Defending our "Turf"?

[Groove]

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I posted this in the CC thread but didn't want to hijack it so I thought I would post it here... Wanted to get some thoughts.

Here's a question for you guys related to a discussion I had with someone other night...

The current situation/solution in some states is telemergency coverage in rural ED's that no EM boarded doc wants to go work in. Essentially, you have a NP running the ED and decides which pt's he wants or needs your input on. You are consulted remotely and provide assistance and management. There are protocols in place that mandate some things MUST be called but much wiggle room.

The reality is that there are too many ED's and not enough EM boarded docs, so does ACEP have to provide a blanket statement or policy supporting or promoting alternatives to staffing ED's that cannot retain EM boarded docs?

Is officially supporting telemergency to a rural ED run by a NP, "better or worse?" than a PCP with a year fellowship in ER or an internist with prior ED experience?

My argument was that I'm against any encroachment of any kind on our specialty. Telemergency does nothing to assuage my fears because all that does is give a false semblance of "control" over a remote ED, when in fact, all it seems to be doing is empowering mid-level providers to staff ED's "alone".

To be perfectly honest, I would rather a physician (FP vs IM vs Surgeon) staff a remote rural ED than a mid-level practitioner. I consider the threat from mid-levels to be undeniable across almost every specialty.

So, back to my question... Does ACEP really HAVE to provide a solution to these types of scenarios? There is political pressure to our specialty organizations to provide solutions to difficult scenarios since we claim that only board certified EM docs are capable of running ED's "properly" for best pt safety. State's like Florida for instance... don't need a solution. That's enough of a desirable state that most of the ED's strongly require EM BE/BC physicians. However, take some of the southern states... quite the opposite. They struggle to attract anyone, so are we required to provide and even endorse a solution that would include an ED "not staffed" by an EM BC/BE physician?

The person I was arguing with about this felt that the threat from primary care specialists was too great, and that supporting NP's via teleconferencing and related endeavors would be vastly preferable.

My take is that both situations are equally threatening and I don't feel that the EM organizations as a whole actually HAVE to provide solutions to every one of these scenarios. I think once you make a blanket statement of support, it's a very slippery slope from then on.

My take is that I think these ED/Hospitals should work it out as best they can, as they have been for this long which usually includes staffing the ED with PCP's with prior experience. We can still claim that ED's are best run by EM BC/BE docs. If the place becomes more desirable and more EM docs are boarded, then the situation solves itself down the road.

What do you guys think? I just think supporting any situation where an EM BC/BE doc is not running the ED just undermines our specialty, in virtually any situation and I feel no need at a political organizational level to provide discrete and definitive solutions for some of these situations where so many variables are involved at the financial,state,hospital,city level...

 

[Birdstrike]

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[Pudortu]

I'd definitely support any MD/DO over an NP. Come on, you saw what they did to Anesthesia. All it takes is that first foothold and then the NPs can start bragging "oh look, even ACEP supports us running rural EDs" and all their half-truths.

 

[docB]

Interesting question. Fortunately ACEP does not have to really solve anything because they do staff EDs. They have the luxury of making a principled stand without having to be responsible for the logistics. Consequently they can, and most likely will, continue to take the stance that all EDs should be run by BC EPs and that since there is a shortage we should continue to create more residency spots for the future.

So I don't think they would ever "support" either non-BC EPs or MLP run EDs.

The difference is that if a big staffing company were to suddenly take such a stand they would have to face the reality of not having coverage for a lot of shifts tomorrow.

I'm interested in your comment about Florida not having an ED staffing problem. It is a desirable place for many. But why did the ABPS thing take hold there if they don't have a problem?

 

[deleted6669]

The acep position is to support pa's over np's. I spoke with the president of emra about this and similar topics at acep in s.f. in october and have also spoken with past presidents of acep regarding the same topic. acep currently manages and supports the society of emergency medicine pa's of which I am a member. the advantage of using an em pa over an untrained fp is that 100% of the care will be reviewed by board certified em physicians and em pa's continually train in em with em physicians. the supervising physicians can require any certifications(atls, etc) and practice arrangement they feel is in the best interests of the pt such as mandatory consults for certain pts, abnl presentations, etc. There is a new "certificate of added qualifications" exam for pa's administered by our national certifying body which was written in part by em boarded docs and requires a min of 18 months of supervised experience and physician attestation of skills for eligibility. the exam was challenging (I passed). http://www.nccpa.net/Emergencymedicine.aspx
from the exam prep page: "NCCPA's specialty CAQ process is predicated on a strong belief in the value and importance of the Physician-PA team, and in support of the procedures and patient case requirement, each applicant must provide attestation from a supervising physician who works in the specialty and is familiar with the PA's practice and experience."
there are many pa staffed/em md supervised rural facilities out there, most on the east coast at this point. the best scenario obviously is a residency trained/boarded em doc but when that isn't possible the next best option is an em pa with em md supervision.
pa's work with and for physicians with their supervision while np's are loose cannons.

 

[bougiecric]

Been meaning to get this off my chest for awhile, seems it's appropriate enough here. Where I work:

• Midlevels staff nearly all patients, including the critically ill.
• Many attendings teach and have midlevels doing our most advanced procedures. This includes intubating, central lines, chest tubes. And at times, midlevels do these procedures even when an EM resident is available.
• There is currently a lively discussion in the ACEP US section mailing list on how to get midlevels credentialed in bedside US. Where I work, many of the younger midlevels are doing US and making clinical decisions based off of them. It's particularly ironic given that the majority of older attendings don't know how to do US at all. It appears very bad when the attendings are staunchly against learning US, and the fresh PA grads are adapting quickly and hungrily picking up US.

Am I going crazy here? I'm very hesitant to say anything within my institution because the culture seems so pro-midlevel. Based on what I see other attendings doing, and the US mailing list, it seems everyone is super gungho to train midlevels to be advanced as possible.

Don't get me wrong -- I very much appreciate the midlevels and work closely with them. I'd reckon that they'd say they equally enjoy working with me.

I don't know the answer, but I can't help but wonder why I did 4 years of medical school and 3 years of residency, when there are (no exaggeration) 25 year old PAs being encouraged to do everything I do.

Edit: This is in a major urban location. Not rural.

 

[la gringa]

most advanced procedures. This includes intubating, central lines, chest tubes. And at times, midlevels do these procedures even when an EM resident is available.

that's INSANE in an ED w/ a residency... where i trained, those ALL belonged to residents, w/o exception. even LP's were almost always done by residents... heck, any loggable procedure was done by a resident - joint reduction, sedation, etc.

in community practice, i've worked with exactly 1 PA who was capable of any advanced procedures - she'd been an anesthesiologist in another country prior to coming here and going to PA school. i'd let her do LP's and heck, once one of the other docs had her try at a tough tube when anesthesia was being poky about coming down.

i am ALL FOR (well trained, experienced!) PA's in the right setting... but in a setting where EM docs are readily available, the MD should take care of MD level stuff. period. i can't STAND having to micromanage the PA's sick patient... especially if i'm gonna not get the same "credit" (RVU's, etc) as if i had just seen the pt myself, but do just as much work, if not more.

i also find that consultants DO NOT want to talk to the PA... again, i end up "supervising" to the point of having to do anything that requires work. i was 1/2 the age of some of my PA's and NP's at my prior job, but the consultants wouldn't do anything that wasn't a slam dunk unless i got involved.... very frustrating.

 

[deleted6669]

i am ALL FOR (well trained, experienced!) PA's in the right setting...
i also find that consultants DO NOT want to talk to the PA... the consultants wouldn't do anything that wasn't a slam dunk unless i got involved.... very frustrating.

thanks for your support of pa's. if you staff a pt you should get at least partial credit. where I work the docs get 50% of my rvu's just to cosign the chart, more if they actually see the pt or do a procedure.
consultants preferences are really institution dependent. I've worked in some places where they refuse to talk to a pa and others where they have no issue with it. the ones who refuse to talk to us seem to be a dying breed of cranky old internists. I got a lot more of that attitude 10 yrs ago than I do now.

 

[Groove]

Interesting question. Fortunately ACEP does not have to really solve anything because they do staff EDs. They have the luxury of making a principled stand without having to be responsible for the logistics. Consequently they can, and most likely will, continue to take the stance that all EDs should be run by BC EPs and that since there is a shortage we should continue to create more residency spots for the future.

So I don't think they would ever "support" either non-BC EPs or MLP run EDs.

The difference is that if a big staffing company were to suddenly take such a stand they would have to face the reality of not having coverage for a lot of shifts tomorrow.

I'm interested in your comment about Florida not having an ED staffing problem. It is a desirable place for many. But why did the ABPS thing take hold there if they don't have a problem?

I'm not sure I can answer that. I don't have any direct insight into how many ABPS EM certified FP's are working in Florida or not, but after speaking with a few IM/FP docs with minimal ED experience and no official training who happen to work in another "relatively" undesirable state where I'm moonlighting. They said that it was almost impossible to find a location in Florida to work the ED. The insinuated that the state as a whole, and desirable ED's largely wanted BC/BE EM physicians for their EDs. They were forced to move to a "undesirable" location to find ED work, in hopes that they can gain enough experience to move back to Florida.

Looking at some of the job searches in Florida seems to reflect this. It's a stark contrast to my state where people, in general, do not want to move unless they are from around this area. This has resulted in many EDs being staffed by non EM boarded physicians, NP's via teleconferencing, PCPs, and residents. The salaries are outrageous also. Supply and demand. Some of you would not even believe some of the salary offers that our grads are getting by staying in the area.

Virtually all of our grads last year who stayed in this area got jobs making well over 400+K and some with sign on's of 80K. One of our guys who will be graduating this year will make almost 500K his first year including his sign on bonus, working 14, 12 hours shifts a month. I can't seem to find stuff like that anywhere else.

 

[Groove]

Been meaning to get this off my chest for awhile, seems it's appropriate enough here. Where I work:

• Midlevels staff nearly all patients, including the critically ill.
• Many attendings teach and have midlevels doing our most advanced procedures. This includes intubating, central lines, chest tubes. And at times, midlevels do these procedures even when an EM resident is available.
• There is currently a lively discussion in the ACEP US section mailing list on how to get midlevels credentialed in bedside US. Where I work, many of the younger midlevels are doing US and making clinical decisions based off of them. It's particularly ironic given that the majority of older attendings don't know how to do US at all. It appears very bad when the attendings are staunchly against learning US, and the fresh PA grads are adapting quickly and hungrily picking up US.

Am I going crazy here? I'm very hesitant to say anything within my institution because the culture seems so pro-midlevel. Based on what I see other attendings doing, and the US mailing list, it seems everyone is super gungho to train midlevels to be advanced as possible.

Don't get me wrong -- I very much appreciate the midlevels and work closely with them. I'd reckon that they'd say they equally enjoy working with me.

I don't know the answer, but I can't help but wonder why I did 4 years of medical school and 3 years of residency, when there are (no exaggeration) 25 year old PAs being encouraged to do everything I do.

Edit: This is in a major urban location. Not rural.

I would say you work in a very unorthodox academic ED environment. I'm personally...kind of horrified that mid-levels are so empowered in your institution and can't help but feel bad for the residents.

This is the kind of thing I'm talking about. Are we getting side-tracked as a political organization by focusing on our stances against ABPS certified FP docs where the real threat to me seem to be the mid-levels that we seem joined to the hip and continue to train beyond what their scope of practice should be.

The reality is that EDs are growing larger, and people treat the ED like a clinic. This brings in an enormous amount of patients that none of us who have had formal training in EM enjoy seeing. I personally don't want to see a girl who simply came in to get a pregnancy test, nor do I want to see every sprained ankle and kid/adult with a benign URI. Most of these patients end up in a fast track, staffed by a NP/PA so that we can see the patients that we actually want to see and were trained to manage. (In philosophy anyway...) The larger EDs grow, and the more patients are given incentives to go to the "free emergency 'clinic'" where you will never be turned away and the lights on are 24/7, we'll continue to need MLPs. MLPs, both PA and NP alike have already created "EM fellowship" tracks to provide them extra experience and extra skill sets for use in the ED. Sooner or later, I fear that the same thing that has befallen Anesthesia will befall us too. Sooner or later, all of these MLP's that we thought we had a false sense of control over will start churning out studies supporting independent practice in the ED. You don't think hospital administrators would be interested in staffing an ED with MLPs that were cheaper? It can and it will happen at some point. The problem is that we don't have the luxury like anesthesia of having a multitude of fellowship tracks to differentiate ourselves as thoroughly and pick up additional sub-specialized skillets that MLPs could not gain access to at the moment.

I just can't help but feel it's a ticking time bomb. In our state, to "protect our turf" we have resorted to teleconference remote management of small EDs staffed with NPs that have gone through a training program. It gives a false semblance of control. We can implement algorithms to "make" them call us if X meets Y criteria, but essentially when you step back and look at the big picture, it's supporting an ED environment that's staffed entirely by MLPs. While we have our back turned to the hidden dagger, we have our face turned, as an organization, towards the open dagger of ABPS and any of "physician" specialty that claims they can manage patients in the ED "as good" as EM boarded physicians.

I can't help but feel that the same war that is happening in gas at the moment, will happen to use in the future.

I'm vehemently opposed to teaching PA/NP's advanced skill sets. Period. I value them, and I respect them, but I want them in the fast track seeing the low acuity patients and the rest of the ED staffed with BC/BE EM physicians.

I can't help but feel that physicians and AMA/ACEP/ABEM (don't get me started on 1 and 3) are so focused on "war with each other" that we're ignoring the true threat to medicine as a whole, which is the grossly liberalized empowerment of the nursing organization to "practice medicine". NP's are already taking over primary care. As they take over, they'll control referral services. As MLPs gain continued foothold in the ED, who do you think they will refer to? Call me a Greek "Cassandra", but I see the future of our specialty and medicine as a whole being continually eroded by MLPs while we spar with each other, only to stop and see that we are surrounded and have been fighting the wrong enemies.

Perhaps a gross overgeneralization, but you get the picture.

 

[AzEMMD]

Been meaning to get this off my chest for awhile, seems it's appropriate enough here. Where I work:

• Midlevels staff nearly all patients, including the critically ill.
• Many attendings teach and have midlevels doing our most advanced procedures. This includes intubating, central lines, chest tubes. And at times, midlevels do these procedures even when an EM resident is available.
• There is currently a lively discussion in the ACEP US section mailing list on how to get midlevels credentialed in bedside US. Where I work, many of the younger midlevels are doing US and making clinical decisions based off of them. It's particularly ironic given that the majority of older attendings don't know how to do US at all. It appears very bad when the attendings are staunchly against learning US, and the fresh PA grads are adapting quickly and hungrily picking up US.

Am I going crazy here? I'm very hesitant to say anything within my institution because the culture seems so pro-midlevel. Based on what I see other attendings doing, and the US mailing list, it seems everyone is super gungho to train midlevels to be advanced as possible.

Don't get me wrong -- I very much appreciate the midlevels and work closely with them. I'd reckon that they'd say they equally enjoy working with me.

I don't know the answer, but I can't help but wonder why I did 4 years of medical school and 3 years of residency, when there are (no exaggeration) 25 year old PAs being encouraged to do everything I do.

Edit: This is in a major urban location. Not rural.

I'm a resident at a program that is similar to what you are describing and it can be extremely frustrating. Some of the attendings seem to spend more time teaching/supervising the PAs than the residents. It's frustrating that the midlevels make double what I do when they have less knowledge and require more oversight than me. We've gotten so far off the political correct meter that we now put midlevels/nurses on a pedestal and crap all over ourselves. I as well have wanted to say something about this but I know it would just be met with scorn.