The appropriate use of APPs should not be determined by economic factors. It should be determined by the needs of our patients. —Sudave D. Mendiratta, MD, FACEP
Explore This Issue
ACEP Now: Vol 40 – No 10 – October 2021
At my urban, academic hospital, we do not hire new graduates, instead requiring two years of higher-level experience in emergency departments before bringing non-physicians on board. We do, however, have a yearlong training program where NPs and PAs work side by side with the rest of our academic team, functioning similar to PGY-1 residents as they gain knowledge and experience with emergency medicine.
The inexperience of new graduates of NP and PA programs is one reason ours and other physician groups, such as USACS, offer training programs for APPs. Dr. Pines explained the USACS model during the roundtable: “We do have a standardized program for APPs where they get onboarding, local mentorship, chart reviews.” Dr. Pines described the curious situation where the utilization of clinical management tools was actually followed with greater devotion by APPs than physicians. “The doctors will know the rule and see the rule and then come up with a reason why they’re going to deviate from the rule,” he said. But physicians are well-equipped for deviation from protocols, with medical decision-making skills honed by a minimum of two to three years of additional training before they can enter independent practice.
Residency Training
Our panel then moved the discussion from APPs to the plight of emergency medicine residents, who have seen, over the past two years, contracts offered and revoked and a job landscape that has gone from feast to famine (read more on the current job market). “They compete for a spot, they get a spot, and then they come out, and if we’re having an oversupply and they can’t find a job anywhere close to where they want to be, that is problematic,” said Dr. Mullen of the current hiring crisis facing emergency medicine residents graduating in the middle of a pandemic.
However, the consensus from the group was that the market for emergency medicine residency programs would sort itself out over time, either by fewer medical students entering a profession that has been rapidly becoming more competitive or by additional residency programs coming online. Those projections did not seem reassuring to my mentee when I informed her of the potential situation in the next two years when she would be submitting applications to the Electronic Residency Application Service.
The conversation of the roundtable quickly focused on a more pressing concern: the pipeline of emergency physicians available to practice in rural environments.
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One Response to “Emergency Physicians Explore the Future of the Emergency Medicine Workforce”
October 27, 2021
Concerned ED DocWhile I appreciate the time and effort some of these doctors have put into conversing with the editor, I feel like they are quite out of touch from our major concerns.
NPs and PAs are in not “advanced practice.” They’re mid-level practice at best. Yes it would be great to use them in a team setting but in reality in most EDs around this country the volume and staffing doesnt permit the ED physician from in-time reviewing what they see and do. This leads to the façade of a team dynamic and physician led ED while in reality it just puts our licenses at risk.
The newer EM grads, especially those in the past 1-5 years of residency (not to mention those currently in residency) didn’t get into emergency medicine to do telemedicine. We became EM physicians because we appreciated the complexity, randomness, and high pace (at times) of emergency medicine. We wanted to do procedures while also being able to take care whatever came through the doors.
Yes, I agree we need to recruit and make wanting to work in a rural environment a priority but thats not going to solve the 9,000 additional grad problem in 9 years.
Do something to stop the proliferation of profit driven (ex: HCA) EM residency programs. Stop promoting the usage of NPs and PAs in place of physicians. Create standards that require staffing requirements and in-time supervision of patients with mid-levels. Promote transparency in billing practices in our names. Stop the “full practice authority” that has proliferated the NPs and created a false sense of equivalency with physicians.