Rick’s Rants: Teamwork and Defining Roles in the ED Part 2

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Outraged EM Doc -

My goal is when we are overflowed with ED physicians, that we can kick PA's/NP's out of the ED department and relegate them to urgent care work only. EMRAP needs to have on the authors of "Patients at Risk," but they wont because they have to bow to the pressure of the NP/PA's who subscribe. In the end, its all about money, which is what got us here in the first place, sellouts like Rick doing "EM bootcamp" to line their own pockets and sell out the next generation of EM docs.

When hospital groups start to realize that the headache and lawsuits stemming from poorly managed patients from PA's/NP's costs them more money than they "saved" by hiring them, there will be a massive reversal. 500 clinical hours and 100% acceptance rates to NP programs does not make a good provider, and is already to leading to worse care for patients. At least PA programs have some semblance of organization and structure. MD/DO >>>> PA >>>>>>>>> NP. Anyone who tries to tell you differently is probably an NP.

W. Richard B. -

Zach, your anger at the situation in our recent communications has been palpable. We have all worked with PAs and NPs and, as in everything, some are excellent and others need help -- help they crave from the EPs but usually don't receive. If EPs were willing to work with APPs I think it would be quickly appreciated that the lives of the EPs would be much more productive and rewarding -- and all the patients would get to see the EP as part of the care team (something that many patients don't currently experience). Everybody gets to see the doctor.

And about your anticipated "massive reversal" -- it's not going to happen. APP suits are 10% of EP suits. The issues always come down to supervision -- something for which the EPs are responsible. And remember -- it was your people - the EPs, that brought APPs into the ED -- not the hospital administrators (they just learned from the EPs). And it was your money (the APP's CME allowance) that paid for the training our Boot Camp courses provided to make your (and 17,000 other) APPs better clinicians. They want to do a great job in the ED and they can with your help. And that doesn't mean signing a bunch of charts at the end of the shift on patients you've never seen. And yes, if EPs and APPs were paid the same well you could have an EP see every patient alone (and spend 40% of their time with the EMR and CPOE) -- but they're not. Are lots of EPs going to have difficulty finding jobs in the future (according to the ACEP WorkForce study) -- Yes. This problem for new EPs is very real -- but it won't be solved by replacing $130,000 APPs with $330,000 EPs -- guaranteed. Ask the hospital administrators and the contract group managers. The bottom line -- you can piss and moan but there's no going back to the old days. As sung by Stephen Stills, "If you can't be with the one you love, honey, love the one your with." EPs need to step up to the plate and take clinical responsibility for the care provided to each and every patient -- and APPs can make the life of an EP so much more productive and gratifying. And Zach, you can. have the last word -- I'm done.

Outraged EM Doc -

I appreciate the responses. As you like your rants, I also like mine. Unfortunately patients (and their care) are affected by hospital administration, and this is the new reality of medicine.


As an ED PA-C, I work within a democratic group designed much like you envision Rick- every patient (even suture removals) are seen by the EP. We are staffed in an acute care setting, work amongst the EP, and largely know our roles and our limitations. Our EPs are excellent resources, oversee all of our cases, and most of the time, offer little than a warm smile to the patient that we are caring for. There are times when it is appropriate for the EP to take over the case due to complexity - and we are all cognizant of these cases and know when to ask for help.

I have to be honest - all of this aggression towards the APP makes many of us regret our decision to be in medicine in general. The lack of respect from consultants and other staff is palpable at all times- if not often verbally expressed. It's an old argument. We are not trying to be physicians. We are an arm of the physician to help provide care and use the EP's time more efficiently. I have been in the ED for 15 years. At some point, our experience should mean something.

I'd happily go back to medical school if the EP wants... Then I will come for their job.

Mike S. -

I feel a lot of the same stuff you go through. I enjoy talking to my physician colleagues about patients that they technically don't even have to see in the ED prior to discharge (based on our practice workflow) because of either some diagnostic uncertainty or some high-risk features in the presentation. Other physicians do the same thing.

The lack of respect you mention that is encouraged, directly or indrectly, by physician organizations or people who want to position themselves as "thought leaders" is tremendously frustrating and a distraction during front-line patient care. Not that it matters to them. For my own professional/emotional health, I have decided to mostly avoid confronting these situations and people directly. Workforce issues are one thing, but their more odious positions regarding PAs and NPs are not based in reason. Reasonable arguments against unreasonable people and positions don't work. So I just move on.

W. Richard B. -

Dear ED PA-C
I had a conversation with a dear friend today and we were talking about the utilization of APPs in her EDs (180,000 visits/yr -- an adult and separate peds hospital). As I have advocated in the past, every patient who is seen by an APP is also seen by a physician. The physician visit may be brief, but it's better than my family member who was evaluaed recently for a post-op PE and never saw a physician despite having a serious and expensive W/U.

Regarding the negative attitude that you encounter -- you are not going away. An EP is not going to replace you. If anything, your job is probably more secure than theirs. But it's no fun working in and environment in which you are demeaned and disrespected. Hopefully, your hava an enlightened ED medical director -- if not, you've got a problem. It is the job of the medical director to set the tone in the ED. It's their job to create a work environment for all the clinicians that is conducive of a long, satisfying career. If you are being disrespected and demeaned by any physicians (EP or hospital medical staff), it is the job of the medical director to confront the problem and resolve it -- especially with the EPs. The ED medical director should make it very claar that creating a hostile work environment for anyone won't be tolerated. They need an "open door" pollicy to address any such issues. With rgard to the hospital medical staff, the Medical Director sits on the hospital Executive Medical Committee and he/she can let the chairs of the departments know (politely) that any disrespectful behavior to any staff in the ED (EP or otheriwise) will be brought to the appropriate committee for resolution.

One last point -- and I may regret letting my personal feelings be known here because I know I will be challenged on this -- but, where feasible I feel the EP should talk on the phone to members of the medical staff who are being asked to see a person in the ED or be involved with an admission -- not the APP. In addition, I think the medical staff are rightfully annoyed when a clerk places a call to one of them and they have to wait for the EP to come to the phone (this says our time [the EP's is clearly more valuable then their time -- so it is OK for them to wait on hold). I think the medical staff will have a more positive approach to ED clinicians when these two issues are addressed by the ED medical director. I'm not saying this position is fair or equitable -- but pragmatically it works -- and the medical staff will be very appreciative.

So hang in there -- talk to your director when you are disrespected and anticipate it will be effectively handled. Let them know of your expectations -- whether it is an EP or member of the medical staff. The days of being a prick are over.

Algis B. -

Rick is right on the respect issue. Effectively leading a team (which is our job as the EP) means understanding the capabilities and roles of each member (nurses, PA/NP, unit clerk, respiratory therapy) and directing them towards a common goal (excellent care of the patient). It doesn't do our patients any good to complain about you own team members. Nobody is going to be incentivized to change your staffing model by someone disparaging other members. Our job is hard enough without introducing additional conflict and we should welcome the opportunity to make our team members better by educating them, which ultimately will allow them to take better care of our patients.

However, this rant (and the one before) fails to capture or explain how we got here or why there is now such controversy. There is some truth that "your people" did this to ourselves by allowing PAs and NPs to see patients in the ED. The more complicated issue is who "your people" are. While it's true that some small independent groups may have pushed for PAs and NPs to be active in the ED, the larger impact comes from mega groups that directly profit from this staffing model. There is no getting around the truth that each PA/NP hired represents reduced labor costs compared with an EP. PAs and NPs would also not be staffing our EDs without the support and policies of our larger national organizations. It's not surprising that some EPs are frustrated by this situation, especially those that work in jobs where they do not have a voice as to how to staff their own ED safely.

The rant also fails to cover the elephant in the room, the vast over supply of emergency physicians in the coming years. When I was applying to residency, it was hard to find a residency not hosted by a large academic hospital, usually a Level I trauma center. In the past 15 years, there has been an explosion of community residencies, some hosted by private for profit hospitals that directly economically benefit from the influx of graduating EPs and the cheap labor costs of residents, subsidized by Medicare. It's unclear to those of us not immersed in academic medicine who is at fault for this. The ACGME, CORD, SAEM, ACEP, and RRC for EM all could have played a role in preventing this, or at least starting the conversation a long time ago and now it's too late for any easy fix to this problem. It's not surprising that the PA/NP discussion has become a hot topic when there will soon be a lack of jobs.

I think instead of trying to turn back the hands of time, we should be advocating for safe staffing models with regards to PAs and NPs, which should include some guidelines from our national organizations on who PAs and NPs should be seeing and how they are supervised combined with empowering EPs to be part of staffing decisions locally. The concern about scope creep with PAs and NPs is valid. My patients would not want me to do their cardiac cath, gallbladder operation or manage them upstairs in the hospital because it is beyond my training and no hospital would ever give me privileges in those areas without the requisite residency training, even if someone agreed to provide me with on the job training. The same rules regarding appropriate patient acuity and patient management should apply to our PAs and NPs.

This is a difficult time to be an emergency physician. We should recognize that and respect each other in our discourse.

Mike S. -

Thanks for the comments. I would love to eject the phrase "scope creep" from all discussions and it frustrates me that professional organizations have further popularized the phrase. It's too semantically overloaded, just like phrases like "supervision" and "independent practice"... means different things to different people. Some of the activities that people demean as "scope creep" are actually *appropriate professional development* as an outgrowth of lifelong learning. I don't have a command of the entire history of emergency medicine, and it's entirely possible I am overstating things, but I seem to recall much controversy in recent years regarding things like procedural sedation and ketamine use by EPs and ED staff. It is mentioned how "patients would not want me to do" X procedures that are not in the purview of the EP, but it seems to me that EPs have appropriately fought aggressively over the decades to expand the scope of their practice to incorporate new things that were not historically in their scope because evidence suggested that, in the right settings and with the right training, these new things were safe for patients and improved patient care.

National guidelines for PAs and NPs, unless they were extraordinarily detailed, sound like a "one-size-fits-none" situation. Guidelines that would encompass 10-bed through 50-plus-bed EDs, EDs of various capabilities, EDs with and without med students / interns / residents, EDs with newly graduated PAs and NPs as well as senior PAs and NPs with postgraduate education, EDs with no physician on site? Every ED is different. Every EP, PA, and NP is different. National guidelines, unless they were either very broad or very specific, would be too clumsy to deal with the multitude of realities on the ground. IMO, best to handle this locally. Like I suggest in this episode (I think... I forget which episode I said some things and what things ended up on the cutting room floor), there are credentialing departments and risk management committees that should already established at each facility that can more nimbly and appropriately handle staffing and credentialing issues.

Imagine if EPs' capabilities were all frozen at the scope of practice of the EP 50 years ago or 25 years ago. No new procedures or techniques, no new medications, no incorporation of new studies suggesting safe pathways to discharge for patients with certain complaints (how many weak chest pain admits "just in case" have we avoided in the COVID-19 era?). Perhaps some other medical specialties would be thrilled with this as it would represent standing against the "scope creep" of the emergency physician. But I think it would be seen as a failure of emergency medicine to not appropriately develop its capabilities in light of the advancement of medical science over time.

Dissapointed EM doc -

I love the PAs and NPs that I work with. I know we are all debating for certain names. Everyone wants respect and acknowledgement and APCS don't get enough sometimes. CMS uses NPP, the term that makes everyone happy but confuses the heck out of patients is APC and APP is somewhere between.

There is a legitimate argument, and I hope this podcast will interview a young physician who has recently entered the workforce, that these huge PE groups are going to be pushing APCs into the workforce for a profit. They are not all created equal. I'm sure these hosts are great but the landscape scares me. The vast majority will be new nursing grads who want an escape from bedside nursing and thus change/advance careers in a year or two. I cannot trust these new grads to "know their own limits like physicians do" when they ask why I am ordering a TSH on an altered patient or why I need a US for the kid with colicky abd pain and maroon diarrhea. How do you know your own limits in the same way when you have a fraction of the training? CMGs like Team Health and USACS are going to operate like a business and they are very good at it. Why should I be excited about having double the cases with someone that is *not* skilled hanging on my malpractice license? I LOVE working as a team. I LOVE teaching and since I now work in the community I get my teaching fix by involving my APPs and bedside nurses as much as I can in my decision making and I try to advance them as much as possible. I'd bet working with Roberts or Sharma would be great!

But we have seen this again and again. Study by USACS. Physician vs PA w/ physician oversight seems comparable. This leads to the out of left field conclusion of independent practice is totally ok or only "Nominal supervision." EM 'residencies' and 'boot camps' are AMAZING for the individual APC and the overall team - but then CMGs use this to push green APCS far too far forward into minimally supervised practice that, is out of the scope of the vast majority of unexperienced APCs. With all due respect, it is not up to the individual medical directors at CMG sites as to what a safe ratio or staffing model looks like. That comes from the top down in a way that maximizes profit. So, as in the episode, what if we disagree on evidence? Are there TRULY safety mechanisms that can look out for the patient in real time in the same way residency training scrutiny does? A staggering number of ERs don't even HAVE a physician, or have one available to consult on telehealth. How is that going to work? A vast majority of hospitals don't have a true M+M committee that scrutinizes ED practice variations. You can't say that if the evidence doesn't matter, these downstream mechanisms actually keep patients safe. They tally the errors - and to a number of employers, these are just baked in the cake costs of operation worth the cost savings and especially if it all lands on the docs malpractice.

As a new grad with debt who has seen his other colleagues pushed to the side, and truly abused by private equity while having the fight of their lives working through the pandemic, this podcast is not only tone deaf but leaves a sour taste in the mouth of many. It is easy for those near retirement to accept these things. And morally, they are probably right. But regardless of the intention of the individual APC, the corporate practice of medicine will make them, at least in some ways, the adversary of the new grad. Who can fault the current residents for being upset over this? What about the new grad who still needs to cut their teeth? Why should someone just out of residency be giving up procedures they still need more of if they wont being doing another for years? I think the discussion about bullying is kind of a cheap way to skirt some of these topics that really concern new grads.

Last I understood, EMRAP was created for the resident. I'm glad that more people have access. But just like ACEP as a whole I have felt those winds change and now it feels more like a headwind than anything else. Most of my former residency classmates and I have discussed this and feel similarly. I appreciate and heed the advice, but I will probably be taking my subscription elsewhere. This episode was missing a very important voice, one that a perspective at the edge of retirement and hosting an APC bootcamp cannot honestly provide.

W. Richard B. -

I think Dr. B's comments are quite thoughtful. In the second paragraph he indicates that we didn't spend much time on how we got here. In 2017 a government publication indicated that there would be an excess of EP -- that's 4 years ago -- but apparently not many people were aware of it. Seems now that the ACEP workforce study was released, all of a sudden it seems we are waking up to this glut of EPs situation. ACEP recently published what it was doing to help solve the problem (5 years ago this would not have been a problem but a blessing as EP jobs were very plentiful). Seems the big target is the number of residencies. There is this move to get the RRC to up the standards to make it harder to have a certified residency. Cutting off the supply of EPs is not the job of the RRC. Its job is to set reasonable standards and to assure that residencies meet them -- not to set standards that are blatantly intended to fix the oversupply problem of EPs.

It's true that ED groups were the first to incorporate the use of PAs/NPs into the ED. some of those groups were small, some large, some democratic, some autocratic. All saw the potential increased income the groups would make. If bringing APPs into the ED was a sin, there was a lot of blame on the part of doctors to go around.

But I see APPs as being able to facilitate the work of the EP -- not replace them. I think EP lives would be much less stressful if at least one APP worked with each EP. The idea is to free up the time physicians waste sitting at a keyboard. They are paid way too much to spend 44% of. their time generating a chart and adding in orders. I believe that every patient expects and deserves the care of a physician in the ED. I believe that physicians should make it clear to patients that the APPs are part of the team who will be taking care of them but that ultimately the doctor is the leader. APPs can see the sickest patients in the ED in conjunction with the doctor. This would serve as great additional training for the APPs.

And regarding the idea that there will be scope creep -- I think you have to acknowledge that who does what is the purview of the ED Medical Director. They, in consultation with their colleagues, establish who can do what in the ED. If there is scope creep it would be because the EPs allowed it. EDs need strong, enlightened Medical Directors -- the quality of care provided in the ED is their responsibility. Without a doubt, having APPs as part of the care team can work effectively. But having APPs independently see the more minor cases alone isn't a long-term strategy for success. This results in EPs having "their" cases and more or less separately, the APPs have "theirs." In this environment EPs could easily see the potential for APPs as competing for their jobs. But remember, those APP cases are going to get charged at least $1,000 for their minor problem ($150 at the urgent care) and they are the responsibility of the supervising doctors in the ED. Don't they deserve a brief visit from the doctor -- you bet. So make it work -- everybody (APPs, EPs and patients) will be happier about the care that is provided and the clinicians will feel much better about their jobs.

Heidi B. -

In the community hospitals, especially under national corporate groups, the medical director has no control over staffing. The director has no ability to have EPs & APC’s see pt’s together - the staffing is too tight & the metric demands, that EP pay is tied to, don’t leave time to do your own charting on shift, never mind see all the APC’s patients. We wind up charting for free after the shift & still have no time for teaching. We aren’t allowed to hire scribes & APC’s have their own massive amount of charting to do. I agree with Rick’s ideas but they are not possible any longer except in academia & the rare democratic group.

Dallas H. -

I have no evidence to support my thoughts but I would suspect that having an APC and a physician. Involved in a case would improve care. At minimum, I review all test results before an APC dispos a patient. So now two sets of trained eyes have evaluated the patient.

Dissapointed EM doc -

and the patient-physician relationship will have left the building for good.

W. Richard B. -

Just go one step further -- go visit the patient. Advise the patient that "APP so-and-so has told me about your case." "How are you feeling? " Do what is necessary to feel comfortable with the diagnosis and treatment. Perhaps a visit every so often if the patient is going to be in the ED a long time. Give feedback to the APP. The idea is team care - nurses, APPs, and EPs. Stop doing all the BS charting and teach your APP the tricks of creating a safe chart. Perhaps you can do the medical decision-making part. Let others put in orders. Let them pull up lab and imaging studies. Show the APP what you're looking for on the images. I believe that a great deal of the angst that EPs are expressing as of late could be substantially attenuated if EPs really did have someone who is licensed to complete the chart, enter orders in the CPOE system and write prescriptions. Every doctor gets an APP!! Every doctor gets to do more thinking and interacting with the patients. Try it.

Heidi B. -

We can’t try it. There is no way the big groups are paying for scribes, let alone an APC per EP. The EP & APC are running themselves ragged side by side, in parallel, with no time to teach or see all the APC patients. No one else is allowed to enter orders. The nurses can’t even over-rude to get fluorescein strips out of Pyxis. These ideas are great, but the majority of us work in a completely different reality. My door to doc time must be 5 minutes, even single covered, or I get paid less, my door to first order must be 15 minutes, my low acuity LoS must be <60 min or I get paid less, regardless of how many level 1&2’s I have & whether i have 6-8 pts per hour arriving. We don’t have a clerk so I make all my phones & often answer the phone as I enter orders at the computer & the nurses are all with patients. This is bare-bones staffing for hospital & staffing group profit that existed before Covid.

W. Richard B. -

Dear Dissappointed,
Let’s see where we agree – Advanced Practice Clinicians do come in all varieties of competence – no doubt. And there is no question that some (many?) CMGs drop them on the front lines with little supervision. Perhaps the EPs working with them are asked to supervise, but they may not want to (and in the process make it clear that the APCs are on their own). But let’s be fair – it is the rare ED group that doesn’t include APCs. Everybody has them – it just makes sense. That includes the truly independent groups, the independent groups with only a few “partners” (some of these have been the most egregious when it comes to fairness and equity), the CMGs (which have a handful of contracts to 600+), groups in which the hospital employees the EPs – every kind. It is not just the large CMG – all the groups are guilty to some degree. I have said this before – EPs were the first to hire APCs – not hospitals. We set the “standard.”

Second, I think, and I have said this before – all ED patients should be seen to some degree by an EP – everyone – the patients expect it, they deserve it and their bill will reflect a concierge level of care even if they never received anything close. APCs should truly assist in the care of the EP’s patients – not see a bunch of patients alone that the EP never sees and whose charts need to be signed at the end of the shift. I think most any EP could see a large number of patients if they were unbundled of the EMR and CPOE system demands. Doctors should be totally relieved of these time-consuming, largely irrelevant chores. Let the APCs do it. On the tougher cases let the EP do some progress notes and dictate medical decision making. Will it require that EPs invest some time when an APC is new –you bet, but the ROI will be a physician whose job allows him/her to make a 35 year career of EM.

Now for the problems – “the podcast is not only tone deaf but leaves a sour taste in the mouth of many.” Now that’s a low blow. And combine that with a referral regarding a “perspective at the edge of retirement and hosting an APC bootcamp cannot honestly provide.” But the topper doesn’t even involve me. The topper – “last I understood, EMRAP was created for the resident.”

Let me put this all into some perspective:
1. The EM Boot Camp courses were created about 9 years ago because nobody had a course in the marketplace directed at the APC and primary care physician working in the ED. Since then, over 17,000 have enrolled. What does that say? It says that these folks are hungry for EM education. They want to do a better job for the patients. They are motivated but may not be getting the support they need in the ED --the support they need from the EPs. I said this before – the APCs in the ED are not going away – it’s not going to happen. They make about a third of what EPs do. Bottom line – “If you can’t be with the one you love, love the one you’re with.” Five years ago EPs were in demand – now less so and soon the forecasted glut will be here. None of us can substantively change this. We didn’t cause the problem – but we have to deal with it. Expectations need to change.
2. Next, the “podcast is not only tone deaf but leaves a sour taste in the mouth of many” and combine that with the assertion that I can’t give an honest perspective because I’m on the edge of retirement and have the APC boot camp. The fact is that I have worked in two single coverage EDs in the center of LA county for 34 years and was a director for 25. I’ve hired lots of EPs and APCs. I have been putting on literature-based course since 1985 – over 500. I’ve talked with thousands of EPs and APCs over the last decades – certainly more than most. I think my perspective is unique – and, in fact, still valuable – but perhaps new graduates don’t like the message. I can understand it – but the world doesn’t care about your loans or your expectations about a job. You and your colleagues have arrived at a very challenging time. Did you deserve it? No – but did we all deserve the pandemic. No. We have to do our best. I have advised EPs to just be the best clinicians they can be. Make people glad you took care of them and offer to help out with chores the group is expected to do – EMS, hospital committees, special projects, etc. Just go the extra step to be an all around stellar member of your group.

3. Lastly – and this is a corker – “I understood, EMRAP was created for the resident.” I just want to say I have no equity in EMRAP, I don’t get paid for my rants. I don’t speak for Mel. But just run the numbers – 260 residencies x 40 residents each = 10,400 atmost. How many ABEM doctors are there = 45,000. What publication trying to reach as many clinicians as possible would favor 10,400 over 45,000. Seems the goal would be to create an educational endeavor that all emergency clinicians could find worthwhile – even APCs.

Nate F. -

I understand the logic of "APPs are here to stay, get used to working with them." It is plain as day that the genie is out of the bottle, and I do see the value in having these practitioners on the ER care team. I have a hard time seeing the model described here actually work in practice.

Please address the elephant in the room. Rick's proposed model of the EP as a supervisor and trainer while APPs do all the work sounds great, but what it really means is that each ER will need dramatically fewer EPs on staff. If you're lucky enough to snag one of these jobs, great, but the thousands of us that sunk hundreds of thousands of dollars and hours of sweat equity into training will be out in the cold. No ER medical director, no matter how strong or enlightened, will be helpful here.

The solution isn't to boot out APPs; I'm not advocating for that and I love the ones I work with. I don't know what the solution is. Maybe we should just look for other gainful employment, because it's quite clear that the vast majority of us will soon be rendered obsolete.

W. Richard B. -

Thanks for writing and thanks for not beating me up. Your assertion that my proposed staffing pattern will squeeze out EPs would be true IF you didn't see all the patients. I want to go back to an approach where everybody gets to see the doctor -- that essentially independent practice by APCs goes away in the ED. That PAs work as intended -- as physician ASSISTANTS -- not physician replacements. As I asserted in my last response, the patients are paying a very premium price in the ED (about $1,600 for a visit that could equally go to an urgent care center for $170 -- See “Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending. The article was by Bill Wang and colleagues out of Harvard and the University of Pennsylvania and it was in the April 2021 issue.). Patients deserve and expect a doctor and they can have a doctor see them with the scheme I've outlined. Regarding RVUs per hour, they may drop a little, but life in the ED would be so much better for the doctors and the APCs and the patients. The incessant drive to increase RVUs per hour is costly -- costly to the existence of the YOU, the EP. You have to protect your 35-year career. Cutting that career short can cost millions of dollars -- you need to have the desire and will to go the distance. No burn out. Tired, sure. You need to get away from the EMR and CPOE and let other less costly people do it. Sure, take a look at medical decision making or dictate it yourself == but no 40% of EP time with computers -- it's nuts.

Brent R. -

At my previous job, physician staffing was decreased and APP was increased. Now instead of the volume being divided by 2 to 3 physicians it is one overseeing multiple APPs. I cannot see every patient. I don't want to see every patient. I don't want the extra liability of care. I would rather be single coverage and responsible for my own actions. So I left and went to a place more hostile to APPs. We have full physician coverage. I can help out my colleagues if needed, but I am not responsible for them. I am much happier.

Also, I don't know what EMR you are using that you spend all your time in front of a computer. With macros and order sets, it only takes me a few minutes each patient for charting.

W. Richard B. -

I'm glad you were able to move to a group more consistent with the staffing you like. I envision these groups will become fewer and fewer over time. A board-certified EP shouldn't have to see every patient alone -- I don't think there is any question that having help will substantially facilitate your patient care. Anybody out there supervising multiple APPs?

Steve Carroll -

The most frustrating part of these two podcasts was the total dismissal of physician concerns over NP and PA independent practice. While those on the podcast are to be commended for wanting to work in an environment with physician supervision, that is not the feeling of all NPs and PAs and it is certainly not the feeling of the AANP and AAPA. The AANP asserts very strongly that NPs should be granted full practice authority from the day they graduate. The AANP has gone aggressively state to state to get independent practice rights for NPs and they have succeeded in half of states simply by legislation and not by improving education standards and training. The AAPA has been (mostly) dragged along for the ride because they don't want to seem less marketable than NPs in the job market in regards to independent practice.

If anything, NP education standards have taken a nose dive. It is now possible to have a bachelor's degree in anything, do an accelerated 1 year BSN, go directly in to NP school without having spent a minute as a bedside nurse, get only 500 clinical hours of training (with some programs putting it on the students to arrange their rotations with zero or little quality control) and practice independent of any physician supervision in half of states. While this is most prevalent in online "diploma mill" NP programs, even well respected brick and mortar institutions are only requiring in the range of 500-1000 clinical hours, a fraction of the 10,000+ (actually closer to 15,000) hours it takes to be a residency trained EM physician with medical school and residency clinical hours. For the PA side it's about 2,000 clinical hours. With as little as 3% of physician training hours, NPs are not qualified to practice independent of physician supervision yet there are already EDs where NPs and PAs are practicing with no board certified EM doc on site or even available for consultation via telemedicine. We would not accept commercial airline pilots with 3% of standard commercial pilot training, we should not accept it in medicine either.

The "Libby Zion" case that I hope will wake people up is the Alexus Ochoa case. An NP with no physician onsite in an ED missed a massive pulmonary embolism in a case that a first year medical student would not have missed. The paramedics brought the patient in suspected a PE as did the bedside nurses. The next 10 hours of her ED stay were marred by many management and diagnostic mistakes and an 18 year old healthy female paid the price with her life. While we all make mistakes (myself included) this NP was allowed to practice independently having only been trained as an FNP and in her legal deposition could not describe having seen a case of PE during her training or provide the risk factors or proper workup for a PE when asked. Exactly zero board certified EM physicians would say the same. A summary of her case is here- https://www.newsnationnow.com/investigation/transparencyinhealthcare/ and a full autopsy on her case is available in the well researched book Patients at Risk.

The problem here is corporate greed and lack of transparency since that hospital chose to staff the ED without any onsite physician supervision because they could pay an NP less than a physician. However, anytime someone expresses an opinion on this, they are labelled as being anti-NP/PA. Nothing could be further from the truth. I welcome and support working side by side with my NP and PA colleagues who are willing to do so with physician supervision. Let's work together to help take care of patients but we should not dismiss the problem that aggressive legislating at the state level is removing that supervision to the detriment of patients are. Anyone who knows me or my podcast knows that I believe that we need to educate all levels of clinicians in order to provide optimal patient care but that optimal patient care is delivered when we work as a team that is led by a board certified EM physician.

If you would like to provide some balance to these podcasts and talk frankly about the concerns that physicians have about NP and PA independent practice, please feel free to contact myself and I would be glad to speak on the podcast or find you many physicians who have previously spoken about these issues.

Steve Carroll, DO

Mike S. -

A recurring theme of comments seems to be "you're not presenting both sides." Whether this was communicated or achieved, the intent of these July and August segments was 1) to bring up the increasingly hostile tone of position statements and social media campaigns from physician organizations towards PAs & NPs, and 2) what the reaction from "frontline" PAs & NPs was to these statements and campaigns. These physician orgs have massive platforms and have been, for months, displaying the equipoise, collegiality, and evidence they feel is appropriate. These statements and campaigns... the other side... has *already been presented* and continues to be presented with increasing vitriol. These segments are the response of three individual emergency medicine clinicians to that other side.

IMO, there are better ways to present the problem than anecdotes about how a PA or an NP did something exceptionally boneheaded, and how that is supposed to illustrate how the entire diverse profession is rotten, despite some of its clinicians having formal, specialty-specific post-graduate education (which has faced opposition from physician orgs) and decades of clinical practice. When there are cases of failure to diagnose, failure to treat, etc., from all types of clinicians in EM, merely pointing the finger across the table and saying "well, look at what THIS guy did" is not going to solve the problem.

One of the many downstream effects of lumping PAs and NPs together into "midlevels" or "APPs/APCs" is that each profession has different professional goals. I was prepared to talk more in detail about AAPA's goals after discussion with state and national PA leaders, specifically in preparation for these segments, but also after years of more casual discussions we've had about the profession, but it was not really in the scope of these segments. I have concerns when physicians, especially ones who may oppose the advancement of the PA profession, attempt to speak definitively on what AAPA's position is. "Supervision" is a tricky word and means different things to different people... discussed this in the first segment in July, I think. PAs want to work in appropriate collaboration with physicians. Best to hear about AAPA's position, Optimal Team Practice, from AAPA itself here: https://www.aapa.org/advocacy-central/optimal-team-practice/ .

Steve Carroll -


I used the Alexis Ochoa case as an example of why NP and PA training is not up to the task of training for completely independent practice because it is an illustrative case, the same way Libby Zion showed us the problems with overworked and overtired residents. Obviously, we can point to cases where physicians made similarly tragic mistakes but when you dig into this case in particular, you find errors that no board certified EM physician would make and I can say that unequivocally. It is a way of putting this all into context in a concrete way- underprepared NPs and PAs being thrust into clinical situations that they are not qualified for with a small fraction of physician training. That is what so many of us are concerned about but these concerns in your podcast were essentially painted as "physicians are being mean when they bring this up."

We can all work in a team led by a physician and that is how it should work. And I find the AAPA's "optimal team practice" to be independent practice under a different name. And I use the word "supervision" intentionally because that is what it is- a supervisory relationship. It can certainly be collaborative but if an NP or PA has a different plan that I don't agree with then we are going to execute what I think is best for the patient because I have ultimate responsibility for the patient while in the ED whether I see them or not.

I will say this- are there master clinicians within the NP and PA ranks who could some day, with enough experience and training, qualify for an independent practice track? Perhaps and I would be disingenuous if I didn't acknowledge that there are a significant number of long time practicing NPs and PAs who could qualify for such a track. I don't know what that would look like- probably passing the same EM boards as practicing EM docs do and documentation of full time work in EM for a long stretch of time (15-20 years sounds about right). But no one is having that conversation- instead the AAPA and AANP are pushing for independent practice and that is what myself and so many physicians are concerned about.

Mike S. -

You say "illustrative case"; I say "euphemism for anecdotal evidence." We're going to have to disagree on what "optimal team practice" means and what the AAPA is pushing for. I don't know how much further a discussion can productively go if one party doesn't believe the other party's statements at face value. The goal is to avoid one-size-fits-none state practice laws that don't reflect the variety of practice settings where physicians and PAs work together. AAPA also doesn't want physicians to have responsibility over patients that they didn't see... so at least you agree with them there.

W. Richard B. -

I agree with essentially all your comments. California, my home state, after opposing the autonomous practice of NPs for a decade lost the fight this year. Two points -- I think in a decent size ED where there is at least one EP, the best way to work collaboratively is as I have suggested in the past. The EP sees everyone to the clinical degree appropriate -- and the PA/NPs facilitates their work -- H/P, progress notes, CPOE -- all in collaboration. No patients are exclusively seen by an APC for the multiple reasons I've elaborated previously. I know some of my APC friends will be disappointed in my position by I think it is the way to go in the ED with an EP. I am only concerned about what happens in the ED and I don't want to address the bigger issues re autonomous practice of APC, but as far as I'm concerned, independent practice should not happen in the usual EDs if avaidable. But, you need to know that there are over 1,300 Critical Access hospitals in the US and each has an ED. Many of these are staffed by a combination of local primary care physicians and APC and some only by APCs. So the question is, "Do you want nobody at these little rural hospitals or APCs who are interested in providing the best care within the constraints in which they work. No ABEM-certified physicians are going to be going to these hospitals. ACEP says everyone is entitled to be seen by an boarded EP -- it's not going to happen -- ever. So we do the best we can. I'll take an APC over nobody any day.

Steve Carroll -

Your point on the rural areas are well taken but the current data says that PAs and NPs don't practice at a higher rate in those rural areas than physicians. Also, these places will say that they try to pay enough to get BCEM docs to work there but I remain skeptical that they actually do so.

Even so- that is one issue- the other issue are hospitals that should have no problem staffing (because they are in areas where people want to live) are replacing physicians left and right with NPs and PAs. It's usually not a wholesale replacement but rather it is insidious. Instead of two docs being on at the same time, its a doc and a PA/NP. Martha's assertion that physicians aren't being replaced is verifiably false and it is happening all over the country. There are financial forces in play that only care about dollars and they are absolutely replacing physicians with NPs and PAs.

W. Richard B. -

I think the data on APCs being in rural EDs is different that APCs being in rural communities in general. I think the are serving in rural communities. Some of these EDs have 5-15 visits a day -- from a career POV this low level of patients would be deadly to an EP's career -- how may procedures, how many MIs, how many multipatient injuries? And these hospitals are all struggling to stay a float -- how are they going to pay what EPs expect to make. Sophisticated ER-focused telemedicine support systems (like Avera) can help APCs with real time support.

And in the hospital situation, I honestly don't doubt you. I'm sure the temptation to pay $130,000 vs $330,000 is pretty compelling. But I have to tell you that these RVU machines are, in my opinion, so harmful to our EP brothers and sisters. Honestly, as long as you have groups where the bottom line comes first and it doesn't matter whether you burn out your EPs (you can always replace them with fresh ones), it's a very bad situation. I agree. Do I have any solutions that I think would work (and the emphasis is "would work"), I'm baffled. The genie is out of the bottle as has been said. Others are suggesting two fundamental ideas -- work to make it harder to have an EM residency and thus shut off the spigot -- or diversity what EPs do -- but nothing will pay them anything close to what they can make seeing patients. So, I don't have an answer -- except my idea that EPs see everyone and are assisted by APC -- but most companies running EDs will reject this idea. I'm very sorry -- this is the best I can do.

Michael C. -

I wanted to comment on this segment for 2 reasons:

The first was to Echo Steve’s feedback on the dismissal of physician concerns, agenda and rhetoric of the AANP and AAPA, and the rise of the online NP program but those points seem to have been well made by now

My Second reason was just some general feedback for the EMRAP team- I am an APD at a program where all of the residents have EMRAP subscriptions and listen almost religiously. Regardless of your intent, the response to these segments has been extremely negative amongst my residents. It’s hard for me to imagine being a resident in EM right now, burdened with unprecedented debt, during a pandemic, on the heals of a devastating jobs report, who turns on their favorite podcast and hears (despite I’m sure pure intentions) an extremely one sided segment that seems to ignore all their greatest fears and anxieties and ends with, essentially an advertisement for APC “boot camps”.

I’m not sure exactly what percentage of your listeners are residents but I suspect it’s a meaningful portion and this segment simply came off as tone deaf and ill-timed. It might be worth keeping those residents in mind in the future

Mike S. -

I don't speak for the EM:RAP team; these comments are just from me. It is understandable that residents feel like they are in a very tight spot. (New grad and experienced PAs and NPs are feeling the job market crunch as well.) But increasing med school debt... not the fault of the PA or NP. The pandemic... not the fault of the PA or NP. The management of the emergency medicine physician profession... not the fault of the PA or NP. Let's get pissed off. Let's fix the system. Let's just make sure we're aiming at the right targets.

The first episode dropped right on the heels of the AAPA House of Delegates voting for a title change that more appropriately describes what our profession does, followed by physician orgs and individual physicians pushing back. I frankly don't think the timing could have been any better.

The About Us page for EM:RAP starts with: "Emergency Medicine Reviews and Perspectives is a monthly audio series for Emergency Medical practitioners." It does not go on to exclude any profession. Turning PAs and NPs into scapegoats for the state of the physician profession while they all slug it out in the same trenches against the same pandemic comes off tone-deaf and ill-timed.

Michael C. -


Great points, those all would have been nice things to discuss during the segment. (Though the job report obviously paints a very different picture for APC new grads compared to physicians). However, your points were not discussed. These issues are simply too intertwined to discuss one portion in a vacuum. I would agree, the timing could have been good if more of the issues were acknowledged but they were not and it came off as tone deaf.

As a result, many of the resident listeners were a bit exacerbated by this segment. I think it’s important to receive that feedback and perhaps even consider in the future, or you could also just ignore it completely.

Mike S. -

I don't know if it will make you or your residents feel any better, and maybe I am revealing too much, but my intent is to extend the olive branch. We recorded this segment in February 2021. Before the delta variant really hit our shores, before the ACEP workforce study. It was supposed to be one 15-minute segment... we ended up recording a little over an hour of discussion, leaving out a lot of stuff in the interest of time even though we were prepared to talk more, and the editors did a masterful job trimming and packaging it into two segments. I enjoyed Dr. Herbert's take in the comments section of last month's segment (https://www.emrap.org/episode/emrap2021july/ricksrants#comment8808) and it touches upon EVEN MORE issues that you didn't bring up. :)

Like Dr. Herbert said, I knew the segment would be controversial, too. As much as we may have kept a light tone in the segment, we did not approach the task lightly. The other facets of the issue have been and continue to be discussed in other forums. We think they are important even though the scope of our discussion here was intentionally limited and did not cover them. I am appreciative to EM:RAP that we were given the time we had. For what it's worth, I hear your feedback.

John V. -

Here’s my take being a mid career EM doc.

1. I do perceive commercial bias in this segment due to Rick’s bootcamp and he was the wrong host for the topic.

2. EM:Rap as a platform needs to stick to expertly educating ANY clinician and cut it out with all these touchy feely episodes on all sorts of highly subjective topics. Its not just “Rick’s rants” either. I just want cme. Please.

3. Emergency medicine is a misnomer. Most ED patients are primary care overflow and dont need an ED doc. The primary care system is broke. I get why APC’s are proliferating in the “emergency” field and why lawsuits for APC’s are low. We as a country are training too many emergency docs and APCs to cut labor costs. Contract mgmt groups love it. Nobody wants to match in primary care programs because that field has already been plundered of its upsides.

4. Contract management groups overstaff APC’s and are moving ever closer to an anesthesia model. But they do not hire APC’s like the one’s who are on this episode. I wish they did. They hire fresh green cheap APC’s and they dont feel responsible for training them any further. Hence boot camps. Is it my responsibility to train them???? Envision business rep at my site said to me “yes, if you dont wanna get sued.” No $hit. And so I blindly “cosigned” 30 charts a day to keep it “legal” until I got a better job.

5. Now I work for a private democratic group. We hire experienced APC’s and they see the primary care stuff, we split the moderate stuff, and I’m free to do critical care without interrupting questions like “How do you suture a fingernail?” I make extra profit off of their cheaper labor. I have a hand in quality control. Its a real team. It works and feels better.

6. Docs are pissed about this subject because more and more of them, unlike in Rick’s day, are looking at careers as bottom level employees of giant soulless healthcare machines being run by profiteering spread sheet managers. They have no voice and are being forced to work in situations that breed resentment and burnout. Hence the tone of “disappointed em docs” views.

W. Richard B. -

Thanks for being civil with me. I personally don't think there was any marketing conversation at all about our boot camps. Our goal with the Boot Camps has always been to provide CME focused on EM for all non-ABEM-certified folks working in an ED. We have had thousands of such physicians take the course, most working in very rural areas.

You don't pay anything extra for any of the "touchy / feely" parts of EMRAP, so don't throw out the baby with the bathwater. Don't listen to the rants (and most have been on non-touchy/feely stuff"

Co-signing charts of patients you've never seen is wrong -- and we all know it. And hiring "green" APCs is unfair to them, the doctors and the patients. Our courses have lots of such APCs and they are scared to work in the ED but want the job. Failing to adequately orient and train is the responsibility of management -- if they don't do it there's lots of room for resentment and anger

"I make extra profit off of their cheaper labor" -- isn't that exactly one of the concerns you mentioned --- but now it's OK because you benefit.

I understand the POV of physicians who are, more or less, forced to work for CMGs that don't have the long view of EM. I admit, in my era there were a lot more "democratic" groups -- many of whom were superb at pillaging from their younger members. Truly democratic groups are probably pretty rare, with many probably having "senior" partners and several tiers below them of junior partners.

I don't think it was a conspiracy of the CMGs to flood the market with EPs in order to lower salaries and increase availability. Of the 260ish EM residencies I bet CMGs are involved with maybe 30. The vast majority of new residencies are not involved with CMGs but were started at hospitals where there were other motivations -- community status, cheap labor, retention of residents as staff, whatever. And just like your group, everyone sees the theoretical value of APC -- as long as they make money for the EPs and not the hospital or CMGs.

Finally, you are right -- Martha Roberts and Michael Sharma are truly exemplary emergency clinicians -- but the better APCs become, the more they tempt their employers to view them as mini-EPs.

My solution -- all patients are seen by an EP -- everyone. APCs are teamed with the EP and they do the H/P (and the doctor can review and do medical decision making). APCs interface with the CPOE computers. They facilitate EP work. A physician may see a patient for 30 seconds if that is appropriate or 10 minutes - but they work as a team. Doctors get to do what they do best for every patient and are freed of the hassle of the computers -- and remember that "nothing" visit bills out at $1,600 so says a recent study. Patients or their insurance companies are paying concierge prices in environments where there may be long waits and little privacy -- at least give them the satisfaction of saying they saw a doctor.

Shu-Haur O. -

These comments are very interesting to read from the perspective of a non US emergency physician (Melbourne Australia - land of lockdown protests...)

I work in an outer metro emergency department which sees roughly 100000 presentations/ year (mixed adult and paeds)
We have 4 NPs that work in our department (usually 1 or 2 on any given am/ pm shift)
They work as generally autonomous practitioners - I only get asked complicated questions when things are not routine (muchlike my interns, HMO and registrars would - what you guys call residents) and only get asked to co sign things which are for vague billing purposes - presentations relating to transport accidents or work related injuries - which, as a public hospital doctor I have very little interest in (which I see seems to be a major difference between me here and you guys over there)

They did start at that "urgent care level" (fast track sutures, broken limbs) but locally our hospital have invested in them by training them and teaching them and now they see pretty much anything outside of the resus cubes.
Why did we choose to do this
1) the NP doesn't move away from our hospital, like the junior medical staff. We are constantly having to teach new medical staff how things get done in our local environment
2) because we know our NPs we also can trust that they know when to ask for help - which is also an issue with new medical staff (just getting to know new staff takes time)

I don't think EPs in my country face the same jobs crunch that is being described - there certainly is opportunity to work in ED in non metropolitan settings. Maybe explore the emigration option to Australia?

Algis B. -

Let's not lose track of the bigger picture here. I have been listening to EMRAP since the start of my residency in 2003. I think the team provides an unmistakable great service to the EM community and I have personally learned a lot about medicine listening to the program and it has been invaluable to my career. I have listened to vigorous debates from clinicians that I respect on TPA administration, sepsis measures and even hand washing.

EMRAP needs to decide if it will just offer CME or delve into issues that are important to the EM community. The program has dealt with issues such as human trafficking, personal perspectives on lawsuits against physicians, disabilities bias, universal healthcare and many other topics. I have learned a lot about these issues through this format and would not have been exposed to them if not for hearing about them on EMRAP.

However, I have heard almost nothing about the ACEP workforce study and the coming glut of EPs, the origins of this problem, contract management companies vs independent groups, physician autonomy, PA/NP supervision, for-profit vs nonprofit hospitals or the advantages/disadvantages of different EP group structures. These issues are important to all of us and especially important to recent residency graduates that are not acquainted with them. This is the first time that I have heard a presentation (it was not a debate) on how to use PAs and NPs in the ED and I appreciate that at least the issue has been brought up. I think the comments above reflect that a lot of people perceive that it was brought up in a biased manner.

Why not bring these issues up and have a similar debate, with clinical leaders we all respect, and get some different viewpoints. I think if we can have a respectful debate on hand washing, we certainly should have one on the current state and future of EM.

Mike S. -

Intent of the talk, as far as I understand, was what I mentioned above... 1) to bring up the increasingly hostile tone of position statements and social media campaigns from physician organizations towards PAs & NPs, and 2) what the reaction from "frontline" PAs & NPs was to these statements and campaigns. The intent was not to debate. The viewpoints of the presenting orgs have been delivered in their own ways. Eager to see what EM:RAP brings out in the future; takes time between episodes being recorded and delivered.

Feel like commonly presented position in these comments is that the topic was brought up in a biased manner. I have no problem admitting to possibility of being biased myself. But if a person earns a living or is going to earn a living through their own practice of medicine or someone else's practice of medicine, whether they are joining the discussion or just listening, there is the potential for them to have bias as well. Just because the person talking is not a PA or an NP doesn't mean they're automatically going to have a rational or correct view on the issue. Happy to see what further discussion occurs here on the issues mentioned, but good luck finding someone who is in the space and without the potential for bias.

W. Richard B. -

Thanks much for your e-mail. Obviously, I agree that non-clinical topics that focus on ED operations and management are definitely fair game for EMRAP. And, regarding your comment about the presentations being biased, not so fast. We had a presentation with two exceptional APCs, the head of 7 EM residencies managed by USACS, a session with an academic vice-chair of a long-standing major residency and you have yet to hear our upcoming session with someone who may represent those who are very much against APCs for one reason or another -- so stay tuned. And I heartily agree that we could use more candid discussion on some of the very difficult challenges that EM is going to face in the future. But I don't think any of these staffing issues is really a debate in that we likely really can't change any of the issues by having a debate and declaring a winner. The winner is going to be decided by the free marketplace. Unfortunately, medicine in this country is so screwed up -- don't get me started. But as long as the apparent goal of the US system is to make money we are going to be stuck with a very expensive "system" that is fine if you have good insurance and bad if you don't..

W. Richard B. -

Mike Sharma -- could not agree more regarding your comments. Everyone commenting here has a horse in the race.

Dave T. -

I want to interject another concern that is really addressed. We always talk about the oversight or the new head from the PA or NP world but there are those of us working in the ED as APPs that have gone through additional and sometime extensive training in the post graduate setting. Not to the level of a full EM residency but it does prepare us to see more complex patients. At what point do we start to take into account the experience APPs have developed through theses programs and years of experience.

W. Richard B. -

What you are saying is absolutely true. I know some PAs and NPs who are exceptional clinicians and who have had a lot of extra training and experience. I think the problem is that the core training of both PAs and NPs is not EM focused but rather primary care focused. That means that every APC who goes into a specialty (urology / neurology, etc) is going to have to undergo additional education and experience. On-the-job training may work in the world of urology and neurology, but it really doesn't work in the ED. I know some groups that have very formalized training for APCs in the ED and as they advance they are given more responsibility, but some groups are not nearly as committed to on-boarding their APCs. When an emergency physician completes their residency we can be assured that they have competence in a core number of skills to work in an ED. Does years of experience help make a better EP -- it just can't help do this. So I think this is the fundamental difference. A 3-4 year EM residency is plenty of time for most motivated physicians to become at least a good EP. The APCs who come to work in the ED, excluding those who have had substantial prior EM experience, have an uphill battle to assimilate all the essential training and experiece needed to comfortqably work in an ED. That's one of the reasons I keep harping on the idea of the APC truly "assisting" the EP. The EP sees everybody, even if less than a minute depending on the problem and EPs stay away from the EHR and CPOE. Get them away from it. They can dictate medical decision making on the more complex cases. Don't assign the APC to see the more minor cases alone unless the EP feels very, very confident in the skill level of the APC (and they don't have time to do the "meet and greet" of every patient. The patients deserve to see a doctor, the average bill on a minor visit in one study was $1,600, the patients may have waited too long. The EP should see all these patients. The goal for EPs should not be to make $450,000 a year but rather to enjoy their work, enjoy their lives, not get burned out and have a career as long as they want it to be -- and not be forced out of EM prematurely..

Dave T. -

Richard, You are 100% correct the that base training of all PAs and NPs (at least FNPs) is primary care or family practice. Really the model for PA education developed by Dr Stead was based on WWII accelerated physician education.

The key as you mention above is the post graduate training. I am very lucky that I am attending a 18month EMPA program that is aligned with a EM residency. While these are not something that should be required they are something that should place PAs and NPs in a different bucket. Before starting this program I was a GP PA in a rural area of TN and KY. In that area ED are very short staffed and pull FP docs for their service. While amazingly trained a FP is not a EP, but they act in this position in a rural area. I advocate the same for post graduate trained PAs in EM. Some of the programs are better than others, but as mentioned above the same can be said for residencies.

I am not at all asking for autonomy, and I don’t believe the majority of PAs are either. I just ask that I, and those with similar training, see patients and make decisions commensurate with the training we have received, and be respected for the knowledge and experience we have gained in post graduate programs.

W. Richard B. -

Once again - 100% in agreement.l. You were fortunate and had the opportunity to take substantial additional training in EM -- unfortunate, PAs who have this additional training are few and far between. So, for most EPs, they have to deal with the variability in skill sets that APCs bring with them. I fully agree that mutual respect is going to be essential if the EM team is going to operate efficiently and smoothly. I agree -- most PAs I talk with are not interested in independent practice -- they just want to work as part of the EM team. Seems fine to me.

Jonathan G. -

You know the saying "divide and conquer"? It's happening with us. I'm not going to comment on the APP thing because plenty has been said. But. Why don't both sides redirect our anger at the CMGs that have ruined our field and continue to do so. They're contributing to many problems, I'd argue including the sad Work Force outlook since they are very likely a good driver behind the opening of many of these new private residencies. I unfortunately don't have any obvious solutions to get CMGs out of emergency medicine, but I feel that if we emergency physicians and APCs can find a way to work together and focus our energy on getting them out and running our own show, we can improve our field. Just my quick two cents

W. Richard B. -

No beating around the bush with regard to where you stand. To be honest, the tension between the EPs and APCs to my mind is very variable. I think in the vast majority of places the two groups work together well and have a cordia

Seems pretty clear where you stand on the CMG issues in EM, Regarding the tension between EPs and APCs, I think most of the EDs have positive relationships between their EPs and APCs. Most of the griping is coming from a vocal minority who may have legitimate concerns, but EPs in most EDs value having their jobs (especially in light of the ACEP WorkForce study), and although no situation is perfect, they want to have strong working relationships with their APCs colleagues. So while the leaders of the professional societies are writing aggressive treaties staking out their territory in EM, I think, on the rank and file level, both groups have largely learned to work together. The CMGs are another story -- remember there are CMGs of all sizes and configurations. Vituity and USACS will tell you that they are not owned by Wall Street and that they take care of their clinician-partners. The CMGs that are owned by Wall Street have one fundamental loyalty -- to their investors. That's not to say that all CMGs don't want to make serious money. The difference may be the aggressiveness by which money is sought and who it goes to. Here's another thing to consider -- who got the money when CMGs bought the ER contracts from EP groups?

Many times millions of dollars went to a small core of senior partners. When this happens the remaining physicians in the group wind up paying for the sale -- the CMG has to get its money back somehow and the only way is thru raising prices, stop contracting with insurance companies and lowering wages or bring on APCs where there were none before. With regard to CMGs starting residencies, they can't -- it's the hospitals that petition CMS to start a residency, and when they do it's not just about EM. It is a hospital strategy that will result in multiple residencies being started within 5 years -- and it just so happens that an EM residency is one of the easiest to start since an ED already exists. Did the CMGs encourage the hospitals to start EM residencies -- probably in some cases. Did they agree to help underwrite the programs -- probably. Will residencies benefit the CMGs -- most definitely. So CMG groups -- all have had the opportunity to sin -- small CMGs, democratic CMGs, CMGs owned by Wall Street. Sure, some CMGs are more likely to have taken advantage of clinicians, but it's not limited to one variety. Wall Street paid serious money to EPs at the top of their groups. Nobody twisted anybody's arm. EPs welcomed Wall Street's money. Was it equitably distributed to all the clinicians in the group? You know the answer. There's plenty of finger-pointing to go around.

Jonathan G. -

Great points sir. I appreciate your feedback- I didn't know it was the hospitals behind the start of private residencies. Long story short, I just wish we could take back our specialty without the feeling that these middlemen are taking advantage of us. But, as you said, I do know a few select EPs benefited from this as well.

W. Richard B. -

As the sole contract holder for the ED in which I worked for 25 years, and observing the behavior of others, it was very clear that protecting the contract was the top priority for a contract holder. Right now, except for EDs where the EPs are hospital employees, every ED has a contract that is highly valued. Going back to the era when the majority of contracts were held by democratic groups is just not going to happen. When you say, "remove the middleman" that person may be a layman in a large group run by MBA non-clinicians (Wall Street managed groups) but if also could be a single emergency physician (a beneficent dictator) or a group of senior partners who founded a group -- these folks aren't going to give up their protected status. The only hope is that whoever is controlling a group will do so fairly. Groups like TeamHealth and Envision have over 600 contracts each because they outcompeted other groups vying for the contract or bought the contract. What did they offer hospital administrators that other groups did not? The reality is that many hospital administrators don't want small democratic groups running their ER. Bottom line -- we need to "learn to love the one were with." Laymen running EDs require the input of EPs. Try to influence these physicians if you think there are better ways to run the group. Be involved with your group, take on some projects that directly help the group, get on some hospital committees so that the Medical Staff gets to see the EPs from a different light. Increase your value to the group and at the same time you'll be in more of a position to initiate change. Good luck

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