Hospital Replaces All EM Docs w/NPs & PAs

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futuredoc15

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Bob Donaldson is clinical director of emergency medicine and president of the medical staff at Ellenville Regional Hospital in New York. His current projects sound much like any medical staff president's goals.What might surprise you is that Donaldson is not a physician but a nurse practitioner"I passed muster, if you will, as the first non-physician, full-time, sole provider here as an NP working in the ER alongside the docs," he says. "It was so successful that we ultimately eliminated all the docs here and replaced them all with nurse practitioners or physician assistants."More here: http://www.healthleadersmedia.com/c...oner-Elected-Medical-Staff-PresidentQuestion: Could this type of thing spread nationwide?
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Pop. 4100. This type of thing is not new in rural settings. And no, it won't spread to larger or urban communities that have access to M.D.s.
 
Wow, you can barely read the ads with all the article in the way on that site.
 
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I wouldn't be surprised for a second if the CEO at my hospital did this. Not for a second. All CEOs care about is money and good press. Period. It's a matter of time before the crush of ObamaCare-less brings this to an ED near you.
 
this is actually not that uncommon in rural areas. pa's have been staffing rural er's solo for decades. waseca hospital, part of the mayo system, is the e.d. with the highest press-ganey scores in the country. it is 100% pa run 24/7:
http://www.startribune.com/lifestyl...KArks7PYDiaK7DUoaK7D_V_eDc87DUiD3aPc:_Yyc:aUU
I know several folks who work here and at similar facilities in maine, vt, new hampshire, etc
most of these facilities see fewer than 15k/yr and have fp or em docs on backup call 20 min away. they also use telemedicine for cva's, etc with larger regional ctrs.
they are not replacing em trained and boarded em docs, they are replacing fp docs. most of their more serious pts they stabilize and ship as these places don't have traunma surg, cath lab, stroke teams, etc
 
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So this NP gets this position via the support of physicians, and then replaces all of the physicians with midlevel providers? Wake up people, it's the weak MDs/DOs that allow this type of thing to happen...unless physicians don't start to stand up for themselves EM could go the way of anesthesia. What's sad is that in the end it's the patients that suffer (no Mary Mundinger, an NP is not equal to an MD ;) )
 
AzEMMD said:
So this NP gets this position via the support of physicians, and then replaces all of the physicians with midlevel providers? Wake up people, it's the weak MDs/DOs that allow this type of thing to happen...unless physicians don't start to stand up for themselves EM could go the way of anesthesia. What's sad is that in the end it's the patients that suffer (no Mary Mundinger, an NP is not equal to an MD ;) )
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I can't disagree with this post, however, I find it interesting that anesthesia is considered left-for-dead. The average anesthesiologist still makes >$130,00 more per year than the average ED physician (2010 MGMA survey). Not $130,000 per year, $130,000 per year more than the average ER physician. If I hear one more anesthesiologist whining and crying about how their specialty has been ruined by CRNAs, I'm going to lose it. I wish CRNAs would come and ruin Emergency Medicine so I can get a $130,000 per year raise. Any volunteers?
 
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Birdstrike said:
I can't disagree with this post, however, I find it interesting that anesthesia is considered left-for-dead. The average anesthesiologist still makes >$130,00 more per year than the average ED physician (2010 MGMA survey). Not $130,000 per year, $130,000 per year more than the average ER physician. If I hear one more anesthesiologist whining and crying about how their specialty has been ruined by CRNAs, I'm going to lose it. I wish CRNAs would come and ruin Emergency Medicine so I can get a $130,000 per year raise. Any volunteers?
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You realize that the reason CRNAs are a threat is because anesthesiologists are greedy and realized they could "bill for supervision" thus opening the door. They wererent happy making 300k, somebody offered them 400k if they "supervised" CRNAs and they jumped at it.

How many midlevels do you "supervise" doc? Your falling into the same trap.
 
Socrates25 said:
How many midlevels do you "supervise" doc? Your falling into the same trap.
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My point was not that anesthesiologist didn't make an error with the CRNA situation, they did. My point was that after all the panic of CRNAs "ruining" their specialty, they still have a specialty where they make >$130,000 more than ER doctors. Emergency Medicine has already been decimated, with the government requiring us to see everyone without requiring the "customers" to pay. For us it's more about survival, literally not having the manpower to cover the shifts and see the the patients that come to us. However, will bringing PAs and NPs into the ED lead to our salaries being undercut by hospital CEOs? Absolutely. I implied that above. Read the whole thread.

As to your statement "you're falling into the same trap": no, I'm escaping from the trap. Very soon, I'll be leaving the specialty completely. I've paid my dues.
 
Birdstrike said:
My point was not that anesthesiologist didn't make an error with the CRNA situation, they did. My point was that after all the panic of CRNAs "ruining" their specialty, they still have a specialty where they make >$130,000 more than ER doctors. Emergency Medicine has already been decimated, with the government requiring us to see everyone without requiring the "customers" to pay. For us it's more about survival, literally not having the manpower to cover the shifts and see the the patients that come to us. However, will bringing PAs and NPs into the ED lead to our salaries being undercut by hospital CEOs? Absolutely. I implied that above. Read the whole thread.

As to your statement "you're falling into the same trap": no, I'm escaping from the trap. Very soon, I'll be leaving the specialty completely. I've paid my dues.
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I can only speak for FL but the trend is new grad EM docs are making more than anesthesia. this is for full/part time only. I haven't gotten all the bids for locums yet so I don't have those comparisons. I can only assume there's so many gas passers out here the market is drying up....at least this is what we're noticing. why hire 1 MD to run 1 room when you can hire 1 MD to supervise 4 CRNA's to run 4 rooms then bill for all 4. no brainer.
 
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So what can an EP due given the resources of a rural hospital that a PA or DNP cannot? Seems more along the lines of not wasting and EPs time in an ambulance than a form of turf encroachment...
 
So the EP would likely be better able to decide those that do need transfer quickly, and those that don't need it at all. If you're saying all you need is someone there to decide to call for an ambulance, then you just need a call bell next to a helipad and let the patients call for themselves.
 
Dr.McNinja said:
So the EP would likely be better able to decide those that do need transfer quickly, and those that don't need it at all. If you're saying all you need is someone there to decide to call for an ambulance, then you just need a call bell next to a helipad and let the patients call for themselves.
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Kind of like the Dilaudid machine I've invented. We just put it in the waiting room, and it will dispense a pain shot for $5. Saves them wasting their time in the ER and me arguing with them.
 
Dr.McNinja said:
So the EP would likely be better able to decide those that do need transfer quickly, and those that don't need it at all. If you're saying all you need is someone there to decide to call for an ambulance, then you just need a call bell next to a helipad and let the patients call for themselves.
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I'm saying that as you go up through the different levels of providers, you start requiring higher levels of resources to justify the expense. You don't fill ambulances with EPs so they can better tell who needs to actually go to the ED. That would be a ridiculous waste of valuable and limited resources.

How many unnecessary ambulance or helicopter transports are needed before you lose money compared to just paying for full-time EP coverage? How much of an increase in morbidity and mortality are you going to see from a physician being on-call 20 minutes away rather than sitting in the ED?

All I'm saying is that I rarely, if ever, see people address the where, when, and why of allocating the recourses invested in a physician. The public and lawmakers don't care about how many years we went to school, but that seems to be the focus the entire physicians side of the mid-level debate...
 
I dearly love my PA/NP colleagues and friends, but the water on the great beach of emergency medicine quickly starts getting deep as you start to walk down off the dunes when it comes to high risk patients (chest pain, pregnant abdominal pain, etc). All it will take is one high dollar case (missed MI, failure to thrombolyse, etc) to persuade their malpractice carrier to move on to greener pastures.

Keep in mind that anesthesia is a very different case. By and large, their high risk, complex cases (open hearts, etc) and expected difficult airways are staffed by docs. The CRNAs run rooms with low risk cases. Routine general anesthesia is so safe (adverse event rates in the 1 in tens to hundreds of thousands of cases range) with modern anesthesia circuits and oxygen saturation/ETCO2 monitoring (i.e. no more waking up brain dead after the scrub tech accidentally disconnects the O2 line) that talk a number of years ago about having an adequately powered study to detect the difference between MD and CRNA care would have required an n of 50-100 million patients.

In emergency medicine, once you're out of urgent care, we are talking about a rather heterogeneous and high risk population of folks who present to the average ED. For this reason, both of the hospitals I work at require real-time attending staffing by PA/NPs who see non-urgent care acuity patients.
 
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DeadCactus said:
I'm saying that as you go up through the different levels of providers, you start requiring higher levels of resources to justify the expense. You don't fill ambulances with EPs so they can better tell who needs to actually go to the ED. That would be a ridiculous waste of valuable and limited resources.

How many unnecessary ambulance or helicopter transports are needed before you lose money compared to just paying for full-time EP coverage? How much of an increase in morbidity and mortality are you going to see from a physician being on-call 20 minutes away rather than sitting in the ED?

All I'm saying is that I rarely, if ever, see people address the where, when, and why of allocating the recourses invested in a physician. The public and lawmakers don't care about how many years we went to school, but that seems to be the focus the entire physicians side of the mid-level debate...
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Interesting point. Should we put an EP on an ambulance to head off unnecessary ED visits and ambulance transports? How many transports/visits would it take to justify an EP? It might work out.

It would never happen because the incentives in medicine are all fouled up on every level but in a perfect world it would save resources.

The reason it would never work is that you'd have to establish a coalition of insurers including CMS and have them pay the doc to save them money. Hospitals and EMS agencies want insured people to call and visit unnecessarily as that's what makes them the most money.
 
docB said:
Interesting point. Should we put an EP on an ambulance to head off unnecessary ED visits and ambulance transports? How many transports/visits would it take to justify an EP? It might work out.

It would never happen because the incentives in medicine are all fouled up on every level but in a perfect world it would save resources.

The reason it would never work is that you'd have to establish a coalition of insurers including CMS and have them pay the doc to save them money. Hospitals and EMS agencies want insured people to call and visit unnecessarily as that's what makes them the most money.
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very true, some of the english EMS have PA's on their trucks to head off unnecessary problems. not sure if that'll work here but it's an interesting concept
 
MSmentor018 said:
very true, some of the english EMS have PA's on their trucks to head off unnecessary problems. not sure if that'll work here but it's an interesting concept
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Seems like it would save money but it would probably require a single payer system to make it actually work.
 
WilcoWorld said:
Irrelevant - the rig couldn't get to her because of all the paparazzi.
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http://news.bbc.co.uk/2/hi/uk_news/6217366.stm

0026: First call to the authorities. Emergency doctor Frédéric Mailliez is driving by when he sees the crashed Mercedes. He is the first doctor on the scene and calls for help.

0028 - 0030: First two police officers arrive. They have difficulty cordoning off the accident from gathering paparazzi.

0032: Fire engine and ambulance arrive. Eight paparazzi are arrested at the accident scene and taken in for questioning.

0125: After nearly an hour, Princess Diana's ambulance leaves for hospital. She has already suffered a cardiac arrest.

---

6 min arrival time for fire and EMS. 59 minute on-scene time. no need for prolonged/technical extrication evident.
 
So there was an hour between the accident and when the ambulance left. It's unclear from the timeline posted how much of that hour was taken up trying to get past the press to Princess Di. While I may have been wrong in my earlier claim, she transected her pulmonary vein. Unless she was already in an OR with bypass ready at the time of the accident she wasn't going to survive.

So it's still irrelevant.

I'm not arguing for having docs on rigs (I don't have enough data to come down on either side), but I think your example does not illuminate the question.
 
WilcoWorld said:
So there was an hour between the accident and when the ambulance left. It's unclear from the timeline posted how much of that hour was taken up trying to get past the press to Princess Di.
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All of the paparazzi were arrested in suspicion of causing the accident, so I doubt it took an hour to arrest them and place them in custody. The timeline certainly would have mentioned if access to the patient because of the paparazzi was an issue. To date, no paparazzi have been accused or convicted of this. There was an investigation of whether the paparazzi caused the accident or failed to render assistance. No conviction.

WilcoWorld said:
While I may have been wrong in my earlier claim, she transected her pulmonary vein. Unless she was already in an OR with bypass ready at the time of the accident she wasn't going to survive.

So it's still irrelevant.
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The six minute call to arrival time is what I wanted to point out. Had nothing to do with paparazzi. That is all.
 
tkim said:
All of the paparazzi were arrested in suspicion of causing the accident, so I doubt it took an hour to arrest them and place them in custody. The timeline certainly would have mentioned if access to the patient because of the paparazzi was an issue. To date, no paparazzi have been accused or convicted of this. There was an investigation of whether the paparazzi caused the accident or failed to render assistance. No conviction.



The six minute call to arrival time is what I wanted to point out. Had nothing to do with paparazzi. That is all.
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Yep -- fatal case of car-pole tunnel syndrome if I've ever seen one....
 
OK - so we all agree that mortality in this case does not reflect on the efficacy of having docs on the rigs. Let's get back to the NP vs MD discussion.
 
WilcoWorld said:
OK - so we all agree that mortality in this case does not reflect on the efficacy of having docs on the rigs. Let's get back to the NP vs MD discussion.
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A post-mortem analysis does not support your point. Trauma + doc on scene in France + 78 minutes on-scene = dead patient. I think your "we all agree" point is assuming facts not in evidence. I shall go with my erstwhile colleague with "undetermined". Likewise undetermined is your strident belief that there was no fault in 1997 in France, including a heretofore not posited point that throngs of paparazzi so swarmed, and were stolid, that EMS (les pompiers-sapeurs (BSPP - Paris Fire Deparment) et SMUR - Service Mobile d'Urgence et Reanimation - which always rolls with a doctor) was restricted for unreasonable amounts of time in accessing the patients.

Diana, Princess of Wales, suffered a traumatic out-of-hospital cardiac arrest, from which she was reportedly resuscitated. From this point, it was more than an hour until she arrived at a hospital >5km away, with approximately 15 hospitals closer (and it took 25 minutes to get to a hospital that should have taken 16, especially at 2am). When she got to Pitié-Salpêtrière Hospital, her chest was cracked, and that is when she was found to have a pulmonary vascular disruption and a cardiac tamponade.

In the US or UK, 0023 hours, multiple fatals - in a city, to a trauma center, survivors likely in the ED by 0050.

Thid altogether too-long recapitulation is solely to say that, no, we do not all agree.
 
I just want to be sure here. Apollyon and tkim are arguing that the death of Princess Di, who had out-of-hospital-cardiac-arrest after blunt traumatic injury reflects on the efficacy of staffing ambulances with docs?

My initial contention that the paparazzi prevented access appears to be erroneous - I retract it. However, I don't think using blunt-traumatic-cardiac-arrest cases is a good way to grade EMS systems, because they will all do very, very poorly.
 
WilcoWorld said:
I just want to be sure here. Apollyon and tkim are arguing that the death of Princess Di, who had out-of-hospital-cardiac-arrest after blunt traumatic injury reflects on the efficacy of staffing ambulances with docs?

My initial contention that the paparazzi prevented access appears to be erroneous - I retract it. However, I don't think using blunt-traumatic-cardiac-arrest cases is a good way to grade EMS systems, because they will all do very, very poorly.
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Undetermined. Not black-letter. See the 2nd and 3rd posts before yours. Undetermined. In the yes/maybe/no world, this is maybe.
 
If I was a lawyer I would open an office across the street...
 
Pons Asinorum said:
What did you put in the search box to dredge this bad boy up?
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Key search-words:

...."bored"..."random necrobump ideas"...."top 10 EM doom gloom threads"..."Is the sky falling, God?"...."best places to set up ambulance chasing outpost"..."how best to ignite troll-tastic PA/MD flame war"....
 
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PAs will very well replaced ED docs in rural areas. You just can't find any docs less Boarded ED docs to work in Rural areas. These rural areas will be left mostly for PA/NP/FP docs.

As for income, I am sure Gas makes more than ED docs in general. I think the trend is changing and definitely in texas. Its all about supply and demand. The more FSEDs open up, the less avail Boarded ED docs will be avail. Each FSED that opens up, you need about 6 ED docs to run it. Thats 6 new openings in the hospitals and where are you going to find 6 boarded ED doc? That is why ED docs are getting such high contracts/Locums rates in Texas. The amount of money I could make doing Locums is obscene right now.

I am sitting right now staffing an ED in one of the big texas cities at $600+/hr for this shift. This obviously is not my contracted rate but they are desperate and HAVE to staff busy EDs with Boarded docs.

I have a good anesthesia friend and our kids go to the same private school. He complains how expensive the school is. Sure its expensive, but when I can pay for 1 yr after working 2 shifts, it doesn't seem so expensive.
 
emergentmd said:
PAs will very well replaced ED docs in rural areas. You just can't find any docs less Boarded ED docs to work in Rural areas. These rural areas will be left mostly for PA/NP/FP docs.

As for income, I am sure Gas makes more than ED docs in general. I think the trend is changing and definitely in texas. Its all about supply and demand. The more FSEDs open up, the less avail Boarded ED docs will be avail. Each FSED that opens up, you need about 6 ED docs to run it. Thats 6 new openings in the hospitals and where are you going to find 6 boarded ED doc? That is why ED docs are getting such high contracts/Locums rates in Texas. The amount of money I could make doing Locums is obscene right now.

I am sitting right now staffing an ED in one of the big texas cities at $600+/hr for this shift. This obviously is not my contracted rate but they are desperate and HAVE to staff busy EDs with Boarded docs.

I have a good anesthesia friend and our kids go to the same private school. He complains how expensive the school is. Sure its expensive, but when I can pay for 1 yr after working 2 shifts, it doesn't seem so expensive.
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Wow amazing. You guys make 5x per hour rates vs anesthesiologists..
 
WilcoWorld said:
Don't make the mistake of using a peak hourly rate to calculate an annual salary.
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Yes. Or regional and micro-regional differences such as underserved pockets in a state already with an overall higher average wage. Averages are what they are for a reason.
 
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