Does the Use of APPs Turn Back the Clock?

13 Comments

Advanced practice providers are becoming a mainstay in the emergency department, but are we turning away from EM’s founding principles?

Recently I was arranging a memorial lecture in honor of one of the founders of emergency medicine. As I thought about this extraordinary person, I reflected upon his body of work, his leacy, and how we have safeguarded it.

In November 1954, Robert H. Kennedy, MD, gave a speech to the American College of Surgeon’s Clinical Congress. In it, he described the ‘Emergency Room’ as the weakest link in the treatment of trauma patients. The ensuing years brought increasing public awareness that the people who staffed the emergency room were not well trained. The country was alarmed to find that gynecologists might take care of a heart attack and ophthalmologists a trauma case. These physicians had four years of medical school, a year of a multispecialty rotating internship, and whatever additional years of specialized training they had received. They were not qualified. What was needed was someone who was trained to care for the broad spectrum of patients and complaints that populate the emergency departments at all times of the day and night. Emergency medicine was born to fill that need. The founders struggled for many years with the House of Medicine to recognize emergency medicine as a specialty. This specialty status was conferred on September 21, 1979.

The struggle then turned to the local recognition of the nature and value of emergency medicine. The medical staff and the general public needed time to begin trusting the physicians in “the pit.” Many years and countless patient and physician encounters have changed the perception of an emergency physician from inadequate to that of trusted colleague and caregiver. Through our collective efforts the emergency department has evolved into the nexus where patient meets hospital. Getting to this point has been arduous, and we still have some headwinds, but we accomplished most of our important goals.

It took 37 years to arrive in our current situation. It is a success story, to be sure.

Fast forward to recent times. Corporate medicine and contract vicissitudes are common, we are evidence driven, we are safety conscious, and above all, we are the leaders of all aspects emergency medicine.

Now the era of the ever-expanding physician extender has emerged in emergency medicine. Why are physician extenders needed? I doubt that anyone assumes physician extenders are better providers than emergency physicians; rather, they are cheaper and, since there are not enough emergency physicians to go around, we must need them. A similar argument was advanced in Missouri when it proposed assistant physician status to medical school graduates who did not match into residencies. They could practice in rural areas after one month with another physician monitoring them. Is it better to have an inadequately trained caretaker or none at all. This is a recurring question in medicine. Every graduate of medical school knows that four years is not enough training to practice medicine. More training to build on the 4-year knowledge base is required. The “emergency room” physicians of the 1950s and 1960s who so appalled the public had four years of medical education before they even had any opportunity to do clinical work. Then, they had additional and varying degrees of patient care training. Despite this training, they were deemed unqualified. Are extenders better trained than those physicians? In fact, are extenders necessary or are they expedient? Extenders are not hired because they provide better care than the physicians they replace. Better care is not what drives their use. They are cheaper to hire than physicians and create a fatter bottom line.

Patient safety is one of the most important topics in emergency medicine. It is inherent in our emergency culture and continues to be driven by federal mandates. How is it safer to have physician extenders and not physicians evaluating emergency patients? We covered this ground 50 years ago. We have already established that emergency physicians who were trained for the job provided the best emergency care. When did that change? When did we start believing someone with far less training could practice our specialty? Did the founders of emergency medicine just not grasp the business of medicine well enough? Perhaps the founders got it all wrong. Does the haze of 1960s idealism now in more enlightened times unfetter us?

In the beginning…there was a need for qualified emergency physicians to see emergency patients in the emergency room. There has been and will continue to be a relentless change in medicine and life, but some things are timeless. The enduring and appropriate concept from the 1960s is that: properly trained emergency physicians matter. This must be our unwavering principle.

Emergency physicians provide the best patient care in emergency departments. We were once committed to this concept. It is time to recommit.

ABOUT THE AUTHOR

James Webley, DO is a Clinical Assistant Professor at the Michigan State University College of Osteopathic Medicine.  He is an EM physician at  McLaren Oakland Hospital in Pontiac, Michigan.

13 Comments

  1. David Michaelson, PA-C on

    Dr Webley, there is no argument that the residency trained, board certifed EM physician should provide the best possible care, the reality is that that is not always the case. The patients that I see regularly in my APP only staffed Critical Access hospital would not agree with you either. The MD/DO’s that we replaced did such a terrible job that the community and the Board lost all faith in them.

    There are excellent physicians as well as excellent APPs. There are also substandard examples of both. As a practicing PA for the past 12 years, I have had a number of occasions where patients have said I was much better than their doctor and wondered if I was accepting new patients in my practice.

    Is there a financial benefit to hiring APPs? Absolutely! Do we deliver substandard care? Absolutely not! Nor do I feel that the use of the highly paid EM physician to handle fast track and urgent care patients is the best use of resources. The caveat to this is that occasionally there are very sick patients that cycle through the FT/UC areas of an ED. Best care is to have someone able to recognize those sick patients and expedite them to the higher level area. This means either an APP who also works in the main ED seeing acute care patients or a doc who is being underutilized for 99% of the time in the FT/UC. Unless you feel that a physicians skills are best put to use treating poison ivy and runny noses.

    EPs have committed to best patient care. Is it best for patients to wait for hours to see anyone or is it better for them to see an APP sooner than they would the MD? I wasn’t practicing in the 50s and 60s but I don’t feel that a gynecologist or dermatologist moonlighting in an ED would be able to deliver the same level of comprehensive care as a well trained, appropriately supervised APP can deliver. This is not a knock on those pioneers of early EM, simply my opinion.

    What truly matters is getting the patient the best possible care with the resources available. EM physicians and the APPs that work with them are able to do that best. Instead of working against this process, we should all be working to make things better for the patient in all aspects of their care, whether they see the doc or the APP.

    • John Castle on

      I’ m of such an age that I remember when the California MDs convinced the state legislature of the inferior care of DOs, and what had been up to the time Los Angeles County General Hospital was changed from a DO institution and osteopathic school to an allopathic institution. Times change.

      This article uses a generic APP nomenclature and though I’m also an RN, my ER work is as a PA. So let me limit my comments to what I know best.

      1. Over and over the studies show that there are no differences in malpractice rates between PAs and docs.
      2. As a PA I will only work under the supervision of a doc. And the state laws are designed to support what us the stand of my professional organization. So What’s the beef if I’m operating as my supervising doc wants me to do? If I’m substandard it’s because my boss has failed to train and/or supervise me.
      3. As a retired military PA I would rather have a milutary PA with me where the bullets are flying than a doc who in many cases doesn’t know how to operate out of the well-equipped hospital where he/ she has all the bells and whistles.

      In summary, nice article but it doesn’t begin to reach any acceptable level of EBM. Back up the “facts” next time rather than just wish for the good old days – the days before the docs allowed the government to control the practice of medicine. There’s no going back anymore and for that I’m saddened.

      John Castle

  2. Paul Spencer on

    As a PA, first working as a paramedic in the 70-80’s I too was distressed when medical control for a cardiac arrest might be a dermatologist in the E.R. Emergency medicine care has vastly improved thanks to efforts of ACEP etc.
    My experience working ~15 years in the E.D. of community hospitals and trauma center was that we routinely outperformed physicians in both RVU’s and RVU’s/hr. We did that for less than $50/hr AND without performance bonus. All we required was a collegial doc to assist us with more complex cases. The most high acuity cases and critical care was expertly managed by physicians.
    Why would you want to turn your collective back on that kind of productivity and efficiency?

  3. Andy Walker, MD, FAAEM on

    “In the beginning…there was a need for qualified emergency physicians to see emergency patients in the emergency room.”

    While I agree with your basic principle, I think you miss a critical point. Depending on the particular ED under consideration, from one third to two thirds of our “emergency patients” aren’t that at all – they don’t need an emergency physician (many don’t need to see ANY physician). Not only do most not have an acute injury or serious illness, many have problems so flagrantly trivial that an average layperson knows they don’t need urgent – much less emergency – care. I’m talking about things like ordinary colds, uncomplicated flu, chronic and stable back pain (and every other kind of chronic, stable, unchanged pain), addicts who want another prescription, etc. Most of the patients who come in with these issues realize they don’t have a serious problem, and wouldn’t bother if they had to make even a token out-of-pocket payment, as little as five or ten dollars, before being seen.
    On top of not needing emergency medical care, many ED patients either don’t pay their bills at all or don’t pay enough (Medicaid) to cover the cost of having a board-certified emergency physician in the ED 24/7. That combination of conditions, neither needing an emergency physician nor funding an emergency physician, means one of two things WILL happen in our EDs. Either we need far fewer emergency physicians than we once thought, and can safely use cheaper providers such as PAs, NPs, and physicians not trained in emergency medicine to see about half of ED patients; or we can keep churning out emergency physicians, try to staff every ED provider slot in the country with a real emergency physician, and take a huge cut in pay across the board.
    Anesthesiology has already faced this issue, worked painfully through it, and adapted to using nurse anesthetists on most surgical cases. Emergency medicine had better do the same – very soon.

  4. Rural ED’s have it really difficult. I did practice in rural Tennessee some years ago, and we could not get emergency trained docs to even consider us as practice site. I remember one doc, fresh out of residency, who came for interview. He had some questions….

    Q: What if you have a bad trauma? A: Well, we manage, stabilize and transfer.
    Q: So you don’t have a trauma surgeon? A: No we don’t
    Q: In difficult airways can you call anesthesia? A: Sure, you can call, but they won’t be here fast enough. So you will have to manage the airway.
    Q: What about a stroke, what happens if you get a stroke patient? A: You manage it, stabilize and transfer.
    Q: So you don’t have neurologist? A: No we don’t.

    Well, you get the idea… Needless to say, we never heard from him again.

    One big problem is that our current training model do not prepare residents for rural practice, which is where most of the need is. Many graduates are so used to the cozy environment with all the tech, specialties and services. Most of rural places are not like that and very few are willing to take on that challenge. So what is the little rural hospital supposed to do…?

    I leave you all with that question, because I don’t know the answer. But it should make us think… how can we provide high quality emergency care when qualify emergency doctors don’t go to where most of the population lives?

  5. Dr. Webley seems to think that every patient that presents to the ED needs the benefit of evaluation by a board certified EM doc. This thinking is archaic and has no basis in fact. Multiple studies have shown that care provided by PAs and NPs equivalent to that of a physician for specified diagnoses. We are the experts in low acuity stuff so that the board certified EM docs can spend their time on the patients who need that level of expertise. We are all on the same team with different areas of focus. I wish EPM would quit with the regular installments of “Are MLPs bad?” We are here to stay and provide excellent care within our scope.

  6. jeff coffman on

    Sad to read this and think this is the direction you want for Emergency Medicine Physicians. Why not use your efforts into help training APP’s. We are vital and increased care/patient satisfaction/throughput/and quality of work life. It is sad that this is your prospective. One thing that changed from the 1950s to now is awareness and effort to increasing the care. Maybe you could devote some of your energy and experience to APPs that work in the ED. Just a thought. It is easier to sit back and make negative judgments, but maybe we can work together to bridge this gap.

  7. This well-written article verbalizes the thoughts of many Emergency physicians. Constant pressures to further sleep deprive and squeeze out of resident physicians as many hours of work as possible up to 80 per week “to maximize their learning potential”, increased CME testing requirements on physicians, expanding the costly MOC (maintenance of certification) hoops we have to jump through… all imposed under the guise of increasing quality, at a time when someone with less education than a recent med school graduate is able to start practicing medicine immediately after 3 years is simply contradictory and illogical. The common thread unfortunately is that money is driving both the residents duty hours, unnecessary recertification requirements physicians must jump through and the acceptance of someone with inferior medical education and zero specialty training as a purported equal quality provider. Either our specialty is aiming for a quality standard that is too high or we are mortgaging off quality medical care to the lowest bidding nonphysical provider… or both.

    Curtailing requirements for physicians and establishing speciality-specific residencies for PAs would go a long ways to remedying these problems.

    Re: the comments above, it’s not just the obvious high acuity cases where the physician education and training is worth its weight in gold. It’s more so in the needle in the haystack diagnoses within the common run of the mill cases (back pain that is actually an epidural abscess, epigastric pain mimicking an MI, the urinary retention that was from Fournier’s gangrene). While RVU/hr is important, spending time to rule out the rare life and limb-threatening conditions is time worth spending. Not knowing what one doesn’t know is the greatest weakness of all, and this can be limited with a more robust education and training system.

    • David Michaelson, PA-C on

      “Re: the comments above, it’s not just the obvious high acuity cases where the physician education and training is worth its weight in gold. It’s more so in the needle in the haystack diagnoses within the common run of the mill cases”, cases such as the mild back pain and occasional overflow incontinence that the perimenopausal woman put off as normal but was diagnosed by myself as compressing spinal tumor, dental pain eventually diagnosed by a NP colleague as AMI. You make the argument as if APPs are not capable of making these diagnoses.

      The APP’s I work with tend to spend more time with their patients than the docs. I’m not sure why this is, but it may be training, possibly due to the lack of performance bonuses (my reimbursement isn’t contingent on seeing more patents).

      I fully agree that not knowing what you don’t know is quite a weakness, but what better way to educate APP than by having them seeing all patients and not just the FT patients. EMP’s go through an intensive residency program to learn their craft, would it be great if APPs could as well, yes, but that passes the cost on to the patient.

      As the other commenters stated, APP’s are not going anywhere and best practice is to accept that and work with APP’s to build on education, improve experience, and deliver better patient care on all levels.

      • Great Post David. I work for a ER group in Central Ohio. We staff 5 different facilities from a Level 1 trauma to a few free standing sites. Our Physicians are second to non, and they take the education and growth of APPs very seriously. We see every type of patient that comes through the door, Fast Track to the Trauma Room. This is upsetting that some physicians have this view about APPs, although they are in the minority.

  8. Very unfortunate to hear this coming from an ED doc. I am currently in PA school and am very excited to get into emergency medicine when I get out (and hoping to get into a residency to further my training). I was a trauma tech in a rural ED before school and saw some AMAZING NP’s and PA’s treating a wide variety of patients. I am confident to say I would choose some of the APPs over some of the docs to treat my family members if they were ever ill. I think it greatly depends on the individual practitioner and not so much the letters after their name. Hoping that respect from our MD/DO colleagues is on the rise in general and that this sort of thinking isn’t the consensus; it sure wasn’t at the hospital I worked at.

  9. Alex Beuning, MD on

    The development of emergency medicine as a specialty as highlighted by Dr. Webley is well described in the outstanding EMRA documentary 24/7/365. It is an amazing history that every EM provider should watch. This revolution in how EM care was provided did greatly improve EM care and all EM providers owe a great debt of gratitude to the founders of EM. I thank Dr. Webley for his dedication to the values of those EM pioneers.
    I would respectfully observe that while many of the benefits of EM specialty creation have disseminated beyond the walls of academic EM centers into the community, the staffing model of EM-residency trained providers covering every ED shift did not. The vast majority of our community and rural EDs have been staffed for generations fully or partially by community primary care physicians. In recent years, NP/PAs have been required to fill this void as less primary care residency graduates feel prepared for this work. The obvious frustration Dr. Webley feels with NP/PAs working in larger EM centers has been occurring in community EM practice for some time.
    EM NP/PAs are not invaders in our EDs, they were invited. They are valuable members of our EM team, helping us care for the increasing volume of patients presenting to our EDs. It is NOT just because they “are cheap”, but because they are willing and able. They are eager for physician leaders to help them improve the care that they provide in a collegial manner. They should be treated with respect.
    Welcoming EM NP/PAs does not mean reducing our expectation for quality EM-focused training, however. I agree completely with Dr. Webley that we need to work to improve the EM- specific training, certification and continuing education. Many physicians, PAs and NPs are doing this already.
    I am the Mayo Clinic EM NP/PA Fellowship medical director. The impressive young men and women who apply to our program uniformly WANT to improve their EM knowledge and skill before seeing patients. For a variety of reasons, their path to EM did not take them through medical school, but they are as committed and excited as any of my ABEM-EMP colleagues about the practice of EM. They often do start the program with significant EM knowledge and skill deficits, but fill in these gaps during the 18-month program. Our EM fellowship graduates earn the respect of the EM and specialty physicians who train them, and after graduation usually work in our lower volume critical access hospitals that desperately need their services. Few if any ABEM-EMPs will agree to work in these rural, lower volume locations. Other graduates work in larger EDs with ABEM EMPs, expanding the capacity of the department without reducing clinical quality.
    So while I would agree with Dr. Webley that EM-residency training is the gold standard training for a new EM provider, it is not the only path to excellent EM care, regardless of practice site. Arguments about ABEM superiority often fail to consider that our broad specialty requires life-long learning and dedication to the field. Three years of EM- residency after medical school is the best start to a successful EM practice, but is not the finish line. Most community EM medical directors would prefer initiative to initials in someone with EM experience. We have many experienced EM NP/PAs in our department who give outstanding care. Without a name tag, it would be difficult to differentiate them from our EM physicians.
    EM physician, PA and NP leaders should endorse EM-specific training prior to EM practice and EM-specific continuing education for EM providers, regardless of their certification pathway. We need more post-graduate training programs in EM for NP/PAs and primary care physicians. Both of these are expanding rapidly to fill this rural EM care void. We should work to assure that these graduates stay engaged with their EM-focused specialty organizations, in order to require continued EM-certification and EM continuing education. Hopefully if we change the focus to how we can work together to make this happen, we will spend less time pointing fingers at each other and more time focused on our patients.

  10. Stephen Jameson, MD, FACEP on

    I agree with Dr. Webley that patients presenting to the emergency department are best cared for by emergency medicine trained physicians. Perhaps I am biased as EM trained, but clearly emergency care has improved in the U.S. since the advent of emergency medicine as a specialty. But just like we cannot expect every eye problem to be cared for by an ophthalmologist or every laceration closed by a plastic surgeon, we cannot expect every emergency patient in the country to be cared for by an EM trained physician. We simply do not have the capacity. After a brief internet search, I found that there were over 136 million ED visits last year through about 5,000 emergency departments in the U.S. With only about 27,000 boarded emergency physicians in the U.S., many of us working part time, we appear to see less than half of all emergency patients. With about 2,000 new EM trained graduates entering the workforce every year we barely keep up with expanding ED volumes and attrition of providers due to retirement and burnout. In addition, EM trained physicians, as Dr. Beuning alluded in his reply to this article, do not typically seek to work in low volume ED’s. Further, we need APP partners in our high volume ED’s to assist in managing the large patient loads there.
    We should not impugn all APP’s in their ability to be qualified ED providers as they already do, and will continue to, play a critical role globally in the provision emergency care, particularly in low volume ED’s. Instead, emergency medicine leaders in ACEP and AAEM should focus efforts politically to establish some form of minimum competency that a provider must possess before working in any emergency department. In my home state of Minnesota, a NP that completes a 2 year, entirely online, program with 600 hours of “clinical time” (essentially shadowing and history taking since they cannot legally do procedures on patients as a student), could pass a written board exam and go right to practicing emergency medicine alone in a low volume ED adjacent to a major highway. This is reckless and dangerous but it’s not the APP’s fault, it is the fault of the facility that hires them and our public policy that would allow this to happen.
    It should be noted that APP’s practicing emergency medicine do not all share the same scope of practice. Many are content with providing fast track care in busy facilities, whereas others want to practice the entirety of the scope of emergency practice. In time, this latter group of APP’s do become highly qualified and proficient emergency medicine providers – in my experience, this commonly takes an aggressive APP about 6 – 10 years in an average busy ER without a formal training program. An integrated system of bringing together larger facilities with low volume ED’s will improve communication and training of rural emergency medicine providers. Those of us in the larger facilities need to reach out to these low volume facilities and offer our professional support and improve emergency medicine across the entire continuum of care.

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