In Practice: Reflections from NPs and PAs

Bianca Belcher, MPH, PA-C, practices neurosurgery in Boston, MA.

 

One of the things that I love most about my profession is its extreme versatility. I’ve been fortunate to meet PAs who are doing interesting things in their careers. As a student, I rotated with Derek Hersey, PA-C for internal medicine, and found his niche of travel medicine extremely interesting. Fast forward a few years, and I am now a practicing PA who consults with Derek before I do any traveling abroad. He gives me guidance on appropriate travel shots based on my region(s) of travel, do’s and dont’s for local foods, and emergency contact information. It is a service that I have come to value greatly! Since I graduated, Derek has really developed his travel medicine practice. Given the current notoriety of the Zika virus, I thought this subject was timely.

Here’s an interview I did with Derek about his experiences in travel medicine…

BB: Tell me a little bit about how you got started in travel medicine?

DH: I was hired at Harvard Vanguard Medical Associates (HVMA) in Cambridge, Massachusetts in 2000, but it wasn’t until 2004 that PAs and NPs started to get involved in travel medicine appointments at the Cambridge practice. I started with 1 to 2 appointments per week and gradually expanded. In 2010, I was given the opportunity to pilot the Shared Medical Appointment (SMA) for Travel Medicine Program. SMAs would bring 5-10 patients together for a group visit. The concept of SMAs made sense because there were a number of subjects that were discussed with practically all patients traveling to any developing countries. SMAs were a very coordinated undertaking; at the time, we would have a dedicated nurse, medical assistant, scribe and a behaviorist who would act as a facilitator during the encounter. The visit would last approximately 90 minutes. They were well received, and I continued to do them until 2012.

In 2011, HVMA started a centralized travel medicine department as part of infectious disease. In 2012, I took on a part-time role in that department, continuing to split my time evenly between travel medicine and internal medicine. As time went on, the travel medicine group started seeing more and more consults for issues such as skin and soft tissue infections (MRSA), latent tuberculosis, complicated urinary tract infections, hepatitis B nonresponse, HIV PrEP, and recurrent Clostridium difficile infection. This trend led to me accepting a full-time position with the travel medicine department.

BB: Interesting stuff! What does a typical weekly schedule look like?

DH: As a department we have 4 advanced practice clinicians –3 PAs and 1 NP. The PAs and NP often practice at a different site each day, covering 13 sites. The schedules are very busy, seeing both adults and children, typically in 30-minute slots. We also see entire families in one extended appointment.  As I said before, we also will see ID consults during the week focusing on the topics detailed above.

BB: Sounds like you really enjoy what you do. What is your favorite part about practicing in travel medicine/infectious disease?

DH: There are many enjoyable aspects about travel medicine. I enjoy preventative medicine and with my IM background have always been interested in infectious disease. I was intrigued by some of the diseases that we don’t see very often practicing here in the U.S., such as malaria, dengue fever, and chikungunya. After PA school I was able to do some international travel, which furthered my interest because I now had some context to apply to these conversations as well as experience to impart to my patients, not just information obtained by reading Travax or the CDC’s Yellow Book.

BB: I haven’t run into many other travel medicine PAs. Do you know of many other PAs doing this?

DH: I suspect that the number of PAs practicing in a specialty such as travel medicine is fairly small but hopefully growing. We have the opportunity to meet other PAs when we attend a conference or an event hosted by the International Society of Travel Medicine.

BB: ID was probably my least favorite class in PA school, but for a trip to Egypt I’d learn just about anything. Does working in travel medicine include actual travel abroad?

DH: Unfortunately, international travel is not part of the basic job description though many clinicians do take part in medical missions in developing countries, and many of the conferences hosted by the ISTM are located outside of the U.S. I would certainly like to take part in a medical mission in the near future. In 2010, one of my internal medicine PA colleagues and I were having serious discussions about traveling to Haiti during the cholera epidemic. Around that same time, there was a significant amount of violence and looting that took place up around Cap-Haïtien, where we had discussed flying into, and as a result aid flights from the U.S. and other countries were cancelled and we were unable to go. Another travel medicine PA colleague helped coordinate a medical mission to Haiti in November of 2014. When speaking to her recently, she touched on the subject of other PAs in travel medicine and remarked, “we certainly need travel/tropical medicine–trained clinicians here in the U.S. to prevent or recognize faraway pathogens that are making their way via global travel to our doorstep.”

BB: What are some of the other groups of clinicians with whom you work closely?

DH: We collaborate certainly with internal medicine, family practice, and pediatrics. Generally, we try to collaborate with all specialties since it is not just young healthy people who want to travel. Quite often we will have patients with multiple comorbidities attempting to go on very adventurous trips. In these instances we may need to discuss patient care with our colleagues in endocrinology, cardiology or oncology, just to name a few. We also have a great relationship with our clinical pharmacy department. Our PharmDs are a great resource to us.

BB: What, if any, creative tools or techniques do you use for travel medicine appointments?

DH: We have created SmartSets in our electronic medical record that help with documentation as well as ordering tests and medications for our patients. We utilize a system called Travax that is an excellent resource and is updated on a daily basis, providing us with guidelines on what is recommended for patients traveling to any country in the world. The Travax packet we provide also includes yellow fever and malaria maps when the risk is present, illustrating to patients which regions of the country have high, moderate, negligible, or no risk of transmission. We review the patient’s itinerary in detail with them, discuss their past medical history, and review immunization records, medications, and allergies. We write prescriptions when indicated and almost always need to administer vaccinations. Detailed literature on various topics such as water and food-borne illness, insect precautions, as well as altitude sickness prevention is provided to the patient in their after visit summary. This document also includes their vaccination record. We also created an over-the-counter checklist for patients to use as a general guide when preparing for their trip.

We all try to give our patients tips and tricks along the way, such as securing their toothbrush to a bottle of water with a rubber band to continually reinforce the fact that they should not be using tap water to brush their teeth. When doing this, they are unable to grab their toothbrush without the bottle of water along with it. We also give patients starting the oral typhoid vaccination some literature detailing a reminder system for taking the 4 provided doses that need to be taken every other day. They can text the word “TRAVEL” on the day they start the vaccine series to the number provided by the manufacturer and they will receive a text every other day reminding them to take their final 3 doses.   

BB: What has been your favorite trip abroad?

DH: That is a difficult question because every trip is so different. I think that my trip to Egypt in 2008 was probably my favorite. We sailed for 5 days down the Nile on a felucca sailboat. It is certainly a more basic way to travel down the Nile compared to the cruise ships that we saw passing us each day. We lived out of our backpacks, sailing during the day with our guide and visiting ancient temples along the way such as Kom Ombo and Edfu. We would pull to the bank at dusk and turn the felucca into an enclosed tent-like shelter and sleep there on the river bank overnight. We took a sleeper train from Cairo to Luxor, then sailed from Luxor to Aswan. Traveled south by convoy to Abu Simbel, then returned to Cairo by way of sleeper train. The trip took about 12 days and was a great experience.

BB: Sounds like an amazing trip. What are some of the most complicated areas in the world to travel based on viruses, parasites, the number of vaccinations needed, etc.?

DH: I would say that Africa is probably the most complicated region to visit considering the potential for so many different pathogens. A trip to a country such as the Democratic Republic of the Congo can involve vaccinations for yellow fever, hepatitis A/B, typhoid, meningitis, rabies pre-exposure prophylaxis, as well as a prescription antibiotic for travelers’ diarrhea (E. coli, salmonella, shigella, campylobacter). This is in addition to insect precautions to prevent dengue fever and chikungunya as well as antimalarial medication to be taken orally for the entire trip to prevent falciparum malaria. Other disease processes in this country include schistosomiasis, leishmaniasis, cholera, tuberculosis, African trypanosomiasis, ebola and viral hemorrhagic fever. Finally, some people traveling to Africa also have the complicating factor of altitude, such as those wanting to climb Mt Kilimanjaro in Tanzania. 

BB: I can attest to how much helpful information you give during appointments. What advice would you have for anyone interested in entering travel medicine?

DH: Travel medicine is a very interesting and fun specialty to work in. It is a growing niche for PAs either as a full-time specialty or combined with internal medicine or family practice. During these encounters we are able to sit down and talk with our patients about topics that are exciting to them. They are very upbeat and positive encounters. Working in travel medicine you get to learn so much about the many developing countries in the world, learn their geography, and discuss the issues that they as a country are trying to manage and combat on a daily basis. If ID and public health interest you, this is a specialty worth looking into. If you are a clinician already working in family medicine, internal medicine, or pediatrics, you probably have the opportunity to see patients who are traveling and can determine if it is something that you would enjoy doing.

BB: Derek, thank you so much for your time and expertise on the subject. I can bet you’ve enticed at least a few people to consider travel medicine in their future!

*Derek graduated from Alderson-Broaddus University in Philippi, West Virginia in 2000. Alderson-Broaddus University’s PA program, started in 1968, is one of the oldest in the country.