Working with MLPs

[Groove]

Can some of you elaborate on the working arrangement with your MLPs in your current shop?

What's your general comfort level?

My current shop is somewhat in disarray due to loss of providers, changing of ED contracts, etc.. and we are moving to having MLPs in the main side of the ED during night shifts with only one EP. For some background... this is a level II, very busy, very sick, 90K annual ED. There are approx 25 beds on the "main side" with the rest usually blocked off. We have a pod set up. 50 something beds total. EP with MLP in each pod, double and briefly triple coverage in the main ED. The other pods are generally lower acuity or "not going to die in the next hour" type of patients and we routinely will staff a pod with a NP and I generally have no problem with this set up. I'm bothered by the thought of running the main ED where anything can happen with a NP who needs supervision. We have one or two really good ones and you have some that I really would not want doing any invasive procedure whatsoever without me there and many times I simply am not comfortable when they put my name down on a patient without me laying eyes on them and agreeing with their work up. Part of me feels this is a situation resultant of poor staffing that is ripe for a bad outcome but I'm curious if this is just the future of EM or if I'm just being overly conservative and paranoid? Do you guys routinely use MLPs in the acute sections of your ED without incident/problem?

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[RustedFox]

Do you guys routinely use MLPs in the acute sections of your ED without incident/problem?

No. Hells to the naw.

MLPs can only pick up triage level 4/5s at my shop. We had one MLP send home a PE because s/he didn't observe this rule. Buh-bye.

 

[Khaos]

I do think we are heading this way to keep us above water. I have seen physicians send home appy's, PE, ACS, etc...so just because an MLP sent one home means nothing to me. Heck, I remember moonlighting in one spot where I saw one patient that I couldn't understand why the doc sent him home...his complaint was HA, oh by the way his temp was 103 orally. That was his only complaint the day before when he was seen and his only complaint when I saw him. He was diagnosed with sinusitis and sent home the day before. Of course he had meningitis. This was 2 years ago.

MLP's in the main ED are coming and I don't see us doing much about it. You can teach them to do procedures just as easy as we were taught as residents. Think of some of the residents you worked with and realize they learned to do all those procedures too. I shudder when I remember some of the IM residents doing some of those procedures. They can work up a belly pain and CP just as easy as we do. The truth is most of what we do is all algorithms. We just don't want to admit it. CP in a greater than 40 year old, unless an obviously bogus story, will get labs, enzymes, ekg, cxr, ASA, pain meds and admission for rule out. Abd pain in an older patient will get belly labs, pain/nausea meds, and a CT scan. Tell me why an MLP can't do that?

I work at a place that sees 100k sick patients and upstairs, if the intensivist is not available right away (they aren't always in house), the respiratory therapist intubates. You can't tell me an MLP can't intubate but you let a respiratory therapist intubate.

I know that many people are uncomfortable with this right now but to keep us above water and to keep the money the same you are going to have to add MLPs that aren't as expensive as adding another doc shift. Of course it will take time. If you are uncomfortable with the MLP, then take the time to teach them or get rid of them for one that you think you can teach.

 

[deleted6669]

Khaos- thank you for that. I appreciate hearing from docs that they are willing to work with PAs who have demonstrated competence. I agree new grad PA/NP folks should be on a short leash for a few years but once you are comfortable with their skills and decision making process it's fair to treat them like a resident and let them come to you for consults(and they will) and support them when they need help. we will help you guys keep the dept from getting over run. in return please help us all to be the best providers we can be. I'm not afraid to say I don't know everything and will seek out a specialty consult whenever appropriate. over time I have worked my way up from fast track to intermediate to working in the main dept and have had supportive physicians and senior PAs helping me along at each step of the way.

 

[Rendar5]

Gotta know which midlevels you can trust and which you can't. Daytime is a separate fastrack area and they solo it coming over for physician second opinions on workups and such. When Fast track is closed, we have them in the main area splitting charts with us. Though, they generally shy away from the more high risk cases (they let chest pains pass right by their hands, even if it's straight forward ACS admission and I encourage them to take the chart to learn, lol). Regardless, while they're there, the volume's low enough that I can keep an eye on all incoming patients so I can direct them to which pt's are appropriate and which aren't, and help them if things get dicey for some reason on these main patients. I trust them to do appropriate workups and to come to me when there's something complex or high risk to ensure that I agree with their plan.

They're generally much smarter and more effective than my PGY-1/2's (family med and transitional residents)

 

[bougiecric]

Khaos: do you believe you have anything to offer a patient that an MLP doesn't?

 

[EM_Rebuilder]

My question is, what are people getting paid to be a MLP supervisor doctor? In Texas, we just have to review 10% of their charts. We have good liability protection in Texas, but they are still a liability.

We get paid a whopping $500 dollars per month to have a MLP under us. Admins argument is that 'all you have to do is sign 10% of the charts'. To me, that's no big deal, the issue are the 14 shifts/12 hours is 300+ patients per month being seen under my license.

So, is $500 fair? What are other people out there getting? I have tried to figure this out before but have not had any luck other than straight RVU places that see/sign most of the MLP charts and keep a percentage of the billing....

 

[deleted6669]

at my primary job the docs take 50% of the production on every chart they sign, more if they also see the pt.
a doc supervising 2 PAs(our standard arrangement) makes 100% of their own production + at least 50% of each PAs so they basically make 2 em mds production/hr + their base salary. not a bad gig for them.
at my 2 rural per diem jobs the docs are just expected to sign our charts and get nothing extra besides our help for doing so. if we are not there they are solo coverage and many days they don't have a pa so see 40 pts/shift by themselves.

 

[Groove]

Thanks for the input. I just can't imagine running 25 beds of sick, sick patients with a NP that is putting my name down on virtually every patient that they are seeing. I'm only human. I can do 2.5-3pph but after that I feel like a train at reckless speed waiting for a loose rail pin. My comfort level is more around 2.3-2.5. With this new system of having a single MLP on the main side with the EP, I can't see a way that I'm not liable for a poor outcome, especially when I'm the one having to sign the chart later. If this is the future of EM, then I want no part of it and I'll actively look for environments that don't utilize this model. I'm fine with MLPs in certain capacities and certainly welcome their help with patients in the ED and there are good/bad ones where I don't need to see every patient, etc.. but running the main part of a busy trauma center ED sounds ludicrous to me. We're talking about MLPs that traditional have been seeing 4's and 5's and some "easier" 3's, now seeing all 3's and 2's.

 

[RustedFox]

I'm fine with MLPs in certain capacities and certainly welcome their help with patients in the ED and there are good/bad ones where I don't need to see every patient, etc.. but running the main part of a busy trauma center ED sounds ludicrous to me. We're talking about MLPs that traditional have been seeing 4's and 5's and some "easier" 3's, now seeing all 3's and 2's.

This is why the policy that I mentioned above is important. You can say "just because one MLP sent one bad one home it means nothing to me"... until you're the guy who has to hold the bag for the obvious missed PE (it was pretty obvious in the case above upon review; everything in the chart suggested PE, from initial vitals to risk stratification to everything). Its not about measuring 'capabilities' or 'models of practice' or whatever. Its about liability and responsibility.

 

[deleted6669]

some systems allow PA/NP folks to see level 3-5 independently and present level 1 and 2 immediately after initial eval like an intern. seems to work pretty well. I used to work at a place like this and there were no problems. if there were 2 critical pts at the same time I ran one in consultation with the doc. generally I would present the pt, they would stick their head in the door for a sec, maybe repeat part of the exam, look at the labs and diagnostics and sign the admit. it's not like anyone is going to send a stemi or dka home even based on a limited 1 min presentation. how much do you need to hear before you say " I agree, sounds like a keeper"? If I was over my head I would present the pt and say " I don't know where to go from here, why don't you take this one" or we would comanage them . over time that happened less and less as I learned from working with some excellent docs.
if you have criteria in place that say " all patients in the main dept over 65 or those with the following XYZ complaints or triaged 1-2 shall be discussed with an emergency physician contemporaneously". we had a green/yellow/red triage system. docs started at red and worked down. PAs started at green and worked up. when fast track and intermediate areas are closed all those folks still arrive and need to be seen when main is the only option. a pa or np is still a good option for seeing those folks even if they are being seen in a different location. just being a "main pt" doesn't always mean ubercomplex. at 3 am strep throat or an ankle sprain are still "main pts" because there is nowhere else for them to go. at many places there isn't enough money to staff 2 em mds 24/7 so if the option is solo coverage or an md/do + a pa/np I think most folks would appreciate the help. Selecting appropriate candidates to work in main is important as well. 5+ yrs of em experience with gradual increase in scope of practice and witnessed procedural skills is a good place to start.

 

[Arcan57]

There aren't enough docs to staff the EDs of America and there is no current cap on mid level production like there is with ACGME residency spots. Combined with the fact that most hospitals that have a choice won't hire non EM trained docs but will take MLPs with little to no experience, the future of
EM is an EP supervising multiple providers. <dons flame ******ant suit> This may change the calculus of 3 vs 4 yr programs due to the increased experience in a supervisory role for 4 yr programs.

 

[RustedFox]

There's a difference between 'presenting the patient' to the attending and working them up/making decisions with guidance/together and "Here, sign these charts LOLZ - now I'm just like you."

The OP's question was 'Do you routinely use MLPs in acute sections of the ED without problems?"

The answer for me, is no.

I taught a lot of the PA classes at a place where I used to live/work. The lack of underlying pathophys or mechanistic understanding of what you're doing (in the curriculum) was staggering. Instead of learning say "Zofran acts on the 5HT-3 receptors as an agonist", it was simply "Zofran is good for nausea and that's good enough." Serious lack of understanding of critial aspects of phys/path/pharm.

 

[SeekerOfTheTree]

There's a difference between 'presenting the patient' to the attending and working them up/making decisions with guidance/together and "Here, sign these charts LOLZ - now I'm just like you."

The OP's question was 'Do you routinely use MLPs in acute sections of the ED without problems?"

The answer for me, is no.

I taught a lot of the PA classes at a place where I used to live/work. The lack of underlying pathophys or mechanistic understanding of what you're doing (in the curriculum) was staggering. Instead of learning say "Zofran acts on the 5HT-3 receptors as an agonist", it was simply "Zofran is good for nausea and that's good enough." Serious lack of understanding of critial aspects of phys/path/pharm.

Thank you. This is precisely my problem. I have no problem with midlevels. I have no problem with PAs that understand that PA means Physician Assistant. I had a PA approach me at a party and ask me where I worked and asked about my salary. She said to me why do you make twice my salary when I do the same things as you. After I explained the difference to her she still didn't seem to get it and said well I guess you went to school two more years...yes that must be it. If you work in corporate you might think you can do the job of your CEO, but realize that your CEO has a lot more responsibility than you and know your role. We are going to turn ourselves into Bobs eventually if we give management of critical care patients away as well.

We are physicians, we should stop loathing ourselves and always belittling our profession in front of mid-levels and nurses just to make them feel better about themselves. We are a team and they are our colleagues and we should respect them; however, that does not make them our equals in terms of clinical knowledge or level or responsibility and liability.

If ER is a profession that you can take a midlevel and train them for five years and they will be as good as you then ER residency is pointless. You could take FM and IM residents and let them work and train under attendings to be as good as us with the clinical knowledge of physician and the path/phys behind it.

 

[RustedFox]

If ER is a profession that you can take a midlevel and train them for five years and they will be as good as you then ER residency is pointless. You could take FM and IM residents and let them work and train under attendings to be as good as us with the clinical knowledge of physician and the path/phys behind it.

This, and not only this but; if the above is true, then I'd like to cancel my existing debt with the federal government. Someone then owes me a lot of money.

 

[RustedFox]

If ER is a profession that you can take a midlevel and train them for five years and they will be as good as you then ER residency is pointless. You could take FM and IM residents and let them work and train under attendings to be as good as us with the clinical knowledge of physician and the path/phys behind it.

I find more and more frequently that there are two flavors of MLPs/people aspiring to be MLPs:

1.) There's the veteran RN who has worked in (specialty) for years and years and wants to increase his/her earning potential and knowledge base, already knows the 'works' of their field, and is looking to further understand the science of medicine and make a real difference...

and 2.) There's the "I just got my RN so I can go and be an NP/PA cause I want to wear a white coat and feel important, but I wanted to cut out as much of that 'science' stuff as possible, because its hard."

I'm fortunate to have more of (1) than (2) at my shop - but I see more (2)s than (1)s in my goings about.

 

[Makati2008]

There's a difference between 'presenting the patient' to the attending and working them up/making decisions with guidance/together and "Here, sign these charts LOLZ - now I'm just like you."

The OP's question was 'Do you routinely use MLPs in acute sections of the ED without problems?"

The answer for me, is no.

I taught a lot of the PA classes at a place where I used to live/work. The lack of underlying pathophys or mechanistic understanding of what you're doing (in the curriculum) was staggering. Instead of learning say "Zofran acts on the 5HT-3 receptors as an agonist", it was simply "Zofran is good for nausea and that's good enough." Serious lack of understanding of critial aspects of phys/path/pharm.

99% of the time I agree with you but the final portion I'll partially disagree. My program was VERY heavy Pharm. wise( so much so that I didn't have to study for it much in medical school->literally the day before the test but then again I might be an outlier?)

Also I agree path and physio is a weakness of PA school. They should focus on that instead of pushing more people out to practice.

 

[The White Coat Investor]

I work with PAs every shift. They generally see the "fast track" type patients. Their level of competence on abdominal pain, chest pain, dyspnea in anyone over 30, and even headache is far too low, much less having them see anyone you might consider intubation in or who could die in the next hour. It sounds to me like your job is becoming a mega-toxic. Consider an exit plan.

 

[EMCritCare]

If ER is a profession that you can take a midlevel and train them for five years and they will be as good as you then ER residency is pointless.

Unfortunately, as EM continues to redefine itself as a specialty focused on episodic ambulatory care and admission triage based on the financial and regulatory landscape in which it finds itself, it becomes increasingly easy for our employers to view us as over priced and over skilled labor. Whether the employer is a mega group or healthcare system or one of the increasingly rare small physician run groups, the financial calculus will pretty much be the same when it comes time to think about how to maximize revenue for those with substantive ownership stake in the enterprise.

A physician skill set is probably unnecessary for the clear majority of what is seen in the ED on a day to day basis. As EM continues to de-emphasize the work up and management of complex and/or critically ill patients in favor of responding to prevailing incentives by catering to ambulatory patients who will be discharged and fill out PG surveys, it becomes harder and harder to argue that an experienced PA or NP can't assume the responsibility of managing the bulk of ED patients. They can order labs and CTs, call consults, admit when in doubt, etc.

If you look at these factors in aggregate: undersupply of EPs, increasing focus of ED resources and attention on ambulatory patients, and a growing supply of comparatively cheap NP and PA labor, it makes sense for management to staff EDs with only the minimum needed level of EP manpower.

If an EP is needed to co-sign in order to maximize billing, then EPs will, not surprisingly, be incentivized or coerced into doing so as to maximize revenue for those with substantive ownership stake (whether they are partners in a physician run group or CEOs in a healthcare system). If an EP is needed in order to assume shared liability/shift liability in the inevitable event of an ambulatory patient who was more complex than it seemed or during the ED stabilization of a critically ill patient, then we will be forced to assumed this role as well.

While it would come at the cost of reduced demand for EPs and reduced need for our services, I believe that the only way to remove the frontline EP from the awkward position of being used as a tool to increase midlevel billings (which he may not get to share in) and almost certainly as a pawn by which to absorb liability, would be to make midlevels fully independent in billing (same pay for same work) and fully independently privileged within hospitals (no automatically assumed involvement of co-worker EPs, no automatic obligation of co-worker EPs to provide consultations as it would constitute double billing within same department for same service encounter, and no assumption of shared liability). No doubt, once the supply of midlevels allows, there would be a significant decline in demand for EP manpower under such a system. But maybe, just maybe, the EP jobs remaining would allow for focus on the sickest patients, those with more complex medical issues, and free us from the headache of limited rewards in exchange for uncontrolled increases in liability.

Let the midlevels practice fully independently. For the majority of ED patients, it probably won't make a difference in outcomes, and they'll probably enjoy the customer service they get from NPs to boot. For the EPs that remain, they'll likely (hopefully) be marshaled to take care of the patients that actually need their skill set.

 

[goodoldalky]

make midlevels fully independent in billing (same pay for same work) and fully independently privileged within hospitals. . .Let the midlevels practice fully independently.

This is pure insanity to me.

The point is that there is a reason medical school and residency are required to practice medicine independently. Medicine is hard to practice, it takes on the order of a decade or more to learn, and it is relatively easy to kill or mangle somebody. Same pay for same work? We are paid like we are because of the training and expertise that goes into our work. The more training and expertise that is required, the higher the quality and cost. The knowledge of the pharmacology, pharmacokinetics, drug interactions, and side effects that go into prescribing even an antibiotic for UTI or CAP improve the quality of care provided and are acquired over a period of ~10 years of intensive study and practice in the case of an MD. That should be reimbursed at a higher rate even if the ultimate prescription looks the same to the patient and pharmacist.

For the majority of ED patients, it probably won't make a difference in outcomes, and they'll probably enjoy the customer service they get from NPs to boot.

I disagree with your logic here as well. We are not paid as emergency physicians to see medication refill and ankle pain and send them home with scripts and ankle splints. We are paid to see the medication refill who happens to be stumbling across a life threatening drug interaction and address it. We are paid to see ankle pain that's actually a vascular catastrophe and pick it up even when they are mistriaged as a level 5. We are not even really paid to run ACLS on the obviously dying patient and intervene but rather to find the patient who is on the verge of dying in a subtle manner and make a difference there. We are paid to find the little landmines that walk into the ED on a daily basis that someone less prepared or less experienced might miss and that's a really difficult thing to do.

Advanced care practitioners can be great at what they do. They cannot, and should not practice emergency medicine independently. To suggest so is to suggest that we accept a lower, more dangerous, inappropriate standard of care. The idea that we should support that idea just because physicians are being tagged with assuming liability for PA's would be a short-sighted solution which would cause about a hundred and fifty seven thousand other more serious problems.

 

[deleted6669]

Even ACEP admits that only 5% of pts presenting to emergency departments across the united states have true life threatening emergencies.
Think about your last shift. how many of your pts could not have been seen with the same outcome by an fp physician or a quality em pa? how many small to medium sized community hospitals don't even staff 100% residency trained and boarded er docs?
one of my jobs is at a busy trauma ctr. Aside from folks going directly to the O.R. for trauma, the cath lab for stemis, and the interventional neuro team for acute stroke, most patients could be seen by someone other than a residency trained, board certified emergency medicine physician with similar outcomes. you guys are great at folks dying right here, right now. but as ACEP admits, that is 5% of a typical ER population. at my busy facility that is maybe 10 pts/24 hrs. the other 190 could be seen by lots of other qualified providers and most of those I could handle with minimal physician input. my last shift for example I took care of a guy with a large intracranial bleed on xarelto. told my atending about it after starting the workup and his only comment was" good job". he didn't even duck his head in the room during the intubation or the remainder of the pts stay in the dept. you guys need to be there for the "big cases" and to be available for the occasional consults, but the majority of what you guys do, including procedures, can be done by other folks as well with different levels of training. most pts who present to emergency departments are not dying in front of you. most have level 3-5 complaints. many could have been seen in an fp office or urgent care ctr.I have all the respect in the world for you guys but you don't corner the market on taking care of folks with emergency complaints. I couldn't do my job without you guys but more and more you couldn't do your jobs as well as you do without someone around like me taking up a lot of the slack, both by seeing lower acuity pts, but by also seeing sicker folks if the whole department is full of them.

 

[SeekerOfTheTree]

Unfortunately, as EM continues to redefine itself as a specialty focused on episodic ambulatory care and admission triage based on the financial and regulatory landscape in which it finds itself, it becomes increasingly easy for our employers to view us as over priced and over skilled labor. Whether the employer is a mega group or healthcare system or one of the increasingly rare small physician run groups, the financial calculus will pretty much be the same when it comes time to think about how to maximize revenue for those with substantive ownership stake in the enterprise.

A physician skill set is probably unnecessary for the clear majority of what is seen in the ED on a day to day basis. As EM continues to de-emphasize the work up and management of complex and/or critically ill patients in favor of responding to prevailing incentives by catering to ambulatory patients who will be discharged and fill out PG surveys, it becomes harder and harder to argue that an experienced PA or NP can't assume the responsibility of managing the bulk of ED patients. They can order labs and CTs, call consults, admit when in doubt, etc.

If you look at these factors in aggregate: undersupply of EPs, increasing focus of ED resources and attention on ambulatory patients, and a growing supply of comparatively cheap NP and PA labor, it makes sense for management to staff EDs with only the minimum needed level of EP manpower.

If an EP is needed to co-sign in order to maximize billing, then EPs will, not surprisingly, be incentivized or coerced into doing so as to maximize revenue for those with substantive ownership stake (whether they are partners in a physician run group or CEOs in a healthcare system). If an EP is needed in order to assume shared liability/shift liability in the inevitable event of an ambulatory patient who was more complex than it seemed or during the ED stabilization of a critically ill patient, then we will be forced to assumed this role as well.

While it would come at the cost of reduced demand for EPs and reduced need for our services, I believe that the only way to remove the frontline EP from the awkward position of being used as a tool to increase midlevel billings (which he may not get to share in) and almost certainly as a pawn by which to absorb liability, would be to make midlevels fully independent in billing (same pay for same work) and fully independently privileged within hospitals (no automatically assumed involvement of co-worker EPs, no automatic obligation of co-worker EPs to provide consultations as it would constitute double billing within same department for same service encounter, and no assumption of shared liability). No doubt, once the supply of midlevels allows, there would be a significant decline in demand for EP manpower under such a system. But maybe, just maybe, the EP jobs remaining would allow for focus on the sickest patients, those with more complex medical issues, and free us from the headache of limited rewards in exchange for uncontrolled increases in liability.

Let the midlevels practice fully independently. For the majority of ED patients, it probably won't make a difference in outcomes, and they'll probably enjoy the customer service they get from NPs to boot. For the EPs that remain, they'll likely (hopefully) be marshaled to take care of the patients that actually need their skill set.

Let's keep up doing what we are doing to our profession and this will be the future. Why require an EM physician even for the sick ones. Line the patient up which PA, NPs and RTs can do apparently at some institutions and send them to ICU. You know most seasoned nurses up there are great at fluid, pressor, and antibiotic management with the PharmDs so we can call intensivist when we need a bronch. Actually ID is consulted to manage antibiotics most of the time and an bronchoscopy NP could probably get cultures so we really don't need the intensivist either. Reduce medicine to actions orchestrated by puppets for money and our profession becomes that of a cheap *****.

But let's keep this up. Let's let NPs and PAs do a little bit more and eventually only fields that will require MDs are surgical fields based on this reductionist mentality.

 

[deleted6669]

delete

 

[Rendar5]

seeker, you're a little early in your training to be so vocal =p if your'e a med student as your profile suggests, a little humility now goes a long way. By all means get bombastic in a few more years when you've got the experience to back you up.

 

[SeekerOfTheTree]

seeker, you're a little early in your training to be so vocal =p if your'e a med student as your profile suggests, a little humility now goes a long way. By all means get bombastic in a few more years when you've got the experience to back you up.

Not a med student anymore. Maybe if few more in years ahead of us had been a little more vocal and politically active we wouldn't be left cleaning up the massive dumps they left behind.

 

[RustedFox]

Not a med student anymore. Maybe if few more in years ahead of us had been a little more vocal and politically active we wouldn't be left cleaning up the massive dumps they left behind.

This, and then some.

*Psst. Change your profile status, dick.*

 

[OCDEMS]

There is an interesting point of discussion that I'd like to hear from the current docs:

When I read virtually anything anymore about the future of medicine, mid-levels are typically at the forefront of the discussion. Some of the points made in the popular media are valid, and certainly there is a prominent place for mid-level providers in the future of medicine, but can anyone articulate to me how it became a near colloquialism in this country to assume that mid-levels are the only way to solve our healthcare shortages?

As a medical student, I see this very organized culture among the physicians that lecture and teach all of us. No other profession I've encountered has such a storied and organized way of disseminating information, and perhaps more so, instilling a way of life to their future colleagues. How did a profession, one typically with at least decent incomes and population, allow this to occur politically? It just seems amazing that the idea of mid-levels as a solution has been allowed to walk past such a politically strong group of professionals. Perhaps I'm missing something. I see it getting talked about on here a lot, and it certainly has traction in our school, but where are the multi-million dollar ad campaigns, bus stop posters, and national discussion on the value of physician-lead patient care? Johnson and Johnson seems to have no problem plastering my TV with nursing commercials. Where is our corporate sponsor?

One thing is for certain, medical school can really grind you some days. It's incredibly intense and, let's be honest, parts of it are a real pain. All of you have done it. I can't imagine spending all of this money and devoting so much of my life to the definitive treatment of my patients only to have someone tell me in 10 years that it was a financial mistake. I am constantly amazed how much we learn and the intensity in which we learn it. I'd be super irritated if it was "unnecessary" and, given the little bit I know so far, I can't imagine it being so. Something tells me that physicians have a good argument to be made and that we're just not fighting dollars with dollars. There has to be some organization out there, some intermediary with our future in mind, asking for physicians to stroke a check, right?

 

[SeekerOfTheTree]

Even ACEP admits that only 5% of pts presenting to emergency departments across the united states have true life threatening emergencies.
Think about your last shift. how many of your pts could not have been seen with the same outcome by an fp physician or a quality em pa? how many small to medium sized community hospitals don't even staff 100% residency trained and boarded er docs?
one of my jobs is at a busy trauma ctr. Aside from folks going directly to the O.R. for trauma, the cath lab for stemis, and the interventional neuro team for acute stroke, most patients could be seen by someone other than a residency trained, board certified emergency medicine physician with similar outcomes. you guys are great at folks dying right here, right now. but as ACEP admits, that is 5% of a typical ER population. at my busy facility that is maybe 10 pts/24 hrs. the other 190 could be seen by lots of other qualified providers and most of those I could handle with minimal physician input. my last shift for example I took care of a guy with a large intracranial bleed on xarelto. told my atending about it after starting the workup and his only comment was" good job". he didn't even duck his head in the room during the intubation or the remainder of the pts stay in the dept. you guys need to be there for the "big cases" and to be available for the occasional consults, but the majority of what you guys do, including procedures, can be done by other folks as well with different levels of training. most pts who present to emergency departments are not dying in front of you. most have level 3-5 complaints. many could have been seen in an fp office or urgent care ctr.I have all the respect in the world for you guys but you don't corner the market on taking care of folks with emergency complaints. I couldn't do my job without you guys but more and more you couldn't do your jobs as well as you do without someone around like me taking up a lot of the slack, both by seeing lower acuity pts, but by also seeing sicker folks if the whole department is full of them.

Great you're a spectacular PA. That's amazing. You would easily have been an MD but you decided not to go to medical school. As long as you realize the role is to assist and be a mid level you're content realizing that there is mutual respect. That's my only complaint with mid levels where there is this I could do your job complex. If your logic is correct we don't need PAs we can train techs to run EDs for cheaper. Give them five year apprenticeship and they'll be like you. According to you we could make medicine like vocational training. Anyone can be taught to go through the motions.

Unless your attending was doing a perimortem c section or actively massaging a heart while rushing a patient to the OR I don't see why he wasn't involved in this 5 percent case which requires EM physicians. This is the problem. Some attendings get lazy and sit around surf their entire shift and make the money on back of mid levels. Matter of time till insurers catch up and cut where they see this. Matter of time.

You did great this case great. I don't know of attendings at my institution that would let a third year manage this without being in the room more than to say hello.

Not to sound like a prick but I appreciate when PAs are around but I have never been like man I wish a PA was here so I would know what to do.

 

[SeekerOfTheTree]

This, and then some.

*Psst. Change your profile status, dick.*

Sorry lol. Changing now.

 

[SeekerOfTheTree]

There is an interesting point of discussion that I'd like to hear from the current docs:

When I read virtually anything anymore about the future of medicine, mid-levels are typically at the forefront of the discussion. Some of the points made in the popular media are valid, and certainly there is a prominent place for mid-level providers in the future of medicine, but can anyone articulate to me how it became a near colloquialism in this country to assume that mid-levels are the only way to solve our healthcare shortages?

As a medical student, I see this very organized culture among the physicians that lecture and teach all of us. No other profession I've encountered has such a storied and organized way of disseminating information, and perhaps more so, instilling a way of life to their future colleagues. How did a profession, one typically with at least decent incomes and population, allow this to occur politically? It just seems amazing that the idea of mid-levels as a solution has been allowed to walk past such a politically strong group of professionals. Perhaps I'm missing something. I see it getting talked about on here a lot, and it certainly has traction in our school, but where are the multi-million dollar ad campaigns, bus stop posters, and national discussion on the value of physician-lead patient care? Johnson and Johnson seems to have no problem plastering my TV with nursing commercials. Where is our corporate sponsor?

One thing is for certain, medical school can really grind you some days. It's incredibly intense and, let's be honest, parts of it are a real pain. All of you have done it. I can't imagine spending all of this money and devoting so much of my life to the definitive treatment of my patients only to have someone tell me in 10 years that it was a financial mistake. I am constantly amazed how much we learn and the intensity in which we learn it. I'd be super irritated if it was "unnecessary" and, given the little bit I know so far, I can't imagine it being so. Something tells me that physicians have a good argument to be made and that we're just not fighting dollars with dollars. There has to be some organization out there, some intermediary with our future in mind, asking for physicians to stroke a check, right?

Mid levels love this argument and eventually PAs will practice independently via this shortage route. Watch. The problem is shortages will always exist in rural locations because training centers are in metro areas and majority of docs stick around after their training in a metro area. mid levels use this argument to get autonomy. Stick to becoming a mid level. Our profession is so self loathing or full of attendings that just want a paycheck that in a decade we will have an over abundance of EPs because Midlevels will staff a majority of the cases and few managers overseeing them will be needed.

Everyone wants to be a doctor yet no one wants to go to medical school. Everyone wants the white coat but no one wants the liability.

 

[xenotype]

If midlevels really do deliver a level of care that is 99.5% as good as physicians at half the cost, then no amount of lobbying is going to beat that economic force. It is good for patients if the labor component of medical care drops by half in cost without a significant drop in quality. You have to prove the midlevels are significantly lower in quality to the beancounters, and anecdotes won't cut it. These are uncomfortable facts for all of us considering our enormous investments in education+training. The healthcare economists and policymakers largely already believe that NP/PA = MD. This is a threat to every field except surgery (for now), as NPs can simply establish tracks for nearly any specialty(alphabet soup) and PAs can do 'residencies'.

 

[RustedFox]

Everyone wants to be a doctor yet no one wants to go to medical school. Everyone wants the white coat but no one wants the liability.

This. Forever. Go back. Go back hard. Imagine the phosphoylation of the protein kinase. Imagine the benzene ring. Imagine methyl alcohol (fun!) but imagine methylation of... whatev'r compound, and the effects upon gene expression. a;dklfj;aj;ldksjfa;kljdf;alkj !!!!!

 

[deleted6669]

I have never been like man I wish a PA was here so I would know what to do.

That is not what I am trying to imply. at some point though you probably have said" damn, it's busy, I wish I had some more help tonight so I didn't have to see 40 pts by myself in the next 8 hrs".
The reality of emergency medicine today is that most docs don't work at academic medical centers and trauma centers, they work in the community where it is rare to have 2 residency trained and boarded docs on at the same time all the time. many places either have solo coverage or MD+PA(s) much of the day. at one of my rural jobs if they don't have a PA on(and many days they don't because they can't fill the slots) the doc is by themselves at a small facility( 10 beds) in the middle of nowhere that has a no divert policy. most of the time they do ok. sometimes they get killed and the docs spend hours after the end of their shifts doing charting because they did zero charts in 12 hrs and saw 35-45 pts with relatively high acuity. it's not uncommon to have 5 very high acuity pts in these 10 beds. just the way the area is. lots of retired folks. I have had entire shifts there in which I see no one under 70. not that uncommon there for the doc and I to be managing separate critical pts at the same time.

 

[RustedFox]

This. Forever. Go back. Go back hard. Imagine the phosphoylation of the protein kinase. Imagine the benzene ring. Imagine methyl alcohol (fun!) but imagine methylation of... whatev'r compound, and the effects upon gene expression. a;dklfj;aj;ldksjfa;kljdf;alkj !!!!!

- and if you don't know what a benzene ring is.... then I don't really want to talk with you. Period. Period.

 

[deleted6669]

you realize most pa programs today require ochem, right?
many also require biochem, genetics, stats, etc
the typical pa school applicant today did exactly the same undergrad bs in biology that you did.
Yale has a fairly typical pa program. these are their min prereqs. most folks exceed these by a fair margin.
http://www.paprogram.yale.edu/admissions/prerequisites/academic.aspx

 

[SeekerOfTheTree]

If midlevels really do deliver a level of care that is 99.5% as good as physicians at half the cost, then no amount of lobbying is going to beat that economic force. It is good for patients if the labor component of medical care drops by half in cost without a significant drop in quality. You have to prove the midlevels are significantly lower in quality to the beancounters, and anecdotes won't cut it. These are uncomfortable facts for all of us considering our enormous investments in education+training. The healthcare economists and policymakers largely already believe that NP/PA = MD. This is a threat to every field except surgery (for now), as NPs can simply establish tracks for nearly any specialty(alphabet soup) and PAs can do 'residencies'.

If this logic is true then why are countries like Canada filled with PAs and NPs...oddly enough the PA market there has slim pickings. Europe and Australia should fast track nurses. If physicians are necessary then a country by now would have realized that and require just in the job training. I know some African and South American countries that allow for this...outcomes are questionable.

You know physician cost is at best around 20% for cost of treatment right? Cut it in half because you pay Midlevels half and that will drop total medical care cost in this country by ten percent.
..that is if hospital still doesn't want a chunk. This is in theory of course.

The best part about this whole thing is the patient still comes to the hospital wanting to see the doctor...even the most uneducated patient expects that.

 

[SeekerOfTheTree]

you realize most pa programs today require ochem, right?
many also require biochem, genetics, stats, etc
the typical pa school applicant today did exactly the same undergrad bs in biology that you did.
Yale has a fairly typical pa program. these are their min prereqs. most folks exceed these by a fair margin.
http://www.paprogram.yale.edu/admissions/prerequisites/academic.aspx

You're like the Jesus of PAs.

 

[deleted6669]

you realize canada, england, australia, South Africa, saudi arabia, holland, taiwan, singapore, and new zealand have all started pa programs programs, right?
there are a number of other countries such as Israel that allow pa practice.

 

[deleted6669]

You're like the Jesus of PAs.

what the hell is that supposed to mean?
Moses, maybe....

 

[SeekerOfTheTree]

you realize canada, england, australia, South Africa, saudi arabia, holland, taiwan, singapore, and new zealand have all started pa programs programs, right?
there are a number of other countries such as Israel that allow pa practice.

Not the majority still in the minority. You realize that right? Numbers of PAs in Canada and England please?

 

[deleted6669]

don't know exact #s.
PAs work in ontario and mannitoba. there are 3 pa programs in canada now. they hire lots of american pas to work both clinically and to teach. I get unsolicited emails from their programs all the time.
Pas work in england and scotland for the NHS. 2 pa programs in england now with another in the works for scotland. they advertise in the pa mags every month. most jobs are surgical, em, or primary care.
UK Association of PAs http://www.ukapa.co.uk/
canadian association of pas http://capa-acam.ca/

 

[SeekerOfTheTree]

don't know exact #s.
PAs work in ontario and mannitoba. there are 3 pa programs in canada now. they hire lots of american pas to work both clinically and to teach. I get unsolicited emails from their programs all the time.
Pas work in england and scotland for the NHS. 2 pa programs in england now with another in the works for scotland. they advertise in the pa mags every month. most jobs are surgical, em, or primary care.
UK Association of PAs http://www.ukapa.co.uk/
canadian association of pas http://capa-acam.ca/

Good so in a little bit we won't need medical school and everyone will be Dr. PA. I should be able to train a nurse in all this to be quite honest. Our job is pretty easy. Don't need school.

 

[deleted6669]

that's not what I said or what I mean. PAs are mostly being used internationally in primary care where we CAN do 80-90% of what a doc can do in an outpt setting right out of school. In specialty fields we are not replacing docs but taking some of the work load(yes, mostly the "easier cases") but also have a role in seeing sicker folks under some circumstances. you will always have a job. I will too. it's likely that your job at some point will require that you work with PAs to some extent. I only ask that you make choices based on the individual pa, not just based on the initials after someone's name. we both know docs we wouldn't let care for our worst enemy and those who are rock stars. there are similar folks in the pa world as well.

 

[xenotype]

If this logic is true then why are countries like Canada filled with PAs and NPs...oddly enough the PA market there has slim pickings. Europe and Australia should fast track nurses. If physicians are necessary then a country by now would have realized that and require just in the job training. I know some African and South American countries that allow for this...outcomes are questionable.

You know physician cost is at best around 20% for cost of treatment right? Cut it in half because you pay Midlevels half and that will drop total medical care cost in this country by ten percent.
..that is if hospital still doesn't want a chunk. This is in theory of course.

The best part about this whole thing is the patient still comes to the hospital wanting to see the doctor...even the most uneducated patient expects that.

Of course this is all true. The US is the only developed country leaping headfirst into midlevels delivering substantial amounts of care, and the actual savings are only 5-15% of total healthcare costs. I don't think policymakers really care though, and hospitals have financial incentives to use as many midlevels as they can.

As for patients wanting to see the doctor- they already fixed that by stapling a D in front of the NP. The NP introduces themselves as Doctor X, and few patients will notice the subtlety. If patients really cared that much about the letters, you'd expect there to be a lot of friction with DOs. I haven't seen much at all. They can call themselves board certified doctors and not break any rules in most states.

 

[Arcan57]

Of course this is all true. The US is the only developed country leaping headfirst into midlevels delivering substantial amounts of care, and the actual savings are only 5-15% of total healthcare costs. I don't think policymakers really care though, and hospitals have financial incentives to use as many midlevels as they can.

As for patients wanting to see the doctor- they already fixed that by stapling a D in front of the NP. The NP introduces themselves as Doctor X, and few patients will notice the subtlety. If patients really cared that much about the letters, you'd expect there to be a lot of friction with DOs. I haven't seen much at all. They can call themselves board certified doctors and not break any rules in most states.

Let's keep up doing what we are doing to our profession and this will be the future. Why require an EM physician even for the sick ones. Line the patient up which PA, NPs and RTs can do apparently at some institutions and send them to ICU. You know most seasoned nurses up there are great at fluid, pressor, and antibiotic management with the PharmDs so we can call intensivist when we need a bronch. Actually ID is consulted to manage antibiotics most of the time and an bronchoscopy NP could probably get cultures so we really don't need the intensivist either. Reduce medicine to actions orchestrated by puppets for money and our profession becomes that of a cheap *****.

But let's keep this up. Let's let NPs and PAs do a little bit more and eventually only fields that will require MDs are surgical fields based on this reductionist mentality.

If we can't provide measurably better care then NP/PA/MLP/APCs, then we shouldn't exist. With respect to RustedFox, no one cares about our facility with organic chem and physiology if we don't provide better patient outcomes, use fewer resources, or both. If we don't add value to the system, then we'll be replaced. EM was able to demonstrate that the expense of training a physician specifically in "acute, episodic care" was worth it to the system. That's why EDs aren't staffed exclusively by failed general surgeons and FPs that couldn't make it in private practice. That makes me feel somewhat good about not being replaced by midlevels in the immediate future. If emedPA's supervisor is cool with him intubating and managing a coagulopathic head bleed without getting out of his chair, I'm pretty sure that doc is going to be replaced as soon as it's feasible.

 

[deleted128562]

I wish, every day, I had done PA or NP instead. Not kidding. What is the point of all this if I'm just going to be viewed as an interchangable cog (who, by the way, also gets to assume all the liability)?

Seems to me that either the midlevels are really overestimating their abilities, or I am getting really ripped off by the medical training establishment who are requiring 7 years of my sweat to do what I could have done in 2.

How on earth should it require 5 extra years of training to learn how to handle the extra "0.5 percent" of patients that need an MD instead of a PA or NP?

 

[ptarmigan]

Mid-levels in the ED are about half as productive for about a third the cost of an MD. In my experience, they just can't crank the RVUs like a board certified EP can. There is also the measurable cost of supervision and training. New PAs don't have a clue what they are doing in an Emergency Department, so add in the cost of 1-5 years of on-the-job training. There is also the decreased physician satisfaction pertaining to working with midlevels, as well as the patient's frustration with not seeing a doctor. Then there is the increased malpractice risk, the lower quality of care, and the increased cost of benefits (because you have to emloy more PAs to do the same amount of work). Keep in mind that PA's bill lower rates to medicare. When you analyze this, the conclusion is that you are paying a little bit more for a lower quality product. The EP is actually a pretty lean and efficient machine.

Maybe the cost/benefit ratio changes in fast track.

 

[keeping-it-real]

The reality is that people don't know what they don't know. I remember as a 4th year medical student thinking I could work in an ER independently. As a senior resident I remember how "easy" emergency medicine was. I also remember the reality check I had my first few months out as an attending. Now a few years out, I probably average 10 hours of CME a month and STILL feel like there is more to learn and to improve on, and only now can I truly appreciate how difficult it is to be great at our specialty.

The problem is though,that in your average ER, most of the problems don't require the mental horsepower and skillset that we trained for; they don't require a "great" emergency physician. And this is increasingly becoming more true with the trend to turn to the ER into a glorified urgent care and with the trend toward more algorithmitic medicine. The result is that just on a pure percentage basis, being ignorant is going to be less likely to produce a bad outcome.

The other problem is that modern emergency medicine (and much of medicine, for that matter) doesn't value the traditional role of a physician. There is no 'reward' for being a learned master of your trade and using a great wealth of information and the most current evidence to deliver care and take care of patients. Patient centered care and "customer service" medicine have basically rendered us 'waiters of medicine.' People don't care how much you know; they just want to be listened to and get what they ask you for. Most people have no idea how ignorant they are about medicine. And due to the current liability situation, there's no reward for using your brain if it means putting yourself at risk for bad outcome. Everyone just ends up over-testing and over-consulting anyway. The final result is that there are very low standards for providing medical care and there has been a de-emphasis on possessing good medical knowledge as it relates to the current practice of medicine. It is for this reason that midlevels can show parity.

 

[SeekerOfTheTree]

I have worked with neurosurg NP who thought she was better than the attending. I worked with a surgical PA who was trying to get in my pants that would complain about how dumb new surgery residents were and she was only a couple of years out. Half the EM PAs are great the other half have the I should be paid as much as you complex. If becoming a physician or being called DR increases liability without significant increasing pay the numbers of these individuals will fall down. The reasons mentioned above for medicine no longer being as cerebral in the US is valid due to liability. This is why good physicians can't outsource most of their clinical knowledge to PAs in foreign lands.

PA route is how residency should have been. If you went to PA school and then were paid like a PA for training that would have been ideal. You could extend that surgery residency to 10 years or ER to 5 and it would be bearable on 120k a year as a PA vs 40 as a resident.

I wish I had been a Midlevels after this talk.

 

[SeekerOfTheTree]

At our hospital I have not seen the cost benefit to PAs in areas other than ER. Trauma surg for example has two PAs day and night that come and see any trauma. Then staff it with attending on call. Guess what the number of things called trauma has increased.

When the healthcare money runs out which it will one day really soon then either Midlevels or us are getting the axe because nobody is going to stand up against lawyers to touch liability. Based on the way things are going there won't be a physician shortage because we won't need as many.