JAAPA Article

[PAtoMD]

Interesting research. Thoughts anyone?

Article name: Emergency physician evaluation of PA and NP Practice Patterns

Results: "Regardless of experience level, NPs were reported to use significantly more resources than PAs."

Conclusion: " Councilors reported great variation in PA and NP scope of practice. The results also suggest that new graduate PAs may be more clinically prepared to practice in the ED than a new graduate NP."

 

 

Edit: I can post pictures of the article if needed

[lkth487]

It was a survey.  Kind of pointless.  If you can't have prospective RCT where you'd assign patients based on chief complaints, you need to do an actual retrospective analysis and the cost of the workup.

[PAtoMD]

9 minutes ago, lkth487 said:

It was a survey.  Kind of pointless.  If you can't have prospective RCT where you'd assign patients based on chief complaints, you need to do an actual retrospective analysis and the cost of the workup.

I should have paid more attention in biostats. But wouldn’t it be unethical/ too hard to do a RCT and assign patients to providers?

 

also a retrospective analysis may be too difficult. No way to know who had influence on their decision making.

Again, I should have paid more attention so please let me know if I’m wrong.

[lkth487]

1 hour ago, SR0525 said:

I should have paid more attention in biostats. But wouldn’t it be unethical/ too hard to do a RCT and assign patients to providers?

 

also a retrospective analysis may be too difficult. No way to know who had influence on their decision making.

Again, I should have paid more attention so please let me know if I’m wrong.

It depends. I think if they are already going to be seen by either a NP or PA, doing it in a randomized manner wouldn't be unethical, after obtaining consent.  As long as you are still delivering the standard of care.  I think it would pass IRB muster.  Retrospective analysis would be time consuming, but could be done. 

 

Surveys are pretty much useless for something like this though.  Imagine the outcry (and rightfully so) if tomorrow someone came out saying PAs provide less safe care than physicians based on results of a survey.  

[rev ronin]

6 minutes ago, lkth487 said:

It depends. I think if they are already going to be seen by either a NP or PA, doing it in a randomized manner wouldn't be unethical, after obtaining consent.  As long as you are still delivering the standard of care.  I think it would pass IRB muster.  Retrospective analysis would be time consuming, but could be done. 

 

Surveys are pretty much useless for something like this though.  Imagine the outcry (and rightfully so) if tomorrow someone came out saying PAs provide less safe care than physicians based on results of a survey.  

This:

1) King County EMS did trials of lidocaine vs. Amiodarine vs. NORMAL SALINE for ACLS, so yes, you CAN randomize pretty much anything with appropriate IRB scrutiny.

2) Almost all bad studies I've seen, including the one which claims that vaccination was retrospectively associated with autism, rely on poorly controlled surveys of dubious methodology.

[PAtoMD]

2 hours ago, lkth487 said:

It depends. I think if they are already going to be seen by either a NP or PA, doing it in a randomized manner wouldn't be unethical, after obtaining consent.  As long as you are still delivering the standard of care.  I think it would pass IRB muster.  Retrospective analysis would be time consuming, but could be done. 

 

Surveys are pretty much useless for something like this though.  Imagine the outcry (and rightfully so) if tomorrow someone came out saying PAs provide less safe care than physicians based on results of a survey.  

I still think in both instances the amount of biases and confounders would to be too great. Along with a costly study.

I do not deny the validity, or lack there of, of a survey as opposed to a RCT. I do however, believe that a legitimate study that would hold up to scrutiny would be very hard to achieve. 

[EMEDPA]

this seems like a common sense result quite honestly. All PAs have to do an EM rotation as it is a requirement. Some NPs do one, and for many of those who do it is only a week in length to a max of 1 month. The ACNPs may do a bit more than this, but most NPs do an FNP program, which generally includes no inpatient rotations. 

I spent 27 weeks(almost 7 months) doing em, peds em, and trauma in the course of my program. 

[lkth487]

45 minutes ago, SR0525 said:

I still think in both instances the amount of biases and confounders would to be too great. Along with a costly study.

I do not deny the validity, or lack there of, of a survey as opposed to a RCT. I do however, believe that a legitimate study that would hold up to scrutiny would be very hard to achieve. 

Sure, every study has problems. We aren't dealing with deductive reasoning or mathematical proofs. But RCT is about as good as it gets and it would be a pretty good way to be objective.  The survey is completely meaningless, that's all I'm saying. I would draw zero conclusions from it.  

[lkth487]

50 minutes ago, EMEDPA said:

this seems like a common sense result quite honestly. All PAs have to do an EM rotation as it is a requirement. Some NPs do one, and for many of those who do it is only a week in length to a max of 1 month. The ACNPs may do a bit more than this, but most NPs do an FNP program, which generally includes no inpatient rotations. 

I spent 27 weeks(almost 7 months) doing em, peds em, and trauma in the course of my program. 

But is a month of md or pa school really make any difference after you've been doing it for a couple of years?

[EMEDPA]

27 minutes ago, lkth487 said:

But is a month of md or pa school really make any difference after you've been doing it for a couple of years?

I guess we would need to study it to know for sure. I cardioverted 2 yer olds on my peds em rotation and did procedural sedation cases. I don't know of any docs willing to train someone to do this stuff on the job who has zero prior exposure. it is the catch 22 of credentialling. you have to have done something before to get credentialled to do it again. docs don't like to teach anymore. they are employees too and it just slows them down. This is similar to the question of "does prior hce matter after X years?" I believe it does if that experience includes things that a new grad might never do otherwise(outside of a structured residency). All paramedics for example can run a code, intubate, cardiovert, etc. I know many (probably most) em pas who have worked in the field for 20 years who have never done any of these things because they didn't have the comfort level going in to say " I've got this one" and they end up limiting themselves to fast track or intermediate level patients for their entire career, letting physicians and those PAs with significant HCE take all the high acuity patients. The former paramedics jump in to the high acuity scenarios because that is where their comfort level is from day 1. A former paramedic is probably not any better at suturing or doing any other benign fast track procedure than someone who was a medical asst or cna, but when it comes to acuity, there really isn't a better background for an EM PA than medic, flight nurse, resp. therapist, or someone with similar high-level prior hce. 

[lkth487]

16 minutes ago, EMEDPA said:

I guess we would need to study it to know for sure. I cardioverted 2 yer olds on my peds em rotation and did procedural sedation cases. I don't know of any docs willing to train someone to do this stuff on the job who has zero prior exposure. it is the catch 22 of credentialling. you have to have done something before to get credentialled to do it again. docs don't like to teach anymore. 

I'm glad you did all that.  But I did peds EM and EM and did none of those things as a med student.  Hell, I didn't do procedural sedation until I was a senior resident.  It's just not that common for a majority of student (or even non EM residents rotating through for a month at a time) to get a lot of that experience.  What you're describing is NOT a typical med or PA student experience.  I've worked at three EDs so far, and in all of them, you're basically seeing some mixture of acute/non acute patients, doing some suturing but that's about all.   In any dedicated academic Ped ED (ie where you have a lot of the students rotating during schools), the fellows will take the bulk of anything acute.  Just the way it is.

[Reality Check 2]

In 26 yrs, the majority of NPs I have worked with have minimal if any procedural training or experience - again NPs usually track to FP, PEDS, GYN, etc.

I was fortunate to train in a Level One trauma center and sutured from day one in rotations with great resident support. By the time I graduated, I had basically run codes, intubated, delivered babies,  assisted in surgery, set fractures, relocated joints and a zillion other things by sheer volume and opportunity. 

Th NPs I have worked with and trained over the years have little to no training in any of this. Their educational tracks don’t even consider these skills.

So any type of survey or study that shows PAs are more prepared and skilled in the ER doesn’t surprise me. I continue to support that PAs are better trained. Period.

[surgblumm]

I read this report when it first came out and commented on a forum but deleted the article. I would request a copy or a link as the information is both positive and negative depending on whois reading it but someone is stating research, the research needs to be evaluated. On my post to another forum, I asked if SEMPA ha weighed in on this as I feel they are the experts in this area and have the ability to go beyond a defensive comment and offer suggestions to the PA world involved in emergency medicine.

[EMEDPA]

14 hours ago, lkth487 said:

I'm glad you did all that.  But I did peds EM and EM and did none of those things as a med student.  Hell, I didn't do procedural sedation until I was a senior resident.  It's just not that common for a majority of student (or even non EM residents rotating through for a month at a time) to get a lot of that experience.  What you're describing is NOT a typical med or PA student experience.  I've worked at three EDs so far, and in all of them, you're basically seeing some mixture of acute/non acute patients, doing some suturing but that's about all.   In any dedicated academic Ped ED (ie where you have a lot of the students rotating during schools), the fellows will take the bulk of anything acute.  Just the way it is.

I was very aggressive as a student and pushed to be in on all the sickest patients and involved with as many procedures as possible. All my em rotations were away rotations and I was living at the facilities. they told me I needed to do 40 hrs/week. I did 60. This was also 23 years ago, so facilities were not as uptight about students then. Several other em-track students in my program had similar experiences.I don't want to work in a place with lots of attendings, residents, and fellows. that's why I won't ever work at a tertiary medical center again. I actually like seeing sick patients and doing procedures myself. PAs are scut magnets at busy hospitals. That is not what I want to do with my life.  

[camoman1234]

On 5/5/2018 at 7:45 PM, EMEDPA said:

this seems like a common sense result quite honestly. All PAs have to do an EM rotation as it is a requirement. Some NPs do one, and for many of those who do it is only a week in length to a max of 1 month. The ACNPs may do a bit more than this, but most NPs do an FNP program, which generally includes no inpatient rotations. 

I spent 27 weeks(almost 7 months) doing em, peds em, and trauma in the course of my program. 

@EMEDPA My wife (FNP) did not have to do inpatient, UC, ER rotations.. In my PA program I did 4 weeks ER (level 1 trauma center) and 2 weeks UC. I had ICU rotations, hospitalist, general surgery, ophthalmology, FM, OB/gyn, psych, plastic/burn surgery.  Not quite sure why you had so many weeks of EM and if those requirements have changed? 

[Reality Check 2]

Some of us chose extra rotations in surgery or other electives - I know I did back in the early 90s and I think EMED did too.

I was the last of the Surgery Track in my program. I did every required rotation but had time for extra and skipped vacation month. We went year round - no summers off.  About 7 of us were chosen for extra surgical rotations as Surgery Track candidates. 

Extra Ortho, Surgical ICU and Plastic Hand helped me land my first job in Ortho after school.

Those extra opportunities don’t exist much any more. Too hard to find. 

I never had to make ridiculous posters in school or do some of the things I see now. We were hands on 100% whenever possible.  It was truly immersion learning that I wish we still had.

[EMEDPA]

3 hours ago, camoman1234 said:

@EMEDPA My wife (FNP) did not have to do inpatient, UC, ER rotations.. In my PA program I did 4 weeks ER (level 1 trauma center) and 2 weeks UC. I had ICU rotations, hospitalist, general surgery, ophthalmology, FM, OB/gyn, psych, plastic/burn surgery.  Not quite sure why you had so many weeks of EM and if those requirements have changed? 

we had to do 5 weeks of em. I  also did my peds rotation as peds em in the ED at a peds hospital (5 weeks). I did trauma surgery to fulfill surgery(5 weeks) and chose 12 extra weeks of em for my preceptorship(we could do extra em or extra fp)

[EMEDPA]

3 hours ago, Reality Check 2 said:

 

I never had to make ridiculous posters in school or do some of the things I see now. We were hands on 100% whenever possible.  It was truly immersion learning that I wish we still had.

yup, same with me. I got BS #2 from PA school so no capstone master's project. my program included 54 weeks of clinicals. it was > 3000 hrs. They still do the same # of rotations, but no longer have the option of a 12 week em preceptorship and instead do extra fp only. 

[ohiovolffemtp]

Read that same article last night.  I think it was most useful as evidence, whether anecdotal or not, of how PA's & NP's are perceived by ED docs, especially those active in the leadership of their profession - ie ACEP counselors.

 

[EMEDPA]

I was at a conference a few years ago at which the then-president of ACEP (Dr Lawrence) stated "PAs are the non-physician provider of choice in Emergency Medicine".