Is it advisable to teach my replacement? Part 2

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Focus on the advantages the next generation can bring to the group.

Dear Director,


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?

Last month we reviewed the benefits of teaching Advanced Practice Providers (APPs) as well as using them in the ED, the possibility of APP independent practice and the economic benefit of APPs to the ED business model. I’ll try to wrap up this discussion today.

Our delineation of privileges


Just the hospital politics alone of having to change the privileging through the credentials committee and the medical executive committee could be difficult to accomplish.  While I understand the business decision to have a higher ratio of APPs than currently, in the hospital setting where committees of physicians are responsible for quality, any drop off by APPs primarily managing the majority of the higher acuity patients in the ED, particularly if they were licensed to do it independently, has the potential to be rabidly attacked by hospitalists, intensivists and other specialists.

Malpractice Risk

As I said, I generally try to see all the patients I’m responsible for, but this isn’t always possible.  I’ve also said I’ve worked in a place where the expectation was that the attending would check a box and sign off that they were in the ED available for consult if required.  At the end of the day, if your name is on the chart and there’s a bad outcome, you can expect to be named in the lawsuit.

You might be able to get dropped, but I wouldn’t count on that.  What each medical director and attending should be able to speak to is how APPs are screened and credentialed and whether your ED has a way to advance responsibility via training and/or certification. It’s not hard to me to prove supervision when I dictate a thorough note, but it is hard when I use a simple attestation phrase that says I was aware of the patient.


At my ED, our APPs introduce themselves as the PA or NP and if patients request to see a doctor, that request is typically honored.  I have seen some great plans about graduated responsibility for APPs tied to ESI levels and what chief complaints and ESI levels require hands on attending involvement.  I do believe that the bigger and more complex your ED is, you would likely require more guidelines, but I worry about people deviating from policy and that being a set up for plaintiff victory in a lawsuit rather than it being based on the medicine.

As I look at my waiting to be seen board, I see a number of ESI 2 patients, many of whom have the flu.  A well-appearing and previously healthy 30-year-old with the flu probably doesn’t need a lot of attending supervision, despite the vitals that hit the SIRS and severe sepsis alerts justifying the ESI 2.

But if you have a policy that says APPs can’t see 2s or 2s must be seen by an attending, you may slow your ED down if the rapid flu test was done at triage and is positive. Remember, Joint Commission doesn’t write your policies for you, but they expect you to follow them and problems occur when you don’t follow your policies.


Currently, we still get to define the rules so it’s critical to consider how you integrate APPs into your practice. This includes recruiting for APPs who are looking to be supervised, establishing guard rails when it comes to what type of supervision is required, defining the work-load, including them in your monthly group meetings and providing continuing education. We’ve required our APPs to attend our department meetings and invited them to attend ED committees and retreats.

Medical directors should be defining the metric analysis, making sure the APPs are hitting targets for productivity and other flow metrics, and along with the lead APP, reviewing quality projects such as head CT use in minor head trauma and complications after wound management.  If they are providing care to higher acuity patients, they should be subject to the same reviews the physician teams undergo for stroke, sepsis, STEMI and other more invasive procedures.

Most of the EDs I’ve worked in have APPs scheduled 24/7 whereas a lower volume ED may use them 16 hours a day or less.  There are some pretty complex scheduling formulas based on arrival patterns and ESI levels that can help you determine the staffing you need. As volume grows, it’s often easier to add an APP shift than to add a doc shift, but it ultimately depends on what you’re trying to achieve and how much growth is triggering the extra hours.

There is a broad disparity in quality and experience of APPs so part of any staffing plan has to include baseline expectations in patient management, making sure APP responsibility doesn’t change based on who is working, as well as ways to responsibly increase responsibility. Experience, training and perhaps even certification, can play a role in allowing APPs to see higher acuity patients with less supervision over time.


APPs have long been an integral part of the emergency department team.  If your team likes having the students, I wouldn’t stop teaching them because you’re afraid of training your replacement, but rather focus on the advantages they bring the group. At our sites, it is critical to have an excellent relationship between the attendings and the APPs where each feels safe communicating their needs or plans to each other and also where the attendings are responsive to the needs of the APP when they’re asking for help.

Over time, I expect more competency standardization to occur. Our job as medical directors is to provide safe, high quality care that is efficient and on budget.  We will be balancing the demands of a work force that wants raises in what’s likely to be an environment of declining revenue while continuing to educate and challenge our APP work force to see higher acuity patients at a more rapid rate.  But these challenges should only encourage you to continue to educate your future APP colleagues.


EXECUTIVE EDITOR Dr. Silverman is Chairman of Emergency Medicine at the Virginia Hospital Center. He also serves as the Director of the Alteon-Mid Atlantic Leadership Academy. 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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