becomes an option for them. 

Dr. Rishi: Desai That makes sense. 

Brianna Cardenas: I would totally agree with what Sonia said. In college systems, we're starting to see a lot more awareness. One of the issues that we're going to touch on today is really the lack of diversity in our profession, and I think because things are just slow to infiltrate layers of education, there's really still not a lot of awareness outside of academia as students are going through, into undergrad, and so forth. So, the awareness is still really low in high school and in middle school. I think that's a prime age where students are really starting to think about like, "Wow. What do I want to do for the rest of my life? How do I want to serve my community?" I think that if we can start to reach younger and younger people, then they'll be aware that, "Hey, this is something that I can do. I can be done by the time I'm twenty-five or twenty-six in some cases. I can just get out and start helping my community." So, I think that those are some goals that we have as just a profession in general is to increase the awareness around what we can do, who we are, and how we can help our communities. 

Dr. Rishi Desai: So, on everyone's mind right now are issues of diversity, equity, and inclusion. Do you mind just walking me through what are some of the concrete things that KGI is doing? Both in terms of recruiting folks to come to KGI, and also, the cohort that you do recruit, how do you train them to think about issues of culture differently than maybe it was being taught even a few years or a decade ago? 

Sonia Otte: Sure. So, just to provide a little perspective of where we are right now. As of 2019, the vast majority of matriculating PA students were twenty-five years old, white and female. We all know those statistics are not truly representative of the US population. We're trying to really fix this imbalance and provide equal opportunity to students of different races, cultures, genders, and gender identities, financial statuses, ages, and experiences. Everything. We're really looking for a diverse student population and we plan to achieve that by taking a few different approaches. 

So, the first is that we really want to have a holistic admissions approach. We're not just looking for 4.0 students. We want someone with dimension and someone who shares in our mission. We do that by looking at a whole person and all of their prior life experiences, not just their academic experiences. We really want someone who loves working with patients. That's extremely important to us and why we require a thousand patient care experience hours before they come into our program. We're also really looking for the applicants' capacity to succeed. So, if they've shown resiliency, either personally or academically, then that's what we're really focused on instead of just the numbers. 

The second approach we're taking is by decreasing barriers in general. So, instead of having ten to fifteen prerequisite requirements, we've really streamlined that and decreased the number to seven. There's even some flexibility within those seven that we've selected. We're also not requiring the GRE. We haven't found a concrete connection between student success on the GRE and student success on our certifying exam. So, for us, it wasn't convincing enough to really create this barrier financially for students who couldn't, not only afford to take the test, but also couldn't afford to prepare for the test. So, we've really removed that from our program. 

The third approach we're taking is a little bit different. We don't want, as you said, to just recruit diverse students. We want to make sure that they stay and thrive. The way we do that is by developing matriculation training modules for our students so they know what to expect in the years ahead. But these modules are not just for the students, they're also for the families and their significant others. We found that students who are underrepresented in medicine support their families or live in multi-generational homes. Their families really need to be on board. So, by the families also taking these training modules, they can learn and understand what the commitment is that the student is making, and they could better understand the journey so they can really be there to support the student through it all as well. 

Dr. Rishi Desai: That's phenomenal. I'm so curious. What is in those training modules for family members? I'm just thinking of my mom and dad taking a module. What's in that module? I'd be so curious to learn.

Sonia Otte: We're still working on that, but what it really will talk about is wellness, burnout, and really just understanding, "This is the expectations that we have for our students. This is the type of time commitment that it will take." A lot of families can feel like the student has sort of neglected or abandoned them by not attending certain family events and things like that. I think if you have sort of that expectation that this is going to be twenty-seven months that is going to be different in your life. I know you may be used to a certain type of support and presence from the student, but this is not a decision they're making. This is part of the commitment that they've chosen that will ultimately change their life. So, that's something we're actively working on and we really do think it will make a difference for some of these students.

Brianna Cardenas: Yes. I think to that point, one of the things about really walking the diversity walk, instead of just talking the talk, is really understanding what do students from diverse backgrounds need to hear? What do they need from their professors? What do they need from their programs in order to really thrive? So, in those pre-matriculation modules, we're incorporating some of the things that have traditionally been barriers for students. I can speak to the Latinx experience going through this type of program and what a lot of my students have expressed in this community is -- especially for Latinx women -- we're expected to work, be caregivers, take care of our younger siblings, and provide for our families. And sometimes, that can be in conflict with needing to study for six or seven hours a day, or however many hours need to be put into this program in order for the student to be successful. So, talking with the families about like, "Hey, this is what the daily life of your daughter or son or etcetera is going to look like. This isn't going to be forever. This is how you can help support them. Please don't be mad at them if they miss birthdays and so forth for the next couple of years. It'll all be worth it. We can get through it together." 

Just really having everybody on board so that they have, not only, like Sonia said, a clear expectation of what's going on but also to know that there are resources available for their students and the students know there are resources available for them as well. I think a really cool thing about being at a graduate institution is that we have resources through student affairs and so forth that are really tailored to a graduate student, not just like a traditional undergrad, because those needs are definitely different. 

One of the unique things that I think we're doing -- still to the point of recruiting for diversity and retaining diverse students -- is that we're really trying to start early. So, reaching out to programs that help with high school students that are interested in the health professions. Doing outreach as early as grade school and primary schools to make sure that students just have this on their radar and they know like, "Hey, this is an option for me when I get out into college or when I'm ready to go on to graduate school."

Dr. Rishi Desai: That's remarkable. There's a phrase -- I'm going to butcher it and I don't know who initially said it -- but something like, "If you can see it, you can be it." Once you see someone talking about something and that person looks like you look, then you're like, "Oh, maybe I can do that thing that they're doing that's so awesome." It kind of makes you aware of your potential. And the fact that you're going young is awesome. What is the youngest age that you're able to kind of target this messaging towards?

Sonia Otte: At this point, we're targeting as young as high school, but our goal is to eventually extend to elementary school in the future. We wanted to kind of solidify it at the high school level, and then, expand downward. 

Brianna Cardenas: Right. We're already developing partnerships with coalitions throughout Southern California that are working with students. They call it the K-14 system. So, I was familiar with K-12 and I had to ask like, "What is the thirteen and the fourteen?" They were like, "That's community college." All the way, hopefully, down to like kindergarten and grade school, because I think at that age it's like, "Are you going to be a doctor or a nurse?" and PA is not even on their radar. So, if we can even just start to plant that seed at a young age, I think that we will really start to see some growth and diversity in the profession.

Dr. Rishi Desai: Having grown up in Southern California, it's very obvious to me that it's a very diverse area and KGI is at the center of that. Do you mind just sharing a little bit about how you think about cultural competency? 

Sonia Otte: Sure. So, our focus as a program is really to advance health care and we're going to do that through educating our students about leadership, and about serving their communities, and about providing compassionate care to diverse populations. All of that is a part of promoting health equity. So, we wanted to make sure that we are putting cultural competency and linguistic competency training throughout our didactic and clinical phases. We're not just hosting one lecture or just doing one course on this. We're really integrating it throughout. It starts from the very first semester when we have a community health course, and we actually have our students out into the community -- meeting members, learning about the health care needs of that community -- and then, they're coming back to our program and creating patient education materials that can really speak to those issues. We hope to also disseminate those materials into the community to kind of help resolve these issues that they've identified. 

And then, we want to carry that theme throughout the program. We don't just want it to stop there. Through all of our case-based discussions that we'll go through and OSCEs that our students will go through, we want them always considering the social determinants of health. We know that if we have patient A with pneumonia and patient B with pneumonia, we don't treat them the same exact way. The reason being is that you don't treat a condition, you treat a patient. We want our students to learn that from the very beginning. So, we will do that. We'll have that as a part of our clinical cases and we also have our students' write reflection papers about what they've experienced on their clinical rotations as well if there is a group or a population that was negatively impacted by some of the social determinants of health. 

But in addition to that, our program is also focusing on LGBTQ+ care because we've noticed that this has been largely absent from lots of graduate medical education programs out there. So, we're really already making partnerships with centers for gender-affirming care so they can help support us through both the didactic and clinical phases of our program. 

Brianna Cardenas: Just a little quick note to add is my goal as the Director of Clinical Education is to make sure that our clinical experiences for our students really reflect the diversity that's here in Southern California. So, our clinical experiences will take place everywhere from big hospital centers with multiple specialties -- and all of the resources that are available to us in Southern California -- all the way to street medicine and mobile clinics, so that students will have the opportunity to work with all different specialties, all different people from different walks of life, different socioeconomic status, and different lifestyles. So, that way, they're ready to serve the people that live here and they're ready to really provide equitable care for all patients that they encounter. 

Sonia Otte: We're also hoping to create a medical Spanish course that our students can also complete prior to them even matriculating into our program so that we can get really the full scope, or as much as you can pack into twenty-seven plus months, to help get them really prepared to serve in these capacities. 

Dr. Rishi Desai: You both are aware that we are a teaching education company and we love to kind of fill knowledge gaps. Maybe both of you can take some knowledge gap or myth or whatever it is that you think that the general public could benefit from learning about, and maybe share that with us now if that's okay?

Brianna Cardenas: To start, I think one of the things that everybody should know about PAs is that according to US News and World Report -- and also, according to many PAs -- we are the number one overall job in the country, the number one health care job according to the latest US News and World Report. So, it's a wonderful profession that people are, generally, really happy with when they are out and working in the field. I think that's really important because we touched on how prevalent burnout is. 

I think another misconception actually comes from our title because we hear "physician assistant", and a lot of people confuse us with medical assistant or they confuse us with somehow belonging to the physician -- like the "physician's assistant" -- and it's just physician assistant. We're actually working to consider a possible name change because of the confusion. It's not just us at KGI, but this is a national initiative that AAPA - which is our national advocacy organization -- is considering. But we really want to start educating people sooner about what we can do, including the PA summer success program that we touched on a little bit earlier. We want to make sure that we're dispelling myths because for the longest time we were called 'mid-level providers', which is kind of a misnomer because we don't provide a middle level of care.

Our background and our capacity in the healthcare system is actually really broad and flexible. We can essentially switch specialties as well. We're trained in a generalist education, so every graduating PA is ready to serve in a primary care capacity when they graduate, or pivot into a specialty if needed. So, we can do everything from diagnose and treat illness and prescribe medications. We can conduct research, perform lab procedures, order and interpret tests and imaging, assist in surgery, and we can even own our own medical practices in some states. With that being said, I think the neat thing about the flexibility of our profession is that owning a medical practice is kind of along the entrepreneurial spirit. And so, the PA profession really has so many pathways in addition to those traditional clinical pathways. We can have that entrepreneurial non-clinical pathway. Some of us work in PA education, so, you can go the academic or the publishing route. There are leadership roles for PAs in all of our advocacy organizations, and even roles for us in pharmaceutical companies, such as medical science liaison. So, I think that just knowing all the things we can do, all the places we can work, and the flexibility of our profession is really important and exciting. 

Dr. Rishi Desai: Just to respond to that...I didn't know that there's a name change on the horizon or that it is even in the cards. You don't need to pay me for these suggestions -- I'm just going to give them to you. So, based on what you said, "The Happiest Clinicians" is one. Another one you can consider is "Clinical Chameleons." Do you like that? Yes? 

Brianna Cardenas: Oh, I like that one. That's a good one.

Dr. Rishi Desai: The final one is more practical, "Clinicians with Less Debt." So, think about those...

Sonia Otte: Nice!

Brianna Cardenas: True!

Sonia Otte: Those are great suggestions! (laughs)

Dr. Rishi Desai: ...as potential suggestions that you can take forward if you wish. Sonia, I'd love to hear your thoughts too. 

Sonia Otte: Yes. I would just kind of echo everything that Brianna just said. The focus that we're taking in our program is really to focus on those different career pathways because I think just knowing that the PA profession is as versatile as you want it to be is what is the most exciting thing. There are a lot of healthcare professions that don't have this type of flexibility. Just knowing that it does mirror a lot of things that a physician could be capable of, of course it's a different scope, but we can still take these academic, research, and leadership positions. More and more PAs are really carving out these leadership roles in healthcare administration and other areas. Just knowing you don't need to have an MD or DO behind your name to do that, I think, is also something that most people don't know. I'm proud that more and more PAs are kind of staking their claim because they do have the knowledge and experience to really succeed in those roles. 

Dr. Rishi Desai: So, one final question I'll pose to both of you then is, let's say you could go back in time and speak to maybe not yourselves, but some version of yourself like ten or twenty years ago. A person that didn't know about the PA profession or, maybe, just learned about it. Essentially, that kind of person might be a listener to this podcast. What would you say to that person as they watch your career as you both seem very successful and happy, and have kind of figured this out essentially? If they're kind of standing at the crossroads and trying to figure out what to do, what advice do you impart? What do you say to that person? 

Sonia Otte: I'll let Brianna take this one first. 

Brianna Cardenas: I guess, if you're a student, just know that one of the traits that's really important in any type of health care professional is willingness and excitedness to help. So, any time that you start to see an opportunity, whether it's volunteering -- the pandemic has created a lot of capacity for volunteer work -- or helping out in your community, just be willing to jump in and help. Be willing to put yourself out there. Be willing to anticipate the needs of what others may need, and just learn to start interfacing with members of the health care community. So, learning to communicate with each other, learning to work together, learning to just embed yourself as somebody who is a helper in your community. It's really important because at the end of the day, if you're an MD, DO, PA, NP, whatever the case is, we just need to be able to work together to help our patients. So, just start getting yourself out there. 

Sonia Otte: And for me, I'd say what we sort of touched on today is that health inequity is a huge problem. It's getting a little bit more press these days, but there's a lot that I think, for instance, if you're early in your career as a health professional, that you could be focused on. So, you don't just focus on being able to treat and educate your patients, but you should really also focus on listening to your patients and learning from your patients. Really listen, really empathize. Learn from their stories and experiences, and learn what they're actually going through. Oftentimes, the thing that you're looking for, you can find in these types of conversations because, as an effective provider, you're able to figure out what their circumstances are and what their abilities are. 

And so, whenever you're creating a comprehensive management plan for your patient, you should be considering their insurance status. You should be considering, "Do they actually have the ability to pay for this visit and pay for the treatments that I'm prescribing to them?" or, "Do they even understand the treatment regimen that I just created for them? Do they realize that I meant that they have to inject insulin more than one time a day? Do they get that part of it? Do they understand that?" And also, "Do they even have the transportation available to them to come to my next visit?" So, I think if you are able to consider all that and you do all that, then you'll truly be successful and be able to gain the trust of your patients. 

Dr. Rishi Desai: That's fantastic advice from both of you. I appreciate that and I appreciate you coming on and sharing your wisdom with us today. 

Sonia Otte: Of course, thank you. 

Brianna Cardenas: Thank you. And just one last thing is that for anybody listening, if you're not sure if you can do this, especially if you're coming from an area that maybe is considered underserved or you're the first person in your family to consider going and getting graduate education or working in the healthcare profession, please know that there are people in the profession who will support you, and help you, and offer resources. We want you to be in our profession and we know that you can do it. So, please reach out and know that we're here for you. 

Sonia Otte: Absolutely. 

Dr. Rishi Desai: That's awesome. It's a great message coming from KGI, an institution that we all trust and respect. So, thank you so much for joining us today. I'm Dr. Rishi Desai. Thanks 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.