PA_Pro_August_2016-final

PA Houry Gebeshian
Headed for Rio Olympics
FROMTHESURGICALSUITE
TOANINTERNATIONALSTAGE
T H E L E A D I N G N E W S R E S O U R C E F O R PA s
A U G U S T 2 0 1 6

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ContentsA U G U S T 2 0 1 6 • V O L . 8 , N O . 7
ABOUT THE COVER
The Wall Street Journal named
PA Houry Gebeshian one of
the gymnasts to watch at the
Rio Olympics.
Photo courtesy of Houry Gebeshian
Inside
C O V E R S T O R Y
From the Surgical Suite
to an International Stage
PA Houry Gebeshian Headed for Rio Olympics
S I D E B A R
Answering the Call to Provide
Care at Olympics
F E AT U R E S T O R I E S
Learning to Lead
PAs Taking Their Place at the Table
Offering Students a Glimpse
of the Future
AAPA’s Preceptor of the Year:
PA Maureen Barrett
18
23
32
26
Departments
Laws + Legislation
The Colorado Academy coalition leads to sweeping harmonization act
Payment Matters
CMS clarifies PA ordering of restraint and seclusion
STAT
AAPA statement in response to NCCPA press release | PAs eligible to prescribe buprenorphine
for opioid addiction | The Hospitalist profiles PAs in executive leadership | AAPA responds to Dear Abby
column | and more
Professional Practice
Contract negotiation tips for early career PAs
Reflections
Life lessons a PA learned hiking the Appalachian Trail
7
10
13
36
38
PA PROFESSIONAL | AUGUST 2016 | AAPA.ORG | 1

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© Copyright 2016 by the American Academy of PAs. PA Professional is published monthly and is a registered trademark
of AAPA, 2318 Mill Road, Suite 1300, Alexandria, VA 22314-6868.
MAGAZINE STAFF
PUBLISHER
Steve Gardner
sgardner@aapa.org
EDITOR-IN-CHIEF
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jrodrigues@aapa.org
WRITER/EDITOR
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AAPA BOARD OF DIRECTORS 2016–2017
PRESIDENT AND CHAIR OF THE BOARD
Josanne K. Pagel, MPAS, PA-C, Karuna® RMT, DFAAPA
PRESIDENT-ELECT
L. Gail Curtis, MPAS, PA-C, DFAAPA
IMMEDIATE PAST PRESIDENT
Jeffrey A. Katz, PA-C, DFAAPA
VICE PRESIDENT AND SPEAKER OF THE HOUSE
David I. Jackson, DHSc, PA-C, DFAAPA
SECRETARY-TREASURER
Jonathan E. Sobel, PA-C, MBA, DFAAPA, FAPACVS
FIRST VICE SPEAKER
William T. Reynolds, Jr., MPAS, PA-C, DFAAPA
SECOND VICE SPEAKER
Todd A. Pickard, MMSc, PA-C
DIRECTOR-AT-LARGE
Laurie E. Benton, PhD, MPAS, PA-C, RN, DFAAPA
DIRECTOR-AT-LARGE
Diane M. Bruessow, MPAS, PA-C, DFAAPA
DIRECTOR-AT-LARGE
Lauren G. Dobbs, MMS, PA-C
DIRECTOR-AT-LARGE
David E. Mittman, PA, DFAAPA
DIRECTOR-AT-LARGE
Beth R. Smolko, MMS, PA-C
STUDENT DIRECTOR
Joseph D. Sutherland
CHIEF EXECUTIVE OFFICER
Jennifer L. Dorn, MPA
V O L 8 | N O 7 | A U G U S T 2 0 1 6
AAPA.ORG

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BCM_MLP_AD-1.indd 1 5/23/16 12:43 PM
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LAWS+LEGISLATION
Big Legislative Win for Colorado PAs
PAs Added Throughout State Statutes
B Y A D A M S . P E E R
ADAM S. PEER, is an AAPA
director of constituent
organization outreach and
advocacy. Contact him via
email or 571-319-4314.
B
y anyone’s measure, June 1, 2016, was a ground-
breaking day for PAs in Colorado: Gov. John
Hickenlooper signed Senate Bill 158 into law.
Known as the“harmonization act,”this legislation
strategically adds PAs to sections throughout Colorado’s
statutes, removing significant barriers to patient care.
Collaboration between the Colorado Academy of PAs
(CAPA) and AAPA led to its passage. The new law goes
into effect Aug. 10, 2016.
This is the largest legislative undertaking by CAPA since
the original PA law was enacted in 1983.
CAPA President Meg Townsend, President-elect Meagan
Hillman, and Immediate Past President Brenda VanderWel,
worked closely with AAPA to review all 44 titles of Colorado
statutes. Their meticulous efforts identified the most effi-
cient and sensible places to include PAs where other
healthcare providers were listed. The first draft was nearly
300 pages long.
“There was so much uncertainty during the first stake-
holder meeting,”recalled Townsend.“The legislative
change that our organization was requesting was massive.
Gov. John Hickenlooper signs Senate Bill 158 into law at the Children's
Hospital of Colorado. Front row: Hickenlooper and children. Back row,
left to right, PA Jocelyn Cavender, state Rep. Dianne Primavera and
PAs Meg Townsend, Alysia Wiley and Meagan Hillman.
PHOTOCOURTESYOFCAPA

LAWS+LEGISLATION | continued
However, by the time we left the meeting we had a stronger strat-
egy and formed new alliances with stakeholders for PAs.”
The story behind this legislation has roots in Seattle. During the
2015 Legislative Summit of the National Conference of State Legis-
latures, AAPA staff sat next to state Sen. Kevin Lundberg, chair of
the Colorado Senate Health and Human Services (HHS) Committee,
and started a conversation about the important role PAs play
in healthcare.
Lundberg normally does not sponsor legislation before his com-
mittee. However, after several months of work, he decided to intro-
duce SB158. State Rep. Dianne Primavera introduced the state
House version of the bill.
It was well received, unanimously passing out of the state Senate
HHS Committee. CAPA testified along with representatives of the
Colorado Medical Society, Colorado Academy of Family Physicians,
Colorado Community Health Network, and the Division of Workers’
Compensation in both chambers. The bill received no opposing
testimony. It was adopted unanimously by both sides of the
state legislature.
“One of the key aspects achieved during the project was board
cohesiveness,”said Townsend.“Now we’re a board that’s 100 percent
united—we have clear goals and a firm strategy to achieve them.”
This legislative victory also opened up excellent opportunities to
engage with other groups active in Colorado’s healthcare issues.
This will lead to further discussions on how the laws can better
authorize expanded roles for PAs in other areas of healthcare,
including mental health.
What Is a Harmonization Act?
Generally, a harmonization act is legislation
that amends various sections of the law
that may only mention physicians, or physi-
cians and NPs, to include PAs. The results
not only mean that there is no longer con-
fusion over whether or not PAs can perform
a medical function that they are qualified to
perform, but that when new sections of law
and regulations are drafted in the future,
legislators and regulators will include PAs.
What did Senate Bill 158 do?
■ Clarifies that PAs may perform any act
that has been delegated by a physician—
including signing forms, making certain
statements and making certain findings
or declarations
■ Allows certain patients direct access to PAs
by naming PAs as primary care providers
■ Specifies that under workers’compensa-
tion, level I accreditation is also extended
to PAs
■ Removes the requirement that a physician’s
name must appear on prescriptions issued
by a PA, except for controlled substances

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PAYMENTMATTERS
CMS Clarifies PA Ordering
of Restraint and Seclusion
AAPA Calls on PAs to Support Change
B Y M I C H A E L P O W E
W
e all know that words matter. That may be
especially true when it comes to regulatory
language that authorizes or guides the inter-
pretation of how PAs and other healthcare professionals
deliver care to patients. For years, the Medicare program,
which is administered by CMS, has been using an anti-
quated and confusing term to describe who could order
restraint and seclusion in hospitals. The problematic term
is“licensed independent practitioner,”or LIP.
Responding to protracted lobbying efforts by AAPA,
CMS issued a proposed rule,“Medicare and Medicaid
Programs; Hospital and Critical Access Hospital (CAH)
Changes to Promote Innovation, Flexibility, and Improve-
ment in Patient Care,”on June 15. One provision of the
proposed rule would officially change the term“licensed
independent practitioner”to“licensed practitioner”in
order to improve hospitals’utilization of PAs.
MICHAEL POWE is AAPA vice
president of reimbursement
and professional advocacy and
an adjunct assistant professor
at The George Washington
University School of Medicine
and Health Sciences. Contact
him at michael@aapa.org or
571-319-4345.

PAYMENT MATTERS | continued
AAPA applauds CMS’recognition that PAs have the education and exper-
tise to provide this level of care. As CMS noted in the proposal,“PAs are
trained on a medical model that is similar in content, if not duration, to
that of physicians.”CMS language in the proposal goes on to say that“Fur-
ther, PA training and education is comparable in many ways to that of
APRNs and in some ways, more extensive.”
Brief History
LIP is not a term that emanates from a law or statute. Rather, it’s a term
created by CMS and also used by The Joint Commission (JC). Because the
term contained the word“independent,”there were questions as to
whether PAs—who practice medicine autonomously, but collaborate with
physicians—were included as LIPs. Over the years, some hospitals contin-
ued to be confused as to whether PAs were included among those profes-
sionals who were officially authorized to order restraint and seclusion, as
allowed by state law and facility policy.
In previous comments to CMS, AAPA recommended that the word“inde-
pendent”be struck from any term describing qualified healthcare profes-
sionals, arguing that“independence”is not a measure of a healthcare pro-
fessional’s educational preparation, competency or ability to provide
quality medical care. Eliminating confusing language supports increased
patient access to care, improves team-based healthcare delivery and
allows PAs to work at the top of their license.
Previous CMS Interpretation Was Positive
The existing LIP language did not necessarily exclude PAs from ordering
restraint and seclusion, but it did create confusion. AAPA worked exten-
sively with CMS to obtain a PA-friendly interpretation of the LIP terminol-
ogy. As far back as 2006, and in direct response to AAPA’s comments to a
CMS rule, CMS issued the following statement,“For the purposes of this
rule, a LIP is any individual permitted by State law and hospital policy to
order restraints and seclusion for patients independently, within the scope
of the individual’s license and consistent with the individually granted
clinical privileges. This provision is not to be construed to limit the author-
ity of a physician to delegate tasks to other qualified healthcare personnel,
that is, physician assistants and advanced practice nurses, to the extent
recognized under State law or a State’s regulatory mechanism, and hospi-
tal policy. It is not our intent to interfere with State laws governing the role

PAYMENT MATTERS | continued
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Adding Your Voice
Go here to tell CMS you support
clarifying a PA’s ability to order
restraint and seclusion.
of physician assistants, advanced practice registered nurses, or other
groups that in some States have been authorized to order restraint and
seclusion or, more broadly, medical interventions or treatments.”
While this statement is certainly useful, those making utilization and
employment decisions in hospitals may not have had access to this lan-
guage or may have chosen to adopt a more conservative interpretation.
Conclusion
The proposed rule, once finalized, will help eliminate confusion about the
right of PAs to order restraint and seclusion under the Medicare program.
In addition, AAPA will ask that the JC align itself with CMS policy and elimi-
nate the term LIP in its manuals and publications. AAPA will submit formal
comments to CMS in support of the proposed change. Comments are due
to CMS by August 15.

STAT | Industry News
AAPA STATEMENT IN RESPONSE
TO NCCPA PRESS RELEASE
The recent decision by the AAPA Board of Direc-
tors to investigate the creation of an alternative
certifying body for PAs was made after careful
deliberation, extensive communications with the
leadership of the NCCPA and in response to the
large number of concerns voiced by PAs to AAPA.
The decision to explore the establishment of a
new certification organization was not made lightly
and reflects the priority of PAs to put patient care
ahead of burdensome and unnecessary recertifica-
tion testing.
The Board’s action was the direct result of the
overwhelming vote by the AAPA House of Del-
egates (HOD) in May to reject the principles that
underlie NCCPA’s recertification proposal. NCCPA is
incorrect when it asserts that AAPA hasn’t engaged
with it about the proposal. We have. At AAPA’s
invitation, NCCPA spoke to national and state PA
leaders at the Academy’s Leadership and Advocacy
Summit in February and, in an unprecedented
move, addressed the HOD in May. The AAPA Board
has also issued numerous invitations to speak
directly with NCCPA leaders, which have been
rebuffed or pushed off to lawyers. AAPA’s invitation
for a board-to-board dialogue remains open.
NCCPA is incorrect when it says it has evidence
that recertification testing helps patient outcomes.
PA Josanne Pagel
AAPA TO TAKE NEXT STEPS TOWARD
CREATING NEW PA CERTIFYING BODY
At its July meeting, the AAPA Board of Directors
unanimously voted to take the next steps toward
establishing a new certifying organization by gath-
ering more information and developing the neces-
sary documents.
“The changes to the recertifica-
tion process proposed by NCCPA
would have such a significant det-
rimental impact on PA practice and
patient access to care that the AAPA
Board decided it would be pru-
dent to begin the work necessary
to establish a new certifying body,”
said AAPA President Josanne Pagel.
“Of course, we continue to hope
that NCCPA will accept our invita-
tion, which was extended after the
May HOD meeting and again after
our most recent Board meeting, to
discuss its recertification exam proposal with us
directly, board to board.”
For more information on the NCCPA recertifica-
tion proposal and the latest news on AAPA's ongo-
ing response, visit www.news-center.aapa.org.
Here is NCCPA's response to AAPA's decision to
take the next steps toward creating a new PA
certifying body.
There simply is no such evidence. NCCPA is espe-
cially incorrect when it says that PAs support its
recertification proposal. We have heard—and
hear daily—from individual PAs and the elected
representatives of constituent organizations who
disagree with the NCCPA plan. AAPA has not yet
decided to stand up a new organization. The Acad-
emy will continue to take the steps that are in the
best interest of PAs and the patients they serve.
For more information on this issue, please visit
and bookmark this website.
THE HOSPITALIST PROFILES PAs
IN EXECUTIVE LEADERSHIP
The Society of Hospital Medicine’s The Hospitalist
reports on the evolving role of PAs and nurse
practitioners NPs in hospital medicine groups and
health systems.“Some PAs and NPs have ascended
to positions of leadership in their HM groups or
health systems, in some cases even supervising
the physicians.”
The Hospitalist interviewed five PAs for the arti-
cle, including AAPA Director-at-Large Laurie Benton
and PA Michael Huckabee, director of the Division
of Physician Assistant Education at the University
of Nebraska Medical Center in Omaha.
Read more about PAs in executive leadership and
management on page 26 of this issue of PA Pro.

STAT | continued
AAPA RESPONDS TO
DEAR ABBY COLUMN
AAPA responded to mislead-
ing information about PAs
published recently in a“Dear
Abby”column. While the original question and Abby's
response were concerning, it was heartening to see the
many positive responses in support of PAs in the com-
ments to the story. AAPA encourages PAs and PA stu-
dents to provide clarifying comments regarding misin-
formation about PAs in any publication or public forum.
TELL CMS YOU SUPPORT PAs’ ABILITY
TO ORDER RESTRAINT AND SECLUSION
Responding to AAPA’s lobbying efforts, CMS issued
a proposed rule containing a provision to officially
remove an antiquated regulatory term,“licensed inde-
pendent practitioner,”to avoid continued confusion
regarding hospitals’utilization of PAs.
Add your voice and tell CMS that you strongly sup-
port their proposal to use the term“licensed practitio-
ner,”especially when it comes to determining which
health professionals are authorized to order restraint
and seclusion for patients in hospitals. The new term
will make it clear that PAs are included among the pro-
fessionals who can order restraint and seclusion for
Medicare beneficiaries. Some hospitals are confused as
to whether PAs are able to order restraint and seclusion
due to the word“independent.”The proposed language
change will remove that uncertainty.
Learn more here and see story on page 10.
PAs ELIGIBLE TO PRESCRIBE BUPRENORPHINE FOR OPIOID ADDICTION
Over the past year, AAPA aggressively lobbied for PAs to be
part of the solution to the nation’s opioid epidemic. As a
result of our efforts, PAs will soon be eligible to become waiv-
ered to prescribe buprenorphine for the treatment of opioid
addiction. On July 8, the U.S. House of Representatives over-
whelmingly supported passage of the House-Senate Con-
ference report to S. 524, the Comprehensive Addiction and
Recovery Act (CARA) of 2016 and the U.S. Senate followed
suit on July 13. The legislation amends federal law (the Drug
Addiction Treatment Act of 2000 or DATA 2000) to permit PAs
to become waivered to prescribe buprenorphine for the treat-
ment of opioid addiction. It will now be sent to the president
for his expected signature.
“As a PA with a background in addiction medicine and com-
munity health clinics, I am pleased Congress is bringing more
resources to bear to tackle the opioid addiction crisis in this
country,”said AAPA President Josanne Pagel.“The inclusion
of PAs in CARA is crucial to our ability to provide proven treat-
ment options to more Americans suffering from addiction.”
Although CARA was crafted in a bipartisan manner, funding
was a contentious issue leading up to the bill’s passage and
shaped many of the bill’s final provisions. This was because
the Congressional Budget Office gave the bill a high cost esti-
mate for the Medication-Assisted Treatment (MAT) Program,
Section 303, of the bill. This unexpectedly high cost ultimately
determined the conditions in which DATA 2000 was amended
to permit PAs and nurse practitioners NPs to become waiv-
ered to prescribe buprenorphine for the treatment of opioid
addiction.
According to Tillie Fowler, AAPA’s senior vice president for
advocacy and government relations,“Although Section 303
of CARA does not include all of AAPA’s policy recommenda-
tions; we believe it is a significant step forward in utilizing PAs
to expand access to treatment for the millions of Americans
who are struggling with opioid addiction. And AAPA will push
to extend this authorization for PAs beyond its current 2021
expiration date.”
Read more here.
INGIMAGE.COM

STAT | continued
NEW PA JOB SOURCE
AAPA recently launched its new“PA JobSource”website, designed to
connect employers with PAs across all disciplines and career levels.
The PA profession is one of the fastest growing and most in-demand
healthcare professions in America and the competition to recruit PAs
has been intensifying nationwide. The profession has grown nearly
40 percent in the last five years and, according to the U.S. Bureau
of Labor Statistics, employment of PAs is projected to continue to
increase 30 percent by 2024.
PA PROFESSOR EARNS
DISTINGUISHED
SERVICE AWARD
PA Heidi Miller, Rochester
Institute of Technology (RIT)
PA program director and
professor, was recently rec-
ognized with a Distinguished
Service Award from the Roch-
ester Academy of Medicine
during a ceremony to honor
her for her service to the
community.
An active member of the
local medical community,
Miller and her PA colleagues have forged strong,
lasting relationships with healthcare providers in
the region to ensure vital clinical rotation sites for
RIT PA students.
Miller is the inaugural director of the PA program,
which she launched in 1993.
NEW SYPHILIS SCREENING
RECOMMENDATION FOR ADULTS
The U.S. Preventive Services Task Force (USPSTF)
recently published a final recommendation state-
ment and evidence summary on screening for
syphilis infection in non-pregnant adults and
adolescents. The USPSTF strongly recommends
screening individuals at increased risk for syphilis
infection. This is an A recommendation. The Task
Force’s recommendation has been published in
the Journal of the American Medical Association,
as well as on the USPSTF website. A fact sheet that
explains the final recommendation in plain lan-
guage is also available. AAPA is a USPSTF partner.
AAPA CREATES NEW LIAISONS
TO OSTEOPATHIC PHYSICIANS
AND PSYCHIATRISTS
The AAPA Board of Directors recently created two
new medical liaison positions—to the American
Psychiatric Association (APA) and the Ameri-
can Osteopathic Association (AOA). The Board
appointed PAs Phyllis Peterson of Texas and Melissa
Bowlby of Ohio to fill the new positions.
AAPA’s medical liaisons are official representa-
tives tasked with building and sustaining relation-
ships with national physician and medical specialty
organizations. Liaisons work to shape PA-positive
policies within the broader medical community by
providing information as policies are formed and
reacting to proposed policies that would be dam-
aging for PAs and bad for patients.
“In the past couple of years, organized psychiatry
has had a growing interest in PAs,”said Jeff Katz,
then AAPA president.“Combined with the move-
ment to integrate behavioral and primary care, the
Board thought it was an opportune time to estab-
lish a formal liaison relationship with APA.”
“AOA is a major, multispecialty medical organiza-
tion that AAPA has previously collaborated with, but
we have not had a formal liaison relationship,”Katz
added.“In 2013, we issued a joint policy statement
supporting team-based medicine and have a strong
staff-to-staff relationship. The BOD felt this was the
next logical step in building that relationship.”
Peterson and Bowlby’s terms run from July 1,
2016–June 30, 2018. With these additions, AAPA
now appoints official liaisons to 22 national physi-
cian and medical specialty organizations.
Read more here.
PA Heidi Miller

STAT | continued
•
NEW AAPA CONSTITUENT ORGANIZATIONS
Three new constituent organizations (COs) were welcomed to the AAPA fam-
ily during the House of Delegates meeting in May. They are the Association of
Neurology PAs, Society of PAs in Clinical Ultrasound and PAs in Critical Care.
COs are independent organizations affiliated with AAPA that collaborate and
combine resources in support of strategic professional goals. They provide
their members with an amplified voice for PAs, advocacy leadership, CME and
networking opportunities.
AAPA’s CO community is comprised of:
Chapters: Fifty-six chapters representing 50 states, the District
of Columbia and five federal services
Specialty organizations: Twenty-seven specialty organizations
of individuals working within a specific medical specialty
Caucuses: Eight groups of individuals sharing a common concern, interest or
goal in healthcare delivery and access
Special interest groups: Nineteen groups of individuals that share
a common goal or interest
EARLY TREATMENT FOR ACUTE
KIDNEY INJURY IMPROVES
OUTCOMES
The initiation of renal replacement therapy less
than eight hours after the onset of stage 2 acute
kidney injury significantly reduces all-cause mortal-
ity at 90 days, according to results from the ELAIN
randomized clinical trial, whose findings were
published recently in the Journal of the American
Medical Association.
PAs SEEK INCREASED CAREER
FLEXIBILITY AND OPTIONS
A new partnership between AAPA’s Center for
Healthcare Leadership and Management (CHLM)
and CompHealth will provide PAs with job oppor
tunities to fit their lifestyles.
The 2015 AAPA National Survey found that 38.8
percent, or more than a third, of respondents indi-
cated that they chose their current specialty due
to“greater flexibility.”
“The PA profession is not one-size-fits-all and
opportunities for PAs shouldn’t be either,”said AAPA
CEO Jennifer L. Dorn. “AAPA and CHLM are commit-
ted to creating progressive work environments
for PAs, the most in-demand medical profession
in the U.S. This alliance with CompHealth will give
PAs exclusive access to a special level of career
customization.”

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COVER STORY
FROM THE SURGICAL SUITE
TO AN INTERNATIONAL STAGE
PA Houry Gebeshian Headed for Rio Olympics
Gebeshian is a PA by night and a gymnast by day.
BY HILLEL KUTTLER
Every day she works at the Cleveland
Clinic, PA Houry Gebeshian welcomes
new lives to the world.“It’s an amazing
experience to see these squirming
babies take their first breath,”she says.
Gebeshian is about to accomplish a
first herself.
In August, she will be competing in the Olym-
pic Games in Rio de Janeiro. The first female gym-
nast to represent her ancestral land of Armenia in
the Games, Gebeshian will do four events: floor
PHOTOCOURTESYOFCLEVELANDCLINICVIAHOURYGEBESHIAN

COVER STORY, continued
exercise, vault, uneven bars and balance beam. The Wall Street Journal
named her one of the gymnasts to watch in Rio.
Gebeshian, who specializes in obstetric surgery, could even attain
immortality in Brazil.
That would occur if she executes a new maneuver she’s devised for the
uneven bars and has successfully completed in practices. (We’re keeping it
under wraps because she’s going to unveil it at the Games.)
In keeping with the sport’s tradition, the move would then be named
for her: The Gebeshian.
Connecting the Dots
Gebeshian’s pathways in gymnastics and medicine have touched at several
points in her career. Always interested in medicine, she started her career
as a certified athletic trainer. She later realized that she wanted to further
her education, switching paths to become a PA. That led her to a clinical
rotation in Cleveland when she was a second-year PA student at Wake
Forest University.
Gebeshian arranged a rotation in podiatric surgery at St. Vincent Charity
Medical Center’s Spine and Orthopedic Institute. Her preceptor was a podi-
atrist and former gymnast, Michael Canales, who she had met years before
in Tokyo at the 2011 World Championships when she was making her first
attempt to earn a berth at the 2012 Olympic Games in London. She ended
up retiring from gymnastics following a calcaneal stress fracture that
ended her chances to qualify for the 2012 Games.
Canales and his wife Dominique Moceanu—Gebeshian’s childhood idol,
former U.S. gymnast, and 1996 Olympic gold medalist—were covering the
event for a gymnastics magazine.“I always marvel at how the dots of life
are supernaturally connected,”he now says of the chain of events.
Gebeshian is a PA in obstetric surgery
at Cleveland Clinic.
PHOTOCOURTESYOFCLEVELANDCLINICVIAHOURYGEBESHIAN

Canales remains impressed with the“rare”skill Gebeshian exhibited during
the rotation, when she did histories and physicals for patients and assisted him
in surgery.
“By the end of the month, she was performing like a first-year resident, an
intern,”Canales says.“Within the first week, she’d picked it up; oftentimes, it
takes a full year, year and a half, for someone new to the OR to know how to
behave. And, she was very humble with our staff, with the OR nurses.”
Reigniting Her Dream
During her month at the institute in 2013, she met another podiatrist, Duane
Ehredt Jr., who was completing his residency training in foot and reconstructive
rear foot/ankle surgery under Canales. The two started dating and were later
engaged. It was Ehredt who encouraged Gebeshian to give gymnastics another
shot. They made a plan, and after graduating from Wake Forest in 2014, Gebe-
shian returned to Cleveland.
Through the guidance of Canales and Moceanu, Gebeshian started training at
Gymnastics World in nearby Broadview Heights, a facility where Canales and
Moceanu trained during their gymnastics careers, and where their children now
train. With no job lined up, no coach to coach her, and no place to live, Gebe-
shian nevertheless followed through with her commitment to Ehredt, and was
on her way to make her Olympic dream a reality.
Reconnecting with Canales and Moceanu wasn’t the only bit of good fortune
to come Gebeshian’s way. When interviewing for a job at Cleveland Clinic, she
told PA James Nahrstedt up front that gymnastics was her first priority, but that
she’d bust her tail to succeed at work, too.
Rather than finding that off-putting, the message impressed Nahrstedt, PA
coordinator for Cleveland Clinic’s surgery department. Gebeshian’s up-front
statement was“a huge positive, because I was looking for somebody pretty
motivated,”he says.
It helped, too, that the demanding schedule he quickly had to fill perfectly
suited her needs: weekly 24-hour and 16-hour shifts.
“I knew she’d be very disciplined. I was impressed,”Nahrstedt says.“When I’m
interviewing for employees, I’m thinking: Who can I train to work for me, who
will fit in well with the group? It was a positive to have someone dedicated to
their routine and what they wanted to accomplish. It was a great fit.”
Gymnast by Day, PA by Night
Gebeshian stays fit, training up to four days a week, up to 20 hours total. But
that’s“very minimal,”she says—far less time than most elite gymnasts devote
to training. So, she adds,“I try to be as efficient as possible.”
Armenia doesn’t contribute toward her training and transportation expenses.
“I’ve done it all on my own,”she says, down to planning workouts on spreadsheets
soon after returning home from those long shifts in the OR.
Gebeshian did recently receive help from a volunteer gymnastics coach,
Levon Karakhanyan, an Armenian-American. A childhood friend, choreographer
Nicole Langevin, plotted her floor routine at a discounted rate, and Langevin’s
husband, Darek Leiner, condensed three hours of Gebeshian’s preferred music
into a 90-second arrangement in dubstep style to accompany her floor routine
for Rio.
When Gebeshian was a child, she looked up to Langevin, who was a fellow
gymnast at the Massachusetts Gymnastics Center (MGC) outside Boston. They
reconnected in 2015 as Rio became real. Turns out that Langevin had also
admired Gebeshian, who is seven years her junior.

“I remember looking over one day and seeing this muscle-bound 10-year-old doing
things like a‘double-back’flip that I’d just learned,”says Langevin.“I realized that I should
watch her for a few years. I knew she’d do great things.”
Gebeshian’s father, Hagop, had an inkling, too. When his daughter was five, he brought
her to the local YMCA“to keep her busy,”he says, but was told that she merited more
advanced gymnastics instruction. That led them to MGC, where, through age 18, she
trained five days a week.
Only after she won state championships and earned a Division I athletic scholarship to
gymnastics powerhouse the University of Iowa, did her father grasp her Olympic potential.
To Armenia With Love
Hagop will accompany his daughter on the nearly 5,000-mile trip to Rio from Boston,
nearly the distance he covered when he immigrated to Boston from Lebanon many years
ago. That’s where he was born, in the Bekaa Valley town of Anjar—an Armenian-majority
area settled by refugees from the Turkish genocide against Armenians in 1915. In Anjar,
there is a memorial to Musa Dagh, a mountain in southern Turkey where Hagop’s parents,
who survived the massacre, had lived.
Hagop has told Houry about the family’s roots there and further back in time, in Arme-
nia proper, but she’d like to learn more. She’s traveled twice to Armenia, and she joined St.
Gregory of Narek Armenian Orthodox Church soon after settling in Cleveland. She’s gotten
involved in several social groups in the church, and the Armenian language, once her
mother tongue, is slowly returning. But because of those 24-hour Sunday shifts, Gebeshian
can’t attend worship services routinely. Fortunately, Ehredt has found a spiritually fulfilling
and enthusiastic community at St. Gregory as well. Gebeshian jokingly calls her fiancé an
“Armenian by choice”.
“He’s helping bring me back to my culture,”she says.“Now, the opportunity to compete
for Armenia has brought me back to my roots. In Cleveland, there’s a great Armenian com-
munity that’s supportive of what I’m doing.”
“I remember looking over one day and seeing this muscle-
bound 10-year-old doing things like a ‘double-back’ flip that
I’d just learned. I realized that I should watch her for a few
years. I knew she’d do great things.”
—Nicole Langevin, owner of Precision Choreography, gymnastic coach
and former elite gymnast

HILLEL KUTTLER is a Baltimore-based
freelance writer and editor who has
written about PAs and healthcare for many
years. He can be reached by email.
So, too, is Cleveland Clinic. After qualifying for Rio, Gebeshian was rec-
ognized and asked to stand at a meeting, and she was recruited to sign
autographs at an Olympic-themed office picnic. Just before she departed
for Rio on August 1, the hospital held a cake reception send-off in her
honor and will host a watch party during her competition.
“To be a PA and an Olympian—that’s kind of cool,”Nahrstedt says of
Gebeshian. He adds that some of the qualities she exhibits at work serve
her well as an athlete, too.“She’s very task-oriented and pays attention to
all the little things. She’s got a very dedicated skill set, and is very good
with patients.”
He says that“it’ll be extra special”to watch the Olympics on television,
knowing that his colleague will be competing. For Moceanu,“with Houry
on the radar, I’ll watch to see how she does, because I have a personal rela-
tionship with her.”
Gebeshian is rightly proud of her accomplishment, acknowledging the
obvious in stating,“Not everyone can say they’re an Olympian.”
But, like the PA in scrubs who ushers patients into parenthood, the
jumping, running, swinging, reaching gymnast plans to cheer on fellow
Olympic athletes after her own competitions end.
“I’m really looking forward to soaking in the entire experience,”she says.
“I want to watch people make their dreams come true.”
If you are interested in joining
Gebeshian as she embarks on her
Olympic journey, follow her on social
media via Facebook, YouTube and
@HouryGebeshian on Instagram and
Twitter. Contact her via email if you’d like
to contribute to her GoFundMe
campaign.
PHOTOCOURTESYOFHOURYGEBESHIAN
Gebeshian with children at Woodward Camp
for elite athletes.

Answering the Call to Provide Care
at Olympics
BY JENNIFER WALKER
PA Judith James sees volunteering to provide emer-
gency care to athletes, spectators and staff during the Rio
2016 Olympics and Paralympics as a natural fit for her. She
has an international background, having grown up in
Seoul, Korea, where her parents worked for the U.S. Army.
And she likes the pace and variety of cases that come
with emergency medicine, which is why she is a noct-
urnist at the East Carolina Heart Institute at Vidant Medi-
cal Center in Greenville, N.C.
Emergency medical services will be by far the dominant
type of care provided during the Olympic Games.The
Games are expected to attract an estimated 500,000 tour-
ists and 70,000 volunteers from around the world to see
10,500 athletes from the 200 member nations of the Inter-
national Olympic Committee (IOC). And the Paralympics is
nearly as diverse, hosting athletes from 170 countries.
A 2013 graduate of the South College PA program in
Knoxville, Tenn., James has had a lifelong interest in
sports. So when she saw the IOC Medical and Scientific
Commission’s call to become one of a select group of
healthcare volunteers, she applied to be among the 5,000
providers who play a key role in one of the world’s big-
gest—and oldest—sporting events. After a lengthy appli-
cation process, the IOC selected James to be part of the
emergency medical services team.
“To have the honor of caring for our athletes and to
know that I am being allowed to make that kind of contri-
bution is just overwhelming,”James says. Also, with 42
sports at the Olympics and 23 at the Paralympics,“the
opportunity to maybe take in the Games is pretty excit-
ing,”she added.
She joins many other PAs who have provided care at
other Summer and Winter Olympics, either as members
of IOC medical services or for Team USA.
In Rio, healthcare volunteers will staff medical stations
inside and outside the competition facilities as well as the
Olympic Village, which will be home to most of the ath-
letes. Selected candidates receive exclusive training for
PA Judith James
PHOTOCOURTESYOFJUDITHJAMES

“To have the honor of caring for our athletes and to know that I am
being allowed to make that kind of contribution is just overwhelming.”
—PA Judith James
the position, and the IOC will provide them with a certificate of participa-
tion as well as cover their food and travel costs in Rio on work days.
Planning and coordinating medical services for the Games is a daunting
undertaking and it starts years before the Olympic torch is lit. Organizers
have to consider the day-to-day medical needs of half a million people;
plan for large-scale emergencies and disasters, like the bombing that took
place at the 1996 Atlanta Olympics; and integrate their medical services
with those of the local public health agencies and hospitals, as well as the
medical communication and medical transportation systems.
“In addition to forming a valuable relations network with professionals
from all over the world, the practical lessons learned from close involve-
ment in this kind of really complex undertaking represents a unique
opportunity for personal and professional growth,”said Adriano Valadão in
a press release. Valadão is responsible for recruitment in the IOC’s Rio 2016
Medical Services Department.
The application process took at least nine months. First, James filled out
an online application. Then, she went through a group online interview
with four other potential volunteers. Several weeks later, a physician inter-
viewed her by phone, asking her questions about her credentialing and
her work, and finally the IOC called her references. About three months
after that, she was accepted as a medical services volunteer in November
2015.“I was over the moon that I was selected,”she says.
As an Olympic volunteer, James had to take about six online courses
that covered such topics as integrity, diversity and the history of the
Games. Then, in February, she received her official placement: She will be a
Field of Play member, providing emergency medical services at a few ven-
ues around the Olympic campus.
James wants others to know that exciting opportunities like this do exist
for PAs.“If you work hard, if you’re a great provider, and if you place your
patients first, the sky’s the limit,”she says.
JENNIFER WALKER is a Baltimore-based
freelance writer and a regular contributor to
PA Professional. She can be reached by email.

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Learning to Lead
PAs Taking Their Place at the Table
BY STEVEN LANE, MA, MPP
PA HEATHER HYLTON ENCOUNTERED A MAJOR BARRIER in her first weeks
on the job as the lead PA for the Department of Medicine at Memorial Sloan Kettering
Cancer Center in New York, in 2012.
“When I first arrived, PAs were not able to prescribe chemotherapy, which poses a
clinical practice issue in a hospital that specializes in the treatment of patients with can-
cer,”she said.“There was no reason for this related to the PA practice act for our state; it
was a matter that needed to be addressed as we expanded the PA program in our
department in order to make care for our patients seamless.”This issue led to the creation
of a task force to examine the issue and resulted in the development of a basic and ongo-
ing competency standard for PAs and NPs alike who wanted to be credentialed to pre-
scribe chemo. “Now there is a standardized process for PAs and NPs in our organization,”
she says.
PHOTOBYSPENCERSELVIDGE

This issue of preparation for leadership is a major component of AAPA’s
2016-2020 Strategic Plan, approved by the Board of Directors in Febru-
ary—“Equip PAs for expanded opportunities in healthcare”is one of the
plan’s four strategic commitments to the profession. And AAPA has put
considerable resources toward addressing this important issue through
the launch of the Center for Healthcare Leadership and Management,
which was set up to help institutions optimally recruit, utilize and retain
their PAs and nurse practitioners (NPs), and to help PAs gain the tools they
need to advance into leadership and management positions.
PA Professional spoke to a number of PA clinical leaders for their per-
spectives on the issues faced by PAs in large institutions and the successes
and challenges they have encountered in their roles. (This story is the
eighth in PA Professional’s series of strategic plan–related articles; you can
read the other seven in the PA Pro archives.)
A Place at the Table
Most importantly, having a PA in a leadership position in their institution
gives PAs an advocate at the highest levels and a voice in the decisions that
affect them.
“That’s the most important thing—having a voice at the table,”says
Amanda Reynado, lead PA at Ben Taub General Hospital, part of the famed
Texas Medical Center in Houston.“We are all aware of the need for PA
leadership. There needs to be a lead PA for every department to voice con-
cerns and represent PAs. Everybody is busy but it’s extremely important
that PA practice is not overlooked—which it easily can be.”
Advocating for PAs, and educating others about PA practice, is perhaps
the biggest part of what PA leaders do every day. The barriers to optimal
PA practice typically arise not from any ill will, PA leaders say, but most
often simply from ignorance or inertia.
“There is just a lack of education—people don’t know what the rules
are,”says PA Deb Yolin, a former CHLM adviser who is now an associate
medical director at a large Boston health system.
Many PA leaders have similar stories to Hylton’s. Often, they were the
first occupants of a newly created position and had to blaze a trail for
themselves and other PAs.
Ron Byerly, PA director for the Geisinger Health System in Pennsylvania,
recalls the situation for PAs being“a bit disorganized and chaotic,”when he
took up his current role in 2009.“All the PAs were managed by individual
departments back then, and departmental managers’knowledge of and
interest in PA management and scope of practice varied significantly,”he
says. At that point, Geisinger leadership“saw a need to increase the num-
bers of its PAs and NPs to fulfill its plans for growth, and realized they
needed some people with experience to help guide that growth.”Byerly
was one of those people.
Learning to Swim
A recurring theme among PAs who have taken on leadership and manage-
ment roles is a sense of being thrown in to the deep end and having to
figure it out as they went along. The role involves many skills that are not
PA Heather Hylton
PA Amanda Reynado
PA Deb Yolin

typically taught in PA school, such as scheduling, managing staff,
developing policy, working with senior administrators, and staff
development.
“I have learned so much; a key part of this learning has been
collaboration with colleagues both within my organization and
across the country, many of whom I have met through AAPA. It’s
been tremendous,”says Hylton, now director of PA services for the
Department of Medicine at Memorial Sloan Kettering.“As a leader,
you need to first learn and embrace an institution’s culture and
how it gets work done. This is essential to effectively driving
change.”
“My first year was very challenging,”agrees PA Cragin Greene,
PA fellowship director and lead PA for the Carolinas HealthCare
System in Charlotte, N.C.“I was not equipped to be in that role. I
had to be manager of up to 60 people; I had never done that
before. The biggest challenge was project management, which I
had not done in PA school. But I picked it up as I went along.”
“Most PA leaders that I know are in the same boat,”adds Rey-
nado.“It’s sink or swim. Over the first six months it was a very
sharp learning curve. I had to learn hospital policy, hiring, budget,
metrics, without a lot of training. I had no MBA or MPH; I had just
proven myself as a leader among other PAs.”
Enter CHLM
It is these issues— helping employers, optimizing PA practice, and helping
individual PAs take on leadership roles—that CHLM was established to
address. Approved by the AAPA Board in 2015, CHLM has found a strong
demand for its services, with the number of engagements increasing four-
fold in its second year of operation and its advisers already starting to book
up for much of FY2017.
Ultimately, PAs and patients alike should benefit from the CHLM’s work.
“Not only are we making the lives of PAs and NPs better, but it trickles down
to patients,”saysYolin.“It all comes down to patients getting better care.
And allowing PAs and NPs to function at the top of their licenses helps them
provide better care. And it slows down turnover. If you have a PA who has
been at that hospital for 15 years he or she will function very highly.”
AAPA's CHLM is changing the way employers see PAs and the way PAs see themselves.
PA Ron Byerly
PA Cragin Greene
PHOTOSCOURTESYOFPASPICTURED

And CHLM can also help an institution’s financial bottom line.
“The work we do at CHLM touches on the areas critical to improving
access and providing efficient care while maintaining the highest stan-
dards of patient safety and quality. Consistently, there are client requests
for assistance with recruitment and retention, staffing models and under-
standing billing and reimbursement,”says Yolin.“Everyone is being asked
to do more with less but we see a lot of wasted resource utilization—work
that is duplicated because staffing models have not been evaluated to
ensure that each healthcare professional is working to the top of his/her
education, competence and licensure.”
Working Hand in Hand With the Provider Team
CHLM works with both PAs and NPs, and of course with physicians, admin-
istrators and hospital staff.“The work we do advising hospitals and systems
on ideal provider utilization really supports the team approach,”says Amy
Noecker, CHLM managing director.“There is a wide range of workplace
environments in which PAs and NPs work and it can even vary between
departments at a single hospital. Sometimes a client would like us to focus
solely on the PA practice environment, but often we are asked to take a
comprehensive look at the entire provider team and how it is operating
together.”
In many institutions, PAs are combined with NPs in departments with
names like the Center for Advanced Practice, and PAs and NPs are often
known collectively by such names as“advanced practice providers.”And
while this kind of terminology is at odds with the optimal recognition of
PAs (and AAPA’s position on nomenclature), it often reflects a reality that
PAs and NPs need to work together to improve patient access and quality
outcomes.
“Whenever you get more than 50 PAs and NPs working together, people
want to group us together,”notes PA Todd Pickard, director of PA practice
at MD Anderson Cancer Center in Houston and a founding member of
PAAMS who was elected to the AAPA Board in May.“It can be very effective
to have a single governance structure for PAs and NPs, and it can be
empowering to work in collaboration and create recognition for the entire
group so that you can effect meaningful change in your system.”
“Absolutely we need to work together with NPs,”Greene agrees.“Espe-
cially at a large institution. We need to work with NPs, we need to combine
forces. NPs have always been good at organizing and we can learn a lot
from them.”
“I count myself fortunate that my NP counterpart is someone I have
known and respected a long time,”says Byerly.“We are much more the
same than we are different. Relying on similarities and not arguing about
differences can really get you to the point where you can solve problems
and provide solutions to leadership.”
Moving Into Leadership
PA leaders advise PAs who are looking to move into leadership roles to
start by seeking out opportunities at their institutions to sit on committees
or workgroups.
“Don’t be afraid of it,”says Greene.“Your job in school is to learn about
medicine and you can’t move up unless you are good clinically so you
need to keep doing that. But as your career progresses you need to recog-
nize that there are people on the ground creating the way care is delivered.
PAs need to be at those tables making decisions. At some point someone
will say,‘We are getting a work group together to deal with problem X,’and
you have to say yes to those opportunities.”
Amy Noecker
PA Todd Pickard

STEVEN LANE, MA, MPP, is senior
strategic writer for AAPA and an editor for
PA Professional. Contact him via email or
571-319-4364.
Resources for Current and Aspiring
PA Clinical Leaders
In addition to its advisory services for healthcare institutions, AAPA’s
Center for Leadership and Management (CHLM) offers leadership and
management training for PAs, both through customized on-site train-
ing and national events. Upcoming events include:
Executive Leadership Conference
November 2-5, 2016 – Winston-Salem, N.C.
Annual CHLM Symposium
May 18, 2017 – Las Vegas, Nev.
To join the AAPA special interest group
PA Administrators, Managers and Super-
visors and its associated Huddle group,
contact Todd Pickard.
For PAs in institutions without a PA leadership position, who are
trying to develop one, it is important to marshal data effectively,
Byerly says.
“First and foremost, you have to prove with facts and data that [a PA
leadership role] will be beneficial to the hospital and practice. You have
to make the case to senior leadership. Have a clear and expert under-
standing of your state’s practice act. Show them you can truly step in
with expert advice.”
State chapters are also a good place to start, Reynado adds.“Do
some research and educate yourself on state legislation. Know specifics
about practice in your state. State chapters can be very helpful with
questions.”

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Offering Students a
Glimpse of the Future
2016 Preceptor of the Year: PA Maureen Barrett
BY DAVE ANDREWS
B
uying a pair of jeans without trying them on—a bit risky. Purchas-
ing a car without taking it for a test drive—slightly dangerous.
Deciding on a career before experiencing what it has to offer—
potentially disastrous.
Choosing the right career path is among the most critical decisions in
a person’s life, and no one knows this better than PA Maureen Barrett, St.
Luke’s University Health Network’s chief surgical PA, and the recipient of
AAPA’s 2016 Preceptor of the Year Award.
For more than 30 years, Barrett has not only worked hard to advance her
own career, but she’s also helped countless students identify their passions
and go on to become highly successful, extremely satisfied PAs.
“Back when I was an undergrad at King’s [College in Wilkes-Barre, Pa.],
I wasn’t exactly sure what I wanted to do, but I always knew it’d be some-
thing in healthcare,”Barrett said.“Lucky for me, we had a PA program and
it was easy to go speak with administrators to learn more about what it
meant to be a PA.”
Through those visits, Barrett was inspired by how diverse and instru-
mental the role of a PA could be. Now, as part of her role as chair of the
PA Maureen Barrett is a
preceptor's preceptor.
PHOTOCOURTESYOFMAUREENBARRETT

PRECEPTOR, continued
department of advanced practice at St. Luke’s, she is focused on instilling a similar
enthusiasm among the next generation of PAs.
St. Luke’s expansive network of hospitals and outpatient facilities is an attractive
prospect for college students to shadow PAs, and rotate through all of the major
specialties.
It became an even more desirable destination once Barrett and a team of her St.
Luke’s colleagues revamped the PA Observer Program to create a more refined and
comprehensive experience for students looking for a real-world glimpse into the life
of a PA.
“The impact this program has on these students is tremendous,”she said.“They
develop a real sense of purpose and genuine excitement about their future career. With
those who choose to go the PA route, we get to see them progress and develop what
will surely be a life-long relationship with their career, which is always very special
to witness.”
Barrett is quick to acknowledge that guiding a program of this nature is not some-
thing she can do on her own; it requires a team effort. Throughout all stages of the pro-
gram—including application reviews, student orientations and volunteer assign-
ments—she works closely with several departments across the St. Luke’s network to
ensure the program runs smoothly.
This kind of collaboration is key because Barrett is continually juggling numerous
administrative demands along with heading up a department. But no matter how chal-
lenging her schedule might be, she does all she can to make time for the students.
“It’s amazing how vested she is in the [PA] profession and the development of these
students,”said Georgina Winfield, director of volunteer services at St. Luke’s.“Whether a
student is passionate about healthcare or decides to pursue a different path, Maureen
will take the time to give them honest, objective, thoughtful advice.”
“Her capacity to be so sincere is a rare characteristic, especially in someone at her
level,”Winfield added.
Barrett receives her award from then AAPA President-elect Josanne Pagel at AAPA
Conference 2016 in San Antonio in May.

Building trust with her colleagues as well as the students is something
that comes very naturally to Barrett. In a large system like St. Luke’s, she’s
faced various challenges to balance the educational needs of all students.
Her ability to build and maintain strong relationships over the years with
the St. Luke’s leadership has been critical in helping her maintain the
PA student rotations and support program expansion opportunities
moving forward.
“On my very first day in the [PA Observer] program, I met Maureen and
was immediately impressed by how passionate and encouraging she was,”
said PA Brie Marks at KidsPeace Children’s Hospital.“I don’t know where she
found the time, but she’s someone who, if you put in the effort, she will
give that back to you and then some.”
Barrett continues to be steadfast in her efforts—throughout the St.
Luke’s University Health Network and across the Eastern Pennsylvania
region—to advocate on behalf of PAs. She lectures frequently at partner
universities, attending symposiums, and participating with the Pennsylva-
nia Society of PAs with a determination to keep advancing the profession.
“Clinicians and patients alike are beginning to realize when they see a
PA, they’re looking at the future of healthcare,”Barrett said.“The PA may
very well be their main provider one day. So now is the time for us to culti-
vate the skills of that next generation to ensure we always deliver only the
highest level of patient care.”
PRECEPTOR, continued
Barrett helps PA students better identify their medical passions.
DAVE ANDREWS is a communications and public
relations professional specializing in the improvement
of healthcare delivery. He is a regular contributor to PA
Professional. Contact him by email.

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PROFESSIONALPRACTICE
Common Contract Negotiation Mistakes
How to Avoid Them and Advance Your Career
B Y J E N N I F E R A N N E H O H M A N
C
ontract negotiation matters! Here are some pointers
on mistakes that are easy to make when in negotia-
tions with a new employer.
Accepting an Offer Before You’ve
Negotiated It
This is a common, and understandable error made fre-
quently by new graduates. In fairness, navigating the gray
area between“You’re Hired!”and“Yes, I’ll take the job!”can
be slippery and confusing for more experienced PAs as well.
During the interview, inquire as to whether you will be
offered a written contract and if there will be an opportunity
to review and if necessary negotiate its terms. By clarifying
this issue at the outset, you signal that you intend to negoti-
ate and reserve the right to give conditional, rather than
automatic acceptance of an offer (pending contract
negotiation).
Not Knowing Your Negotiation Priorities
and Alternatives
Since negotiation is a dance of requirements and compro-
mise on both sides, it’s critically important to know what
your priority issues are and which you’d be willing to give
ground on. Most PA contracts offer a variety of topics where
negotiation can occur. Salary is just one piece of your com-
pensation package—other areas for negotiation can include:
■ Start date
■ Vacation and paid holidays
■ Dues and memberships
■ Relocation expenses
■ Sign on bonuses
■ Medical and dental benefits coverage
■ Paid life, disability, or other insurance coverage
■ Retirement plans
■ Location/practice sites
■ Bonuses
■ CME
■ Shares in the practice
JENNIFER ANNE HOHMAN is
the founder and principal of PA
Career Coach, a service dedicated
to helping PAs create rewarding,
healthy and patient-centered
careers. Contact her via email.

PROFESSIONAL PRACTICE | continued
Not Having a Strategy for Discussing Salary
It’s a mistake to go into an interview without a practiced, tactical response
to the question of“What are your salary expectations?”Anticipate being
put on the spot with this question! When asked, try to defer discussing
your salary target by asking what salary range they have determined for
the position. It also helps to state that you are interested in the entirety of
the compensation package, benefits included, in considering salary. What
you’ll need in your back pocket: your salary range goals, based on your
research (the AAPA Salary Report being an excellent, in-depth resource) for
when it comes time to state what you want.
Not Framing Negotiations in Terms of Mutual Benefit
It really helps my clients to deal with the stress and contentiousness of
negotiating to frame the process as a collaborative one, intended to create
a long-lasting employment relationship. Some questions to consider:“How
can we create a contract whose clarity and mutual benefit reflect the sort
of practice team we want to have?”and“How can we look creatively for
solutions to areas where we disagree?”will help you craft a mutually ben-
eficial contract and employment relationship (if the employer is interested
in doing so; not all are). Key to this process is understanding what the
employer wants and needs from the agreement. What are their bottom
line requirements and negotiable areas? The fact is, failing to hash out
differences now makes them harder to have them resolved once you
are hired.
Not Knowing Your Deal-Breakers
Before the negotiations start, know what would not be acceptable to you
in terms of compensation/benefits and common PA contract trouble spots:
non-compete clauses, malpractice coverage, restrictions on your ability to
volunteer or work for another employer part-time. One of the most valu-
able aspects of the negotiation process is the insight it affords you into the
values and quality of employer before you’ve committed to working for
them. Sometimes even your best efforts to negotiate will fail and it is best
to move on.
Failing to Document Your Negotiations
Getting the details of your negotiations down on paper—on the final,
signed draft of the employment agreement—is essential! So often there
are discrepancies between what is stated in discussions and what ends up
in a contract. The time to fix this is before you’ve started working for a new
employer. So many PA’s I’ve spoken to over the years have been told that
offer/contract discrepancies would be“taken care of”only to find, a year or
more later, that excuses were still being made to avoid reconciling them.
Sometimes this becomes the reason a client is looking for a new position.
Use your just-hired leverage to avoid this scenario at the outset.
I hope these suggestions will help readers to feel more empowered and
prepared to establish positive employment terms with employers! If you
have any contract negotiation stories or lessons learned you’d like to share,
please write me at pacareercoach@gmail.com.

REFLECTIONS
Walking It Off
Lifelong Lessons on the Appalachian Trail
B Y D A V I D PA U L K , PA - C , E D D , D FA A PA
A
little over a year ago, in April of 2015, I was—along with
my able colleagues—building a new PA program at
Mary Baldwin College in Fishersville, Va. We were writ-
ing hundreds of pages of documents for accreditation, attend-
ing to thousands of details. And I was drowning. No, more like
killing myself, with a regimen of Mountain Dews, Rice Crispy
Treats, four hours of sleep a night, and nothing that resembled
exercise by any stretch of the word. The awful diet and lack of
exercise, coupled with chronic sleep deprivation and over-
whelming stress eventually put me in a hospital with chest pain
and a healthy fear that this was the big one. Seven years earlier,
in 2008, I had suffered a traumatic brain injury secondary to
barotrauma off the coast of Mexico, rendering me unable to talk
(at least coherently) or walk (at least normally). I could not walk
through April of that year, or even say the word,“April.”My mis-
use of my body, and lack of sleep, also resulted in a return of
some of my earlier brain injury symptoms, including dysfunc-
tional balance, slurred words and cognitive dissonance. April has
been tough on me at times.
I didn’t die (hopefully that’s obvious), but I did receive a wake-
up call in the form of an awful pained look on the face of Sarah,
my wife. Her look, as I went through the cardiovascular workups,
was painfully reminiscent of my recovery from the brain injury
as she and my family suffered through my various disabilities,
which, unfortunately, included an inability to speak coherently,
DAVID PAULK, PA-C, EdD,
DFAAPA, is director of the PA
program at Mary Baldwin College
in Staunton, Va., a well-known
speaker on child maltreatment
and a keen hiker.
PHOTOCOURTESYOFDAVIDPAULK
Paulk and his dog, Abe, on the Appalachian Trail

REFLECTIONS | continued
or even walk without falling down. She looked at me through her lovely green
eyes with a resignation that said nothing she could do would save me from my
own slow, self-inflicted demise. Did I say wake-up call? No, this was the mother
of all wake-up calls.
So I started walking. And walking some more. Which led me to hiking, and
then hiking some more. I’d love to tell you that this wakeup call was all I needed
and that after that my wife, and my life, were extraordinarily happy. But pro-
foundly changing a life is tough, to say the least, and frequently, those around
you bear the brunt. Yet, she endured—a testament to her infinite patience
and love.
We live approximately 15 minutes from Shenandoah National Park, which
contains more than 500 miles of beautiful trails, including a section of the storied
Appalachian Trail. More than 50 pounds melted away as I walked. I felt better. My
moods improved. Yet, still, something was missing. Something else needed to
be done. I suppose that’s when I got the idea to hike the length of Shenandoah
National Park. That’s 107.1 miles (if you believe the maps) between Front Royal
and Rockfish Gap, Va.
I’m a member of the local National Alliance on Mental Illness (NAMI) board of
directors and we decided to use my walk as a fundraiser for much-needed
resources for those in our community (click here to donate). It became apparent
to me that I needed more than just hiking to train for this, so I enlisted a faculty
member’s husband, who I affectionately call“Attila,”due to his remarkable ability
to make every high-intensity“core”workout session feel like a call to the cardiac
gods to shuffle me off this mortal coil. I decided I would set off the first Saturday
in April from Front Royal, and, with my best friend, a 105-pound Chesapeake Bay
Retriever,“Abe,”I would reclaim April as we walked south.
We set out April 2, Abe carrying a 10-pound pack loaded with his food and
water, and me carrying a 62-pound pack (yeah, I know, too much) loaded with
dehydrated meals, water, shelter, sleeping bag, clothing, first aid, antibiotics,
stove, cookware, bear spray, knives, etc. The first clue that we were not going to
have the relatively flat trails I had been training on hit me squarely as we climbed
2,000 feet within the first few miles on rocky, twisting trails. We had walked
approximately six miles or so, when the wind picked up to more than 60 mph
(67 mph according to a Park Ranger) with wind-chill temperatures near zero. We
“I am, for the most part, responsible for the joys and triumphs as well as the
sadness and failures in my life, whether in my role as a PA, a PA educator, a
husband, a father or a friend. On the trail, your fear and needs manifest in decidedly
uncomplicated fashion. Where is water? Where will I sleep? More simply, perhaps,
where will I place my foot, how will I climb, and descend the mountain before me?”
—PA David Paulk
PHOTOCOURTESYOFDAVIDPAULK

REFLECTIONS | continued
hunkered down after draining the last of our water (I had not yet mastered the
art of maintenance drinking), cooked our meal, and collapsed in the tent with
the wind sounding like a flock of 747 birds taking off just outside our flimsy shel-
ter. Sleep was impossible, as we both shivered and listened to trees, very big
trees, drop to the forest floor, seemingly right outside the tent. Dawn revealed
snow, and cold, and winds of only around 30-50 mph. The experience of the first
night made it imperative, in my mind, that we spend the next night in one of the
shelters maintained by the Potomac Appalachian Trail Club. These three-sided
structures are placed approximately every 10 miles through the park. My mis-
read of the map, however, led us to walk 20.7 miles to Pass Mountain Hut, which,
in my exhausted brain, was supposed to be only a 10-mile walk. And only two
days had passed.
This long second day led me to understand several things: mountains have
upsides and downsides—both pose challenges, gazing up too much can crush
the spirit and trip the feet, and I’m capable of, well, much. I met some wonderful
people on this cold second night, and friends for life were formed. Abe liked
them also. They helped me with pack adjustments, I divested myself of weight,
and eventually, I got down to around 50 lb. (I know—still too much). We still stay
in touch.
The abject aloneness of my trek would, at times, cause me to reflect on how
I found myself in the middle of nowhere desperately wanting a warm bed and
a hot meal. Actually, anything warm would suffice. Several times, I thought to
myself, I must have been out of my mind to do this thing. Self-imposed insanity,
I thought. I came to understand that the toughest obstacles are those we create,
whether through fear, fear of losing control, self-imposed stress, deadlines,
issues, concerns, etc. My point? I am, for the most part, responsible for the joys
and triumphs as well as the sadness and failures in my life, whether in my role as
a PA, a PA educator, a husband, a father or a friend. On the trail, your fear and
needs manifest in decidedly uncomplicated fashion. Where is water? Where will
I sleep? More simply, perhaps, where will I place my foot, how will I climb, and
descend the mountain before me?
I learned the toughest trail is the few inches between my ears. The best growth
also resides there. I’ve learned:
1. I’m capable of way more than I thought I was.
2. Mental and physical health are vitally important.
3. Liking oneself (even for the first time) is a worthwhile endeavor.
4. The little things don’t matter; the big things rarely do.
5. People matter. Relationships matter. Always have, always will.
So, we walked off the trail following 10 hard days, both of us 10-15 pounds
lighter. A total trip, including side hikes for water, of 113 miles. Over 14,000 total
feet of climbs and descents. Record cold temperatures and extremely high
winds. All in the shadows of rocks over 1.2 billion years old; towering, majestic
trees; budding flora and fauna; and breathtaking pauses at outcrops and vistas
made more so by a soaring hawk or a Peregrine falcon examining you with
seemingly uninterested, but oh-so-interested eyes. Beauty only fully appreciated
by being a part of it, being within it. And, at the end, as I rested beside the road,
lighter and exhausted, Sarah arrived to pick me up. Perhaps she saw a change in
me. Not sure, but a smile had replaced the pained resignation in those lovely
green eyes.
Click to watch video on Paulk's adventures on the AT.

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