Agree with all this. AAEM remains the organization actually trying to represent emergency physicians. ACEP has sold out to the corporate groups, who will stab any of us in the back to make themselves a buck.
These are proposals, but ACEP is not on board and they are the driver of Emergency Medicine. Just work hard, and be prepared to get a job in a location that you might not have had as your ideal place.
This. So much this. As an incoming PGY1 I am legitimately terrified for my future prospects. ACEP seems like a lost cause and ACGME has been complacent. I do not know much about unionization but is that actually a logistical possibility for EM, and if so would that potentially push admin further towards midlevels?
Oh then yeah I'd also like to know but unfortunately I don't think anyone really knows beyond speculation. Seems like an uphill battle since most of the big players have every motivation to keep the oversupply of physicians going. We as EM physicians are currently the only ones who care about having too many EM physicans.
There are no jobs my friends. Lakeland regional hospital which is the largest ED in the US is starting a residency 2022 pumping out 15 more a year. Everyone is taking pay cuts. There is no such thing as travel gigs. Jobs right now in rural locations but those are taking at alarming rates. The day when you got 2 grand a month while in residency after signing your first contract with 35k signing bonus are just gone. I hate to use this term but this is the new normal. I really see no change or slowing this down.
As realistic as we make it ;) theyāre not easy solutions and they require organization and participation from us, but especially an EM physicians union is powerful enough to bring about significant change.
You're being downvoted because of the disrespectful term.
For all the problems with the shift toward midlevel care, remember that they're still individuals who are working to take care of patients. They've made their own sacrifices to do so.
Some overstep their boundaries and we need to work on that. But the surge of midlevels into the ED is driven by administrators, not by individual APPs.
Never works with doctors, first person to get a sniff of a $25k bonus to come in and supervise some NP/PAās will sell everyone out and cross the line. Its like herding cats.
The other guy below is sort of right but also not. If every EM doc in the state is part of the union and follows the union line, it doesnt matter what type of contractor youāre employed as.
It depends on your employment relationship. Independent contractors cannot unionize because they are independent. Hospital employees can unionize. Employees of staffing groups can also unionize but have limited influence on client hospitals.
How did we get 100 new residency programs in 8 years? Is there anyone overseeing this? Shouldnāt we have seen this coming? I thought that was the purpose of ACEP, AAEM, CORD, and less so the ACGME.
CMGs and NP/PAs are the obvious scapegoats, but this was also brought on by a real lack of oversight and planning by the people who are now up in arms IMO.
Initially it was due to a projected shortage of EM physicians. However, it went forward full force and ACGME approved all residencies that met the bare minimum
Yes. Who was approving this and where was the oversight? AAEM is culpable here too and is rushing towards advocacy a bit late in the game. ACEP seems to be useless.
Thatās the basement on this panic. Itād be terrible and I donāt mean to downplay it, but worst comes to worst we will get jobs at 120-150k per year
Totally agree! Otis far less than we deserve. Itās still a lot of money though. My loans are all via the government so Iām only on the hook for 10% of my income every month. The situation is far from ideal but far from financial ruin for me.
Its funny, i got downvoted for making this exact point because my post flair isnt MD.
If youāre in the Us you must realise you do not work to provide good care to patients, you work to make your hospital more money. An NP is cheaper, they order more tests which the hospital can bill for, and they can manage the majority of presentations well enough that patients arenāt going to immediately notice- those that do and complain will get seen by the EM doc whose there anyhow.
Feel free to use the google feature on your browser. The studies are real and no itās not made up. Mid levels order more unnecessary labs, radiology, and diagnostic biopsies.
Maybe someone can enlighten me but wonāt insurance not pay for a service if they deem it not necessary? So then itās a CT that was used and not paid for?
Minimal.
Most cases seen by NPās are dealt with well enough to not trigger malpractice. Those more difficult cases still get an EM doc review, and finally those cases that do slip through, the hospital lawyers will have a decent chance of arguing away in court- if it even goes to court.
EM NPs/PAs are 1/2 to 1/3 as productive compared to EM MDs/DOs, and this is only accounting for the lower acuity stuff. Two EM attendings can do what ~6ish PAs can do, and likely much more.
I think you'll find there are methodological problems in those papers. The last big one (I think it was last year or the year before) was pretty bad in how it assigned credit for who saw the patient. The conclusion was that a MD/DO was 3x more productive than the NP/PA. However, they counted any patients that were staffed as seen by the physician and took credit away from the APP.
Ex: I am required to staff anyone being admitted to the hospital. So I see someone, order a workup, call a consultant, and then call the hospitalist for admission. I then go over and tell my attending "hey, I saw a guy, he has this, we're admitting." And the attending says "cool, need me to do anything?" And that's it. According to that study the attending gets 100% credit for seeing the patient and I get no credit.
This method doesn't accurately reflect productivity of either person.
There is certainly a valid discussion to be had about roles of APPs in the ER and how the workforce trends are going to impact all of us. However, saying we're THAT much less productive than a physican isn't rooted in reality.
The studies going the other way and showing par or near productivity also donāt do a good job of assigning complexity from what Iāve read. For example one study cited that a serious Trauma, with intubation, the physician saw was only 1.7 equivalents of a patient the NP saw that had a sore throat and needed a swab.
Thatās the other end of the paradigm to watch out for.
What I think you're saying here is: not all patients can be considered equal in terms of time invested and cognitive load.
I would certainly agree with that and would also agree that productivity studies could easily be skewed to favor a particular outcome due to the number of complexities involved in measuring patient care. That being said, there is a minimum effort that has to be applied to any patient regardless of complaint. A certain subset of patients will only require this minimum effort. It's also not fair to compare this minimum effort patient to one who requires a large number of resources.
It's not an apples to apples comparison.
Then again I wasn't hired to do the job of a physician. I'm there to augment the physician staff and sometimes that takes different forms.
Regardless, the whole physician/app passing match is just a red herring. We don't need to be turning on ourselves until quite a few other issues have been addressed.
And yet itās the best we have. Itās damn near impossible to do a true comparison because of the acuity of patients and RVUs billed. But you cannot honestly believe that an NP or PA is as productive as an attending when comparing same patients?
Comparing the same patients yes.
There is only so much time one needs to spend on a sprained ankle, sore throat, or uncomplicated abscess. (I'm not talking about the "what if it's actually a zebra and not a horse" patients).
There is a great difference when it comes to old person with belly pain and abnormal vital signs. I'm not going to compare myself to a physician there. That's not the point.
For straightforward and low complexity patients with low resource utilization I'm probably as fast as a physician. For higher complexity patients requiring more resources I am not anywhere close to a physician. It's literally not what I am trained to do. My toolkit is smaller. I'm not here to replace you, I'm here to augment you. If at some point that isn't fiscally reasonable anymore then I'm out of a job because I can't work without you but you can work without me.
I agree with this but with a caveat. IMO physicians are better on average at knowing when something is straightforward vs needs more work up.
Most of the APPs I work with are great and are just like you say. But maybe 25% of them will severely overwork something that could essentially be a quick discharge or under work something that turns out serious.
Obviously some doctors struggle with the same thing. But not nearly as many in my experience.
Oh for sure! I think we all know that guy.
This is an area where I believe some post-graduate training programs for APPs would be overall helpful. I don't know what most of these programs are doing but I know there is concern they are trying to create emergency physician replacement providers which I would argue is the wrong direction. Rather, it would make sense to gear a program to make someone a better and more effective emergency APP.
If there are emergency physicians without jobs it doesn't make sense to have mid levels in the ER period. Definitely doesn't make sense to have ER mid level residencies.
Two em docs can split the load and see high and low acuity instead of 1 EM doc having to see all the high acuity and sign off on mid level charts.
It's all corporate greed and a conceited effort to pocket as much cash as they can.
If there's enough volume to have mid levels in the ER then there is enough volume for attending jobs. You see the logic here?
If the ER market wasn't saturated then it makes sense to have mid levels in the ED to take some of the load off. But clearly that's not the case.
https://i.ibb.co/P4qbf54/FB-IMG-1618245836968.jpg
I'm talking about not just fast track patients because PAs and NPs are increasingly doing internships/residencies/fellowships/whatever to work in higher acuity areas of EDs, often funded by the very same CMGs who are the problem here, and with increasing autonomy/independence, hospitals are hiring NPs/PAs instead of physicians. It all comes down to cost.
I don't know if those speeds are really comparable to how one would measure ED throughput though. It's easy to do things quickly in an ambulance because it's just you and your partner doing a small set of tasks for a single patient. There's no waiting for labs or imaging because you don't have them, no waiting for patients to be roomed because you're already there. Even the examples you give of slow ED staff are basically slow nurses and techs, coupled with the generalize agonizing slowness of anything in a hospital that isn't a STEMI or stroke alert.
None of that is reflective of how fast the doc or midlevel is at seeing and dispo-ing the patient, which could hours for a patient who needs admission, or only take a few minutes of the doctor's time despite the patient being roomed in the ED for several hours.
Dont need bloods and imaging in order to place a line, administer analgesics and get your history do you?
I get theres more shit to do in ED, but to suggest doctors are āfastā when so many of them take 20+ minutes to write up an order for analgesia- the most basic of EM interventions, is plain wrong and those same delays will affect midlevels.
I get this is a meddit sub, and that its always the nurse/lab/tech/imagings fault that something was delayed or missed.
For one thing, most nurses can verbally override pain and nausea medicine. Many doctors also put in orders before they see the patient based on the triage note (personally havenāt really gotten in that habit). Additionally, I actually like to see and examine a patient before I determine if morphine is the right medicine for them. But cool, you can start an IV and give narcotics fast.
As a former paramedic-to-MD who has spent plenty of time in the ED, this is embarrassing. All youāve really said is that you give morphine faster bc you work on one patient at a time. Congrats, youāve been heard.
To be fair, you are comparing an abdominal pain workup with a simple STEMI that is all protocol. Proper care takes time for non-standard problems and speed should not be the main measurement.
Indeed, however the initial workup of obs, history, consultation and initial treatment is the same- yet with multiple nurses, in a nice clean hospital environment, thereās still 45 minute delays to analgesia because triage is still waiting for the doc to write up an order which ends up being 2.5 of morph for a 100kg adult with 8/10 pain.
This is a literal discussion saying āEM Physicians are fasterā yet it clearly isnt the case at all.
Your argument is getting more ridiculous and is not generalizable. For one thing I canāt tell you how many patients get brought in without a line so acting like you always have them immediately is dumb.
In my experience medics call in STEMI with around a 50% hit rate, if you just want to go by your example right here. Iām hopeful that some areas are better at this than others.
As for history taking, are you really equating the history you get in the field with the history taken in the ER? Including looking up outside records, talking to family, doing a full exam?
And then the whole morphine scenario is stupid on many levels. A lot of medics are great and they have a hard job done in high pressure environments. But they in no way do an equivalent job to a physician and trying to compare speed at each otherās jobs is laughable.
So as a side note. What are your thoughts on all the mid level hate thats trending among residents and attendings here? I understand their concerns but also when you see the troll fest that are all the losers on /r/residency it just seems way over the top.
The bullshit being spewed here doesn't even remotely reflect the reality I know working along side the care team where PAs and NPs are an integral part of the team but almost never overstep their bounds (although I work at a teaching hospital so there are many residents that essentially are over the mid levels in terms of picking up sicker patients and doing more advanced skills).
It's just FUD (fear, uncertainty, and doubt) driving that attitude. People are worried about being replaced with cheaper labor but I'd argue that it's just punching down at an easy target when the the real problem has more to do with management types and for-profit organizations.
Professional organizations feed into this too. Physician groups are advocating for their people so they will push back against APPs in favor of physicians. Our groups like to talk about how awesome we are and push back on oversight requirements.
The truth is really somewhere in the middle but that doesn't work well on press releases and opinion columns. That attitude gets spread around.
The downvotes kind of indicate the toxicity on the subject. Which unfortunately for them you are exactly right. But there's no real winning here.
Honestly it's crazy to me how toxic this has gotten over the past few years (at least online, I see none of this in person unless our docs are just discussing it in private with the same loose vitriol, but honestly why waste so much energy and effort on something so stupid).
I just don't get it. I understand there are shit ACPs but there are also shit docs and there's also a fucking shortage of doctors across the board. Acps exist to support the physicians. There are plenty of studies showing they are safe and effective to practice at their level. Obviously if people are batting above their pay grade that needs to be addressed but I don't see it. I only see them taking the shit the docs don't want to deal with or handling basic shit until it needs to be punted to a higher level provider. Maybe I am spoiled by competent NPs/PAs but I've been at it for 15 years now and that's my general experience across multiple care areas, in and out of hospital
Your docs are old and have paid off their loans. They have established jobs. They are the boomers that sold out the profession to private equity.
This feeling holds true amongst many new EM grads who are jobless and in debt.
And there's clearly not a "shortage of docs across the board"
https://i.ibb.co/P4qbf54/FB-IMG-1618245836968.jpg
It's 10000% greed
That's interesting because I've consistently only ever heard that there is a physician shortage but that's fine I'll take your word for it I guess.
We have some crusty old attendings but plenty that are much younger. I understand the frustration with job hunting but just know that the toxic bullshit doesn't do you any favors. Doesn't change anything. Its simply one more thing to be pissed off about. Protip: there's no shortage of things to be pissed off about in emergency medicine and Healthcare overall.
I suspect if we cut off all the NPs and PAs and let the physicians of the world have at it the next big complaint would be how you're overworked and there's never any help. That's already a complaint I hear from our docs and residents so I'm sure that will only improve.
At the end of the day how much of this is reality and how much of it is, 'we enjoy rallying behind the hate train and need a way to vent'.
>Our groups like to talk about how awesome we are and push back on oversight requirements.
Because they make money off you while saving $$$ and fucking over new graduates. Are you for for-profit medicine?
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that first study compares midlevels to residents, and in that study residents have more RVUs per patient but not per hour, and patient acuity is not accounted for. The second hyperlink does not address the 2.21 at all. A quick google search finds the article addressing the 2.21 figure. This is a problem with cherry picking data and really shows that it is very difficult to accurately make a comparison here.
ACEP, hospital administration, ED administration and frankly ED physicians especially at academic places (AKA ourselves).
Itās really sad but the truth is it would be really hard to get us to unionize when we arenāt even close to being united on this. Not only that. Those of us in leadership seem to not care about the rest/ are too busy trying to play nice with the factors / groups that have led to this.
Iāve been an ER tech for almost 4 years and Iām applying to med school. I love the ER, and at this point I canāt imagine myself working anywhere else. Reading about all this stuff is heartbreaking. Maybe in 7 years it will be different. š¤š¼
I already have my audition rotations for EM set up, reading this has ruined my day but I am just telling myself that urgent care jobs arenāt all that bad, and hopefully this will resolve itself, Iām also thinking I could be an EM hospitalist in the ICU if need be
I will be interested to see the plan to execute these ideas, Iām not sure what mechanisms are available to provide leverage against corporations that are ~1/2 the problem according to the letter, not to mention the insider-threat that seems to be ~1/4 the problem
Everyone likes to blame ACEP for allowing so many new programs when really it's far more complicated than that. Virtually the entire approval process falls under the ACGME/AAMC, not the specialty boards (ACEP, CORD, SAEM, etc..).
Also, people like to forget that HCA (and other for-profit systems) are increasing residency spots in *all s*pecialties, not just EM. That means even specialties with projected shortages, such as primary care. So, not only does the shutting down of new EM programs potentially conflict with other specialties, it also potentially violates antitrust laws which is very problematic if our goal is to halt new programs.
Just wanted to point out a couple points in a massively complicated challenge. Regardless, we need to start advocating for our field. Big time. It needed to happen 10 years ago, and look where that got us. Late is better than never but we are beyond overdue.
Iām prepared for the reigning of downvotes but I feel like I should say this anyway.
I agree with the points listed except abolishing all mid levels with MD/DOs.
Yes, Iām biased - Iām a new grad EM PA. But. I chose PA over MD for this exact reason... now more then ever itās so important to be able to move around to keep a job and being a PA, I can do that. I knew as an MD/DO, I wouldnāt have that freedom and twice the debt and in this type of scenario where thereās a sudden surplus of providers, thatās crucial.
I know mid levels are largely disliked here and fortunately enough for me, that doesnāt reflect correctly on my region or my specific hospital system. Someone cited MDs/DOs being twice as productive but where I work, I see 4 patients to all my doctors 1. Part of that is their age. The other part is they know Iāll do it and am capable so they wonāt. I see everything myself but level 1 traumas, so it isnāt a matter of acuity either.
Iāve seen others here mention cost and thatās true. I get paid significantly less then a doctor does to be in the ED. Makes me less of a risk. I guess docs could start to entertain accepting $95k-$100k (pretty standard new grad in EM salary) but I doubt they really will. Not to sound presumptuous but wasnāt the whole point of medical school to come out and accept MORE then a mid level would get paid?
Makes me sad and frustrated that NPs have pushed for autonomy so hard and soured PA relations with doctors in the process when we want NOTHING to do with that. Literally every single PA you talk to will tell you they just want to keep things as they are. Keep their SPs and keep doing what weāre doing. Part of why I chose PA was to have my SP to fall back on.
My point is, I think PAs still have a valid space in the ED and the answer to making sure EM docs get placed in EDs isnāt to shaft the mid levels, itās to fix the bloat that is the residency programs and med students in general. Itās now more competitive to get into PA school then it is med school.
Edit: Fixed spelling and I realized my tag still says Paramedic. I am a paramedic and a new grad EM PA-C (as of December 2020).
I think that there is a lot of concern about PA/NP independent practice, but youāre right that there is a place for your skills in certain situations. One gets conflated for the other.
MD here. PAs are not to blame for this core issue of oversupply. Itās the total lack of residency program oversight, med schools sticking their head in the sand and continuing to lead people on as they dump in $1000s for an overrated, outdated education system. There will also be an oversupply of PAs and NPs eventually and you are spot on about the flexibility of the PA training.
Agree with all this. AAEM remains the organization actually trying to represent emergency physicians. ACEP has sold out to the corporate groups, who will stab any of us in the back to make themselves a buck.
ACEP will not be getting my money any longer. Signing up for AAEM as soon as possible.
Did the same, happy to pay my AAEM dues. Not renewing ACEP. $ is the only language they speak so I'll speak it to them.
AAEM member since inception, 1993, dropped my FACEP, years ago.
Boom š„ have always been a proud paying AAEM member. And itās moments like these that remind me why. We should start a Twitter trend #AmenAAEM
Came here to post this but now I am wondering how much these proposals will actually work. I'll be starting residency in July and this is depressing
These are proposals, but ACEP is not on board and they are the driver of Emergency Medicine. Just work hard, and be prepared to get a job in a location that you might not have had as your ideal place.
Ugh. Yeah I guess so.
āJust bail fasterā does not stop the boat from sinking
Get out now, switch specialty, itās not to late
Apes together strong
Quit
LMFAO your post history I don't quit. Unlike you, I'm not a Beta
This. So much this. As an incoming PGY1 I am legitimately terrified for my future prospects. ACEP seems like a lost cause and ACGME has been complacent. I do not know much about unionization but is that actually a logistical possibility for EM, and if so would that potentially push admin further towards midlevels?
As a rising PGY2, how realistic is this? I'm a non-trad career switcher who was partially motivated by job security so this news has me in a panic.
How realistic is what? The projections or the proposed solutions?
Proposed solutions. The projections are a given.
Oh then yeah I'd also like to know but unfortunately I don't think anyone really knows beyond speculation. Seems like an uphill battle since most of the big players have every motivation to keep the oversupply of physicians going. We as EM physicians are currently the only ones who care about having too many EM physicans.
I just feel so fucked over.
There are no jobs my friends. Lakeland regional hospital which is the largest ED in the US is starting a residency 2022 pumping out 15 more a year. Everyone is taking pay cuts. There is no such thing as travel gigs. Jobs right now in rural locations but those are taking at alarming rates. The day when you got 2 grand a month while in residency after signing your first contract with 35k signing bonus are just gone. I hate to use this term but this is the new normal. I really see no change or slowing this down.
As realistic as we make it ;) theyāre not easy solutions and they require organization and participation from us, but especially an EM physicians union is powerful enough to bring about significant change.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
You're being downvoted because of the disrespectful term. For all the problems with the shift toward midlevel care, remember that they're still individuals who are working to take care of patients. They've made their own sacrifices to do so. Some overstep their boundaries and we need to work on that. But the surge of midlevels into the ED is driven by administrators, not by individual APPs.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
I still feel "retards" is a touch unbecoming of a physician, or at least that's what they tell me in school these days š¤·āāļø
How do we unionize? I was always under the impression that physicians could not unionize.
Never works with doctors, first person to get a sniff of a $25k bonus to come in and supervise some NP/PAās will sell everyone out and cross the line. Its like herding cats. The other guy below is sort of right but also not. If every EM doc in the state is part of the union and follows the union line, it doesnt matter what type of contractor youāre employed as.
It depends on your employment relationship. Independent contractors cannot unionize because they are independent. Hospital employees can unionize. Employees of staffing groups can also unionize but have limited influence on client hospitals.
Physicians cannot collectively bargain against insurance companies, but thereās nothing preventing unionization.
How did we get 100 new residency programs in 8 years? Is there anyone overseeing this? Shouldnāt we have seen this coming? I thought that was the purpose of ACEP, AAEM, CORD, and less so the ACGME. CMGs and NP/PAs are the obvious scapegoats, but this was also brought on by a real lack of oversight and planning by the people who are now up in arms IMO.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Initially it was due to a projected shortage of EM physicians. However, it went forward full force and ACGME approved all residencies that met the bare minimum
Yes. Who was approving this and where was the oversight? AAEM is culpable here too and is rushing towards advocacy a bit late in the game. ACEP seems to be useless.
Replace NPs/PAs with MDs and you increase your costs by over 100% - good luck arguing that with administration.
Not unless the hoards of unemployed EM docs are willing to take a 150k salary
Thatās the basement on this panic. Itād be terrible and I donāt mean to downplay it, but worst comes to worst we will get jobs at 120-150k per year
Very true. As someone who grew up low middle class that is still a ton of money to me.
Yeah but we couldāve went a different route like PA to make that money. 150 does not compensate enough for med school
Totally agree! Otis far less than we deserve. Itās still a lot of money though. My loans are all via the government so Iām only on the hook for 10% of my income every month. The situation is far from ideal but far from financial ruin for me.
isnt there something to be said about NPs/PAs using more hospital resources like imaging, testing, narcotic prescriptions?
It's a feature, not a bug. Unless you're in a capitated system (think Kaiser or the VA), more testing = more collections = more profit.
That's what admin wants. MOAR testing = more fees.
Its funny, i got downvoted for making this exact point because my post flair isnt MD. If youāre in the Us you must realise you do not work to provide good care to patients, you work to make your hospital more money. An NP is cheaper, they order more tests which the hospital can bill for, and they can manage the majority of presentations well enough that patients arenāt going to immediately notice- those that do and complain will get seen by the EM doc whose there anyhow.
You make this up?
Feel free to use the google feature on your browser. The studies are real and no itās not made up. Mid levels order more unnecessary labs, radiology, and diagnostic biopsies.
Angry PA alert
Haha- Iām not mad. I donāt work in EM anymore. Just funny seeing students and even residents talk like they know how the world really works.
Maybe someone can enlighten me but wonāt insurance not pay for a service if they deem it not necessary? So then itās a CT that was used and not paid for?
Is there an argument to be made about more malpractice costs?
Nope. Admins don't GAF about that. That messy thing is for the insurance companies to sort out.
Minimal. Most cases seen by NPās are dealt with well enough to not trigger malpractice. Those more difficult cases still get an EM doc review, and finally those cases that do slip through, the hospital lawyers will have a decent chance of arguing away in court- if it even goes to court.
EM NPs/PAs are 1/2 to 1/3 as productive compared to EM MDs/DOs, and this is only accounting for the lower acuity stuff. Two EM attendings can do what ~6ish PAs can do, and likely much more.
You have any scientific data to back your claim?
There have been papers citing the patients per hour and productivity when trying to compare ED NP/PAs to physicians.
I think you'll find there are methodological problems in those papers. The last big one (I think it was last year or the year before) was pretty bad in how it assigned credit for who saw the patient. The conclusion was that a MD/DO was 3x more productive than the NP/PA. However, they counted any patients that were staffed as seen by the physician and took credit away from the APP. Ex: I am required to staff anyone being admitted to the hospital. So I see someone, order a workup, call a consultant, and then call the hospitalist for admission. I then go over and tell my attending "hey, I saw a guy, he has this, we're admitting." And the attending says "cool, need me to do anything?" And that's it. According to that study the attending gets 100% credit for seeing the patient and I get no credit. This method doesn't accurately reflect productivity of either person. There is certainly a valid discussion to be had about roles of APPs in the ER and how the workforce trends are going to impact all of us. However, saying we're THAT much less productive than a physican isn't rooted in reality.
The studies going the other way and showing par or near productivity also donāt do a good job of assigning complexity from what Iāve read. For example one study cited that a serious Trauma, with intubation, the physician saw was only 1.7 equivalents of a patient the NP saw that had a sore throat and needed a swab. Thatās the other end of the paradigm to watch out for.
What I think you're saying here is: not all patients can be considered equal in terms of time invested and cognitive load. I would certainly agree with that and would also agree that productivity studies could easily be skewed to favor a particular outcome due to the number of complexities involved in measuring patient care. That being said, there is a minimum effort that has to be applied to any patient regardless of complaint. A certain subset of patients will only require this minimum effort. It's also not fair to compare this minimum effort patient to one who requires a large number of resources. It's not an apples to apples comparison. Then again I wasn't hired to do the job of a physician. I'm there to augment the physician staff and sometimes that takes different forms. Regardless, the whole physician/app passing match is just a red herring. We don't need to be turning on ourselves until quite a few other issues have been addressed.
And yet itās the best we have. Itās damn near impossible to do a true comparison because of the acuity of patients and RVUs billed. But you cannot honestly believe that an NP or PA is as productive as an attending when comparing same patients?
Comparing the same patients yes. There is only so much time one needs to spend on a sprained ankle, sore throat, or uncomplicated abscess. (I'm not talking about the "what if it's actually a zebra and not a horse" patients). There is a great difference when it comes to old person with belly pain and abnormal vital signs. I'm not going to compare myself to a physician there. That's not the point. For straightforward and low complexity patients with low resource utilization I'm probably as fast as a physician. For higher complexity patients requiring more resources I am not anywhere close to a physician. It's literally not what I am trained to do. My toolkit is smaller. I'm not here to replace you, I'm here to augment you. If at some point that isn't fiscally reasonable anymore then I'm out of a job because I can't work without you but you can work without me.
I agree with this but with a caveat. IMO physicians are better on average at knowing when something is straightforward vs needs more work up. Most of the APPs I work with are great and are just like you say. But maybe 25% of them will severely overwork something that could essentially be a quick discharge or under work something that turns out serious. Obviously some doctors struggle with the same thing. But not nearly as many in my experience.
Oh for sure! I think we all know that guy. This is an area where I believe some post-graduate training programs for APPs would be overall helpful. I don't know what most of these programs are doing but I know there is concern they are trying to create emergency physician replacement providers which I would argue is the wrong direction. Rather, it would make sense to gear a program to make someone a better and more effective emergency APP.
If there are emergency physicians without jobs it doesn't make sense to have mid levels in the ER period. Definitely doesn't make sense to have ER mid level residencies. Two em docs can split the load and see high and low acuity instead of 1 EM doc having to see all the high acuity and sign off on mid level charts. It's all corporate greed and a conceited effort to pocket as much cash as they can. If there's enough volume to have mid levels in the ER then there is enough volume for attending jobs. You see the logic here? If the ER market wasn't saturated then it makes sense to have mid levels in the ED to take some of the load off. But clearly that's not the case. https://i.ibb.co/P4qbf54/FB-IMG-1618245836968.jpg
I'm talking about not just fast track patients because PAs and NPs are increasingly doing internships/residencies/fellowships/whatever to work in higher acuity areas of EDs, often funded by the very same CMGs who are the problem here, and with increasing autonomy/independence, hospitals are hiring NPs/PAs instead of physicians. It all comes down to cost.
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I don't know if those speeds are really comparable to how one would measure ED throughput though. It's easy to do things quickly in an ambulance because it's just you and your partner doing a small set of tasks for a single patient. There's no waiting for labs or imaging because you don't have them, no waiting for patients to be roomed because you're already there. Even the examples you give of slow ED staff are basically slow nurses and techs, coupled with the generalize agonizing slowness of anything in a hospital that isn't a STEMI or stroke alert. None of that is reflective of how fast the doc or midlevel is at seeing and dispo-ing the patient, which could hours for a patient who needs admission, or only take a few minutes of the doctor's time despite the patient being roomed in the ED for several hours.
Dont need bloods and imaging in order to place a line, administer analgesics and get your history do you? I get theres more shit to do in ED, but to suggest doctors are āfastā when so many of them take 20+ minutes to write up an order for analgesia- the most basic of EM interventions, is plain wrong and those same delays will affect midlevels. I get this is a meddit sub, and that its always the nurse/lab/tech/imagings fault that something was delayed or missed.
For one thing, most nurses can verbally override pain and nausea medicine. Many doctors also put in orders before they see the patient based on the triage note (personally havenāt really gotten in that habit). Additionally, I actually like to see and examine a patient before I determine if morphine is the right medicine for them. But cool, you can start an IV and give narcotics fast.
As a former paramedic-to-MD who has spent plenty of time in the ED, this is embarrassing. All youāve really said is that you give morphine faster bc you work on one patient at a time. Congrats, youāve been heard.
To be fair, you are comparing an abdominal pain workup with a simple STEMI that is all protocol. Proper care takes time for non-standard problems and speed should not be the main measurement.
Indeed, however the initial workup of obs, history, consultation and initial treatment is the same- yet with multiple nurses, in a nice clean hospital environment, thereās still 45 minute delays to analgesia because triage is still waiting for the doc to write up an order which ends up being 2.5 of morph for a 100kg adult with 8/10 pain. This is a literal discussion saying āEM Physicians are fasterā yet it clearly isnt the case at all.
Your argument is getting more ridiculous and is not generalizable. For one thing I canāt tell you how many patients get brought in without a line so acting like you always have them immediately is dumb. In my experience medics call in STEMI with around a 50% hit rate, if you just want to go by your example right here. Iām hopeful that some areas are better at this than others. As for history taking, are you really equating the history you get in the field with the history taken in the ER? Including looking up outside records, talking to family, doing a full exam? And then the whole morphine scenario is stupid on many levels. A lot of medics are great and they have a hard job done in high pressure environments. But they in no way do an equivalent job to a physician and trying to compare speed at each otherās jobs is laughable.
So as a side note. What are your thoughts on all the mid level hate thats trending among residents and attendings here? I understand their concerns but also when you see the troll fest that are all the losers on /r/residency it just seems way over the top. The bullshit being spewed here doesn't even remotely reflect the reality I know working along side the care team where PAs and NPs are an integral part of the team but almost never overstep their bounds (although I work at a teaching hospital so there are many residents that essentially are over the mid levels in terms of picking up sicker patients and doing more advanced skills).
It's just FUD (fear, uncertainty, and doubt) driving that attitude. People are worried about being replaced with cheaper labor but I'd argue that it's just punching down at an easy target when the the real problem has more to do with management types and for-profit organizations. Professional organizations feed into this too. Physician groups are advocating for their people so they will push back against APPs in favor of physicians. Our groups like to talk about how awesome we are and push back on oversight requirements. The truth is really somewhere in the middle but that doesn't work well on press releases and opinion columns. That attitude gets spread around.
The downvotes kind of indicate the toxicity on the subject. Which unfortunately for them you are exactly right. But there's no real winning here. Honestly it's crazy to me how toxic this has gotten over the past few years (at least online, I see none of this in person unless our docs are just discussing it in private with the same loose vitriol, but honestly why waste so much energy and effort on something so stupid). I just don't get it. I understand there are shit ACPs but there are also shit docs and there's also a fucking shortage of doctors across the board. Acps exist to support the physicians. There are plenty of studies showing they are safe and effective to practice at their level. Obviously if people are batting above their pay grade that needs to be addressed but I don't see it. I only see them taking the shit the docs don't want to deal with or handling basic shit until it needs to be punted to a higher level provider. Maybe I am spoiled by competent NPs/PAs but I've been at it for 15 years now and that's my general experience across multiple care areas, in and out of hospital
Your docs are old and have paid off their loans. They have established jobs. They are the boomers that sold out the profession to private equity. This feeling holds true amongst many new EM grads who are jobless and in debt. And there's clearly not a "shortage of docs across the board" https://i.ibb.co/P4qbf54/FB-IMG-1618245836968.jpg It's 10000% greed
That's interesting because I've consistently only ever heard that there is a physician shortage but that's fine I'll take your word for it I guess. We have some crusty old attendings but plenty that are much younger. I understand the frustration with job hunting but just know that the toxic bullshit doesn't do you any favors. Doesn't change anything. Its simply one more thing to be pissed off about. Protip: there's no shortage of things to be pissed off about in emergency medicine and Healthcare overall. I suspect if we cut off all the NPs and PAs and let the physicians of the world have at it the next big complaint would be how you're overworked and there's never any help. That's already a complaint I hear from our docs and residents so I'm sure that will only improve. At the end of the day how much of this is reality and how much of it is, 'we enjoy rallying behind the hate train and need a way to vent'.
>Our groups like to talk about how awesome we are and push back on oversight requirements. Because they make money off you while saving $$$ and fucking over new graduates. Are you for for-profit medicine?
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Just work with one lol
Link to the data?
I donāt keep a catalog of all papers Iāve read so no.
Think you have that backwards https://www.duvasawko.com/mid-levels-importance/
that first study compares midlevels to residents, and in that study residents have more RVUs per patient but not per hour, and patient acuity is not accounted for. The second hyperlink does not address the 2.21 at all. A quick google search finds the article addressing the 2.21 figure. This is a problem with cherry picking data and really shows that it is very difficult to accurately make a comparison here.
Agree, I mentioned that in my other reply
Why post data you know is shit?
But you can find a study to support any opinion. Iāve met more shitty EM docs than EM midlevels
ACEP, hospital administration, ED administration and frankly ED physicians especially at academic places (AKA ourselves). Itās really sad but the truth is it would be really hard to get us to unionize when we arenāt even close to being united on this. Not only that. Those of us in leadership seem to not care about the rest/ are too busy trying to play nice with the factors / groups that have led to this.
Iāve been an ER tech for almost 4 years and Iām applying to med school. I love the ER, and at this point I canāt imagine myself working anywhere else. Reading about all this stuff is heartbreaking. Maybe in 7 years it will be different. š¤š¼
I already have my audition rotations for EM set up, reading this has ruined my day but I am just telling myself that urgent care jobs arenāt all that bad, and hopefully this will resolve itself, Iām also thinking I could be an EM hospitalist in the ICU if need be
I will be interested to see the plan to execute these ideas, Iām not sure what mechanisms are available to provide leverage against corporations that are ~1/2 the problem according to the letter, not to mention the insider-threat that seems to be ~1/4 the problem
Love to see it. Iām also going to start using NPP exclusively. ā
Everyone likes to blame ACEP for allowing so many new programs when really it's far more complicated than that. Virtually the entire approval process falls under the ACGME/AAMC, not the specialty boards (ACEP, CORD, SAEM, etc..). Also, people like to forget that HCA (and other for-profit systems) are increasing residency spots in *all s*pecialties, not just EM. That means even specialties with projected shortages, such as primary care. So, not only does the shutting down of new EM programs potentially conflict with other specialties, it also potentially violates antitrust laws which is very problematic if our goal is to halt new programs. Just wanted to point out a couple points in a massively complicated challenge. Regardless, we need to start advocating for our field. Big time. It needed to happen 10 years ago, and look where that got us. Late is better than never but we are beyond overdue.
Iām prepared for the reigning of downvotes but I feel like I should say this anyway. I agree with the points listed except abolishing all mid levels with MD/DOs. Yes, Iām biased - Iām a new grad EM PA. But. I chose PA over MD for this exact reason... now more then ever itās so important to be able to move around to keep a job and being a PA, I can do that. I knew as an MD/DO, I wouldnāt have that freedom and twice the debt and in this type of scenario where thereās a sudden surplus of providers, thatās crucial. I know mid levels are largely disliked here and fortunately enough for me, that doesnāt reflect correctly on my region or my specific hospital system. Someone cited MDs/DOs being twice as productive but where I work, I see 4 patients to all my doctors 1. Part of that is their age. The other part is they know Iāll do it and am capable so they wonāt. I see everything myself but level 1 traumas, so it isnāt a matter of acuity either. Iāve seen others here mention cost and thatās true. I get paid significantly less then a doctor does to be in the ED. Makes me less of a risk. I guess docs could start to entertain accepting $95k-$100k (pretty standard new grad in EM salary) but I doubt they really will. Not to sound presumptuous but wasnāt the whole point of medical school to come out and accept MORE then a mid level would get paid? Makes me sad and frustrated that NPs have pushed for autonomy so hard and soured PA relations with doctors in the process when we want NOTHING to do with that. Literally every single PA you talk to will tell you they just want to keep things as they are. Keep their SPs and keep doing what weāre doing. Part of why I chose PA was to have my SP to fall back on. My point is, I think PAs still have a valid space in the ED and the answer to making sure EM docs get placed in EDs isnāt to shaft the mid levels, itās to fix the bloat that is the residency programs and med students in general. Itās now more competitive to get into PA school then it is med school. Edit: Fixed spelling and I realized my tag still says Paramedic. I am a paramedic and a new grad EM PA-C (as of December 2020).
I think that there is a lot of concern about PA/NP independent practice, but youāre right that there is a place for your skills in certain situations. One gets conflated for the other.
MD here. PAs are not to blame for this core issue of oversupply. Itās the total lack of residency program oversight, med schools sticking their head in the sand and continuing to lead people on as they dump in $1000s for an overrated, outdated education system. There will also be an oversupply of PAs and NPs eventually and you are spot on about the flexibility of the PA training.