Rick's Rant - Emergency Physicians vs APCs in the ED

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Vitaliy K. -

Love you, Rick! Thank you for all the kindness you have shown to PAs over many years. Few points come to mind. First, just because there may not be a legal requirement for a Collaborative Agreement does not mean APCs do not collaborate. Frequently, the situation is quite the contrary. Each group could implement their collaborative requirements at their practice level. Second, just because we find it convenient to group people, PAs are not NPs and vice versa. PAs from inception have been advocating for strong collaborative teams. You mentioned that for yourself or your family members, you would prefer to be seen by the EM Board-certified MD. Without a doubt, some situations do require the highest level of expertise. Personally, my preference would be to have a Plastic Surgeon with his first-assist PA come down to the ED to repair my superficial laceration while I chew on my complimentary turkey-sandwich. The point is, if you are unlucky to need the services of the ED, you would probably prefer a team-approach and not worry about unnecessary formalities or titles. No PA is going to do something that is entirely out of their comfort zone. Finally, last time I checked, there is a provider shortage. The ED jobs are not going anywhere, especially when ED is a dumping-ground of the healthcare system. Medscape headline reminds me of a slogan from an animation sitcome the South Park, episode 118, “They took ‘Err Jobs!”

W. Richard B. -

K., We started the boot camp courses about 8 years ago specifically to support the care provided in the ED by PAs, NPs and physicians who were not EM-boarded. The need was great given that over 15,000 have participated. It was a pure play with no hidden agendas -- the goal has been to simply provide the best care that we can to ED patients. I have been a supporter of the collaboration of all clinicians in the ED for decades and we have had them in our ED for 15 years. I'll let others work out the nuances of collaboration agreements, the hiring of APC vs physicians and other hot potatoes. My goal is to make sure that whoever is working in the ED is comfortable knowing they are giving good, evidence-based care.

Will McGill -

I am a practicing EM physician assistant and I am entrusted to do a lot in my clinical environment working as a solo APC in a critical access hospital ED. Because I did not attend a formal EM residency, I depend on the EM community to host courses to develop, maintain and refine my knowledge, skills, and abilities. I constantly re-evaluate my performance, identify weaknesses, then binge on CME opportunities to improve the quality of my care. But I also recognize that much like raising children, it takes a team approach to treat complex patients. There is always someone out there smarter than me, and when the going gets tough I know to phone a friend. This is the key item - no one, whether PA/MD, FM doc, EM doc, etc. is the be-all and end-all of medicine. Being mindful of one's strengths and limitations, and being able to recognize when one needs help and knowing how to reach out for help, is the key to success in the ED for providers at any level.

We all come to this job at a different baseline; from there, it is up to us to maintain and grow our competency over time. EM boarded docs have the advantage of beginning their attending-ship following completion of an accredited EM residency program. PAs/NPs/non EM docs do not. Still, with dedication to learning, introspection and self-reflection, and mechanisms in place to encourage professional growth, over time we all can converge on the same degree of competency. We just need the right resources and opportunities available that enables this to happen.

That said, rather than focusing on who does or does not belong in the ED managing patients, I think emphasis should be placed on facilitating a sense of community among all EM clinicians, welcoming outreach when friends call for help, and opening up as many training opportunities as possible to make us all the best EM clinicians we can be. The formal-EM-trained physician is best suited to take the lead with this. As Dr. Bukata has said many times on EM:RAP, EMA, RMM, etc., the horse has already left the barn - we are here to stay. So help us succeed. I feel the EM:RAP community is doing a tremendous job already with this. Perhaps it is time for the EM-community at large to follow suit.

(As an aside, examples include expanding ultrasound training opportunities for non-EM docs, opening up the LLSAs to non-ABEM providers, welcoming non-EM docs as affiliate members to EM societies)

W. Richard B. -

Wow. Very eloquent. I think my comments to Vitaliy in the prior post sum up my feelings -- let's have the right people for the job and let's work collaboratively to get the best outcomes for our patients.

Brian S. -

Thank you Dr. Bukata. I work as an N.P. in Urgent Care, and the E.R., along with continuing to practice as a Paramedic in a rural 911 emergency service. Along with a multitude of other educational opportunities, I have completed your organization's E.R. Boot Camp and find all of your insight beneficial.
I'm thankful that you addressed this topic in such a public forum. I think continuing to bring awareness to such a sensitive topic is critical. I appreciate the fact that such a well respected physician, as yourself, can openly say that you simply want the best care available, no matter the clinician's credentials. Some physicians simply want care from another physician, no matter the competency, or education, of a Nurse Practitioner or a Physician's Assistant. I believe with focus on personal and professional growth all clinicians will someday find equality in the environment he/she decides to practice. I once asked a physician, "If there were one deficiency in the role of Nurse Practitioners in the E.R. setting, what would it be?". He responded with, "Many of you don't invest the time to become the best that you can be". I'm not sure if he was accurate, or not. But, I have seen some of my colleagues that are more excited about the location of the next exotic conference, than they are about the clinical growth that might take place at that conference. However, I suppose the same might be said about others. Additionally, I agree with "let's work collaboratively". I don't think that collaboration necessarily needs to be a document sitting in a file cabinet, or even floating around in cyber-space. I do think that collaboration should be an illustration that all clinicians are like-minded in the sense of delivering high quality, efficient, and economic care.
In closing, I hope that other Nurse Practitioners, and Physician Assistants, persistently pursuing personal and professional growth will use their platforms to motivate others to similarly invest in their futures. I believe that type of motivation will not only create more trust and autonomy; but, it will also deliver better care to an ever-changing, and more challenging landscape of healthcare.

W. Richard B. -

I couldn't agree more with the theme of your comments - we all need to be committed to being life-long learners. The job of keeping up and staying abreast of the most recent develops in EM is hard since we are such a specialty in breadth. We need to know peds and ortho and cardiology and derm -- you name it. So intellectually getting to be really good at EM requires that everyone who renders frontline care -- doctors, APCs, nurses recognize their obligation to keep up and in the process provide the best care they can -- no matter what your job is on the clinical team.

Clayton M. -

First, let me say thank you for the APC's in Emergency Medicine segment I realize there are numerous opinions and competing allegiances on the matter. A difficult issue to broach, but much appreciated. Just a few additional thoughts from a PharmD, PA-C.

We love working with emergency trained physicians who challenge and make us better every day. I don't believe any current APC is looking to replace an EM boarded physician. However, there are contradictory statements made by both the AAEM and AMA in regards to PA scope of practice which are infuriating to say the least.

No clinician wants to work under the proverbial glass ceiling.

It's difficult to argue a physician shortage, but in the same breath argue against advanced training for PA's and NP's. That's not the exact wording of the AAEM position statement, but it seems to be the spirit. Also the statement that PA's and NP's should only work under the direct supervision of an EM boarded physician is interesting. As you somewhat alluded to in your segment do non-EM boarded physicians have to work under this model? Do they provide better care? No one knows. I would argue that a Family Practice trained physician without significant ER experience may be less well equipped than an extensively trained ACP in Emergency Medicine to operate independently in an ER. However, this occurs daily with little to contention from the medical community.

I understand I have significant bias towards this topic, but the two arguments I have heard regarding the separation of ACP's and physicians are "have completed basic sciences" which many of us have done previously or could easily complete and "residency". If we're going to argue experience is the best teacher this supports an argument for long tenured PA's likely being better providers and/or why the argument against PA/NP residencies.

I've said all of this to say not every APC is ready to operate independently especially in an ER; however, there has to be a way to eliminate the glass ceiling for APC's that takes into account the significant training and experience. Is there a significant difference between a 33 month medical school (which there are more and more of) and a 27-30 month PA curriculum? Likely not. Whether this entails more APP residencies leading to expanded clinical privileges or an increased number of significantly abbreviated PA to physician bridge programs I'm not certain, but would like to see more open conversation in this area.

Thanks again for your time and all the effort!

W. Richard B. -

You bring up some excellent points, particularly regarding the proximity of a 33-month medical school curriculum and a 28-month PA curriculum. And if a PA has, for example, 5 years of full-time EM experience seeing any patient who presents to the ED and staying current with the literature, it does make a great case that the end product would be potentially very similar regarding the capabilities of both EPs and PAs. And if this is true, then the argument about a glass ceiling also becomes hard to avoid.

More specifically, I graduated from medical school in 1970. I can tell you much of the first two years was a total waste of time. And I was a resident in a mediocre 2 year EM residency. I am absolutely sure there are PAs who could run circles around me had it not been for my producing Emergency Medical Abstracts monthly for decades. There is no question that most of the current EM resident grads are likely awesome EPs, but I think a PA (or NP) who works full time in a busy ED for 5 years who can see any patient and is conscientious about "keeping up" with the literature and learns skills like ultrasonography -- that the skill set of the PA and a board-certified EP would become progressively asymptotic. This view is likely perceived as heretical by many EPs, but, I'm just calling a spade a spade. My bottom line -- we should all work collaboratively, nurses, APCs, physicians to achieve one goal -- the best clinical outcome and patient experience we can achieve.

Carlos J. -

Hey Dr. Bukata!

Thanks so much for broaching this difficult topic, I've been practicing EM as a PA around ten years now. In my decision to go into PA school vs medical school was fundamentally an economic decision in terms of looking at the cost-benefit. Pursuing MD school would essentially mean that I would have to start over and embark upon a path of 7-8 years to become a newly-minted EM MD at the cost of hundreds of thousands of dollars not including the cost of applications and travel for interviews vs. Leveraging my experience in EMS and Fire and my already paid for undergraduate education into a 2-3 year ivy league PA program where the scope is essentially choose your own adventure at a cost (at that time) of 70k including the Masters.

Since then I've had the pleasure of working in a variety of EM practice environments and I found the key to success and joy in work is just that, your practice environment. Currently working in a large urban facility with a robust residency program, and frequently charged with teaching EM residents as we have become the go-to for most of the hands-on procedures.

Unfortunately I do come across a lot of MDs in training whether it be from EM or other services they're still very torn even this far in about whether they made the right decision and if it would provide for a long and fulfilling career in their chosen field, especially now that some programs have extended their EM residency to four years. Conversely I have yet to find a PA who wasn't in it to win it. It's an excellent way to have a fulfilling scope and still maintain a great work-life balance, and it is not the end-all be-all considering you can still pursue medical school at any time, shout out to my former EM PA colleague Eric Chow currently in his second year of anesthesiology residency at Johns Hopkins!

W. Richard B. -

We are about 10 weeks into the COVID pandemic and there have been remarkable changes in EDs throughout the country. While EDs were preparing for the anticipated surge another dramatic change occurred -- ED volumes went down 30-50%. Patients just stopped coming. The main theory why this occurred was that patients didn't want to catch the virus in the hospital. Physician hours were cut and tough decisions had to be made regarding which providers would stay and who would go. If anything, this intensified the potential tension between APCs (the C is for Clinicians -- nobody likes to be called a P -- a Provider). But it still comes down to what combination of clinicians will provide the most appropriate, efficient and rapid care and, in the process create patients who are happy to have been treated by you

There is no question that many APCs have had to actively make the choice of going to APC school or medical school. Medical school as it now stands is a painful slog. It's 8 years or more. To be a PA it's 28 months (and about 2.5-3 years for an NP). It's not an easy choice and one of the brightest NPs I know frequently voices ambivalence about her choice vs medical school. But no matter the choice, APCs and EPs are the proper mix in the vast majority of EDs and both APCs and EPs can find satisfaction with their work when they practice in a well-run ED with great throughput times and where clinicians are not working excessively long shifts (12 hour shifts are out) and have the support they need.

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