Future of Midlevels in EM and Implications For Attending Workload

[Arcan57]

Dreamingthelive's post in the academic vs. community thread about the supervisory role of academic attendings raised some interesting points when dovetailed with the current discussion regarding the soul of EM. Right now the majority of us work at places with an attending/midlevel ratio >1. Anesthesia is frequently cited as a model for future staffing and the ACT model seems to be most commonly 1:4. Given that it's harder for midlevels to make the leap to solo practice in EM due to inability to risk-stratify our patients prior to arrival, what do you think the predominant staffing model will look like in 5 years (or what should it look like)?

Birdstrike has voted for independent practice for midlevels (without possibility of transfering liability) or to have absolute control over the HR aspects of midlevels if they are not independently practicing. While I think he outlines the two medicolegally safest paths for EPs, I don't think either will be common.

I think we are going to start seeing jobs where the ratio is <1, although my thought is that providing anything resembling real supervision to 4 midlevels isn't logistically possible (although I'm sure there will be some CMG jobs that offer higher pay for the risk to your license). I could definitely see stable jobs with a 1:2 or 1:3 ratio where the attending is present to provide that extra 15% for a physician assessment and to provide technical assistance/political cover for the midlevels. In essence, rather than being a fast-track or low-acuity provider the midlevels would be essentially permanent residents.

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[DreamingTheLive]

As I've alluded to before....

NPs, as a cohort, are fighting for COMPLETE autonomy. In my humble opinion, this is neither in the best interest of patients, nor the best interest of Emergency Medicine physicians or the specialty of Emergency Medicine (Caveat: NPs staffing "fast track" ONLY would be possibility).

SIGNIFICANTLY less education. SIGNIFICANTLY less experience. Might as well make EM residency 3 or 4 MONTHS instead of 3 or 4 years.

This would likely dramatically reduce the need for ED physicians in the future and likely decrease pay and satisfaction as well......All for what?

I'm not saying the "Sky is falling" (Hi WhiteCoat), and we're in a diminishing mini-golden age for EM right now, but if we don't enact changes to protect ourselves and our specialty....yup....in 5 or 10 years.....The sequel to the "Rape of Emergency Medicine" will be titled: "SKYFALL"

I hope like hell I'm wrong.

 

[Birdstrike]

Of all the things in EM that would concern me in the future, this midlevel issue concerns me the least. Anesthesiologists have been saying the sky will fall for 25 years after their CRNA-genie was let out of the bottle. As of 2013 MGMA, their mean salary holds at $428,000 and 75th%ile at $508,000. Liability may be a concern, but I personally, am not concern about midlevels negatively affecting salary, or job supply for EPs or physicians in general. If anything, they'll be used to generate productivity, while skimming the profits they generate.

 

[DreamingTheLive]

Disagree. As we've touched on before.

Senior Anesthesia residents I know who are looking for jobs say the market is TOUGH right now. Many are forced to do a fellowship to latch on in certain markets.

Spend some time in the Anesthesia forum and come back and tell me that Mid-Levels are NOT negatively affecting their jobs, now and in the future.

I realize that I'll likely be in the MINORITY on this one (for now, at least)....And that is the saddest part.

 

[TrumpetDoc]

Disagree. As we've touched on before.

Senior Anesthesia residents I know who are looking for jobs say the market is TOUGH right now. Many are forced to do a fellowship to latch on in certain markets.

Spend some time in the Anesthesia forum and come back and tell me that Mid-Levels are NOT negatively affecting their jobs, now and in the future.

I realize that I'll likely be in the MINORITY on this one (for now, at least)....And that is the saddest part.

Heck we have it hard now in "certain markets".
Try getting into San Diego/Utah/etc. (Knowing that WCI's group is doing a rare hire for next year).


Thumb typed from iPhone using Tapatalk

 

[Birdstrike]

Disagree. As we've touched on before.

Senior Anesthesia residents I know who are looking for jobs say the market is TOUGH right now. Many are forced to do a fellowship to latch on in certain markets.

Spend some time in the Anesthesia forum and come back and tell me that Mid-Levels are NOT negatively affecting their jobs, now and in the future.

I realize that I'll likely be in the MINORITY on this one (for now, at least)....And that is the saddest part.

I don't care what the Anesthesia forum says.

I know my MGMA surveys shows the bottom 25th percentile of Anesthesiologists make:

$325,000

50th percentile (mean) makes: $427,000

75th makes: $508,000

90th: $584,000


If a bunch of Gas residents in tight markets are freaking out (like the typical hyper-vigilant doctor personality always will) and feel the need to do fellowships to gain a leg up, and the rest want to doom-and-gloom over those numbers the my response is,

"Okay."

I only hope that in the next 10-25 years I share their problems and their MGMA numbers alike. I personally don't think you can draw any conclusion about the future of Emergency Medicine, because a bunch of senior Anesthesia residents in A-list cities, where there's way too many residencies, way too many doctors, and way too many residents, are all vying for the perfect job and feel distressed. Look at their MGMA numbers. If you find doom-and-gloom there, that applies to EM in some way, then so be it.

I never thought I'd say it, but I think the doom and gloom on this forum, is getting to be a little much even for me ("Gasp!").

 

[DreamingTheLive]

You're right. An MGMA salary survey concerning Anesthesia clearly demonstrates that mid-levels will have no bearing on the future of EM. I don't know how I missed that.

 

[Birdstrike]

You're right. An MGMA salary survey concerning Anesthesia clearly demonstrates that mid-levels will have no bearing on the future of EM. I don't know how I missed that.

You were the one that argued that you can look to anesthesia, to see how mid-level creep affected their job market and apply it to EM. I'm agreeing and saying, "You're right. It will do to EM, just what it did to the Anesthesia job market." And to find out what effect that had, look to MGMA. Even if you factor in the supposed Anesthesiologists who can't find jobs, are unemployed and presumably would factor in with a salary of zero in those surveys, their overall salaries have survived their feared Mid-Level Armageddon pretty well. All I'm saying, is that in my opinion FWIW, EM will make it through increasing mid-level presence just fine, from a salary and job-market standpoint. I'm just not afraid of mid-level competition, like some people are. That's all. I could be wrong.

It's been nice sparring, but it's past Birdstrike's bedtime. Nighty night.

 

[Groove]

My current gig has given me my first real experience with truly competent and exceptional MLPs (NPs and PAs). I have always worked with MLPs that made me nervous and were not comfortable nor competent seeing anything other than 5's and 4's. In my current group, we have some of the best trained NP/PAs that I've ever worked with and I really mean that. I essentially view them as colleagues even though I sign their charts and they come to me for advice on the occasional pt. Their weakness lies in high acuity pt's and also in procedures but this is to be expected. The good ones, I've noticed... have learned to step outside the typical nursing algorithmic mindset and "think" more like a physician. They can easily handle most 3's, many of which are sick and end up getting admitted. Most of them have been doing this for awhile so I don't know whether to attribute it to their training, a wealth of experience, or both. Either way, I don't worry much at all when I'm working with them. We have a few newer ones that are less experienced but they seem to know their limits.

Total independent practice would sig undermine the specialty and I don't see that as the preferred future of EM. You might very well find yourself losing contracts to hospital employed EDs fully staffed by MLPs. Isn't there one in Indiana? I certainly don't think that would be best for pt care. I think most NP/PAs know their limitations and wouldn't want complete autonomy in a high acuity ED. I don't view our specialty as similar in any way to anesthesia where bad outcomes are (relatively) infrequent with bread and butter cases. Deaths, codes, you name it... are part of our field and I think hospitals would get sued in a heart beat if they had predominately run EDs with NPs. I don't even think nursing on a whole would want to push for autonomy in the ED of all places to further their efforts for independent practice. It would be prudent to make a push in the areas of medicine with the least amount of risk to avoid headlines and lawsuits.

I think EM will continue forward with the larger EDs continuing to push for and require EM BC/BE docs albeit with lower ratios of provider to MLP. In that sense, it should be very similar to the anesthesia model but I don't see that we have any choice. EDs are being inundated with non emergent pt's and in order to keep us enjoying our practices and seeing/treating real emergencies, like we were trained to do..., we'll need NP/PAs to help with the sheer volume. Economically, CMGs will continue to push for this as I've already been noticing... It's cheaper to have MLPs with Physician supervision even if there is additional medico legal risk. If you are a doc who refuses to sign the charts, they'll just find someone who will and won't complain due to the financial incentives.

Do I like signing MLP charts? No. Hell, I'd feel the same way about co-signing anyone's chart. But... I don't see that the future gives me much of a choice though it makes me feel MUCH better when I'm signing charts of very well trained and competent NP/PAs that I trust.

 

[Arcan57]

The shop in town with the (IIRC) highest ratio of midlevels to EPs also is by far the best paying. Currently the midlevels at my shop add probably $30-40/hr to what I would otherwise be making. If you're looking for a true EM type job, a ton of midlevels is going to be your best bet because they'll be shielding you from the majority of the low-level stuff. The downside is that you're constantly being bombarded with input from midlevels trying to dispo their patients as well as having fewer patients you can mentally sign off on due to their instability.

 

[The White Coat Investor]

That's exactly the dilemma. $30-40 an hour more, or don't use midlevels. That said, I think it would be a mistake to go to a ratio less than 1:1 (docs to midlevels). Our busy shifts we're at a ratio of 2:1, and that still means I get involved in 3 or 4 midlevel cases a shift, perhaps 1 of which I go see and recreate the H&P or do a procedure on.

Typical for me would be that the mid-level sees 12 patients (1.5 per hour for an 8 hour shift, we're a relatively low pph shop remember):
6 go to me, and 6 go to the other doc.
Of those 6, I just "sign the chart" on 3, I hear about 3, and I see 1.

I feel bad for the employee docs who don't control this decision. If we decide to use mid-levels, its our risk vs income we're deciding, but at least we get the decision. We also get to decide when and who to hire and fire and how much to pay them. If a suit is making the decision, that sucks. One more reason SDGs >>> CMGs and hospital employees.

 

[emergentmd]

I used to be against MLP but after working with them for 4 yrs, I love them. My salary is bumped by 30/hr doing really very little work. They ask some questions but I prob spend less than 5 min a shift answering questions.

They also deal with all the sutures, abscess drainage which are time consuming and I actually am bored of doing them.

I don't see how they will reduce my salary unless they overtake the ER and by that time, the new residents will be affected. I will be in retirement by then

 

[NE2014]

I used to be against MLP but after working with them for 4 yrs, I love them. My salary is bumped by 30/hr doing really very little work. They ask some questions but I prob spend less than 5 min a shift answering questions.

They also deal with all the sutures, abscess drainage which are time consuming and I actually am bored of doing them.

I don't see how they will reduce my salary unless they overtake the ER and by that time, the new residents will be affected. I will be in retirement by then

How noble of you to look out for the profession! Fits with your other posts. I'm surprised you haven't moved into the admin suite yet to sell the rest of your colleagues up the river.

You are the worst kind.

 

[Brahnold Bloodaxe]

This thread was created almost 2 years ago now. Have you guys observed any trends in the ensuing time? Has midlevel utilization in the ED made strides in recent years, or is the situation holding steady?

 

[Psai]

You were the one that argued that you can look to anesthesia, to see how mid-level creep affected their job market and apply it to EM. I'm agreeing and saying, "You're right. It will do to EM, just what it did to the Anesthesia job market." And to find out what effect that had, look to MGMA. Even if you factor in the supposed Anesthesiologists who can't find jobs, are unemployed and presumably would factor in with a salary of zero in those surveys, their overall salaries have survived their feared Mid-Level Armageddon pretty well. All I'm saying, is that in my opinion FWIW, EM will make it through increasing mid-level presence just fine, from a salary and job-market standpoint. I'm just not afraid of mid-level competition, like some people are. That's all. I could be wrong.

It's been nice sparring, but it's past Birdstrike's bedtime. Nighty night.

Cardiothoracic in the last decade would disagree with you. Pay was the same but the job market sucked. Why? Because the people who had jobs kept them and kept cranking out cases. It's not like there were huge drops in insurance reimbursement. So the new guys got totally screwed over and had trouble finding jobs.

It does seem like they're having something of a renaissance though, I'm seeing a lot more interest than before

 

[deleted6669]

This thread was created almost 2 years ago now. Have you guys observed any trends in the ensuing time? Has midlevel utilization in the ED made strides in recent years, or is the situation holding steady?

speaking as a pa I can tell you the following: most urban PA jobs are becoming fast track only as places now staff mostly em trained and boarded docs. In rural areas that can't support an EM doc, PAs work double coverage alongside a FP physician or solo coverage seeing all comers. this is what I prefer to do, although it certainly limits where I can live/work.

 

[TheComebacKid]

I don't see how they will reduce my salary unless they overtake the ER and by that time, the new residents will be affected. I will be in retirement by then

I know this was posted 2 years ago, and I'm not sure if this was a sarcastic tongue-in-cheek comment. But just reading this as someone who just started intern year, absolutely enrages me. You, as a person, have absolutely no respect for the integrity of our profession. The successful career that you experienced was largely due to the hard work put in by those who came before you, who advocated for you, paved the way for you and shaped the specialty. You on the other hand, are content with eating the fruits of their labor, without ensuring that those who come after having the same rewarding experience. If your comments were in jest, I can brush it off, but if you are being serious, I'm really saddened.

But, I digress.
----------------------

I for one think the idea of "mid level encroachment" is an actual thing that warrants significant attention on the part of the leadership of our specialty (i.e. ACEP).

I think mid level providers are well trained, hard working, bright, and dedicated people. In fact, I can't think of a single mid level provider that I have ever worked with that was not an absolute pleasure in addition to being very competent at what they do. That being said, there is absolutely no question that most mid level providers feel confident enough in their training to manage very critical patients. I think that is irresponsible and outside of their scope of practice.

What I'm getting at is that it seems great right now to put them in Fast Track so they can deal with all the low acuity patients that we don't want to deal with. But that isn't going to last. The ANA is a ridiculously powerful lobby that really advocates for their constituents, and they are most certainly looking for ways to increase autonomy of NPs in particular. This is bad for our profession, and for patients. I know the arguments as to why or why not mid levels should be practicing independently has been beaten to death and I won't get into a whole detailed discussion about that.

Regardless, I can't help but envision a bunch of anesthesiologists sitting at a country club, drinking scotch, saying essentially what we are saying in this thread which is that "CRNA's are great! They do all these easy cases! Make my life so much easier" and sharing a great laugh. My anesthesia colleagues are paying for that now. The notion that this should be brushed off because they are freaking out about finding jobs in "tight markets" is absolutely ludicrous. An anesthesiologist has invested a great deal of time, personal and monetary sacrifice in order to become a well trained physician. While there may be many "straight forward" cases in the field, there are times when straight forward cases head south really fast, and their extensive training allows them to intervene appropriately. These people have earned their badge, studied significantly more than mid levels, to be awarded the highest possible degree for their craft.

It's irresponsible IMO for the leadership in the profession to allow this to happen and to not advocate for their fellow physicians. This idea that "SF is a tight market, but hey, you can make a ton as an anesthesiologist in Boise!" doesn't sit well with me. If the SF VA wants to cut costs and do away with board certified anesthesiologists completely, where is the advocacy? Where are the studies that show that board certified anesthesiologists provide safer care? Where are the surveys asking patients if they would prefer to be sedated and intubated by someone with significantly less training? Where are the surveys of insured patients saying that they will be taking their business elsewhere to places that have board certified physicians? They probably don't exist because people like emergentmd are happy to line their pockets without looking after their own. I promise you the ANA is making a point to put out studies and surveys that show that patients really love their NPs. Physicians on the other hand think they are invincible and that they don't need to be bothered because "a mid level will never be able to get my job!". Ignorance is bliss.

We should stop thinking about the now and the extra $30/hr we make, and start thinking about the long term outlook of our profession as a whole. 30/hr is not a trivial amount of money, however, it does in fact come with a significant cost. We owe it to ourselves and to those who come after us to protect our specialty.

 

[Psai]

That's how the older generation now handles things. "Who cares about you? I got mine and it's mine til I die." They are the most entitled generation in existence, just taking all the good things that happened in their lifetime for granted and using their power to steal even more from the generations to come. They hate paying taxes but have no problem eating up more social security and medicare than they contributed to the system. They are all about short term gains at the expense of long term losses for others. I don't blame them as I would probably have done the same thing in their shoes but it's incredibly selfish and shortsighted.

I'm training to become the best doctor I can be and provide the best possible care for my patients. I'm not interested in becoming a fireman to fight against self-inflicted emergencies caused by undertrained midlevels who are unhappy with the ever increasing role that the older generation has allowed for due to their laziness and greed. I'm not interested in pushing electronic paper around to soak up liability for nurses by risking my license.

 

[coachB]

I know this was posted 2 years ago, and I'm not sure if this was a sarcastic tongue-in-cheek comment. But just reading this as someone who just started intern year, absolutely enrages me. You, as a person, have absolutely no respect for the integrity of our profession. The successful career that you experienced was largely due to the hard work put in by those who came before you, who advocated for you, paved the way for you and shaped the specialty. You on the other hand, are content with eating the fruits of their labor, without ensuring that those who come after having the same rewarding experience. If your comments were in jest, I can brush it off, but if you are being serious, I'm really saddened.

But, I digress.
----------------------

I for one think the idea of "mid level encroachment" is an actual thing that warrants significant attention on the part of the leadership of our specialty (i.e. ACEP).

I think mid level providers are well trained, hard working, bright, and dedicated people. In fact, I can't think of a single mid level provider that I have ever worked with that was not an absolute pleasure in addition to being very competent at what they do. That being said, there is absolutely no question that most mid level providers feel confident enough in their training to manage very critical patients. I think that is irresponsible and outside of their scope of practice.

What I'm getting at is that it seems great right now to put them in Fast Track so they can deal with all the low acuity patients that we don't want to deal with. But that isn't going to last. The ANA is a ridiculously powerful lobby that really advocates for their constituents, and they are most certainly looking for ways to increase autonomy of NPs in particular. This is bad for our profession, and for patients. I know the arguments as to why or why not mid levels should be practicing independently has been beaten to death and I won't get into a whole detailed discussion about that.

Regardless, I can't help but envision a bunch of anesthesiologists sitting at a country club, drinking scotch, saying essentially what we are saying in this thread which is that "CRNA's are great! They do all these easy cases! Make my life so much easier" and sharing a great laugh. My anesthesia colleagues are paying for that now. The notion that this should be brushed off because they are freaking out about finding jobs in "tight markets" is absolutely ludicrous. An anesthesiologist has invested a great deal of time, personal and monetary sacrifice in order to become a well trained physician. While there may be many "straight forward" cases in the field, there are times when straight forward cases head south really fast, and their extensive training allows them to intervene appropriately. These people have earned their badge, studied significantly more than mid levels, to be awarded the highest possible degree for their craft.

It's irresponsible IMO for the leadership in the profession to allow this to happen and to not advocate for their fellow physicians. This idea that "SF is a tight market, but hey, you can make a ton as an anesthesiologist in Boise!" doesn't sit well with me. If the SF VA wants to cut costs and do away with board certified anesthesiologists completely, where is the advocacy? Where are the studies that show that board certified anesthesiologists provide safer care? Where are the surveys asking patients if they would prefer to be sedated and intubated by someone with significantly less training? Where are the surveys of insured patients saying that they will be taking their business elsewhere to places that have board certified physicians? They probably don't exist because people like emergentmd are happy to line their pockets without looking after their own. I promise you the ANA is making a point to put out studies and surveys that show that patients really love their NPs. Physicians on the other hand think they are invincible and that they don't need to be bothered because "a mid level will never be able to get my job!". Ignorance is bliss.

We should stop thinking about the now and the extra $30/hr we make, and start thinking about the long term outlook of our profession as a whole. 30/hr is not a trivial amount of money, however, it does in fact come with a significant cost. We owe it to ourselves and to those who come after us to protect our specialty.

If you consider ACEP to be "leadership", think again. They have long been in the pockets of the CMGs. Just look at the ads and who sponsors everything at the annual meeting. The CMGs are among the most interested and active in increasing the role of APPs as it lines their pockets even further. And, no, it's not any of the physicians working for these groups who are benefitting. As others have pointed out, in many shops, your name will end up on charts when you never even heard about the patient. And you're expected to sign off, making more money for the shareholders, executives, etc. while you shoulder the additional risk.

But you have a choice. You can choose the environment in which to work. If more people would be willing to just say, no I'm not going to work under those conditions, then the system as is would eventually, and perhaps quite quickly, fall apart. Unfortunately, too many graduating residents are far too willing to accept a role as a replaceable cog in a giant machine. Sometimes the reasons are important - family, location, etc. But those are the value decisions being made.

 

[Birdstrike]

If you consider ACEP to be "leadership", think again. They have long been in the pockets of the CMGs. Just look at the ads and who sponsors everything at the annual meeting. The CMGs are among the most interested and active in increasing the role of APPs as it lines their pockets even further. And, no, it's not any of the physicians working for these groups who are benefitting. As others have pointed out, in many shops, your name will end up on charts when you never even heard about the patient. And you're expected to sign off, making more money for the shareholders, executives, etc. while you shoulder the additional risk.

But you have a choice. You can choose the environment in which to work. If more people would be willing to just say, no I'm not going to work under those conditions, then the system as is would eventually, and perhaps quite quickly, fall apart. Unfortunately, too many graduating residents are far too willing to accept a role as a replaceable cog in a giant machine. Sometimes the reasons are important - family, location, etc. But those are the value decisions being made.

Good post. Lots of truth here.

 

[Birdstrike]

That's how the older generation now handles things. "Who cares about you? I got mine and it's mine til I die." They are the most entitled generation in existence, just taking all the good things that happened in their lifetime for granted and using their power to steal even more from the generations to come.

All people over a certain age are selfish, entitled and steal?
Uh...ok.
I wonder at what age you think everyone becomes old, entitled, selfish thieves. Over 35? 40?

They hate paying taxes .

You'll hate them too, when you finally get your first attending check and realize half of its gone.

I'm training to become the best doctor I can be and provide the best possible care for my patients.

Focus on this. Let mid levels focus on being the best midlevels they can be. They're not to be blamed for the doors others opened for them.

the older generation has allowed for due to their laziness and greed. I'm not interested in pushing electronic paper around to soak up liability for nurses by risking my license.

This isn't even due to "the older generation" as you call it (by what age you define that, I'm not sure). Most EM attendings over age 40 or 50 or even 60 and beyond had no role in the genesis of mid level presence in EDs. This was done by a minority of people in what you might loosely term leadership positions. Most EM docs are, and 20 years ago were, just trying to get through the next shift, without any master plan to bring in mid levels to profit then shaft the young. Any money skimmed from midlevels and taken as profit wasn't skimmed by the average ED pit doc. It was likely skimmed by CMG administrators and shareholders. But the typecast an entire generation of doctors misses what really brought this all on.

 

[d2305]

I was surprised that a major hospital here (Baptist) has an acute care clinic without a physician onsite. There is no way I'd work in a rural ER by myself.

 

[Brahnold Bloodaxe]

This thread was created almost 2 years ago now. Have you guys observed any trends in the ensuing time? Has midlevel utilization in the ED made strides in recent years, or is the situation holding steady?

Any other observations regarding the above?

 

[xaelia]

I think I'd enjoy supervising a PA/NP environment where my role was less hands-on and more overseeing high-quality care and resource utilization.

But, I'm weird.

 

[deleted109597]

I think I'd enjoy supervising a PA/NP environment where my role was less hands-on and more overseeing high-quality care and resource utilization.

Problem is, in the CMG world, you don't get to do that. They don't present the patients to you, and if you disagree with them, you get a meeting with your boss about how "telling other qualified people what to do is wrong." Of course, they still want you to sign the charts and be responsible for their work, just don't try to meddle in the full cardiac workup of teenagers, or ddimers for everybody.

But, I'm weird.

No comment.

 

[xaelia]

Problem is, in the CMG world, you don't get to do that.

Not denying such a scenario doesn't exist – but the current FFS environment with CMGs may not resemble the HMO/capitated environment of the future.

 

[Arcan57]

Problem is, in the CMG world, you don't get to do that. They don't present the patients to you, and if you disagree with them, you get a meeting with your boss about how "telling other qualified people what to do is wrong." Of course, they still want you to sign the charts and be responsible for their work, just don't try to meddle in the full cardiac workup of teenagers, or ddimers for everybody.

No comment.

That's not how it is for every CMG. I also don't think I would stick around that environment.

 

[BoardingDoc]

That's not how it is for every CMG. I also don't think I would stick around that environment.

Agreed. I'm currently working in a place that uses PAs in the ED. They are treated exactly like residents. They present the patient to the attending who then has final say on all decisions made. Maybe this is just a fundamental difference because this place isn't run by a CMG, but I'd be surprised if every CMG out there was like that.

 

[Boatswain2PA]

Agreed. I'm currently working in a place that uses PAs in the ED. They are treated exactly like residents. They present the patient to the attending who then has final say on all decisions.

Really? Every sore throat, rolled ankle, cough, toothache, suicidal ideation, scabies, etc?

You are not using your PAS right....

 

[MSmentor018]

" Of course, they still want you to sign the charts and be responsible for their work"

No comment.

that's the f!2ked up part. you never see or get presented the pt, hope they did the right thing or at least document to swerve the chart in a safe direction and yet you take all the liability with any pay.

 

[Psai]

Really? Every sore throat, rolled ankle, cough, toothache, suicidal ideation, scabies, etc?

You are not using your PAS right....

If I'm overseeing someone's work, I want to know what they're up to. Don't want some cough d/ced from the ED with my signature on the chart and find out a month later that I'm getting sued because the guy actually had lung cancer and "I" missed it.

 

[BoardingDoc]

Really? Every sore throat, rolled ankle, cough, toothache, suicidal ideation, scabies, etc?

You are not using your PAS right....

If the attending is signing the chart why wouldn't they be aware of the patient?

EDIT: Psai beat me to the punch on this one.

 

[Boatswain2PA]

If the attending is signing the chart why wouldn't they be aware of the patient?

EDIT: Psai beat me to the punch on this one.

That's one way to do it. Of course, it you're going to do it that way, wouldn't you just hire physicians only....at 2-4 times the cost.

Or....you could hire PAs and upervise them appropriately --- which means achieving an understanding of their competence, strengths, and weaknesses, and then setting guidelines with that PA about what patients need to be seen by you, run by you, or simply seen and discharged. If you do THAT, and then help correct the weaknesses, your PA will help you run the department.

 

[BoardingDoc]

That's one way to do it. Of course, it you're going to do it that way, wouldn't you just hire physicians only....at 2-4 times the cost.

Or....you could hire PAs and upervise them appropriately --- which means achieving an understanding of their competence, strengths, and weaknesses, and then setting guidelines with that PA about what patients need to be seen by you, run by you, or simply seen and discharged. If you do THAT, and then help correct the weaknesses, your PA will help you run the department.

I agree with your statement in theory. I worry that the practice would be different though. My initial response was in regards to Dr. Mcninja's comment about trying to oversee PAs and being repremanded for taking an active role when it's seen as necessary. If we can have a perfect world where PA's know when to fly solo, when to get a hand and when to say "hey, this is out of my league" then I would love to jump on that train. My guess (and I've got limited experience here so I could certainly be wrong) is that a good deal of the time you're either going to have the PA presenting most if not all of the patients, OR you're going to have them flying solo on patients that they should not be managing alone and I'm going to be the one holding the bag at the end of the day.

If I have to pick between those two choices, I'd take the former. That said, if the happy middle exists, I'm obviously all for it.

 

[Boatswain2PA]

I agree with your statement in theory. I worry that the practice would be different though. My initial response was in regards to Dr. Mcninja's comment about trying to oversee PAs and being repremanded for taking an active role when it's seen as necessary. If we can have a perfect world where PA's know when to fly solo, when to get a hand and when to say "hey, this is out of my league" then I would love to jump on that train. My guess (and I've got limited experience here so I could certainly be wrong) is that a good deal of the time you're either going to have the PA presenting most if not all of the patients, OR you're going to have them flying solo on patients that they should not be managing alone and I'm going to be the one holding the bag at the end of the day.

If I have to pick between those two choices, I'd take the former. That said, if the happy middle exists, I'm obviously all for it.

Doc's getting "reprimanded" for running their department (ie: "taking an active role") is a proble

Your "perfect world where PA's know when to fly solo, when to get a hand and when to say "hey, this is out of my league"" exists many places and should be the goal of not only every PA, but every EP as well.

I've never worked anywhere I've had to"present most if not all the patients," nor would I ever work in such a place.

I'm single coverage in pretty slow EDs most of the time, but I likely get a higher acuity percentage in rural America than in urban America. My goal in these little rural EDs is to give the exact same level of emergency medicine as you would give there. No, I'm not cracking a chest to cross-clamp the aorta on a coding trauma patient, but you aren't either in these EDs where the closest trauma surgeon is 3 hours away. But I'll manage a home-dialysis uncontrolled diabetic who is in DKA again for almost 48 hours in my ED because the roads are closed and aircraft aren't flying because of the weather. And I'll manage it the same way you would there....by realizing that I'm a little "out of my league" and phoning a friend (intensivist & nephro).

I also part time in a urban ED where I am lucky to work with BC EPs. The big "group" we work for has a myriad of rules of what patients must be briefed up to the EP, most of them are ridiculous...such as before any CT, any abd pain, any preg vag bleed, etc. But at the beginning of each shift I ask the EP how much he/she wants me to brief them and they always simply say "Boats...go see the patients, call me if you have any questions!"

They know my skills, and they know I will ask them if I need any help. They also often just sit there and pop out a question or two to me as they are reading my note.

That's how you supervise a PA.

 

[Hercules]

That's one way to do it. Of course, it you're going to do it that way, wouldn't you just hire physicians only....at 2-4 times the cost.

Or....you could hire PAs and upervise them appropriately --- which means achieving an understanding of their competence, strengths, and weaknesses, and then setting guidelines with that PA about what patients need to be seen by you, run by you, or simply seen and discharged. If you do THAT, and then help correct the weaknesses, your PA will help you run the department.

I have to disagree. If I can thin-slice see the PA's patient and sign their chart in 1-3 mins and the PA sees 2-3 pph then I get to bill at 100% instead of 85% and I'm collecting anywhere from 6-9 additional RVUs per hour for less than 10 mins of my time. That's much more cost effective than hiring additional physicians. Plus I'm aware and have seen all patients that bear my name and liability. Plus (even though it sounds like you are highly trained and provide good care) patients can never say they weren't seen by a doctor when they file the inevitable complaint/lawsuit.


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[Boatswain2PA]

I have to disagree. If I can thin-slice see the PA's patient and sign their chart in 1-3 mins and the PA sees 2-3 pph then I get to bill at 100% instead of 85% and I'm collecting anywhere from 6-9 additional RVUs per hour for less than 10 mins of my time. That's much more cost effective than hiring additional physicians. Plus I'm aware and have seen all patients that bear my name and liability. Plus (even though it sounds like you are highly trained and provide good care) patients can never say they weren't seen by a doctor when they file the inevitable complaint/lawsuit.


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Can't argue with that. One big hospital system in my town does the same thing with all level 1-3 visits.

 

[Brahnold Bloodaxe]

We are now nearly 3 years into the 5 year timeframe the OP was seeking predictions on.

What is the verdict so far? Have you noticed midlevel utilization being increased since you first read this thread in 2014, or are things holding steady?

 

[jw3600]

I dunno about the verdict of MLPs role but I can see emergentmds money grubbing, mine over yours, attitude hasn't changed much...

 

[Brahnold Bloodaxe]

Let's be civil, I didn't necromance this thread just to resurrect petty personal squabbles. I'm genuinely curious as to what the observable trend has been in midlevel utilization since the creation of this thread in 2014.

(And in defense of EmergentMd, a money grubbing, mine over yours attitude is precisely the type of mindset the medical profession needs to have, in my opinion, in order to avoid being exploited in the current climate by other, eh...stakeholders. I'll throw in the minor caveat that this mindset has to be tempered by an effort not to kill the goose that lays the golden eggs in the manner of the anesthesiologists.)

 

[jw3600]

I used to be against MLP but after working with them for 4 yrs, I love them. My salary is bumped by 30/hr doing really very little work. They ask some questions but I prob spend less than 5 min a shift answering questions.

They also deal with all the sutures, abscess drainage which are time consuming and I actually am bored of doing them.

I don't see how they will reduce my salary unless they overtake the ER and by that time, the new residents will be affected. I will be in retirement by then

Let's be civil, I didn't necromance this thread just to resurrect petty personal squabbles. I'm genuinely curious as to what the observable trend has been in midlevel utilization since the creation of this thread in 2014.

(And in defense of EmergentMd, a money grubbing, mine over yours attitude is precisely the type of mindset the medical profession needs to have, in my opinion, in order to avoid being exploited in the current climate by other, eh...stakeholders. I'll throw in the minor caveat that this mindset has to be tempered by an effort not to kill the goose that lays the golden eggs in the manner of the anesthesiologists.)

What point in training are you at? Because I'm a 4th year going into EM. His comments aren't VERBALLY offensive but this attitude is literally ****ting on my entire generation's ability to function as a physician in the next 1-2 decades. It's the same attitude people have about climate change. "Me and my grandchildren will be dead, so who cares?" It's pretty damn selfish.

If you're an attending maybe you don't care, I don't know.

 

[NinerNiner999]

Just a thought nobody has touched on yet - CMG's can be blamed for the creep of MLP autonomy, but at the end of the day, they need to make the hospitals that they contract with happy. Most physicians in local communities want their patient managed by ED physicians. Period. CMG's can try to push their model to local hospitals during bid pitches and through schedule manipulation, but at the end of the day, it is the contract holder (i.e. the hospital) who will dictate how many MLP's are running around in their hospitals.

I think this model will gravitate towards the hard to staff locations (very rural) and lower acuity departments (admission rate <8%). For the rest of the hospitals (the vast majority), physicians will continue to be preferred by medical staffs.

 

[namethatsmell]

Just a thought nobody has touched on yet - CMG's can be blamed for the creep of MLP autonomy, but at the end of the day, they need to make the hospitals that they contract with happy. Most physicians in local communities want their patient managed by ED physicians. Period. CMG's can try to push their model to local hospitals during bid pitches and through schedule manipulation, but at the end of the day, it is the contract holder (i.e. the hospital) who will dictate how many MLP's are running around in their hospitals.

I think this model will gravitate towards the hard to staff locations (very rural) and lower acuity departments (admission rate <8%). For the rest of the hospitals (the vast majority), physicians will continue to be preferred by medical staffs.

Completely agree.

Increased mid level staffing is a boon for CMGs to milk profits while absorbing basically none of the liability as they get to displace it on the individual docs at the site. I know of one shop where all the docs threatened to leave over this and the agreement to placate them was that the ED medical director now signs all the mid level charts.

Realistically it will take a major complaint from a lucrative group of specialists the hospital wants to keep happy (like orthopods) or a major safety event before a hospital admin will act.


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[GeneralVeers]

Where I work there is such a shortage of EPs that it is physically impossible to have an EP see all of the low-level patients. Having MLPs see the minor stuff helps out greatly because we can focus on the more complex cases. I really don't like seeing sore throats, dental pain, and doing lac repairs on kids.

 

[NinerNiner999]

Our job has shifted from having a lower volume of mostly sick patients all present with real disease (needles) to seeing more patients with lower acuity and being forced to find the needle in the haystack. Having an army of people sifting through the hay to bring the doctor a needle is definitely the most cost effective model. The only way for it to work though, is for there to be a lot of hay...

 

[namethatsmell]

Where I work there is such a shortage of EPs that it is physically impossible to have an EP see all of the low-level patients. Having MLPs see the minor stuff helps out greatly because we can focus on the more complex cases. I really don't like seeing sore throats, dental pain, and doing lac repairs on kids.

I mostly works in a similar area and midlevels are very helpful for these patients. The issue comes when a CMG starts saying "why don't we have the NP/PA see a few level 2s also." And the slippery slope begins...

I do wonder how much liability we actually incur by consigning a chart for a patient we never saw or knew about being in the department. Anybody have any examples or thoughts on this?




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[Brahnold Bloodaxe]

I mostly works in a similar area and midlevels are very helpful for these patients. The issue comes when a CMG starts saying "why don't we have the NP/PA see a few level 2s also." And the slippery slope begins...

Which brings us back to the reason I bumped this thread....has the slippery slope gotten more slippery since this thread was created in 2014, or are things holding steady?

 

[RustedFox]

I'm five years in attendinghood.

I say its steady. We actually did a little experiment at my home shop where we had a 3:1 MLP-to-physician ratio for a few shifts. Before anyone freaks out, this was how this came about:

Our day was structured as follows:

Physician 1: 6a-3p
MLP 1: 9a-9p
MLP2: 12p-12a
Physician 2: 2p-12a
Physician 3: 8p-6a

Physician 2 was getting overrun with volume, so we created a "princess shift" from 3p-8p. Originally, this was open to physicians ONLY. We then ran into the problem of.... not having any physicians to fill the shift with regularity. While hiring new arms for the bullpen, we let the MLPs work a princess shift or two, with Physician 2 understanding that he was only to be air-traffic control, and not to actively pick up patients unless really needed.

It was an abortion. 3 MLPs: 1 Doc was terrible. The doc ended up having to be involved in a hell of a lot more than she/he expected to, and the MLPs were very clearly "in over their heads". In the end, every single physician said "I won't work this model. No way."

Now, we're structured as follows:

Physician 1: 6a-3p
MLP 1: 9a-9p
Physician 2: 12p-10p
MLP 2: 2p-12a
Physician 3: 8p-6a

Its a little better. Word is that we're going to be shaking things up to make it a "two doc afternoon", because that's when our volume spike is.

 

[MSmentor018]

I mostly works in a similar area and midlevels are very helpful for these patients. The issue comes when a CMG starts saying "why don't we have the NP/PA see a few level 2s also." And the slippery slope begins...

I do wonder how much liability we actually incur by consigning a chart for a patient we never saw or knew about being in the department. Anybody have any examples or thoughts on this?


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all of it.....Wrong diagnosis caused teen’s brain damage, plaintiff alleged | Verdict Search

notice EMcare and EM1, the companies that the doc and pa worked for was completely released from liability and the doc/pa/hospital took the hit. so if you're sued, will your group save you?

 

[MSmentor018]

Which brings us back to the reason I bumped this thread....has the slippery slope gotten more slippery since this thread was created in 2014, or are things holding steady?

absolutely. we're now replacing our docs with a PA. instead of having 2 MD and 1 PA on the evening shift, it's 1 doc and 2 PA's. basically I am responsible for my own pts, hopefully the the sickest in the dept. while supervising and signing off on a ass ton of charts that could be sick/not sick.