Rick’s Rants: Emergency Department Staffing: Coda

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Julio P. -

This was a very well put together (yet brief) conversation. I appreciate Dr. Carroll and Dr. Bukata explaining the differences with training regarding NP and PA and that in order to work as a well oiled machine for the sake of patient safety and quality of care there needs to be an experienced, highly educated and trusted physician at the helm.

I don't want to be the one that misses something deadly all the while knowing that I could have leaned on a physician colleague in a team based approach if this wasn't such a polarizing topic. I'm old enough to know (not as old as Rick ^_^) but this is not the hill I want to die on. Independent practice should not be an NP or PA working alone with no back up and no way to "phone a friend"

My opinion, there needs to be more internships, fellowships, residencies; whatever we choose to call them in order to elevate and augment the training we get from our graduate programs

Great December snack gentlemen, keep'em coming!

Steve Carroll -

Julio- thanks for your comments. We obviously agree that a physician led team is the way to practice safely. I will also always be supportive of more training and I'm an educator at heart who supervises students and residents of all types in the ED and runs a podcast that does the same thing. We should not be providing shortcuts to independent practice.


W. Richard B. -

Thanks for your note. I don't think there is any question that a team working collaboratively in the ED is the way to go. This absolutely requires that the physician on the team knows and accepts their responsibility. No more EPs who want to stay clear of the APPs patients. They need to fully understand that they are responsible for EVERYTHING that goes on between patients and clinicians in the ED. There are not "my" patients and "your" patients. As I've noted in the past, most patients in EM (either directly or thru their insurance company) are paying concierge-level charges and deserve concierge-level service. I think that in most EDs it would be great to have the physician briefly see each patient -- even if for just a minute. The patients have a right to expect this. I know that this POV will generate lots of push-back, but what would you expect for your family members if they were in your ED.

I know there are some rural EDs that have no physicians and are staffed solely by APPs. In these situations there are often no alternatives. But in this case there should ALWAY be some back-up at least by telephone 24/7. I worked at an isolated Native American clinic for one year. I was the only doctor for 50 miles in any direction and I definitely know that anything can present in these situations. I was also the doctor for a tribe at the bottom of the Grand Canyon. Believe me, I know. I think isolated clinics staffed solely by APPs should seriously consider having 24/7 audiovisual support by an ABEM-certified EP. Check out the extraordinary program provided by Avel eCare ( https://www.avelecare.com/what-we-do/emergency/ ).

So I hope I'm clear where I stand. EM is not for the lighthearted. Anything can present to the smallest ED. We need to make an effort to do the best we can to support all the work done by our APP colleagues. And, damn it, I am the oldest doctor I know and I don't like it one bit.

william s. -

we practice independently without physician seeing patient on all patients we discharge up through level 3. if the patient is a level 2 we bring in the attending. If the patient is admitted we bring in the attending. It takes one full year for a PA or NP to earn their independence. I've been an NP for 7 years and fortunately we are respected in our group, and treated like coworkers.

Steve Carroll -

Hi William

Thanks for your comments. To be clear, in the model you describe I don’t have too many issues with that. You are working in a physician led team where patients are staffed appropriately with the physician and it’s mandatory to do so with level 2 or above. My only quibble would be to say if the NPs and PAs are seeing lots of level 1s and 2s (even with physician supervision) is that an Indicator that you need more physician coverage? However, I can be relatively ok with it because you are still working in a physician led team. Even if the physician doesn’t see every patient they are still there for consultation.

Unfortunately the AANP is aggressively pushing that a new grad NP should be able to staff an ED solo from the day they graduate with no physician present. While this may not represent your thoughts on the subject for better or worse they are very politically powerful and are slowly getting what they want state by state. Having an ED staffed by solely an NP or PA without physician oversight is not hyperbole- it’s already happening. Look us the case of Alexis Ochoa from Oklahoma to see an illustrative case. This is already happening in primary care where NPs and PAs have their own practices with no physician on site or no collaborative agreement for review of their practice. If you agree that an NP or PA shouldn’t staff an ED solo then we are overall agree on the major points, if you think that’s ok then we don’t agree.

Not everyone shares this opinion but I think we could probably develop a track where those who have been actively practicing for a long time (10-15 years sounds good) could take the same exams as physicians and be granted independent practice but that doesn’t seem to be anywhere in the conversation. There are certainly master clinician NPs and PAs who could qualify and would do well on such a track but this doesn’t seem to be anywhere in the conversation. The AANP and AAPA want independent practice as soon as you graduate and it’s just not safe for patients.

Thanks for your comments


william s. -

In addition, to practice as an NP in our ER system we require at least two masters, AGACNP and FNP and yes we wouldn't hire on line NPs. My first masters required 1200 supervised hours in ICUs, and ERs for my AGACNP, and 800 for my post graduate masters for FNP. I have precepts over 3 dozen PAs from Case Western Reserve and their program is incredibly intense. I think it comes down to hiring the best trained APPs for the ER, and for the ICUs.

W. Richard B. -

Sounds like you have a serious amount of training and experience. I would have to surmise that you are the exception to the rule and that most of your NP and PA colleagues are not close to you in this regard. The problem is that there are new grads that are being asked to work in the ED (and hopefully under very close supervision). The variability in training and experience are the problem. With a Board-Certified EP you would expect substantially more consistency. And there is the elephant in the room -- the EP workforce is predicted to progressively exceed capacity every year going foreward and the salary differences between Boarded EPs and APPs. A very natty issue indeed.

Angela W. -

Interesting conversation. I am in complete agreement about working in a care team, however, I believe that there is a lot of missing information and misinformation in this discussion. One main difference is that the Nurse Practitioner has a limited scope of practice in a specific specialty area and so the clinical hours are focused in the specialty. A Physician has an unlimited scope of practice and does clinical hours in all the specialties. There is a certification called Emergency Nurse Practitioner based as a Family Nurse Practitioner with an additional certification required to become an Emergency Nurse Practitioner. I would suggest reaching out to AAENP (American Association of Emergency Nurse Practitioners) to get the real and complete picture. An NP also has to maintain an RN. In my case that is Nursing School, years of experience at the bedside in a high volume ER and a nationally ranked program with dual certification as an FNP and ENP. It is not just a two year journey as portrayed in the discussion.

W. Richard B. -

Your experience and accomplishments are pretty exceptional and that's why it is so difficult to generalize about an entire group of practitioners. -- but you do have to acknowledge that there are new grads who have been dropped into the ER as well. Same with the PAs. I'm confident that there are a substantial number of APPs who are awesome, but on average, there is a lack of focused, intensive training in PA and NP school to work in the ED. And when I mean work in the ED I'm talking about APPs seeing all the patients, not just the lower acuity patients (if you don't have an opportunity to see the more challenging patient in conjunction with the doctors I think your job will not be particularly satisfying very long. Make no mistake, -- EDs are addicted to APPs, Hospitals, contract management groups, even small democratic groups see the allure of APPs. But everybody involved with APPs needs to put in the time -- to mentor them, review cases with them, have a careful on boarding process with them and have an expectation that a certain skill level will be reached over time, and they'll not be asked to see patients for which they're not prepared.

Steve Carroll -

Hi Angela

Thanks for your comments. I would argue against one point that you make that an NP has a limited scope of practice while a physician has an unlimited scope of practice. This is functionally untrue. While technically a physician could work in multiple specialties, with few exceptions then can't do so without doing another residency. As an EM doc, I can't switch into neurosurgery tomorrow without doing a residency. However, on the NP and PA side, they can switch between specialities with no additional training. You could be a GI NP/PA one day and a cardiology NP/PA the next day. For a physician, you would have to do an entirely new residency.

I am aware of the ENP certification and I will always say that the more training you have, the better. However, the training involved to gain ENP certification is still nowhere near what physicians will do in medical school and residency. While beside nursing experience is certainly a plus before applying to NP school, it is not necessary and it is also not the same field. When nurses (or any healthcare workers) go to medical school they don't get to shorten their training due to their prior experience with a very limited number of exceptions. There are a few medical school programs that will shorten pre-clinical training if you are already a PA but the important thing there is that they are shortening the pre-clinical training, not the rotations and not residency. Also, nursing is a fundamentally different field than medicine, even if you were a nurse for 10-20 years before NP school, you are working in a different field with a different mindset and training. It will certainly assist you but it can't be a 1 to 1 substitute for the clinical hours that a physician completes. Anything less is a shortcut to independent practice.

Vitaliy K. -

Rick, I'm all for working on a physical-lead team (MD, DO) and have been doing this for about a decade as an ED PA. I respect my physician colleagues and treat them as expert consults when I have a complex case. I can easily equate my ten years of doing Emergency Medicine as unofficial residency, but I'm okay with that and love the collaboration.
However, I disagree with your statement that all my patients need to be seen by a physician, even for a brief minute. What's the point? To try to sell the idea of being seen and touched by a God? It would only slow things down and decrease throughput, revenue, and satisfaction. If the patient is requesting or needs more resources, that's a different situation.
Why would a recent residency grad tell me how to take care of abrasion or a URI in a fast track, even for a minute? If there's a complex situation and I have options, I will consult someone I feel has the experience, training, and demonstrated reputation in handling a complicated case. So this goes back to your initial concerns—education and time in training matters. But, we don't need some pointless abstract rules to guide us there. It has to be an individualized approach based on each department's needs and situation.

Thanks again, Rick, and looking forward to the next episode.

With love and respect,


W. Richard B. -

Thanks for writing. I have to agree that at some point experience, on-the-job training and having a consistent program to keep- up with the literature will make extraordinarily capable PAs/NPs. I feel that APPs should be helping with everyone in the department, not just the more minor cases. I think this will create a much more rewarding experience with the APPs and increase the longevity of their careers. Given this scenario, with APPs seeing all manner of patients, I do think there is value in the patients being seen by the physicians as well (at least all the Level IV and V reimbursement codes). Sure there will be some minor cases and these may not need to see the physician as well. This concept will clearly be perceived as old-fashioned, but given the total charges for people who go home will average $1,600, I don't want people to say I went to the ER, waited 2 hours and a doctor never saw me. Also, I think on Level 4 and Level 5 payment levels a physician should unequivocally see a doctor as well. I think this will reinforce that we are working as a team. Frankly, it doesn't matter if the APP can treat the patient absolutely perfectly. It is about perception. If there is another ER in the area, you want to keep your patients always coming back to your ED and not go to the competitor. That means patients need to be seen quickly (value their time), have a very positive experience with the staff and feel they received good care. On Level IV and V cases the idea that the doctors, APPs, and nurses are working as a team to address the patient's problem is impressive. It's part of the "show" as Greg Henry would say. Would you not feel better if your mother's care for her abdominal pain was the joint responsibility of a team consisting of all three caregivers -- I would. It is not about competence, but rather, the idea of meeting and exceeding expectations.

You sound like a very experienced clinician. Your ED is fortunate to have you. I'm hopeful that you view your participation from a broader perspective. EDs are about creating as positive an experience for the patients and family as possible -- very short wait / team approach to care / everyone in sync re displaying a positive attitude -- just like you would wish for your mom.

Dave T. -

I like this segment but I do want to address some concerns, and this is my 2 cents and would love additional feedback.

1. OTP, as described by Dr Carroll and in AAPA is "eliminate the legal requirement for a specific relationship between a PA, physician, or any other healthcare provider in order for a PA to practice to the full extent of their education, training and experience. Dr Carroll took this to mean that we, as PAs are working to remove all barriers, but what we are actually working toward is for the decision to be made at the local practice level. States vary widely in their legal limits for PAs. This makes it difficult for PAs who want to work in different places or need to move. I as a military PA have alot of freedom and having moved from post to post I have seen large restrictions in states. To carry a federal DEA for deployment I require a state license. Initially being stationed at Fort Campbell I looked into a KY license and did not get it because they do no support full DEA schedules for PAs. This is what is wrong, states shouldn't define Physician to PA ratios, oversight or staffing, it should be determined by the PA at the group level based on experience across the team.

2. I mentioned this prior but we need to take into account level of training in the post graduate setting and time practicing post PA/NP school. There is 100% a huge difference between a board certified physician and a new PA/NP but as time goes by this gap narrows, it never closes, but the oversight that is needed for a new graduate is not needed for a 10 year PA/NP. Additionally I have had the privilege of attending a 18month EMPA residency/fellowship that is paired with a EM residency. I am not a EM physician but I feel that my training does allow me to have large left and right limits than a new grad or a PA/NP coming in from another specialty. I dont feel I should have to present all patients to an attending as I have for the past 18 months, but I always want that physician near, phone call or face to face, to talk over a difficult patient or procedure.


Chris C. -

I have to say I agree with some of the points made here, others I do not. I am an NP. Let me first say I agree that I would never want to work solo in an ER anywhere, and I agree that the NP/PA training is insufficient to justify that position. I truly believe that NP programs need more clinical hours and tighter admission requirements in general, and the fact that we (NP's) have allowed these degree mills to flourish is detrimental to the profession and similarly to the EM resident workforce issue is going to bite us in the future. I agree that in an ER there should be a physician in house or in cases of rural/critical access hospital, at least a robust tele/online consultation system, such as the case is for teleneuro in many practices. That being said, I do not believe every patient that presents to an ER requires a physician to see them. Maybe in an ideal world/ system where ER were not used as a PCP or UC, and every patient who presented to an ER exceeded the resources available at PCP then ok I agree. I believe that level 4/5 straightforward minor complaints can be handled without direct physician involvement, and maybe the case for some of the level 3 cases. I do agree with Rick that I don't want to be relegated to fast track and I do want to work side by side with my physician colleagues on all types of cases, and have them available for consultation on all cases.
I was a bit perturbed by Rick's comments, where he in some cases states that he respects NP/PA and then suggests that we handle "menial tasks", that physician should not have to be burdened with such as documentation and CPOE. I felt he basically compared us to a scribe/secretary.
I also want to comment on the full practice authority issue, I do not believe that AANP is advocating for independent practice in an ER. The particular issue is that at a state level for primary care, NP should be able to practice without a physician in practices limited to the scope of the np training. I do not agree that this should be day one after graduation, I personally believe that at least 3 if not 5 years of collaborative practice should be a requirement to gain full practice authority. I also do not believe this should apply to many specialties such as the ER. I think that even within the ER setting, 2 things should be considered, first that NPs working in Er should attain the ENP specialty certification in addition to the FNP cert, and Er groups consider graduated practice program, where newer NP's are required to present all cases for a time period, and as years of experience, and training progress that some cases may be handled independently.
I hope I have added some value to this conversation

W. Richard B. -

Thanks for taking the time to write. I agree with everything you said until line #6. I didn't say every patient "requires" a visit by the physician -- I think it would be great to make it clear that the patient's care was a team effort by a brief visit by the doctor. If this is not practical, I understand. But if I were king I would view this as a very positive goal for which to shoot -- and I acknowledged that there would be pushback. Just think of what patients would want. I definitely think it would mean a lot to them. What would you want for your mother? And did I ever use the term "menial tasks?" I hope not. But when collaborating on level 4 and 5 cases It does seem that the "paperwork" (documentation of the H/P or perhaps just CPOE. These tasks are a PITA but they must be done along with interval reassessments and progress notes. I agree with everything else. Fundamentally, the physicians working in the ED are responsible for all the medical care delivered there. I think that this is the expectations of the C-suite, Medical Staff, and patients and that we should try to effectively collaborate on the care of all the patients.

Frederick B. -

Emergency NP here. Went to Emory's Emergency NP program and completed an additional Fellowship in EM at Virginia Tech. I currently practice as a sole provider at a critical access facility in Kansas. A level 4 Trauma center. I have General Surgery and Family medicine docs as backup, but I am the only provider in house 24/7.

I would like to preface this by saying, I strongly agree in an ideal world that all Emergency Departments should be staffed by Attending Board Certified EM physicians. There is no question that EM docs are better trained and prepared to manage emergencies then myself or my colleagues. There is also no question that NPs and PAs whom have not completed additional EM training should not be staffing hospital EDs by themselves. My question, though, is what would you have our rural critical access hospitals do to provide that staffing? They cannot afford an EM doc salary even if they could manage to attract one to their facilities. Do they just not have an emergency department? Do they staff it with a family medicine doctor? Is a Family Medicine doctor better qualified then an APP who has done extensive training in EM? What is the solution if not APPs trained in emergency medicine. To say that independent practice is bad is ignoring the reality of the situation. Someone has to provide care to these people and if ED docs aren't willing to go to these places and work for a salary the facilities can afford, isn't the next best thing an EM APP?

Frederick B. -

A little more in depth comment:
Throughout the podcast, many references are made to NPs in the Emergency Department only having 500 hours of training and all being Family Medicine with no background in EM. It also specifically states that ED APPs are not working in rural environments. While this certainly comprises some of the APPs in the ED, it is not all of us. Most brick and mortar programs graduate their classes with significantly more than the minimum hours. In many cases it is on par with PAs (which absolutely should be the minimum requirements). There also are Emergency NP schools. Emory University, for example, is one. These programs specifically train their students to perform in EM and their students take EM board exams.

Personally, I went to an Emergency Medicine NP school and completed 2000 hours of clinicals, almost all of which was in major trauma centers. I then completed an additional year long fellowship in EM. I now work part time at Bellevue ED and full time as the sole provider in a rural hospital in Kansas. I am, in fact, the only Emergency Medicine trained provider within 108 miles. I am the only provider in my hospital (which employs numerous family med docs) comfortable with RUSH exams and ultrasound in general. I am not an ED physician and do not claim to be your equivalent. I do claim that myself and my colleagues provide better care than our community would have without us.

I 100% agree with the fact that APPs are not nearly as well trained or qualified as ED docs. I personally would greatly prefer to be seen by a doc than an NP for myself or my family. In an ideal world, all EDs should be staffed by ED docs. With that said, myself and many of my colleagues provide care for places that cannot afford nor attract ED docs. We provide a necessary service for communities which have been ignored by the medical community as a whole. It is unfair and untrue to paint APPs as unqualified and untrained and it is even more unfair to ignore the fact that even if many of these small communities could afford ED docs, most of them have no interest in coming to serve these areas. The question absolutely should not be are APPs as qualified as EM docs; we aren't. Maybe it should instead be, how can we either get ED docs to rural areas OR change the requirements so that only adequately trained Emergency APPs are staffing these facilities and have access to a boarded EM physician (through telehealth or just a phone call) in case of questions.

W. Richard B. -

I think it's important to put the recent rants in context. They are all about staffing and training issues-- particularly in light of the impending glut of EPs. We've had on two exceptionally knowledgeable APPs (Mke Sharma and Martha Roberts); the director of 7 residencies staffed by USACS physicians, Dave Seaberg;; the Assistant Directory of a major academic ED with a legacy EM residency, Peter Viccellio; a physician who has strong opinions about the differences betweem the training of APPs ve EM-Boarded physcian, Steve Carrol; and the Presidents of ACEP and EMRA, Gillian Schmitz and Angela Cai (some of these have been recorded but not released yet). The point being that I am trying to have all sides of the issues covered by a diverse group of clinicians.

I think I've stated my position numerous ties -- I am a strong believer of APPs working in the ED. I believe there is a need for close collaboration between them and the physicians, that APPs should be able to see any patient in the department and, if feasible, physicians should make a courtesy call on all the patients seen by APs.. Regarding APPs working alone in rural areas, I'm also a vocal advocate for APPss working in this setting and that every reasonable effort be made to provide them back-up through some telemedicine system ( Avel eCare being the gold standard). I believe there should be affiliations between Critical Access hospitals and the closest comprehensive ED so that APPs working at a rural facility can rotate through the larger ED on a periodic basis. And I agree Boarded EPs will rarely be staffing Critical Access or similar hospitals. And because of all these reason we started our Boot Camp courses -- not to replace EPs but to help assure tha the APPs, independent of where they practice, provide the best care they can.

tom f. -

jeez.. that was a very detailed and illustrative set of comments. it certainly is somewhat complicated. It is so very easy to become defensive about it, whether you are a doc or APP/NP/PA. so very interesting and I think far from simple.
it is edifying to hear such well-spoken ideas and arguments for both sides, especially when we are actually on the same side, that of the patient.

I had not heard of the tragic Alexus Ochoa case until tonight.

I need to go back and see the other pods on this discussion.
thank you all.

tom fiero, ED in merced, ca. just another provider.

W. Richard B. -

Thanks for the kind compliments. Yes, this is all pretty complicated, but I think it boils down to several truths.

First PAs and NPs are not going to be leaving the ED -- there are just too many compelling arguments that those staffing the ED and paying the salaries can't ignore (they have licenses to see patients and they cost much less than EPs).

Next is the issue of the gradually increasing physician glut. The glut has already begun and will get worse year after year until by 2030 there will be an excess of about 8-9,000 EPs. If, like 10 years ago, there was a dearth of EPs, there would likely not be any issues and everybody would be happy except those who pay to staff the clinicians in an ED.

Now that there is tension between EPs and APPs largely brought on by the salary difference between them. Now EPs are complaining about "quality." As one who used to pay clinicians to work in the ED, I believe that APPs should definitely be in the ED. The issue is supervision.

APPs can be extraordinarily helpful to physicians in the ED. Physicians have the ultimate responsibility for seeing that everyone is receiving evidence-based care. Until physicians are confident that APPs can provide evidence-based care to Level 1-3 cases the physician should see all of those patient for a brief co-visit. All level 4 and 5 Level cases should be handled jointly. The EPs need to see ALL Level 4 & 5 patients in conjunction with an APP. The term is physician "assistant" or "associate" -- same with the NPs.

I've heard some complaints that I want APPs to be the doctors' secretaries. Yes, I want help. EPs need to get away from the damn computers. APPs are the only ones in the ED, except EPs who are licensed to take complete histories and do physical exams and document them in the EMR. They are the only clinicians able to write progress notes in the chart. EPs should expect the "assistance" of APPs to do some of this charting and order entry. It's either the EPs or the APPs doing this work -- nobody else. Can an EP see more patients if he/she had the "assistance" of another clinician -- of course.

So that's how I see it. The EPs are responsible for everyone. No independent practice because APPs have a license that allows independent practice but remember, the EPs are responsible for EVERY patient in the ED. No separate fast tracks operated solely by NPs. Patients who come to an ED deserve to be seen by a physician. They are going to receive a very substantial bill -- a bill consistent with what a physician would charge. If they want to be seen solely by an APP, they can go to an urgent care center. As soon as they become ED patients, a higher standard of care is expected -- and we need to deliver on that expectation. Otherwise, we are just very expensive urgent care centers for the Level 1-3 patients.

I'm sure my views will likely piss off all the clinicians, however, be assured it will not be a case of either party winning. Running a contemporary ED will require the close collaboration of both EPs and APPs to provide timely evidence-based and to meet the expectations of our patients from a service prospective.

W. Richard B. -

Wow. Powerful stuff beautifully written. But I don't expect you to take a bullet for me or shield me from the travails of EM -- it's just part of the job. We are in this together with the aim of providing the best care we can. Have a great New Year.

Michelle L. -

Thank you EM:RAP, Rick and Steve for discussing this point of view!

W. Richard B. -

Would very much suggest that you submit your comment to ACEP Now. About 45,000 people get it. It is a truly powerful. I don't know that all APPs will agree with you on all of it, but it paints a truly powerful relationship.

patrick h. -

Of course we are bickering amongst each other while the real villains are contract management groups.
As long as private equity is involved emergency care will be worse for it.

W. Richard B. -

Two comments. USACS is no longer involved with any private equity group. They bought their ownership share back from private equity about a year ago. Secondly, does anyone have any idea what to do about private equity groups? I can't envision any Federal rulings that in any way would control these groups. They have been with us for 30 years. I can't see a scenario where anything would change. And remember, with the EP glut becoming a tangible reality, physicians will have even fewer ways to respond to CMGs. The only thing that would be possible is for the doctors to form a union -- but I doubt there would be much stomach for this. Most EPs have to work -- they don't have the option to stop given their financial obligations. So, at least for the foreseeable future, you need to "learn to love the one you're with."

Ronald R. -

You lost me. You would have more credibility if you also talked about family practice physicians in rural ED. An EM NP or PA is much more prepared. Shame on you.
You give NP examples of mistakes but I can give you multiple examples of patient deaths from physician incompetence.
You don’t give NPs any credit for their years of RN education and experience. You insult me with your outright lies.

I’ll be canceling my subscription and encouraging all APPs to boycott EMRap. Keep an eye on social media.

Ronald R. -

Here are a couple of physician examples.
FP physician in the ED admits a 70 healthy patient with "diarrhea". Had abd pain and fever.
Radiologists documents portal venous gas. Did not order a lactate but AG was 20. No IV fluids except maintenance at 100/hr, no antibiotics, no blood cultures done.
No CT because "GFR was 50"
Admitted from 2300 to when I was called at 0530 because his BP was 50/30.
I can keep going. You get my point.

So how about you fix your own house before insulting all of the APPs with complete BS that is not even close to the truth. Lets talk about the dirty secret of FP physicians in rural ERs and the number of patient deaths. Talk about their massive 8 week ED rotation during residency. Compare that 8 weeks with my 2 year EM fellowship AFTER 12 years of ICU/ER as a RN, 17 years has a nurse anesthesiologist (CRNA) and 7 years of rural family practice as a FNP. Lets talk about how we can't get EM physicians to come to rural America, we struggle to find FP physicians but they aren't qualified to do ER.

You stay in your academic ivory tower and throw stones.

I really liked EMRap until this point. I can't believe they let you put out these lies and misinformation. I'm really shocked, I thought highly of them until now. Come over to my EM/Critical care page on FB that has 25k members. I recommend EMRap a lot there.

Ronald R. -

I just found out that Steve Carroll is a "proud member of PPP". The same organization who denigrated veterans.

How does EMRap justify giving him a platform for his hateful lies and rhetoric?

W. Richard B. -

Hey, slow down, slow down. I think you've got the wrong guy here. I have never worked in an academic ED -- I have worked in a single EP-covered ED since I graduated the USC residency in 1975. Prior to my EM residency I was in the Indian Health Service and was the only doctor for 50 miles in any direction and the doctor for the Supai tribe at the bottom of the Grand Canyon. So please don't give me that crap that I don't understand.

And, our company wrote and produced the EM Boot Camp course (the Original version has been taken by well over 17,000 PAs/NPs and non-em-Boarded physicians). We created it because we wanted to give everyone who has not had the extensive experience and training that you've had, a chance to learn more about how to practice in an ED. You are off the bell-shaped curve but you'll have to acknowledge that many APPs need some additional ED-specific training.

I gave the commencement speech a couple of years ago at the A.T. Still paramedic graduation in Mesa, AZ. I am a big believer in the team sport of emergency care -- doctors, APPs and nurses. We need to have the right clinician see the right patients. And EPs must take real-time responsibility for all the care provided in the ED -- no signing a bunch of APP charts at the end of the shift.

Sure there are physicians working in rural hospitals who shouldn't be there -- absolutely. And I know how difficult it is to get some of the Critical Access hospitals covered. I fully understand that there are EDs with no physician in attendance and I know some very conscientious APPs who work in this setting.

So, please back off. I think my actions fully support APPs collaborating with physicians in order to provide the most evidence-based, pro-patient care for our mutual patients.

Ronald R. -

My apologies. There is a podcast called EM Basic boot camp.

W. Richard B. -

And we had Steve Carroll on to give all sides of the ED staffing issue discussion a fair chance to join the discussion. Dr. Carroll was not in any way inflammatory and comported himself very professionally.

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