Yale merging physician residency with PA residency

[Steve_Zissou]

Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency

Author(s): Tsyrulnik, Alina; Goldflam, Katja; Coughlin, Ryan; Wong, Ambrose H.; Ray, Jessica M.; Bod, Jessica; Chekijian, Sharon; Della-Giustina, David | Abstract: Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking...

escholarship.org

From their abstract:

Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate program within an existing physician residency program and produce emergency medicine-PA (EM-PA) graduates of comparable skill to their physician counterparts who have received the equivalent length of EM residency training to date (evaluated at the end of first year of EM training).

The curriculum was based on the Society for Emergency Medicine Physician Assistants (SEMPA) recommendations with a special focus on side-by-side training with EM resident physicians. In reviewing the program, the authors examined faculty evaluations, as well as procedure and ultrasound experience that the trainees received. We found comparable evaluations between first-year EM-PA and physician trainee cohorts. This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated.

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[Dr Mantis Toboggan]

Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency

Author(s): Tsyrulnik, Alina; Goldflam, Katja; Coughlin, Ryan; Wong, Ambrose H.; Ray, Jessica M.; Bod, Jessica; Chekijian, Sharon; Della-Giustina, David | Abstract: Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking...

escholarship.org

From their abstract:

Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate program within an existing physician residency program and produce emergency medicine-PA (EM-PA) graduates of comparable skill to their physician counterparts who have received the equivalent length of EM residency training to date (evaluated at the end of first year of EM training).

The curriculum was based on the Society for Emergency Medicine Physician Assistants (SEMPA) recommendations with a special focus on side-by-side training with EM resident physicians. In reviewing the program, the authors examined faculty evaluations, as well as procedure and ultrasound experience that the trainees received. We found comparable evaluations between first-year EM-PA and physician trainee cohorts. This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated.

The CMGs don’t even need to kill us off, we’re doing it ourselves.

 

[deleted126335]

The CMGs don’t even need to kill us off, we’re doing it ourselves.

There are professorships and chairmanships to be had by academic physicians giving corporate medicine the “evidence” they need to replace high priced (physician) help with less high priced (PA, NP) help.

 

[Dr Mantis Toboggan]

There are professorships and chairmanships to be had by academic physicians giving corporate medicine the “evidence” they need to replace high priced (physician) help with less high priced (PA, NP) help.

Sad and true.

 

[Fox800]

Judases.

 

[southerndoc]

PA's may be comparable to PGY-1's, but let's not forget there are 2 more years of training for residents (3 at Yale since it's a 4-year program). They should compare the graduates of the PA residency with graduates of the emergency medicine residency. I wonder if there is a difference then.

I have mixed feelings about this. I almost feel betrayed (I graduated from Yale's EM residency), but at the same time, I much prefer seeing a PA do an EM residency instead of an NP doing online schooling and haphazardly piecing together their own clinical rotations.

 

[AlmostAnMD]

Maybe we are just outdated.

For years I've heard that midlevel care isn't "good enough" but maybe in the eyes of the public, and eventually the law, it really is acceptable to just have your "provider" be "good enough" and not miss "most things" in the name of saving $$$$$$, the only god most people worship.

Seems to be the trend. In the future maybe all of us will just be supervisors like anesthesia.

Starting to see a future where all emergency care is basically just NP and PAs. If we're going to betray ourselves by doing studies like this, maybe that's just the future to embrace. The obvious point of the study is to try to justify our replacement, and this lays much of the groundwork.

This is a huge, huge step towards our demise as a whole. It's just sad to see our own people putting fuel on the fire.

Was gonna write a nastygram email to Yale's chair or alina tsyrulnik "MD" (corresponding author listed that evidently "thought" of this) but gonna cool down for a bit first and just let this sink in.

There's a lot of sky-is-falling stuff posted here year in and year out but this is huge. We are literally trying to justify our own replacement. Trying to imagine any other career where people study someone else replacing them. Maybe robot kiosks at McDonald's?

 

[Modanq]

Nail in the coffin.

 

[bravotwozero]

There's a lot of sky-is-falling stuff posted here year in and year out but this is huge. We are literally trying to justify our own replacement. Trying to imagine any other career where people study someone else replacing them. Maybe robot kiosks at McDonald's?

I think I need to start taking a break from this forum. If I hang out here long enough, I might end up on antidepressants or something....

 

[deleted126335]

Maybe we are just outdated.

For years I've heard that midlevel care isn't "good enough" but maybe in the eyes of the public, and eventually the law, it really is acceptable to just have your "provider" be "good enough" and not miss "most things" in the name of saving $$$$$$, the only god most people worship.

Seems to be the trend. In the future maybe all of us will just be supervisors like anesthesia.

Starting to see a future where all emergency care is basically just NP and PAs. If we're going to betray ourselves by doing studies like this, maybe that's just the future to embrace. The obvious point of the study is to try to justify our replacement, and this lays much of the groundwork.

This is a huge, huge step towards our demise as a whole. It's just sad to see our own people putting fuel on the fire.

Was gonna write a nastygram email to Yale's chair or alina tsyrulnik "MD" (corresponding author listed that evidently "thought" of this) but gonna cool down for a bit first and just let this sink in.

There's a lot of sky-is-falling stuff posted here year in and year out but this is huge. We are literally trying to justify our own replacement. Trying to imagine any other career where people study someone else replacing them. Maybe robot kiosks at McDonald's?

Money is tight. Resources are scarce. Second best is good enough. We just can't call it second best.

 

[AlmostAnMD]

Money is tight. Resources are scarce. Second best is good enough. We just can't call it second best.

I think that's really what I meant to say, yeah. Trying to put second best into the mainstream and put some data behind it calling it equivocal and keep those expensive docs out of the picture. Think of the profits!

 

[VA Hopeful Dr]

I think I need to start taking a break from this forum. If I hang out here long enough, I might end up on antidepressants or something....

We have a thread for that:

https://forums.studentdoctor.net/threads/whisky-drinkers.840916/

 

[Rekt]

PA's may be comparable to PGY-1's, but let's not forget there are 2 more years of training for residents (3 at Yale since it's a 4-year program). They should compare the graduates of the PA residency with graduates of the emergency medicine residency. I wonder if there is a difference then.

I have mixed feelings about this. I almost feel betrayed (I graduated from Yale's EM residency), but at the same time, I much prefer seeing a PA do an EM residency instead of an NP doing online schooling and haphazardly piecing together their own clinical rotations.

There's no need to have mixed feelings. We don't even have enough positions for EM residency grads. Why do we need to dilute the pool more? And if the rebuttal is "they can see low acuity patients", then they don't need a residency.

Screw Yale for doing this. All of their faculty is scum.

 

[namethatsmell]

This PA program and "study" flies directly in the face of the AAEM Position Statement on Emergency Medicine Training Programs for Non-Physician Practitioners.

Is the AAEM gonna take Yale to task?

 

[namethatsmell]

So AAEM has their section on "Remarkable Testimony" to call out bogus EM expert witnesses testimony and sanction these bad apples...

Is it time for the AAEM to create something like "EM Cannibals" to specifically sanction EM docs who actively try to enrich themselves/their careers by destroying the viability and future of our specialty?

 

[WilcoWorld]

I'm not trying to defend an MLP takeover, please bear with me.

This isn't a study. It's a proof of concept paper. If you read it, they're simply saying something like "we run an APP and Physician EM residency at the same site, and it seems to work out OK."

If someone else claims this establishes that APP = MD, we should call them out for not understanding the paper.

Let's not make the same mistake. Interpret this like a scientist. What conclusions can you soundly draw from this paper?

I think the most reasonably proposed conclusion in this thread was from @dr doze - someone at Yale is now one 'line on their CV' closer to promotion.

 

[Fox800]

In reality:

"We made our own midlevel residency program, then graded our midlevels roughly the same as our PGY-1 residents (subjectively), because we like them, and the Yale administration and EM chair pressured us to make sure this program succeeds.

At the same time, our PGY-1 residents (at a four year program which takes advantage of our name to get an extra year of cheap labor) would never be deemed competent to independently practice medicine in the manner that national midlevel organizations are advocating for - we are trying to better prepare midlevels "advanced" practice providers to do exactly that."

 

[Fox800]

Here's the big question: what are their midlevel "residents" paid compared to the PGY-1s?

 

[deleted941485]

This is pretty much as bad if not worse than the UPenn Study looking at Radiographers and comparing outcomes to Radiology Residents.

 

[namethatsmell]

I'm not trying to defend an MLP takeover, please bear with me.

This isn't a study. It's a proof of concept paper. If you read it, they're simply saying something like "we run an APP and Physician EM residency at the same site, and it seems to work out OK."

If someone else claims this establishes that APP = MD, we should call them out for not understanding the paper.

Let's not make the same mistake. Interpret this like a scientist. What conclusions can you soundly draw from this paper?

I think the most reasonably proposed conclusion in this thread was from @dr doze - someone at Yale is now one 'line on their CV' closer to promotion.

I agree this is not a study, though they refer to the program as a "pilot study" which certainly muddies the waters.

If this were a study, I would have expected the authors to include basic info like methods, subject characteristics, a meaningful discussion of the strengths/limitations/weaknesses of what they're doing...ie anything to add reasonable context to their finding: "We found comparable evaluations between first-year EM-PA and physician trainee cohorts." In isolation, this is a pretty bold, if unclear, statement to make. But in light of the current (lack of) context the authors provide, this assertion is actually pretty meaningless.

As for a conclusion I can likely draw from the one table is this paper: for every intubation, LP, central line, reduction etc their PA learners performed, it probably meant that was one less procedure/learning opportunity for their EM residents.

 

[deleted941485]

I agree this is not a study, though they refer to the program as a "pilot study" which certainly muddies the waters.

If this were a study, I would have expected the authors to include basic info like methods, subject characteristics, a meaningful discussion of the strengths/limitations/weaknesses of what they're doing...ie anything to add reasonable context to their finding: "We found comparable evaluations between first-year EM-PA and physician trainee cohorts." In isolation, this is a pretty bold, if unclear, statement to make. But in light of the current (lack of) context the authors provide, this assertion is actually pretty meaningless.

As for a conclusion I can likely draw from the one table is this paper: for every intubation, LP, central line, reduction etc their PA learners performed, it probably meant that was one less procedure/learning opportunity for their EM residents.

We know now where the academic physicians' heads are these days. Again UPenn tried pulling this crap a few months back.

 

[deleted547339]

I'm not trying to defend an MLP takeover, please bear with me.

This isn't a study. It's a proof of concept paper. If you read it, they're simply saying something like "we run an APP and Physician EM residency at the same site, and it seems to work out OK."

If someone else claims this establishes that APP = MD, we should call them out for not understanding the paper.

Let's not make the same mistake. Interpret this like a scientist. What conclusions can you soundly draw from this paper?

I think the most reasonably proposed conclusion in this thread was from @dr doze - someone at Yale is now one 'line on their CV' closer to promotion.

You are giving people way too much credit.

 

[deleted547339]

This sort of S has to stop. You think I’m going to evaluate a PA-s and a PGY1 the same? Get the f outta here.

Yes, AAEM needs to call this out

 

[AlmostAnMD]

I'm not trying to defend an MLP takeover, please bear with me.

This isn't a study. It's a proof of concept paper. If you read it, they're simply saying something like "we run an APP and Physician EM residency at the same site, and it seems to work out OK."

If someone else claims this establishes that APP = MD, we should call them out for not understanding the paper.

Let's not make the same mistake. Interpret this like a scientist. What conclusions can you soundly draw from this paper?

I think the most reasonably proposed conclusion in this thread was from @dr doze - someone at Yale is now one 'line on their CV' closer to promotion.

You're missing the point

This is laying the ground work for more to come. I'm not talking about the info in the paper, I'm talking about what the real end goal is in even publishing it--the real goal here is not stated anywhere in that paper.

 

[WilcoWorld]

You are giving people way too much credit.

Well, that's kinda my jam.

 

[Angry Birds]

Nuts.

 

[WilcoWorld]

You're missing the point

This is laying the ground work for more to come. I'm not talking about the info in the paper, I'm talking about what the real end goal is in even publishing it--the real goal here is not stated anywhere in that paper.

I get that point & don't disagree. I prefer to critique it on a scientific basis, I recognize that my approach has it's limitations. You do you.

 

[deleted547339]

You're missing the point

This is laying the ground work for more to come. I'm not talking about the info in the paper, I'm talking about what the real end goal is in even publishing it--the real goal here is not stated anywhere in that paper.

“an informal poll of residents” - uh, yea, an intern who thinks they could get fired isn’t going to tell the chair “stop ruining my career”. Also, it seems like there’s enough procedures to go around is such a joke.

If SAEM isn’t willing to condemn this, we should. Maybe we can sticky “SDN blackballed residencies”

 

[alpinism]

I think its time we began formally sanctioning these faculty members.

They're blatantly harming their own residents for their academic careers.

 

[RustedFox]

Before anyone says: "We need to prove why we're not replace-able by the MLP crowd"... Um, no. No. N-no. The burden of proof is on the MLP crowd to prove that they can even play on the same level.

That "Yale" has done this is Peter Rosen-tier blasphemy.

I said this long ago, and it bears repeating: Pass the USMLE STEP exams, and I'll call you equivalent. Until then, forget it - you don't have my academic horsepower.

 

[Fox800]

And it’s not like Yale is one of those “powerhouse” residency programs…

 

[Arcan57]

For a moment I thought they were talking about having put PA’s through all the years of an physician residency. Which is scary because that would work out just fine in terms of producing an independent practitioner.
On the other hand, it seems to make all sorts of sense that an PA that spent an entire year only in the ED would have reasonable evaluations compared to an intern that may spend 6 months of the year off service. Quicker pickup of ED workflow but lower ceiling due to no exposure to the next level of care.

 

[Brigade4Radiant]

PA's may be comparable to PGY-1's, but let's not forget there are 2 more years of training for residents (3 at Yale since it's a 4-year program). They should compare the graduates of the PA residency with graduates of the emergency medicine residency. I wonder if there is a difference then.

I have mixed feelings about this. I almost feel betrayed (I graduated from Yale's EM residency), but at the same time, I much prefer seeing a PA do an EM residency instead of an NP doing online schooling and haphazardly piecing together their own clinical rotations.

Lol if you think ENP will not be allowed into these residencies also it wont be up to you it will be up to the CMG overlord

 

[bougiecric]

They should compare the graduates of the PA residency with graduates of the emergency medicine residency. I wonder if there is a difference then.

But with this, you're implying that PAs and physicians start from the same place. What is the point of medical school if it's only the post-graduate training that matters?

 

[deleted126335]

Lol if you think ENP will not be allowed into these residencies also it wont be up to you it will be up to the CMG overlord

Too much animosity between the professions. Can’t train em both together. Will be every medical students’ last choice of program.

 

[southerndoc]

But with this, you're implying that PAs and physicians start from the same place. What is the point of medical school if it's only the post-graduate training that matters?

They certainly don't start at the same place. 2 vs 4 years

 

[turkeyjerky]

But with this, you're implying that PAs and physicians start from the same place. What is the point of medical school if it's only the post-graduate training that matters?

I think (or hope) he's saying that an intensive 4 year post-graduate training program applied to a PA grad, would like result in an adequate independent practitioner, but not necessarily an equivalent one.

So, how long til HCA starts opening up PA residencies?

 

[Matthew9Thirtyfive]

Yeah this paper is a hot pile of garbage. The authors don’t give us any information about the PAs. Are they new grads? Do they have experience already? We’re they given any onboarding prior? Im betting they were hand picked for this.

They also say flat out that because there were so few PAs, none of the data is statistically significant. Like literally the “study” wasn’t powered to show anything other than you can have a PA residency and a physician residency at the same site.

It’s a piece of **** paper, but it’s still dangerous because it’s real purpose is to just provide “data” that you can successfully do both and that the PAs will be “equivalent” to interns (despite the paper not actually being able to show that). It’s just fodder so they can continue selling out the profession.

It really just boggles my mind. Is money really that important to these people that they will gladly sell out patients and their own colleagues?

 

[Mushdoc]

On the one hand I feel like a lot of what we learn in Med school is pointless. Especially for specialists going into say psych or ortho. It used to be valuable when the overwhelming majority of docs where generalists and maybe did one year of post graduate training. Now everything is so specialized.
On the other hand there is definitely still lots of value. NP/PAs who have been doing an ICU for a year or two at an academic do know a lot from experience, but it’s still amazing how much they don’t know and how much knowledge they lack about basic concepts. Sure a PA student who does ER for a year is gonna do ok compared to a PGY-1 but that baseline knowledge really lets you get more out of training and adds up in the end. Especially all the time spent on off service and Med student clinical.
Ideally at some point Med school should be three years followed by a rotating PGY1 general year where you have real responsibility and then you specialize.
I think many European places basically let you switch around as much as you want until you find what you want to specialize in and in the meantime you make a medium salary

 

[GeneralVeers]

It really just boggles my mind. Is money really that important to these people that they will gladly sell out patients and their own colleagues?

Why are you asking this question?

 

[Matthew9Thirtyfive]

Why are you asking this question?

Cause I don’t understand why someone who is already making good money would destroy their profession for a little more.

 

[GeneralVeers]

Cause I don’t understand why someone who is already making good money would destroy their profession for a little more.

You've just summarized the entire recent history of Emergency Medicine.

 

[Matthew9Thirtyfive]

You've just summarized the entire recent history of Emergency Medicine.

Yeah I’ve seen it in the threads here. It just blows my mind. Are these docs all in the boomer generation, or are the younger generation of docs just as greedy?

 

[Arcan57]

But with this, you're implying that PAs and physicians start from the same place. What is the point of medical school if it's only the post-graduate training that matters?

Gate keeping.

 

[sylvanthus]

Hahahha were so f’ed. I cant see any way to combat the massive forces at work against us. Midlevel enroachment, CMS decreasing reimbursement, EM residency expansion, CMGs, etc etc. One or two of these we could probably fight, all of em, nope donesies.

 

[kumatie]

This specialty is dead.

 

[namethatsmell]

This specialty is dead.

 

[ace_inhibitor111]

In reality:

"We made our own midlevel residency program, then graded our midlevels roughly the same as our PGY-1 residents (subjectively), because we like them, and the Yale administration and EM chair pressured us to make sure this program succeeds.

At the same time, our PGY-1 residents (at a four year program which takes advantage of our name to get an extra year of cheap labor) would never be deemed competent to independently practice medicine in the manner that national midlevel organizations are advocating for - we are trying to better prepare midlevels "advanced" practice providers to do exactly that."

I’ve been looking at all these academic EM research and apparently everyone thinks subjective evaluations by faculty on a Likert scale are the “gold standard” in how effective of an EM physician you are loool

 

[WilcoWorld]

I’ve been looking at all these academic EM research and apparently everyone thinks subjective evaluations by faculty on a Likert scale are the “gold standard” in how effective of an EM physician you are loool

No, not everyone.

a) This was published in West JEM. Certainly not our most respected journal.
b) The "gold standard" of resident evaluation is the ACGME Milestones, which are quite different from a Likert scale.
c) THIS WAS NOT A STUDY OF PA VS PHYSICIAN ABILITY. From the abstract: "This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated."

 

[AlmostAnMD]

Dude

it doesn't matter where it was published. It could have been published in the Syrian Journal of Medicine and Basket Weaving. It's just as alarming if it were published there or JAMA. I couldn't care less about where it was published. For West JEM specifically I know it's a worthless throwaway magazine because they let me publish in it.

It was clearly published as a first step towards an equivalency paper some white tower idiot will eventually publish to get tenure. We're all looking at a hole in the ground where the foundation goes for a massive skyscraper of nonsense and all you can see is the hole, not the skyscraper to fill it

This topic is not now, nor ever, a debate over likert scales and it should never be mentioned again. The more I think about how you're reacting to this........are you at Yale?????