How PAs and NPs impact emergency room care

A recent survey in the American Journal of Bioethics, indicates that 80 percent of patients expect to see a physician when they come to the emergency department.

Parents were more insistent about their child see a physician or resident for even a minor condition such as a sprained ankle.

Patients indicated a preference for seeing a resident alone for non-urgent conditions (60%) and compared to a physician assistant (42%). Interestingly, these numbers did not vary dramatically from a resident’s preference to see a resident alone (65%) over a physician assistant (38%). Patients willingness to see a nurse practitioner (NP) was less across the board, 32% of residents, 44% of non-medical patients, and 75% of physician assistants (PAs).

One of the greatest flaws of the study is a narrow patient population – English-speaking, educated, urban. Another point of interest would be to take a larger sample size and to stratify preferences based on age. The idea of NPs and PAs practicing in the emergency department is relatively new and has increased dramatically since the initiation of new duty hour regulations for residents in the 1990s. Their visibility may increase even more with the new ACGME duty hour rules. The younger population of patients in the emergency department may be more willing to see PAs and NPs than the older population.

Another problem inherent in the study is that when you ask patients their preference for medical care in the hypothetical setting, it becomes difficult for them to answer the question honestly. In some ways, the act of posing the question itself – a question which relates directly to a patient’s expectations – biases people towards answering a certain way. It makes sense to prefer to see a practitioner with the most training – with physicians, followed by senior residents, at the top of the list – regardless of the medical problem. And the question which always lingers in the back of someone’s mind, especially in the hypothetical setting, is “what if the condition is a bad sprained ankle, or maybe a little worse – a break perhaps?” If, in a real situation, the patient is less concerned about this possibility, they may be more willing to see a nurse practitioner or PA.

One interesting question is whether these perceptions are changing over time – over the course of the last 5 years. My hypothesis is that they have, and that patients are becoming more comfortable being treated by practitioners without the MD behind their name. Another interesting question is whether years of experience matter – would a patient rather see a PA who has trained for 30 years, or an attending physician who has trained for 1 year? These questions further complicate matters.

Here is the bottom line, from my perspective as a health care provider: I think it is important for patients – and for residents, PAs, and NPs – to understand that the purpose of a hierarchy in medicine is to provide more support staff, not to compromise patient care. Our primary – and most important – job, as residents, PAs, and NPs, is to recognize our limitations and to ascertain whether one of our patients needs a higher level of care. Even patients who seem healthy may be sick. The common line in emergency medicine is, “Be humble or be humbled.” We need to keep this in mind with every patient we see and have a low threshold to ask for assistance.

The expectation that patients be seen by physicians is a longstanding one, but it is beginning to change. With ED volumes as high as they are, there are simply not enough emergency physicians to see every non-urgent patient . That expectation is not only unrealistic, but it is also not necessarily beneficial to patients. PAs are often very experienced at suturing simple lacerations or taking care of ankle sprains – and are often as good or better at it than physicians, depending on their experience level.

I think as times change, as PAs and NPs become more visible in the emergency department, and as long as we continue to remember our limitations as trainees (even attending physicians ask one other for help or advice from time to time, and emergency physicians call specialist consultants down to the ED if they are concerned about a patient), we will continue to provide good patient care in a health care system with a variety of trainees, all with different levels of experience and expertise.

This anonymous medical resident blogs at A Medical Resident’s Journey.

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  • Anna

    We had a PA and a paramedic when my kiddo got stitches the first time. They were awesome. Second set of stitches, PA either had no experience or no interest in dealing with children. We finally had to say, “Get someone else, or we are going to the children’s hospital” which was another 30 minutes away. We ended up with a calming RN and a doc.

    Honestly, I am going to deal with whomever is able to work with our family in a way that is competent and respectful. The letters after the name are not that important to us.

  • http://natickpediatrics.net rob lindeman

    There’s a word for the attitude of entitlement felt by a person with a
    Non-urgent complaint, complaining about seeing an NP or a PA in the ED: chutzpah.

    Folks, if you want to see an MD, go see an MD, don’t go to an ED. Or call an MD at least.

    As for knowing limitations: that applies to all of us at every stage. It’s a near certainty that someone out there is thinking, regarding NPs and PAs “they don’t know what they don’t know”. It’s a perniciously elitist idea. I don’t know what I don’t know either. Neither do you.

    • Fam Med Doc

      Dr Lindeman: I agree on the chutzpah. The self-entitlement of some is impressive.

      I disagree with you in part about mid-level providers: their fund of knowledge & training is too small for primary care. I don’t think it’s elitist to be wary of them in the primary care setting. It’s just a logical response. My lengthy experience with mid-levels is far from positive.

  • Brad Alm

    Rob, You honestly had me laughing out loud! Thanks for the great comments about not knowing what we don’t know. How true.

  • stitch

    Had an interesting situaltion a few months back; patient sent to ED by ambo after MVA. Deep laceration to hand, possibly due to broken glass. No apparent loss of function, xray was negative; patient was evaluated by PA with sign-off by attending ED physician. Wound was sutured (more than 8 cm and irregular.) Having trained not that long ago in a program where any hand injury was evaluated with specific training in dealing with hand injuries, this rather surprised me, especially when patient showed up in the primary care office for follow up with a loose bandage and a bleeding wound. Is this an issue of the PA, or is it insufficient supervision by the attending, or combination of both?

  • Heather

    I’m thrilled when we see a midlevel provider. It usually means that my child isn’t that sick and we will get to go home in a little while. We have seen midlevels who immediately go and get an MD or admit, those times my daughter has been very sick. I don’t care who we see as long as they are qualified to help or will go get someone who is if we are outside of their comfort level.

  • Dave Mittman, PA

    What was the idea of the blog?
    If it is that when asked, people would rather see an emergency medicine PHYSICIAN, rather than an assistant or a nurse….Duh.
    Let’s ask people AFTER they have seen a good NP or PA how they felt the care was. And let’s measure outcomes.
    that is how we all make progress.
    Dave

    • Kim Spering, MSN, CRNP, FNP-B.C.

      Completely agree. Also love how the blog is written by an “anonymous” resident. Put your name on it for credibility, like the rest of us.

      Every one of my patients who follow-up from ER visits by PAs or NPs has been happy with their care (and I ask).

      We certainly “know what we know…and what we don’t.” That argument is tired and old. Physicians also know what they don’t know, and refer to specialists…just like we do if warranted.

      And Fam Med Doc…sorry your experience with us in Primary Care has not been positive. I can tell you that my collaborating physician would disagree…as would many, many others.

      I am also NOT a “mid-level” anything. Who, then, exactly, is a “low-level”? Nurses? Respiratory Therapists? Pharmacists? I daresay they aren’t, nor would they be pleased to be called that. You may call us Advanced Practice Clinicians, or Nurse Practitioners or Physician Assistants/Associates. With all due respect, get rid of the “mid-level.”

      • Fam Med Doc

        Dear K Spering,

        My very real & serious concern about mid-levels is that they are way under trained for primary care. It took 4 years of medical school & 3 yrs of a brutal residency to become a competent physician. Mid-levels want to do it in only 2 yrs. Then they want to be the sole “primary care provider ” to the patient. Sorry, but this is irresponsible & dangerous to society. 7 years, yes 7, is the minimum it takes to become a good physician providing primary care. The only reason this mid-level proliferation in primary care is being tolerated & alas, promoted by some is the unfortunate scarcity of primary care doctors.

        • Nichole Bateman, PAC

          Fam Med Doc,

          I’ve spent the last 18 years honing my skills as a Primary Care Provider. Do you really think that I came out of my training thinking that I was perfectly competent and trained in all I needed to know? Do you really think that every physician leaves their training – including residency – without some trepidation about being responsible for patients’ healthcare? And, do you really think that 7 years of training perfectly equips you just because you have MD behind your name?

          If you’re honest, the answer to all of those questions is a resounding NO. We all know the medical “cowboy” out there – the guy/gal that doesn’t think twice about an aggressive approach to a patient’s condition – the one who doesn’t EVER second guess their decision. I doubt that most of us (regardless of the initials behind our names) exit our training thinking that we’ve acquired all the skill we’ll ever need – for you to assume that PAs and NPs have no reagard for their experience level (or lack thereof) is presumptuous. I’m glad that I work with physicians who appreciate me and my skills and I’m thankful for my docs from my early career. They were patient but demanding mentors who expected me to provide quality care. I have a long mutually respectful relationship with my docs now. They know I don’t venture into territory that I shouldn’t. And when I find myself there unexpectedly as we all occasionally do, I recognize that and make appropriate medical decisions for the benefit of my patients – just like most of the MDs that I know.

        • Kim Spering, MSN, CRNP, FNP-B.C.

          You are entitled to your opinion, but research does not back it up. You also forget that most of us NP and PA providers already have practiced as RNs for at least 10 yrs. on average before starting in our programs. I entered my MSN program as the youngest RN with 10 years’ experience — a background of critical care, medical-surgical, women’s health, administration, and as adjunct faculty for a college. I was not alone in my past experience, either.

          Many in our programs have already been medics in the armed services, or functioned in other aspects of health care before going back to our programs.

          So, please, before stating it is “irresponsible and dangerous,” please show me the research. There ISN’T any.

          • Fam Med Doc

            I had many years working in the hospital doing direct patient care (7 years actually). But it’s totally a different type of work compared to the job of primary care physician. I don’t use those years in evaluating my qualifications because I know it doesn’t apply. The mid-level argument that previous non-physician experiences apply are like the guy who wants to be a pilot who says “I worked at the airlines for years, just not as a pilot, but I’m really qualified.”. Yet this guy wants those previous years of non-pilot experiences to count towards his experience as a pilot. It just apply. Flying a plane is different then the other non pilot jobs at the airline. Nurses are ESSENTIAL, but their job is different than a doctors & doesn’t provide the necessary skills & knowledge base required to be the primary care doctor.

            Interesting, i only hear mid-level providers use this argument, never doctors. It’s as if mid-levels are trying to falsely inflate their credentials to improve their argument.

  • Cheryl Greenstein, PA-C

    Well put Dave. It’s the only way to do the study

  • Nichole Bateman, PAC

    I find it interesting that you assume that a PA is capable of suturing only “simple lacerations” or evaluating ankle sprains. I work in a high volume Urgent Care clinic often staffed by only one provider in my small community. Our average walk-in load is 30-50 patients/11 hr day depending on the day of the week. Not long ago, I had a 48 patient day. Among the myriad of typical urgent care patients were two admissions (one was transferred to a neighboring facility for a heart cath, the other a pyelo), two I/D of large abscesses (both responded well to procedure/treatment I administered), diagnosed a molar pregnancy and facilitated her connection to our OB/GYN and lastly, sutured a facial laceration in an elderly lady who fell (and yes, I evaluated for precipitating reasons for why she fell in the first place as well as for distracting injuries since she had a facial/head wound). Not all days are like that here, but I can handle those days when they come.

    Your assumption that most PAs and NPs are capable of evaluating for simple/minor health issues is insulting to me as a professional and makes me wonder if you’ve worked with an experienced PA/NP to redirect the error of your assumption. I’m proud to be a PA and take pride in what I do – I know my clinical comfort and know to listen when a patient’s needs are outside my realm. I don’t apologize for what I don’t know. When you meet someone who knows it all, send them my way – I’d like to meet them.

  • Tim Keeler PA-C

    The other end of the spectrum, from the above study, would include the uneducated, inner-city, economically challanged patient with limited access to care. As a PA ,in Emergency Medicine 18 years, I have personally seen the change in acceptance of providers. The PA’s at my institution i.e. Level 1 trauma center have more experience then many ED physician. It’s not what you know it’s applying what you know and a recognition of injury and illness that presents to the ED. I agree that the best approach is a team effort with each member recognizing their strengths and weakness. The simple laceration/ankle sprain has become common place of the PA because the ED residents aren’t receiving the appropriate training in wound closure and splinting. How many aortic discesstion, appy’s, ACS, CVA, PE/VTE/DVT, DKA, Sepsis, GI bleeds/perforations/SBO, TOP, mesentric ischemia, GSW, spleenic ruptures, trauma, pneumothorax, psychosis, toxic/substance/OD, DKA etc – Understanding the Krebs cycle is nice but experience/expertice is not title dependent.

  • solo fp

    Experience really is the key to primary care. The 4 years of med school and 3 years of residency are great, but ten or more years of experience usually makes for a better primary care doc, PA, or NP.
    Case in point, the local hospitals keep trying to put new FP residency grads 5 minutes from my practice. 100% turnover every 2 years and records keep coming in. Patients can sense inexperience.
    Relate to the ER, insured patients do not realize there is no discount for seeing a PA or NP. My local ERs have a lot of locum tenen docs and older docs. Often the PA with ten years of primary care experience is better than the 60 yo doc who is counting down to retirement or the doc who is out of state and doing shift work five days in a row for a quick paycheck.

    • Nichole Bateman, PAC

      Appreciate your response. PAs/NPs aren’t the entire answer to all that’s wrong with healthcare but discounting and minimizing our role entirely isn’t either.

    • Fam Med Doc

      I agree partially with you that “experience really is the key to primary care”. Experience AFTER a foundation of a lengthy & comprehensive training background is the necessary ingredient in becoming a competent primary care physician. It’s called medical school & residency. Mid-levels (PA’s & NP’s) do not go thru this training yet still expect to do similar stuff. Impossibly dangerous. I will not comment to your specific ER example as I do not work in such an environment. But in primary care, mid-levels are dangerous.

      Everyone wants to be a doctor but no one wants to go to medical school.

      • Kim Spering, MSN, CRNP, FNP-B.C.

        Fam Med Doc:
        I am still waiting for your answer to my comment above. Where is the research that says that we NP and PA providers need 7 years (4 yrs. of med school and 3-plus years of residency) to do what most family practice providers encounter on a day-to-day basis? I daresay you are OVER-qualified for the most part.

        I have now worked in the health care field for over 20-years. I currently work in a high-acuity Internal Medicine specialty, which is more specialized than my first Family Medicine position. Upon my graduation over a decade ago, I was adequately prepared with my MSN training and RN background of 10-plus years to work in a family medicine practice with my collaborating physician. Since then, I have only enhanced my learning and skills as a provider…just as any clinician (NP, PA, or physician) would.

        We do not need to go to medical school to fulfill the need of our patients. We are not “dumbing down” the needs of primary care. We fulfill them quite nicely, thank you. Again…please look at the research that shows our qualifications in this regard. Let me show you one such website, in case you are not familiar with our worth:

        http://www.aanp.org/NR/rdonlyres/34E7FF57-E071-4014-B554-FF02B82FF2F2/0/QualityofNPPractice4pages.pdf

        We all have a role to play in patient health care. Minimizing our roles as NPs and PAs will do nothing to help our patients, but merely acts to divide us. Is that really what our patients deserve? I think not. It doesn’t matter if we serve roles in family practice, the ER, or specialties.

        There are certainly enough patients to go around. It’s time to stop the “turf wars” and start working collaboratively for the benefit of all.

        My not-so-humble two-dollars’ worth. :)

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