Rick’s Rants: Changes in Emergency Medicine

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Brian Y. -

I think it is impossible to ignore the NP issue on this. We as physicians need to refuse to train our replacements. If you do not think NP's are trying to replace you, you are not paying attention to what is happening across the country. Plus NP's are not qualified to be seeing the complicated and nuanced patients that come to visit us. If we want to continue to give quality, first rate care, it needs to come from physicians or supervised PA's.

W. Richard B., M.D. -

I think the days of trying to have only Board Certified EPs in the ED are over. I'm personally fine with having PAs and NPs working collaboratively in the ED -- it just makes sense.

And I may be old fashioned, but I also feel that physicians need to take responsibility for all the care rendered in the ED. Whether the EP is an employee of the hospital or an independent contractor with a practice management group I believe the Medical Staff and administration expect that physicians will be responsible for the care rendered in the ED. Does this mean the EP must see every patient? Definitely not. But EPs need to be expected and willing to supervise the care being provided. This may mean going in to see a patient briefly at the end of a visit or early on with the APC. It depends on the level of confidence that the EP has in the APCs on duty.

Let's be candid. EPs make about $330,000 a year and APCs make about $130,000. Whether it be the independent ED group, the contract management companies or hospital who employed the clinicians, everybody loved APCs when first on the scene because the ED groups and hospitals all made more money. But now EPs are feeling squeezed. Volumes are down, ED revenues are down. Those that staff the ED have only two choices -- try to increase the ED volume (it doesn't seem to be working -- our local ED is still down about 30%) or cut staffing (and who is the most expensive clinician?).

Refusing to train the NPs or PAs isn't going to work -- you make quickly find yourself without a job. Try to be the best EP you can -- stay up on the literature / make sure the patients like you (it isn't optional) / make sure the ED staff and the hospital Medical Staff like you and be willing to go the extra mile in helping out the department. In other words, be the doc that every ED director wants to hire (and the last fired).

You are trying to deal with a harsh reality that you don't like. Emergency medicine is not like it was 10 years ago -- and there is no going back. To survive EPs need to "learn to love the one they're with." I know there is a growing angst over this issue -- but the dollars will prevail and there is definitely a place for EPs, PAs and NPs in the ED -- as long as the EP is responsible for all the care rendered.

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