"APPs are the #2 problem in emergency medicine". My response to ACEP.

Grinder993 · March 1, 2021

This is my reponse to the ACEP current Presidents response to comments in this months issue of Emergency Physician Monthly. I will list the link at the end.

February 28, 2021

Dr. Rosenberg,

I read your most recent interview in EP Monthly with great interest. You and I can agree that emergency medicine has changed in ways that none of us expected during the current pandemic. Who would have thought the ED volumes would drop to such a degree as to lead to layoffs and furloughs of EM physicians, PAs, and NPs. I have no doubt that these trends will turn around in time.

There are a few points you made in your article that I would like to address. You state that the #2 problem in emergency medicine is the utilization of APPs, “the nonphysician providers are constantly saying they’re cheaper than we are, and they can do our job.”

You go on to state, “When we look at the workforce and when we look at the job opportunities and we look at rural emergency medicine, and rural is almost every state in the country, has some rural challenges and western Texas is obviously very different than northern Maine, but nonetheless, many similar challenges.

In those rural areas, we have PAs in Maine that have independent practice. We have nurse practitioners in other states that have independent practice. And we have primary care physicians who are working in many of these locations who don’t have access to resources from ACEP. And yet, we at ACEP consider ourselves the gold standard of board-certified residency trained emergency physicians.”

This is the statement that deserves unpacking. I am a solo emergency medicine PA covering multiple rural critical access emergency departments in northern Maine. PA’s in Maine do not have “independent practice”. We have a system of graduated autonomy that is based on practice setting and years of experience of the PA. The final determination of the level of autonomy is at the practice level between the PA and the MD/DO. This allows for greater utilization of the highly skilled PA workforce. This makes far more sense than a “one size fits all” model created by the state.

NP’s are the only “APP” that have successfully achieved fully independent practice in 28 states. ACEP is doing itself a disservice by refusing to recognize the difference in training and the mission behind the PA and the NP. There is a remarkable difference and the persistent use of the term “APP” or “Mid-level” is simply lazy.

I began my medical career as a Navy Corpsman, then 10 years as a Paramedic and finally I achieved my goal which was to become a PA. After completion of PA school, I elected to do a 12-month emergency medicine PA residency program. Fast forward to today, I have been practicing as a PA for 15 years, I have over 30,000 practice hours in the ER and have treated more than 80,000 patients.

I have worked in just about every ER setting, from large urban academic ERs to small critical access ERs. I have seen the misuse and abuse of the PA and I have had the pleasure to work in areas where the MD and the PA were truly a respectful and collegial team.

In your interview you seem to attack the notion of PAs and even non-ACEP trained physicians covering these rural critical access ERs in areas like northern Maine and west Texas. I am disturbed by this. Is there evidence that a disservice has been done? You have presented yourself as the “gold-standard” of emergency care. This may be true, but it does not mean that safe and excellent emergency care cannot be provided by non-ACEP trained providers. There is no data to support this insinuation.

What are these areas to do when ACEP trained MD’s do not want to live in these very rural areas, much less work there at what they can afford to pay? An ACEP trained MD has loans to repay and vastly most choose to work in large urban ER’s where they are paid much higher and have far greater back up and support.

When I speak to physicians at the larger regional hospital here in Maine where we transfer our sicker patients and those who need any specialist, they have frequently thanked me for being out here. They have said to me “I don’t want to go out there, you don’t have much support or backup.” So, who is going to come out here? If the ACEP MD is not, then who? Rural America still accounts for tens of millions of people who are sick, getting sicker and have the fewest resources.

I was excited to see you mention the power of telehealth. Let me tell you, I believe that I have seen the future of the ACEP MD, and it is telehealth. At one of the remote facilities I cover, we have an ED telehealth relationship with Dartmouth. It is an incredible and awesome service. In the trauma bay we have a full telehealth set up with monitor and microphones and a large red button on the wall. If I have a patient I need to consult on, all I must do is hit the button and I have an ACEP MD in the room with me. It may be a trauma, it may be a complicated septic patient, whatever it is, they are there like an angel on my shoulder. At that point I become their hands and together we deliver the best medical care possible in these austere and rural settings.

If ACEP wants to remain relevant in rural America, this is how you do it. The PAs are on the front line because there is no physical way for there to be enough ACEP MDs to cover the need in rural America. But through “force multiplication” with systems like what Dartmouth is doing, ACEP can expand its abilities to be available and provide that guidance in the areas where they are most needed. ACEP MDs are not needed in large urban ER’s where you have 5 MDs on at a time. They are needed out here where you have 1 MD for 100 square miles.

I would like to thank you for taking the time to read this and I apologize if I strayed at times. But I felt compelled to respond. I ask ACEP to stop fostering the attitude that PAs are a problem, we do not want your job. But we do want the right and respect to walk beside you.

I will close with this personal story. On the first day of my PA EM residency program, I introduced myself to my attending, a retired Army Colonel; “Hi my name is Rob I am one of the new PA residents.” His only response was “I don’t care if you are a PA, I will hold you to the same standard I hold my residents. There is only one standard of care in medicine and if you can’t handle that, get the hell out of my ER.” That statement shaped my career.

Respectfully,

Robert D. Booth, MSPAS, EMPA-C, CAQ-EM

‘The Future of Emergency Medicine is Bright’ (epmonthly.com)