What is the NNT for an EM physician to have a better outcome...

[Boatswain2PA]

. I’ve told my rural family members to never stop at a critical access ED under any circumstances

I do the same thing. I've seen terrible care in rural EDs by FP docs and NPs. I've seen some great care too, but the range of competence there is astounding. It is getting much much worse with the race to the bottom as NPs crank out thousands of new grads hungry for jobs, pay that is tanking, and administrators happy about it

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[CoolDoc1729]

In this study there were no differences between tests ordered by EPs and the PAs.

Since my ER now routinely has a 10 hour wait because all the nurses quit, our wise cmg overlords have decided that the PA/NPs will start the workup in triage for all ESI 2-5 patients. Some of them do fine. Some of them come ask if they don’t know what to order. Others don’t.

One thinks he knows everything. He has had two patients code in triage since this started. But they were resuscitated back to health, so “it’s ok”, right?

Another orders CT/CTA head on every dizzy or weak person and every headache. We are not allowed to place IVs in triage so that means every dizzy person, headache or weakness does not get any imaging for ten hours and also can’t be dispo’Ed for ten hours, unless one of us has time to go see the patient and cancel the study. So it destroys the flow and also has caused delayed diagnosis of two strokes and one bleed.

I realize these are anecdotal but isn’t that kind of the problem? You don’t know whether you’re getting a cowboy, an overworker-upper or a rational well trained person until you’ve worked with them for months-years, and as a patient I’d have no confidence at all, because the training is so varied and so under regulated.

 

[lucid_leprechaun]

Since my ER now routinely has a 10 hour wait because all the nurses quit, our wise cmg overlords have decided that the PA/NPs will start the workup in triage for all ESI 2-5 patients. Some of them do fine. Some of them come ask if they don’t know what to order. Others don’t.

One thinks he knows everything. He has had two patients code in triage since this started. But they were resuscitated back to health, so “it’s ok”, right?

Another orders CT/CTA head on every dizzy or weak person and every headache. We are not allowed to place IVs in triage so that means every dizzy person, headache or weakness does not get any imaging for ten hours and also can’t be dispo’Ed for ten hours, unless one of us has time to go see the patient and cancel the study. So it destroys the flow and also has caused delayed diagnosis of two strokes and one bleed.

I realize these are anecdotal but isn’t that kind of the problem? You don’t know whether you’re getting a cowboy, an overworker-upper or a rational well trained person until you’ve worked with them for months-years, and as a patient I’d have no confidence at all, because the training is so varied and so under regulated.

I think this gets to the heart of the issue. I know fantastic PAs/NPs. The issue is establishing independent practice as the accepted norm when the overall education standard is so low. Kind of have to make policy based on the worst case scenario. Maybe there should be some kind of advanced testing after which you could practice more independently.

 

[skougess]

I think this gets to the heart of the issue. I know fantastic PAs/NPs. The issue is establishing independent practice as the accepted norm when the overall education standard is so low. Kind of have to make policy based on the worst case scenario. Maybe there should be some kind of advanced testing after which you could practice more independently.

Yeah and maybe we could do the testing in three discrete “steps”. And maybe extend the education to four years and standardize it. And then some kind of a standardized post grad training to ensure competency. Nah that sounds like a lot of work.

 

[RustedFox]

Yeah and maybe we could do the testing in three discrete “steps”. And maybe extend the education to four years and standardize it. And then some kind of a standardized post grad training to ensure competency. Nah that sounds like a lot of work.

What a radical idea!
We could call it something... say... "medical school" ? !

 

[doctalaughs]

I am willing to bet that experienced EMPAs would have had better scores than FP boarded physicians.

This is always the twisted argument that midlevels like to use no matter the specialty… somewhere, someplace there is an “experienced” PA/NP practicing in a niche of medicine for the past 20 years that is better suited in that field than a random doc. NEVER comparing the average midlevel (even one that did a 12 month “residency” /certificate of training) to those average docs. And then using that to argue expanding use of midlevels across an entire field!!!

I’m a dermatologist. Of course there are a few PAs in derm for 20+ years that I know who are far better at bread/butter derm than family medicine physicians. There are ALSO new PA/NPs (even those with a brand new shiny derm “certificate of advanced training”) AND horrible derm midlevels out 20+ years who would not know the difference between dried crusted food and skin cancer (a real consult I got).

The problem is that patients don’t get to pick and don’t know any better. So physician training is the only gold standard base.

 

[Old_Mil]

Are EM docs over trained for what they do?

The problem isn't that emergency physicians are over trained for what they do. It is that hospital managers by and large don't want them doing what they are trained to do.

 

[Birdstrike]

I’m a dermatologist. Of course there are a few PAs in derm for 20+ years that I know who are far better at bread/butter derm than family medicine physicians. There are ALSO new PA/NPs (even those with a brand new shiny derm “certificate of advanced training”) AND horrible derm midlevels out 20+ years who would not know the difference between dried crusted food and skin cancer (a real consult I got).

The problem is that patients don’t get to pick and don’t know any better. So physician training is the only gold standard base.

What kind of food?

 

[RustedFox]

What kind of food?

Don't... don't do it.

@dchristismi will stroke.

 

[deleted6669]

NEVER comparing the average midlevel (even one that did a 12 month “residency” /certificate of training) to those average docs.

I would take the average EMPA postgrad program grad over the avg FP doc who doesn't work in the ED every time. They have 12-18 months of intense EM training(in many places equivalent to EM MD PGY1 s) compared to the typical FP grad who gets a month or 2 in med school and maybe 3 months in residency. Maybe. Typical EMPA grads also come from backgrounds like paramedic, ED nurse, resp therapist, etc. These folks have self-selected for EM throughout their education, compared to folks focused on primary care.

 

[p1acebo]

I would take the average EMPA postgrad program grad over the avg FP doc who doesn't work in the ED every time. They have 12-18 months of intense EM training(in many places equivalent to EM MD PGY1 s) compared to the typical FP grad who gets a month or 2 in med school and maybe 3 months in residency. Maybe. Typical EMPA grads also come from backgrounds like paramedic, ED nurse, resp therapist, etc. These folks have self-selected for EM throughout their education, compared to folks focused on primary care.

When you say equivalent to an EM MD PGY1, are you suggesting those postgrad programs are 22-24 EM shifts a month, plus 5 hour weekly didactics, plus 24 hour call while rotating in the ICU, plus studying for the in service, plus journal club, plus M&M, and everything else expected of a resident?

I haven’t seen one similar, I suppose if you could send me a link to one and prove me wrong sure, otherwise that statement is disingenuous. Most of the programs I have see are more or less learning on the job with some didactics mixed in. There is nothing wrong with trying to get more training, but I don’t think non physician clinicians understand what “residency” really is.

 

[deleted6669]

Yale New Haven Hospital Emergency Medicine APP Residency Program - APPAP

YNHH Emergency Medicine APP Residency Program Program Information Yale New Haven Hospital (YNHH) Emergency Medicine APP Residency Program 464 Congress Avenue, Suite 260 New Haven, CT 06519 203-737-4303 https://medicine.yale.edu/emergencymed/education/residency/pa/ Contact Information Kevin...

appap.org

ACEP SSO Service

www.sempa.org

Einstein | Jefferson Health

www.einstein.edu

I know folks from all 3 of these. The PAs train alongside the MD residents. Your patient, your procedure. Same off service requirements, etc.
These are the programs I am currently aware of:

Emergency Medicine Links/Residencies

EM RESIDENCIES/FELLOWSHIPS/POSTGRAD PROGRAMS(32)Albert Einstein Emergency Medicine PA Residency (PA): https://www.einstein.edu/education/non-physician-programs/em-physician-assistantJohns Hopkins Emergency Medicine PA Residency (MD):https://www.hopkinsmedicine.org/emergencymedicine/emergency_medi...

www.physicianassistantforum.com

 

[RustedFox]

PLPs collecting "Certificates". Colorized: 2021.

 

[Birdstrike]

Playas

 

[RustedFox]

EDIT: I put it where it belonged. Feel free to remove.

 

[Mount Asclepius]

The #2 cause of burnout: People thinking they are physicians when they aren’t, can do what we do, try to take a shortcut to get there, never understand that they didn’t get there, and then argue incessantly that they did. They work to ruin the profession of medicine in concert with a sea of administrators that add little value to the patient.

(There isn’t a shortcut to burning out. You have to do it the long, hard way. Hint: It starts with medical school. If you want to practice medicine, you have to study medicine.)

 

[p1acebo]

Yale New Haven Hospital Emergency Medicine APP Residency Program - APPAP

YNHH Emergency Medicine APP Residency Program Program Information Yale New Haven Hospital (YNHH) Emergency Medicine APP Residency Program 464 Congress Avenue, Suite 260 New Haven, CT 06519 203-737-4303 https://medicine.yale.edu/emergencymed/education/residency/pa/ Contact Information Kevin...

appap.org

ACEP SSO Service

www.sempa.org

Einstein | Jefferson Health

www.einstein.edu

I know folks from all 3 of these. The PAs train alongside the MD residents. Your patient, your procedure. Same off service requirements, etc.
These are the programs I am currently aware of:

Emergency Medicine Links/Residencies

EM RESIDENCIES/FELLOWSHIPS/POSTGRAD PROGRAMS(32)Albert Einstein Emergency Medicine PA Residency (PA): https://www.einstein.edu/education/non-physician-programs/em-physician-assistantJohns Hopkins Emergency Medicine PA Residency (MD):https://www.hopkinsmedicine.org/emergencymedicine/emergency_medi...

www.physicianassistantforum.com

The websites don’t specify if they are actually doing the same amount of shifts as the residents, and if they do I stand corrected.

Sounds like great programs to produce a PA that might be able to practice like a PGY 2, not an attending.

 

[deleted6669]

The websites don’t specify if they are actually doing the same amount of shifts as the residents, and if they do I stand corrected.

Sounds like great programs to produce a PA that might be able to practice like a PGY 2, not an attending.

I would take an EM PGY 2 over a boarded family medicine physician, wouldn't you?

 

[Mount Asclepius]

In 1979 the medical community settled the argument on what it takes to practice in an ED. Fighting over who is second best is a fruitless endeavor.

 

[deleted6669]

In 1979 the medical community settled the argument on what it takes to practice in an ED. Fighting over who is second best is a fruitless endeavor.

Agreed that EM residency training and boarding is best. Until there are enough EM boarded docs to work in every ED in the country and those docs are willing to work in all of those places, second best will remain an important distinction.

 

[Mount Asclepius]

Agreed that EM residency training and boarding is best. Until there are enough EM boarded docs to work in every ED in the country and those docs are willing to work in all of those places, second best will remain an important distinction.

2030 is just around the corner where a surplus of 10K emergency physicians is projected. At that point EPs will take any job they can get. Non-EPs trying to work unsupervised in EDs are subsequently going to feel the squeeze.

 

[deleted6669]

2030 is just around the corner where a surplus of 10K emergency physicians is projected. At that point EPs will take any job they can get. Non-EPs trying to work unsupervised in EDs are subsequently going to feel the squeeze.

No argument from me on that point.

 

[skougess]

I would take the average EMPA postgrad program grad over the avg FP doc who doesn't work in the ED every time. They have 12-18 months of intense EM training(in many places equivalent to EM MD PGY1 s) compared to the typical FP grad who gets a month or 2 in med school and maybe 3 months in residency. Maybe. Typical EMPA grads also come from backgrounds like paramedic, ED nurse, resp therapist, etc. These folks have self-selected for EM throughout their education, compared to folks focused on primary care.

Couldn’t disagree more. A monkey can learn central lines/intubations/etc with enough reps. No PA is going back to master Step 1-3 material which IS useful for patient care in the ED setting even if NPs/PAs regularly get away with blowing it off and pretending they can learn it all “on the job” as they go.

 

[MedicineZ0Z]

Comparing physicians and PAs as solo providers in a rural... : JAAPA

f the host institution were analyzed. Although minor variances in metrics were appreciated, transfers, 72-hour returns, and death rates were all similar among provider types. Results from this work do not demonstrate a clinically meaningful difference among ED metrics between physicians and PAs...

journals.lww.com

Just came off shift where I worked alongside an EM doc a few years out of 3 year residency. Last patient with pneumonia failing bipap with hypercapbeic failure. Elderly, obese, COPD on 5 L at home, multiple neck surgeries on what little neck there was, kyphotic, malampatti 3. Looked like a terrible intubation. Did DSI with ketamine and when we laid pt back the neck was stiff as a board with neck locked in flexion. Just a terrible situation.

Doc got that tube so smoothly it was just amazing. Made it look easy. Got it in about 3 seconds.

I'm confident I could have gotten it too. Would have taken longer. I would have "ticked" down the tongue instead of just inserting to just the right depth and position....but I'm confident I would have gotten it.

Would the outcome have been different had I been single coverage? I dunno.

In my experience there is an obvious difference in how EM trained docs think and practice. But how much of a difference does this make with actual outcomes? There HAS to be a point of diminishing returns with training (are 4 year EM residencies better than 3? What's the NNT?) Are EM docs over trained for what they do?

What is the NNT to show an improved outcome for an EM trained doc over a non-em trained doc, or over an experienced EM PA, or a fresh PA, or a nurse....

I don't know what the NNT is but a garbage study written by an ultra biased author is not even close to acceptable evidence.

 

[MedicineZ0Z]

I would take the average EMPA postgrad program grad over the avg FP doc who doesn't work in the ED every time. They have 12-18 months of intense EM training(in many places equivalent to EM MD PGY1 s) compared to the typical FP grad who gets a month or 2 in med school and maybe 3 months in residency. Maybe. Typical EMPA grads also come from backgrounds like paramedic, ED nurse, resp therapist, etc. These folks have self-selected for EM throughout their education, compared to folks focused on primary care.

The PA didn't go to med school. Nor is the medical knowledge level even remotely similar. I work around some of the most well trained EM PAs with years of exp and the gaps in knowledge is pretty staggering. They know some areas very well then know jack about other parts of medicine. Those missing gaps = missed diagnoses and bad outcomes. Even management of common issues is often done poorly if it doesn't fall into the areas the PA happens to know well.
And don't even get me started on peds or gyn....

 

[GassYous]

Nowadays nursing students are going around saying they went to "med school"

 

[MechEDoc]

To your first point: We know, and it’s terrifying. I’ve told my rural family members to never stop at a critical access ED under any circumstances. And yes that includes when they feel they have a life-threatening emergency. I tell them to take their chances with the drive. This whole “it’s better than nothing, right?” Is patently false. Mismanagement is worse than nothing.

To your second point: Don’t worry, we’ll be knocking at your ED doors with resumes VERY soon.

Very true. I have worked and currently work rural / critical access emergency medicine. You can get outstanding care sometimes (precisely 9 days of the month), ok care another 4 ish days of the month, and not so ok care the rest.