ACEP Article on Working with APP's

[ohiovolffemtp]

This month's ACEP Now has an article called "Optimizing our collaboration with Advanced Practice Providers".  It includes a statement: "Despite the publicized experiences of a few, the vast majority of APP's are, in fact, directly supervised for patients with Emergency Severity Index levels 1-3".

While it's certainly not my experience in my current full-time job where I do solo coverage in a critical access hospital, it also wasn't my experience in my last full-time job in a level III trauma center staffed by one of the large national EM staffing companies.  I routinely saw mostly level 2-4, and only on some of the level 2's and 3's did I have "direct supervision".  Many of these patients I managed autonomously.  Sometimes the doc read the chart, other times it was a "do I need to see this patient?,  No, OK".  This even included patients I admitted.

What are other folks experiences, especially those who aren't doing solo coverage?  Are folks running their patients by docs that much?  Are docs documenting face-to-face encounters that often?  A caveat, I have worked with docs who in an RVU based compensation environment pop in even on simple lacs.

My concern is that ACEP isn't recognizing the difference between a new PA in their first few years of practice who's still learning EM vs a PA with 5+ years of experience who can and should practice largely autonomously using the EM doc as a consultant as needed, similar to how they should use other consultants like gen surg, cardiology, hospitalists, etc.

[Eastcoast PA-C]

Policy in my system is that an ESI 2 is “co-managed” and the doc is supposed to see the patient as well (only happens in reality about half the time). ESI 3 needs to be presented verbally. ESI 4&5 are just charts being co-signed. I routinely go a full shift with none of my patients being seen by the attending.

I currently have 5 years of experience, all EM.


Sent from my iPhone using Tapatalk

[LT_Oneal_PAC]

At my residency, there is no policy and the staff PAs see level 2 by themselves. Everything is co-signed though with a “i was present in the ED” phrase from the attending.

I really appreciated the article, especially considering AAEM now having a reporting system for anyone who is concerned about APP practice in a blatant attempt to garner anecdotal reports of misconduct with no basis in real data. I also loved how ACEP clearly states that if you don’t like signing charts, it actually isn’t necessary in most states so talk to your admin about not doing that. Hopefully people will actually get on board and unnecessary mandatory co-signing will go away.

[narcan]

6 hours ago, LT_Oneal_PAC said:

ACEP clearly states that if you don’t like signing charts, it actually isn’t necessary in most states so talk to your admin about not doing that. Hopefully people will actually get on board and unnecessary mandatory co-signing will go away.

This wouldn't change the liability of the attending, would it? With so many CMGs running emergency medicine now, if the attending on shift can avoid co-signing a chart, perhaps the "corporate physician" can become the co-signer/collaborating physician of record and thus take away the biggest source of anxiety for EPs who feel less than excited about working with APPs on a daily basis. 

While I am not looking forward to the increase in malpractice premiums, if we're seeing patients independently with no physician involvement, we really need to own the liability for disposition. The only way to raise the standard is to raise the standard.

[MediMike]

1 hour ago, narcan said:

This wouldn't change the liability of the attending, would it? With so many CMGs running emergency medicine now, if the attending on shift can avoid co-signing a chart, perhaps the "corporate physician" can become the co-signer/collaborating physician of record and thus take away the biggest source of anxiety for EPs who feel less than excited about working with APPs on a daily basis. 

While I am not looking forward to the increase in malpractice premiums, if we're seeing patients independently with no physician involvement, we really need to own the liability for disposition. The only way to raise the standard is to raise the standard.

That is the key is finding some way to change the liability, think that would help some.  Problem is you have physicians complaining about the liability, but they are the same ones complaining about OTP/FPA which is essentially the only way to remove that liability.

No win situation.

[EMEDPA]

At my 2 solo jobs I see everyone and do everything unassisted.

At my double coverage job I generally let the doc know if I am about to intubate/cardiovert, etc, but we alternate charts regardless of acuity so they don't care. the hospital encourages them to run bad traumas, codes, strokes, stemis, etc , but it generally doesn't happen because they have their own pts to deal with and I have mine and whoever is up for the next pt just takes the medic report and dives in.

[ohiovolffemtp]

I'm hoping that those of us who self select to post here aren't the "publicized experiences of a few" but rather reflective of the actual work practices of most EM PA's.  Perhaps SEMPA should survey their members so that better data could be put before ACEP.

[Boatswain2PA]

On 7/27/2019 at 10:37 AM, ohiovolffemtp said:

"Despite the publicized experiences of a few, the vast majority of APP's are, in fact, directly supervised for patients with Emergency Severity Index levels 1-3".

Probably selection bias with who they surveyed, and what is the definition of "directly supervised".

I think most EM PA/NPs work in tertiary centers where they are more closely supervised.  Furthermore, most have corporate rules about requiring supervision, and ACEP may be just going by those corporate rules which may not reflect reality.  For example, I work PRN for VEP who requires me to get approval from my attending before I do a  CT, a pelvic, etc.  However that is not the reality.

[BirdDogPA]

On 7/29/2019 at 9:13 PM, ohiovolffemtp said:

I'm hoping that those of us who self select to post here aren't the "publicized experiences of a few" but rather reflective of the actual work practices of most EM PA's.  Perhaps SEMPA should survey their members so that better data could be put before ACEP.

I would have to say we represent the majority. I have a number of friends doing solo coverage, practicing at the top of there license who have no interest in ever making a post in here.