The Horse is Out of the Barn

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Care Crisis — Physicians terminated from all Edward-Elmhurst Health System clinics replaced by APPs.

Effective April 1, 2020, all seven urgent care clinics of the Edward-Elmhurst Health System will replace physicians with nurse practitioners.  At least 15 physicians have been eliminated, and physicians will no longer provide patient care or medical direction in the urgent care clinics. The hospital system indicates its business model will provide lower acuity care at a lower cost.


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In the state of Illinois, advanced practice registered nurses can work independently of physicians after completing at least 4,000 notarized hours of clinical practice under physician supervision.[1] Prior to that practice experience, advanced practice registered nurses can work in a ‘collaborative practice agreement,’ which does not require the presence of a physician.[1]

This represents a growing US health system trend to replace physicians with advanced nurse practitioners and nurse anesthetists.[2] There are no widely accepted standards for training, type of experience, benchmarking, quality care and patient safety in team-based systems, which have abandoned physician-led medical care,[3]  but such standards are desperately needed, as the training and care capacity between physicians and APPs can vary tremendously.

This issue was also published in an article on Medscape (15 Docs Fired From Illinois Health System to Be Replaced With NPs). Commentary to the Medscape article raised several issues.


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There were many anecdotal stories about advance practice providers misdiagnosing or mistreating diseases – such as missing digoxin toxicity, diagnosing cellulitis as gout, treating lung cancer with antibiotics, or misdiagnosing a post-surgical issue as a simple hernia.

A few commenters were upset at assertions that physicians could provide better care than advanced practice providers. One commenter asked why physicians would go to school for so long to do an APP’s job. One commenter cited multiple studies that NPs provide high quality, cost effective care and criticized other commenters for posting “ridiculous anecdotes” criticizing APPs. Another said that “physician buttholes do not stink less because of three to four years of medical school, and a three- to four-year paid apprenticeship.”

Other commenters noted that the training necessary to independently manage patients was inconsistent. One stated that “going to medical school and doing residency will soon be a very expensive waste of time.” Another stated that physicians require 15,000 to 20,000 hours of training while NPs receive 500 hour clinical training in “medicine,” which is more than the requirements of hair dressers to trim hair.

A physician with a Masters degree in Policy and Procedure Development noted that “to devalue the need for expertise is to cast the value of life aside.” Another commenter quipped that “The right way to cut medical costs [is not by] replacing critical value with inadequate experience.”


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Some commenters predicted bad outcomes and increased malpractice claims with the proposed model. One stated “there will be disasters which result in mortality … [w]hich is fine as long as you or your family member is [not one of] these statistics.”

Several commenters felt that negative press and assertions that physician training was necessary to evaluate and treat patients was pitting providers and professional groups against each other.

The trend in turning over more patient care to APPs also creates a duty to do so in a responsible manner. Hospitals and clinics cannot be forced to employ physicians if state laws allow them to employ other professionals in place of physicians. While hospitals and clinics can cut costs by replacing physicians with APPs, the public has a right to know the education and training of a provider before deciding whether to utilize that provider’s services.

Standard of care and thresholds for malpractice should remain uniform regardless of the level of training of an independent provider. An APP who performs independent services as an emergency physician must be held to the standard of a competent emergency physician.

Allowing different standards of care when managing patients in similar circumstances would lead to patient harm. There should also be uniform standards and educational requirements for all independent providers. Currently, there are not.

The American Academy of Emergency Medicine has created a policy statement regarding the Edward-Elmhurst Health issue and has given us permission to republish that statement here.

The American Academy of Emergency Medicine is expressing its concerns over the recent firing of 15 physicians from the urgent care centers operated by Edward-Elmhurst Health in Chicago. The Academy represents board-certified emergency physicians, some of whom practice in urgent care settings, and most of whom receive patients sent from urgent care centers when their medical condition requires a higher level of care.
Urgent care centers, while created to serve lower acuity patients, do in fact see a significant number of patients who have serious medical problems. It is well known that even a routine complaint such as a headache may be the harbinger of a life-threatening illness.
We therefore are concerned by the report that these physicians were fired in a cost-cutting move by Edward-Elmhurst Health. The AAEM believes that the skills and training of non-physician clinicians requires that they function as part of a physician-led team with immediate, onsite, physician supervision.
The AAEM asks that the decision to replace physicians with NPs and PAs be reconsidered. The community served must be informed and deserves a chance to be heard on the removal of these physicians. There are better ways to cut costs of health care delivery than removing the most qualified person who cares for the patient.

We hope that this will be the first step in a discussion that will create better health care for all of our patients.

References:

  1. From Becker’s Hospital Review.com updated Dec 3, 2019 at 11:10 CST
  2. Kristina Fiore, MEDPAGETODAY, Nov 26, 2019
  3. Physicians for Patient Protection (https://www.physiciansforpatientprotection.org)

ABOUT THE AUTHORS

SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee. He can be reached at his legal web site http://sullivanlegal.us.

Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

2 Comments

  1. I have mixed feelings about this.
    True low acuity patients do not need a specialist physician, in fact, they don’t need much of anything except for some appropriate guidance and symptomatic treatment. The key here is “True”. Discerning the difference from a cough due to URI vs a cough from PE does require advanced clinical skills. We all have seen cases of PE’s on their 3rd round of antibiotics misdiagnosed and mistreated by urgent care clinics staffed by APP with little or no supervision. If patient knew they have a low acuity condition, they most likely would go to the Urgent Care. The problem is the vast majority of patients don’t know. If APP are going to be seen undifferentiated headaches, chest pains, abdominal pains, etc., they must be held to the same standard as emergency physicians. If hospital administrators, in their infinite wisdom, think that cutting costs by replacing EP’s with APP’s is a smart move, they must let the public know so patients can decide on what type of providers they want for their health care.

  2. Patrick J. McHugh, D.O., FACEP on

    Well said.

    Do not believe the article stated EP’s are being replaced by APP’s. This change involves urgent care facilities — not ED’s. My hope is that undifferentiated HA’s, CP’s, abdominal pains, and all other potentially-sick patients are referred to the closest ED. Time will tell if they are referred immediately, or only after a myriad of testing is ordered/billed.

    Am also curious if the lower cost the health system touts refers to their staffing costs or those paid by patients.

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