Why would anyone do an emergency medicine residency?

[Indebt4Life]

Please see the links

https://www.annemergmed.com/article...1QXZw4K72hrKy9DKLTEBsjRUg3k0SzIlTulZIXig#sec2

https://www.annemergmed.com/article/S0196-0644(18)31384-2/pdf

The American College of Emergency Physicians, provided a grant for this program. The programs goal is for ENP's to practice pretty much as EM docs with or without supervision.

Candidates becoming ENP's will be required to complete accredited and approved programs(don't know by what entity?) at different nursing/medical schools (so no standardization). These candidates, once graduated with their certificate("board certified") will be hired by various places to work side by side with ED docs. They may or may not be vetted, depending on the facility at which they are hired. Since the ED docs(including directors) will know nothing about their education, they will assume the programs are legit. There is nothing to stop these ENP's from going to states where they are allowed to practice unsupervised (almost half of the united states) and work in ED's with no oversight. They can brag they are certified and do what they wish.

There are three pathways to becoming an emergency nurse practitioner(ENP). One of them does not even require a "program" if they have enough clinical experience and ER procedural skills. (THIS IS NOT A TYPO) The programs have to be accredited and through an approved program. Problem is, it doesn't clarify approved by whom. Once they pass the certification, they are "board certified". Mind you, the programs vary from school to school. In any case, once they are certified, they will be able to see critical patients and perform certain procedures, same as an ER doc.

The worst part? EM residents will be forced to compete for procedures with these NP's. And spineless directors will do nothing to help them because they will not want to deal with the nursing conglomerate. So the residents' education will suffer.

Good luck! ACEP used your money to pay for this grant and the demise of your specialty.

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[miacomet]

Don't know. I sure regret it.

 

[thegenius]

Why would ACEP do this? Is it because the leader of ACEP came from a CMG? Won't this directly reduce the demand for board-certified ER docs?

 

[evilbooyaa]

Chief "Innovation" Officer of Envision Health care. LMAO. Love that a physician of all people holds that job title.

So you have a DNP professor and an executive of a CMG saying more NPs in EDs.

No conflicts of interest, absolutely none at all there.

As an outsider to EM, feels bad that people in power are adamant on torpedoing the whole profession. Sounds like the same story I deal with in the Rad Onc forum on a day to day basis....

My personal wish, is that if this happens, those programs that are participating in training this ENP are immediately outed on SDN (especially if they are with residents).

 

[CCM-MD]

What a mess.

 

[Vandalia]

Why does someone go to the CIA (Culinary Institute of America) when any 16 year old can get the same basic job at McDonalds? Why does Le Bernardin pay Eric Ripert a couple million dollars a year when they can get a "chef" for minimum wage?

 

[namethatsmell]

ACEP doesn't care about the future of us worker bees. They care about money. So go after what they care about.

We should all reach out to our former residencies and encourage the current PDs to stop buying ACEP memberships for their whole program and stop sending their programs to their meetings. ACEP may actually notice and care if attendance at their annual meeting suddenly nosedives.

In the meantime, until ACEP clearly stands up against midlevel up-staffing and physician down-staffing they will never get another cent from me.

 

[DO3]

This is the last straw. Will never again pay ACEP dues. ACEP is nothing but a huge con. The proof is in the pudding...ACEP is beholden to the pocket of every single CMG. They don’t care about the individual physician. I’m done.

 

[Indebt4Life]

You are right! These organizations don't care. If you want to become involved in an organization that cares about the value of a medical education and has seen the mess caused by midlevels playing doctor, then PM me and I will tell you how. Do something about it.

 

[Indebt4Life]

This is the last straw. Will never again pay ACEP dues. ACEP is nothing but a huge con. The proof is in the pudding...ACEP is beholden to the pocket of every single CMG. They don’t care about the individual physician. I’m done.

ACEP used your MONEY to pay for this grant!!!!!

 

[miacomet]

Whatever. Let's see a really busy ER run by NPs. It will be laughable. Have at it. Just don't make me sign charts and be there.

 

[Dr Mantis Toboggan]

“Physicians ask him his comfort level with specific procedures, many of which he learned at Emory (eg, lumbar punctures, intubation, placing central lines). Typically, unless the procedure is a simple laceration repair or an incision and drainage of an abscess, the physician will show him how the procedure is done and then ask him the next time to do it under supervision.”


Wow. I surely hope Emory isn’t really having NPs intubate and place central lines. That’s pretty crazy if true.

 

[GonnaBeADoc2222]

I think we're screwed. CMGs already "optimizing their practices" by decreasing physician hours and increasing midlevel hours.

They do not care about humans, they care about "productivity."

"Affordable" health care is such a hot button political topic now and an easy way to decrease "cost" is to cut physician pay.

Need to find escape hatch...

 

[southerndoc]

This is why I wished John Rogers had never resigned as ACEP president. He may not be EM residency trained or EM boarded, but I will attest that he would have done more for emergency medicine nationally than any other ACEP president in history. His actions in Georgia have spoken wonders. He was one of the key players that caused tort reform to happen in Georgia and has been a key player in balance billing and other emergency related legislation.

 

[thegenius]

This thread is utterly depressing. Thank god I haven't paid ACEP or ABEM or anything of these other organizations. I cannot think of anyone who sticks up for doctors.

Govt/CMS doesn't care
CMGs don't care
Insurers don't care
Pharmacists don't care
Do Hospitals care? Prob not

And pt's sue us if we don't make their chronic pain a 0, don't give them abx or admit them when want to be admitted.

The only thing good about EM is the stuff that happens once a year that is represented on one of the other concurrent threads (the GTFO thread).

 

[AlvinKamara]

This is so disheartening as a pgy1


Sent from my iPhone using SDN mobile

 

[boomshaketheroom]

“Physicians ask him his comfort level with specific procedures, many of which he learned at Emory (eg, lumbar punctures, intubation, placing central lines). Typically, unless the procedure is a simple laceration repair or an incision and drainage of an abscess, the physician will show him how the procedure is done and then ask him the next time to do it under supervision.”


Wow. I surely hope Emory isn’t really having NPs intubate and place central lines. That’s pretty crazy if true.

I know critical care NPs/PAs place art/central lines unsupervised after like 10 supervised of each. They dont get to intubate where I am, though.

 

[Winter2014]

As a first year medical student who was very interested in EM....I think I am going to start looking into other specialties. This sucks.

 

[Nedsson]

As a first year medical student who was very interested in EM....I think I am going to start looking into other specialties. This sucks.

+1. One of the things that had drawn me towards EM was that I felt it was an area where Physicians and not just midlevels would always be needed...whoops.

 

[Darth Doc]

Acute care NPs at my institution to central lines on the floors - not in the ED. As a resident, I did get bumped for an opportunity to put a central line on my patient because a NP wanted to teach her NP student. At that point, I didn't have a single central line under my belt. I was off-service on night shift. No attending to back me up. I'm not bitter... not a bit.

I suspect this could end up making ED docs like anesthesiologists - managers of chaos of a busy ED full of midlevels, signing their charts, and stepping in when things tank... I can refuse to work in that environment, though. If MDs refuse to work in that situation, then it can't happen. The problem is that some people are desperate or will do anything if it pays enough, no matter the risk to their patients or to their liability.

Independent practice for midlevels? No way. Not even in family practice. I was a midlevel, so I can say this louder and stronger and with more authority than most.

On the other hand, We already have midlevels in the EDs. I don't see anything wrong with them being more certified and hopefully proving they have some extra skill/knowledge to work in the ED.

 

[Indebt4Life]

So are we just going to abandon every specialty that is being infiltrated by midlevels? If this is the case, leave medicine. Because the writing is on the wall...midlevels are trying to infiltrate EVERY single specialty and primary care. They have been successful in some not all. What is happening is WRONG!! It's wrong. Don't just resign yourself to this reality. This will 100% affect us. You and your family will need care and you will find yourself with Dr. Suzy, ARNP, MSN, BSN, ACLS,DFHADLKHALKFJLADJG.

PM me if you are interested in our movement. We need active, motivated young medical students and physicians!

A perfect metaphor: We have a shortage of pilots, why don't we make flight attendants pilots. They can take a online pilot school and do 500 hours of "shadowing". This is INSANE.

 

[miacomet]

I don't think procedures are the biggest deal. It's the lack of a thought process that's most concerning with many, many midlevels.

 

[Indebt4Life]

ndependent practice for midlevels? No way. Not even in family practice. I was a midlevel, so I can say this louder and stronger and with more authority than most.

I am sorry. Could you please clarify this ? What do you mean no way? I am asking because midlevels are already independent in 22 states and COUNTING.....I say counting because new bills are being introduced this legislative season to allow NPs to be independent in the remaining states.

 

[Burnted_out]

I don't think procedures are the biggest deal. It's the lack of a thought process that's most concerning with many, many midlevels.

Exactly right. At times it "seems" some midlevels are competent, but if anything out of the ordinary or chart comes up, it's a disaster because they don't know what to do.

 

[SpartanWolverine]

... you will find yourself with Dr. Suzy, ARNP, MSN, BSN, ACLS,DFHADLKHALKFJLADJG. ...

You missed "ENP-C"

"Now, by passing the Emergency Nurse Practitioner (ENP) Certification examination, NPs may add ENP-C to their list of credentials."

 

[hundreddaysoff]

Thank god I haven't paid ACEP or ABEM or anything of these other organizations.

Was lack of board certification an issue when you were looking for jobs?

 

[thegenius]

All the major specialty organizations have abandoned us. I read up a bit on this issue. Physiciansforpatientprotection.com

Interesting website but it has virtually no information. Who are these people and what have they done so far with donated money? Have they accomplished anything?

 

[thegenius]

Was lack of board certification an issue when you were looking for jobs?

Umm....no. Not sure why you ask. But I was hired with the understanding that I would get board certified.

 

[USCDiver]

Umm....no. Not sure why you ask. But I was hired with the understanding that I would get board certified.

He asked because you said you hadn’t paid ABEM

 

[hundreddaysoff]

Umm....no. Not sure why you ask. But I was hired with the understanding that I would get board certified.

I ask because the main reason I'm paying ABEM is to get board-certified. All these politics aside, I'm afraid that if I don't get boarded, I'll have trouble finding a decent ER job.

If you aren't paying ABEM, then you won't be boarded, correct? If so it'd be somewhat of a surprise to me and I'd consider not getting boarded myself. (But I probably would anyway in the end since I'm not much of an idealist about all this stuff and if I'm onboard with y'all that ACEP/AMA etc are evil soulless capitalists then ABEM is probably the least of all those evils.)

 

[thegenius]

Ahh...Yes well I paid ABEM to get boarded. I think I was getting a little cavalier throwing out acronyms.

I am not a member of ACEP though, nor any other professional organization similarly, like AMA. And in the future before I do commit paying dues to these professional medical associations, I might pay more attention to their leadership, where they came from, their mission statements, what they intend to do to protect my job, keep salaries up, and other important things to me.

 

[LeroyJenkinsMD]

I don’t think NPs are going to be working solo in big EDs any time soon given that physicians from other specialties have been pushed out. This is nothing more than people profiting off of ego. NP are desperate to prove themselves and will pay whatever it takes to get more letters after their name.

 

[TheComebacKid]

I cannot think of anyone who sticks up for doctors.

You know who should stick up for doctors? Doctors. And I'm not talking ACEP which is a joke of an organization. I'm talking about us. But we don't. Med school/residency is hard. People just want a job that pays a lot of money. You think the people who are cashing in from TeamHealth currently care that NPs are going to take over in 10 years? No, they will be out by then. They have no respect for the profession, or for patient care, or for future physicians.

All of the physicians that work for CMGs and pay ACEP dues should take some responsibility, not the NPs or anyone else. If I was an NP I would do exactly what they are doing.

A perfect example of this is just hospital policies. Chances are you work at a hospital that is RUN by nurses. Nurses didn't have to put up with the time/investment of medicine, so they are comfortable working a 12 hour job where they focus on staffing ratios, clinical policies, and other administrative things. As a result, so much of everything we as a physicians do is based on nursing driven protocols. Physicians just don't want to deal with this stuff, so we were initially happy when the nurses wanted to do it, until they took over and screwed us. There's no turning back.

Same thing is happening with NPs. I hear people all the time talk about how great some NPs are when it comes to low acuity patients. "I'm happy they see those patients so I don't have to" they say. In similar fashion to the example above, they will take over.

STOP paying dues to ACEP who is selling you out. STOP working for a CMG that pays you better to supervise 4 midlevels and sign their charts and taken on all the medicolegal liability. STOP letting them intubate "because Suzy NP is a decent midlevel". Make ourselves the commodity we should be and demand better wages. If there is a physician shortage, then fine, make more physicians to provide better patient care, not this "heart of a nurse brain of a doctor" garbage that NPs pile on.

Physicians need to stop being so spineless. Also, the amount of sucking up I see physicians do to NPs/PAs makes me sick. "Some of them have really good training, Bobby the PA has been doing this for 20 years!" That doesn't replace medical school and residency.

 

[Frazier]

From the way it sounds, these ENP-C folks can see patients independently. Great.

It's clear from the played-out echo that comes up every week on here how you guys hate signing PA notes and being responsible for others clinical decisions. Great.

But, now you're pissed about a new development where you're removed and aren't liable?

Pretty much everything in healthcare is driven by ego and money.

The NP's likely want the certification for ego and hopes of commanding increased $$$.

Know why the majority of docs and medical students on here cringe? HINT: The same factors. Ego ("I did 7 years of miserable training, damn it! ...You mean memorizing all those disorders of metabolism COFACTORS wasn't necessary to the competent practice of EMERGENCY MEDICINE? Blasphemy!) and $$$ ("Oh crap, this is going to drive down demand and therefore hurt my income").

SDN tends to lean radically against APPs.

The guise of "this is an outrage, we must stop this for our dear patients!" is somewhat laughable being how most ED docs are burnt out, don't like/hate the majority of their patients, and want to maximize their hourly wage so that they can minimize their patient care hours.

You guys complain about having to see too high a PPH in the ED. How does one fix that? Get more physicians! Oh wait, you guys are pissed off about residency expansion which would create more physicians.... Okay, let's not go for more residents, let's increase APP's! Oh, wait we don't like that idea either because they will take our jobzzz having not once memorized every way the body can use pyruvate! Okay, let's not increase the workforce in any way, but hmm how do we get the ever increasing amount of patients seen in a reasonable time?! "Looks like you need to increase that PPH, doc!"

It's fine that the above is the reality, but at least own it: a perfect solution that makes everyone happy is impossible.

Let's be real.

 

[wamcp]

From the way it sounds, these ENP-C folks can see patients independently. Great.

It's clear from the played-out echo that comes up every week on here how you guys hate signing PA notes and being responsible for others clinical decisions. Great.

But, now you're pissed about a new development where you're removed and aren't liable?

Pretty much everything in healthcare is driven by ego and money.

The NP's likely want the certification for ego and hopes of commanding increased $$$.

Know why the majority of docs and medical students on here cringe? HINT: The same factors. Ego ("I did 7 years of miserable training, damn it! ...You mean memorizing all those disorders of metabolism COFACTORS wasn't necessary to the competent practice of EMERGENCY MEDICINE? Blasphemy!) and $$$ ("Oh crap, this is going to drive down demand and therefore hurt my income").

SDN tends to lean radically against APPs.

The guise of "this is an outrage, we must stop this for our dear patients!" is somewhat laughable being how most ED docs are burnt out, don't like/hate the majority of their patients, and want to maximize their hourly wage so that they can minimize their patient care hours.

You guys complain about having to see too high a PPH in the ED. How does one fix that? Get more physicians! Oh wait, you guys are pissed off about residency expansion which would create more physicians.... Okay, let's not go for more residents, let's increase APP's! Oh, wait we don't like that idea either because they will take our jobzzz having not once memorized every way the body can use pyruvate! Okay, let's not increase the workforce in any way, but hmm how do we get the ever increasing amount of patients seen in a reasonable time?! "Looks like you need to increase that PPH, doc!"

It's fine that the above is the reality, but at least own it: a perfect solution that makes everyone happy is impossible.

Let's be real.

APP? Correct term is midlevel

 

[miacomet]

APP? Correct term is midlevel

While it upsets me thsty EMR refers to me as a "provider" it makesr happy that midlevels are referred to as such.

 

[GonnaBeADoc2222]

The guise of "this is an outrage, we must stop this for our dear patients!" is somewhat laughable being how most ED docs are burnt out, don't like/hate the majority of their patients, and want to maximize their hourly wage so that they can minimize their patient care hours.

You guys complain about having to see too high a PPH in the ED. How does one fix that? Get more physicians! Oh wait, you guys are pissed off about residency expansion which would create more physicians.... Okay, let's not go for more residents, let's increase APP's! Oh, wait we don't like that idea either because they will take our jobzzz having not once memorized every way the body can use pyruvate! Okay, let's not increase the workforce in any way, but hmm how do we get the ever increasing amount of patients seen in a reasonable time?! "Looks like you need to increase that PPH, doc!"

It's fine that the above is the reality, but at least own it: a perfect solution that makes everyone happy is impossible.

Let's be real.

No reasonable EP worth their salt should have an objection to seeing 2 pph, provided that they work in a supportive environment (acceptable EMR that doesn't crash 3x/shift, good scribes / dictation software, reasonable consultants and nurses).

To address your points:

1) Residency expansion not only expands the supply pool (bad for EPs) but is also bad for patients. A residency should not be allowed to start at a low acuity non-trauma center community hospital - CMGs and large regional hospital systems that act like CMGs are pushing this through to further their financial interests.

2) The correct term is midlevel. There is nothing "advanced" about most of these people. APP is a PC term invented by CMGs and their professional societies, again, to further their financial interests. There is nothing about this that is good for patients. Society needs to make a decision: do you need a be a residency trained physician in order to practice medicine or not? We went to medical school and learned all of those details to understand the "why" behind what we are doing. The choice is between having a technician who is following a protocol vs an expert who understands the "why" behind their actions and when seemingly innocuous presentations deviate from "protocol."

3) "Reasonable time" is a debatable definition. Potentially high acuity presentations such as chest pain and abdominal pain should be seen as soon as possible. Clear viral syndrome w normal vitals, dental pain, chronic pain, suture removal, conjunctivitis, etc. etc, can wait 6 hours for all I care. These are low acuity charts with low billing anyway.

We've lost folks. People aren't going to all up and leave their CMG jobs, stop going to ACEP, etc.

I imagine the only way this changes is when some politician's kid is diagnosed with "viral syndrome" by Dr. *****, DNP, MS, ACLS, PALS, ATLS and it turns out to be ALL or Kawasaki's.

 

[InternistDO]

From the way it sounds, these ENP-C folks can see patients independently. Great.

I'm pretty sure thats not what this means.

But, now you're pissed about a new development where you're removed and aren't liable?

I'm pretty sure this isn't true either

 

[emergentmd]

This is a smaller issue than all of the new residencies popping up supported by CMGs. Another nail in the coffin of EM. Sad but not different than most other fields are facing, just different issues.

 

[Indebt4Life]

It is a HUGE conspiracy. Trace the money. It's all about the money. Turn on the TV...look at the wechooseNPs commercial, the Johnson and Johnson commercial about how amazing nurses are....these commercials are playing in primetime. Ask yourself where this money is coming from? How did the AANP get so much power? Robert Wood Johnson Foundation. That's how.

Now, read the recent HHS report, go to scope of practice (page 35?). What do you think is happening on a FEDERAL level?
https://www.hhs.gov/sites/default/f...0mJsZ3auZncldL3K_P5uUU5R9SwA3dpbl7bqBtzCHc_2o

 

[LeroyJenkinsMD]

It is a HUGE conspiracy. Trace the money. It's all about the money. Turn on the TV...look at the wechooseNPs commercial, the Johnson and Johnson commercial about how amazing nurses are....these commercials are playing in primetime. Ask yourself where this money is coming from? How did the AANP get so much power? Robert Wood Johnson Foundation. That's how.

Now, read the recent HHS report, go to scope of practice (page 35?). What do you think is happening on a FEDERAL level?
https://www.hhs.gov/sites/default/f...0mJsZ3auZncldL3K_P5uUU5R9SwA3dpbl7bqBtzCHc_2o

Can’t wait to get my online law degree so that I can start suing nurses who skip medical school and play doctor.

 

[Darth Doc]

I am sorry. Could you please clarify this ? What do you mean no way? I am asking because midlevels are already independent in 22 states and COUNTING.....I say counting because new bills are being introduced this legislative season to allow NPs to be independent in the remaining states.

I mean - no way is it a good idea. I 100% know it exists. My husband is a NP. I know that the AAPA is now promoting independent practice. When I became a PA it was ingrained in us that a benefit of PAs is that we are supposed to always work with MDs because we can't know everything. in the last 20 years a lot has changed, and it's not to help patients - it's to help themselves.

 

[Stagg737]

Interesting website but it has virtually no information. Who are these people and what have they done so far with donated money? Have they accomplished anything?

I'm part of the FB group which has been around for a while and is the source of the website. The website's a relatively new venture, but we're hoping it will lead to a more powerful voice for doctors on the subject of mid-level independence in the public and political arenas. As a group we've stopped several bills from being passed and are in contact with quite a few legislators at the state level. We've also had a couple of members run for their states' congress. If you want more info or are interested in joining, PM me and I'm happy to provide more info and inform the one of the senior members of PPP (who is on SDN) that you're interested.

I know it probably sounds like some scam or some randomly thrown together group, but the FB group has almost 10,000 physicians in it. This is a legitimate group with the goal of protecting our patients through several means. One of them being to prevent further expansion of mid-levels practicing unsupervised.

 

[RealHLA11]

After doing 2 EM rotations as IM, and now as a hospitalist, I have the utmost respect for EPs and think y'all deserve every penny that you make. My facility has great EPs and we rarely have to question an admission. But I dont even want to imagine the sh*tshow of BS admissions that will be coming through from midlevels. I would quit in a heartbeat if admin pressed for us to accept those admissions no questions asked.

 

[emergentmd]

After doing 2 EM rotations as IM, and now as a hospitalist, I have the utmost respect for EPs and think y'all deserve every penny that you make. My facility has great EPs and we rarely have to question an admission. But I dont even want to imagine the sh*tshow of BS admissions that will be coming through from midlevels. I would quit in a heartbeat if admin pressed for us to accept those admissions no questions asked.

Oh its coming or will be. Our hospital system has a no question transfer policy. If someone calls, a bed is assigned. You get the call after and all you can say is "yes"

 

[turkeyjerky]

Oh its coming or will be. Our hospital system has a no question transfer policy. If someone calls, a bed is assigned. You get the call after and all you can say is "yes"

Is this only for only for transfers or also admissions from the ED?

 

[emergentmd]

Is this only for only for transfers or also admissions from the ED?

Just transfers but where I work it might as well be admissions. All APP admissions are run through the EM doc on. But we have a good hospitalist group that will take almost anything

 

[medstud22]

Holy cow! I cannot believe that your governing body is supporting this idea! You guys need to put a kaibash to this urgently! You can’t let this start up and take over your profession. This will solely benefit CMGs that’ll hire these sub trained providers to replace you guys for cheap. Will not reduce the over all cost at all and patient care will tank, the profits for CMGs will soar. Do whatever necessary, refuse to train these bozos, start another governing body or whatever. This is where it starts.

 

[RealHLA11]

Oh its coming or will be. Our hospital system has a no question transfer policy. If someone calls, a bed is assigned. You get the call after and all you can say is "yes"

That sucks. We get final say...obviously I take most things but if emergent workup isnt complete, pt sounds unstable, subspecialist doesnt accept, or "patient doesnt like this hospital and wants to be transferred your similarly capable facility", I'm not accepting.

 

[RNtoMD87]

I know critical care NPs/PAs place art/central lines unsupervised after like 10 supervised of each. They dont get to intubate where I am, though.

Really? I've seen RNs and RRTs intubate where I am.