Future of PA's in ED

[Emerson]

I had a conversation recently with a few of my attendings as it relates to the future of the PA in emergency medicine. My perspective is that there would be an increased presence and scope of the mid-level provider, but they shared a different perspective. They shared a similar opinion as the future of the ED is going to see significant decreases in volume with higher acuity patients. Insurance companies combined with triage screening for what is considered emergent (i.e. France) would direct patients that are non-emergent to local care clinics and urgent cares. With that, he feels the role of the PA will be obsolete in the next 5-8 years as the landscape changes. Physicians will manage less volume with higher acuity and suture techs ($15 /hr) will be trained in varying procedures.

I thought i'd open this up for discussion.

[andersenpa]

if the docs are already seeing these high acuity pts in the current ED then the only change is a shift of PAs from EDs to UCs. Then these sites will have many PAs with a doc there for supervision.
The only real change would be if there are PAs seeing the high acuity pts and they would then lose out after the switch.

there is going to need to be a major change for EDs (serious real triage) to keep the fluff cases out though....

[EMEDPA]

UNLIKELY. Acep (american college of emergency physicians) is very interested in supporting pa's in emergency medicine and see an ongoing role for us. they helped develop the CAQ exam and are involved with developing emergency med pa postgrad programs(there are 16 now with several others in the works). em pa's are here to stay. their roles will vary depending on where they work with the full spectrum represented from triage to fast track to working in main to working solo in rural settings seeing everything.

[Emerson]

E -

Do you have ACEP literature that supports this view? I'd really like to read it if you do. I definitely see the rural PA remaining very active, but the point was that in the future there would be no 'fast track' or patients with low acuity being allowed to be seen in the ED. Insurance companies are certainly going to play a heavy hand in this. We have fast track criteria that allows us to treat and street, but also get involved in higher acuity cases as well. I'd like to start doing some research and provide some ACEP data in order to create a bit of a shift in their current way of thinking if possible.

[Timon]

I know I am only a pre-PA but as a former business executive I do not see how this would in any way limit or remove the role of PA's in the next 5-8 years.

If anything I can see the scope of practice for PA's expanding as PA's are cost efficient for hospitals.

As someone managing a hospital why would I hire 2 Physicians to manage an ER making $210+, and let's say 4 people doing triage / suture tech at $15 an hour when I can hire 1 MD/DO and 4 PA's for the same price and have better quality of care?

Current trends for PA's has indicated an increase of role and responsibility over the past 10 years.. based on that trend and the cost benefits of PAs I can only imagine that the roles and responsibilities of PA's only expanding and possibly dipping / decreasing the 20% extra work that physicians do that PAs currently do not perform. The supply of patients can only increase with the amount of baby boomers that will be needing treatment in addition to natural population increases. This would result in an increased demand of mid-level healthcare providers.

Although we are all in healthcare to help people, the reality is that this is a business of helping people. From there, as a hospital, we would want to have increased traffic to increase revenue due to the principle of economy of scale. The more patients and services treated / rendered the more revenue a hospital will make especially with the number of patients that will be on medicare and obamacare.

The legislation of public healthcare systems and managed care will then dictate elasticity (of how much one is willing to pay for a product or service). Due to this principal, insurance providers, government, and managed care systems will be more stringent on how much services are billed / costs due to hospital efficiency. Because of these reasons I suggest that PA's are really the way of the future with PA's doing most of the work and MD/DO's transitioning more into a supervisory role with PA's acting like middle management.

If one were to make a SWOT analysis I would break it down like this from a hospital management perspective (keep in mind I'm doing this on the fly but I could put together a more comprehensive analysis with references if requested):

Strength of PA's
- Cost efficient
- Able to perform 80% of a MD/DO's function
- Increased patient services
- Increase in patient capacity
- Decrease in patient waiting times
- Ability to write prescriptions (transcriptions)

Weakness of PA's
- Less in depth knowledge than a Physician
- Relatively new field that some patients have no had exposure to yet
- Some patients will demand to see a MD/DO and refuse treatment from PAs

Threats
- A/NP lobbying to extend into ED
- Lobbyist pushing for limited scope of practice for PAs
- MD/DO's who view PA's as a threat and will push to increase the amount of physicians
- Nurse specialties and techs to divide the role of PA duties

Opportunities
- Helping managed care decreasing their delay of services rendered to patients
- Possibly transitioning into a role similar to NPs of opening their own practice in rural areas with decreased charting from a MD/DO

[Emerson]

Timon -

What percentage of PA's currently working in emergency medicine have the same ability as their attendings to manage ICU players? Your quote on "80%" is in reference to a primary care setting, not emergency medicine. I suspect this conversation will be group specific. If your group utilizes the PA concept to move low acuity patients and to manage fast track, I could see that level of care disappearing for the PA. On the other hand, if you have PA's that can intubate, place central lines, chest tubes, etc I could then see an expanded role - thus, the evolution of ED residencies.

[Timon]

I understand that our knowledge is limited in pathophysiology which limits us in most ED. I was under the impression it was at the discresion of that ER in accordance to state laws. That being said I am aware of one ED where PAs have acuity which is in Corona, CA. This is why I was under the belief that the roles and responsibilities of a PA could possibly expand in the future with additional training.

[EMEDPA]

E -

Do you have ACEP literature that supports this view? .

sent you a pm

[EMEDPA]

another postgrad program announced today:
http://www.carilionclinic.org/Carilion/EM_Fellowship

The one-year fellowship program was developed to help meet a growing need for specially trained mid-level providers to treat emergency department patients, said Kim Roe, senior director of the Department of Emergency Medicine at Carilion Clinic.
The need for the training is also indicative of the trend toward hiring nurse practitioners and physician assistants to help meet patient need without relying on doctors. In recent years health policy experts have said physician assistants and nurse practitioners will play an increasing role in treating people, especially in rural and underserved regions of the country.

[primadonna22274]

That's interesting E...I have their IM residency on my radar.

[RetNavyPAC]

Thanks for the plug :-) We're working on our website right now.

[PAMAC]

ive mentioned this a few times, but the hospitals in my region are or have phased out PA's in the ERs. a lot of this is marketing (they broadcast that you see a doctor in so many minutes rather than wait, and having doctors see you is more PR saavy than having PAs, despite the obvious savings). surrounding the ERs are hospital owned minute type clinics. usually they are the ones that feed into the hospital, though, and they are staffed by PAs and NPs. so its a bit of the reverse.... the clinics sort of do the triage for the ER. if its too complex, then its across the parking lot they go. its tough to have a patient in the ER that doesnt need to be there, and then tell them to head to the clinic because they dont belong there. their foot is already in the door. the phsysician groups have made the pitch that if they get in front of the patient and do triage quick enough, they are the experts at identifying issues that need addressing.

my brain says it makes sense to have PAs in the ER, but after seeing what im seeing here, i actually dont see the kind of future for PA's and NP's there that id like to have.

[EMEDPA]

my brain says it makes sense to have PAs in the ER, but after seeing what im seeing here, i actually dont see the kind of future for PA's and NP's there that id like to have.

I think you are seeing a regional issue. almost everywhere else is adding pa's/np's. at my last job we stopped using moonlighting residents and replaced them all with pa's. the RESIDENTS were having to staff all their cases WITH THE PA'S anyway so it just made sense to give them the boot. they made more money/hr than the pa's and were about 1/4 as productive.

[PAMAC]

I think one of the other things is that these ER physicians groups don't have residents. Their physicians are full timers, board certified. They tried a fast track for a while where I am, and they wanted it to be the domain of their mid levels, but the higher acuity conditions on some nights greatly outnumbered the fast track stuff. I guesse it made more sense for them to just staff the docs and move folks through quicker, because they shed the mid levels after a few months.

[med218]

Which area do you live in PAMAC?