Director’s Corner: Should I be teaching my replacement?

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Part 1

Dear Director,


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We’ve had PA and NP students rotate through the ED for years.  But now I feel like my hospital might be looking to replace docs with a cheaper option and I’m afraid I’m actually teaching them to replace me.  Should we stop letting them rotate in the ED?

Advanced Practice Providers (APPs) have been in EDs forever…at least dating back to when I volunteered in the ED in the 1980s.  I’ve worked with APPs in all of my EDs for over 20 years and they’ve been an integral part of our team.  I’ve been privileged to work with some phenomenal APPs who I would prefer over some physician colleagues during a busy shift.  I’ve also worked with people right out school who took years to develop my trust.

Most busy EDs staff APPs as 30-50% of the total provider hours.  Over the last decade, Dr. Greg Henry, myself and others have written articles in EPMonthly about the risks and benefits of APP usage in the ED.  However, the frequency that I see APP advocacy groups advocating for independent practice and aggressively stating their benefits over physicians, anti-APP statements on social media along with the actions of hospitals replacing urgent care physicians with APPs have intensified discussing the role of the APP in the ED.


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Much of the discussion below is aimed at medium to high volume community EDs, not in rural or hard to recruit for settings.  The gold standard for caring for all patients in the ED remains a board certified emergency physician. I believe it is better to keep a smaller ED open to care for the community with a trained provider than to close the ED because no board certified emergency physician is able to work there.

Benefits of Teaching

Without worrying about “being replaced,” there are many positives to having advanced practice provider students rotate through the ED. First, teaching can be fun and hopefully your attendings (and any APPs) enjoy the opportunity to teach.  Secondly, from a recruitment point of view, you should never be short staffed as you have a recurrent crop of applicants doing month long interviews on a regular basis.  Having the opportunity to evaluate work habits, assess personalities and see how quickly students learn new techniques is unique when comparing it to the standard 30-60 minute interview that is followed by reference checks.

What do APPs Offer?


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APPs offer value to the ED by offering high quality care at a reduced cost compared to a physician.  I’ve seen APPs work on the main side seeing all patients, solely in a fast track, at triage, and be available for essentially all procedures.  I’ve worked in EDs where every APP patient from a toothache to a CHF admission was seen by a physician prior to the APP discharging them and I’ve also been handed a stack of paper charts to sign off on every four hours throughout the day.

Every ED operates a little differently and has different needs.  ED medical directors, as managers, should be finding a way to maximize the efficiency of the APPs to address those needs. The quality and experience of the APPs will also vary from site to site.  Whereas I have a pretty clear idea of the knowledge and experience base that a residency graduate will start their career as an attending, I have found more variability in experience among fresh grads from PA and NP programs. This means the ED and medical director must have an orientation process that develops consistent, high quality care within a short training period.

The best APPs I’ve worked with are fast, hard working, have excellent medical knowledge and judgement, and understand their limitations.  The best APPs always know not only what they know but also when to get help.  The same is true for an ED attending. After all, that’s often why we call consults.

On the attending side, we need to know our APPs well enough to know when they need supervision.  It would be very rare for me to spend a lot of time, energy or stress supervising an APP on a laceration repair or ankle injury. Equally, it would be very rare for me to not be at the bedside if the APP was starting to manage a critical care patient.  My own practice is to try to see the overwhelming majority of patients that are primarily cared for by the APPs.  Currently, my philosophy on this is mostly about meeting patient expectations and providing reassurance.

It’s rare that I change management in the fast track population though a Bell’s Palsy presented to me as a dental pain and a case of strep in an 8-year-old with fever and abdominal pain come to mind.  Many of my colleagues report cases of potentially missed bad outcomes on higher acuity patients had they not seen the patient after the initial APP evaluation and changed the course of the work up.

Independent Practice

A friend of mine brought their elderly mother to their local ED for chest pain.  They were never seen by a physician and told me afterwards, they wouldn’t go back to that particular hospital if that was their model.  Point being, many, if not most patients, when they come for an “emergency” expect to be seen by a physician.

Follow the Money

Conventional wisdom is that APPs see about half the patients as an attending at probably less than half the cost.  However, in reality, a good APP in a fast track can probably average over two patients an hour, which is a good return on the hourly rate without a considerable drop off in quality or speed in this patient population compared to a physician.  Therefore, your group could be more profitable by having an APP running your fast track instead of a single physician.

Over the last few years, physician salaries have continued to rise while insurance reimbursement has frequently declined. Depending on what happens with laws regarding balanced billing, many ED groups could have declining revenue. Already, in many EDs, in order for physicians to avoid a rate cut, physician hours have been replaced by APPs because they cost less.

Although I’m well aware of stand-alone urgent care facilities being staffed by APPs without onsite physician supervision, I think it’s a big jump to think that can happen in the ED. Anesthesiologists frequently supervise up to four CRNAs at a time (depending on acuity) and the physicians I know generally like this model.  They’re at the critical aspects of the case, make good salaries, and are available for unexpected changes in a patient’s status.

Many of us have supervised two APPs at a time in a fast track setting or one APP on a higher acuity side and have generally found this to be reasonable.  However, the ability to supervise multiple APPs depends on the patient acuity as well as how many patients you’re expected to see independently.

I’m aware of some EDs who are trying to more closely follow the CRNA model where one attending supervises several APPs who see the patients and the attending is just there to supervise.  This reminds me of a residency model where three to four providers could have 30 patients and you are supervising every patient, including the critical care patients.

This could be a very uncomfortable feeling for most community emergency physicians as this isn’t what we signed up or trained to do, and many of us may not like the speed or stress associated with it.  I know of a few docs who left their job for “greener” better paying pastures, to be put in a model supervising APPs, only to return to their old job within six months.  Time will tell if that is a business decision that emergency physicians support because of the pay or if they speak with their feet and walk away from the job.

In Part 2

Next month we’ll discuss the impact of delineation of privileges, the malpractice risk associated with supervising APPs, how to integrate APPs in the ED and ultimately whether we should continue to provide education to this community.

ABOUT THE AUTHOR

EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Chief Performance Officer with Emergency Medicine Associates, a founding partner of Alteon Health. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman

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