Viewpoint: Midlevel Providers Aren't the Solution to the EP Workforce Shortage

Ginde, Adit A. MD, MPH; Camargo, Carlos A. Jr. MD, DrPH

doi: 10.1097/01.EEM.0000383972.88808.e7

There will not be enough emergency medicine residency trained physicians to cover our nation's emergency departments for many years. (Acad Emerg Med 2008;15[12]:1317.) This shortage is even more pronounced in smaller and rural EDs and in the face of continually increasing demand for emergency care.

So who covers these EDs? In 2008, 31 percent of physicians practicing in EDs — more than 12,000 physicians — were not emergency medicine residency trained or emergency medicine board certified. (Ann Emerg Med 2009;54[3]:349.) They are family physicians, internists, surgeons, and pediatricians who provide emergency care when an emergency medicine-trained physician is not available. This emergency medicine workforce shortage was a major topic of the 2009 Future of Emergency Medicine Summit, which brought together representatives of the leading emergency medicine organizations. (Schneider SM, et al. The future of emergency medicine. Ann Emerg Med 2010; in press.) Numerous potential solutions were discussed, including increasing emergency medicine residency slots, loan repayment for emergency physicians, joint emergency medicine-family medicine training, and using scribes to improve efficiency. One recommendation that has become increasing popular is the use of midlevel providers such as physician assistants and nurse practitioners.

Indeed, the introduction of midlevel providers to emergency care is already occurring in great numbers. In 2005, 13 percent of all U.S. ED visits were covered by a midlevel provider, up from only four percent in 1993. (Am J Emerg Med 2010;28[1]:90.) At first glance, this may seem like a win-win scenario. Midlevel providers help expand the efficiency of emergency physicians, and cover some of the workforce gap. Their cost to the hospital is lower than a physician's, and at least for minor presentations, patient satisfaction appears to be high. (Am J Emerg Med 2000;18[6]:661.) An increasing scope of practice and level of autonomy, however, calls into question whether midlevel providers are collaborating with emergency physicians or actually replacing them.

We fully support emergency medicine residency training, and believe that emergency medicine board certified physicians are the gold standard for providers in the ED. When emergency medicine-trained physicians are unavailable or unwilling to cover some EDs, such as smaller and rural EDs, however, many non-emergency medicine-trained providers, both physicians and midlevel providers, continue to fill the void. While physicians attract a greater amount of criticism and scrutiny, midlevel providers, who do not have formal emergency medicine training and fewer overall years of medical training than physicians, are often embraced as a solution to the workforce shortage.

While NPs are licensed to practice independently in some states, PAs must collaborate with physicians. The scope of practice and degree of autonomy for both groups is state-dependent. Neither group has developed accredited emergency medicine training programs for specialization in emergency care. Yet independent practice is becoming increasingly common. (See figure.) In paging through ED job announcements, we have encountered postings that state, “We are currently seeking a PA who is comfortable working autonomously in our ED.” In 2005, five percent of all ED visits nationwide were seen by midlevel providers without onsite physician involvement, up from one percent in 1993. (Am J Emerg Med 2010;28[1]:90.)

But indirect physician supervision of PAs and their independent practice is legal, isn't it? Supervision and scope of practice for midlevel providers are defined at the state level. Most states allow provision of emergency care and define supervision as the availability of a physician, but participation in care or even physical presence in the facility is often not required. Physician supervision by co-signing charts or prescriptions days to weeks after the ED visit is occurring throughout the country, although it is unknown how widespread this practice is. How much oversight is truly being provided for these patients?

But isn't this is only an issue for rural EDs, where any provider is better than no provider? Not really. National data show that 86 percent of midlevel provider visits without physician involvement are in urban EDs. (Am J Emerg Med 2010;28[1]:90.) While the number of these visits has remained stable in rural EDs, they have markedly increased in urban EDs over the past decade. Emergency physician workforce shortages are probably not driving this as much as practical and financial considerations; ED administrators may hire less expensive midlevel providers instead of emergency physicians. With emergency medicine residency graduates having difficulty obtaining jobs in some desirable urban markets, it's possible midlevel providers may actually be taking jobs away from emergency medicine residents rather than solving the emergency medicine workforce shortage and maldistribution.

What about acuity? Midlevel providers don't really need a physician to directly supervise the care of patients with obvious ankle sprains and minor lacerations. This may be true, and data support the quality of care by independent midlevel provider care for minor ED presentations. (Lancet 1999;354 [9187]:1321.) Of ED patients seen in 2005 by midlevel providers without direct physician supervision, however, six percent arrived by ambulance, 37 percent had urgent/emergent acuity, and three percent were admitted to the hospital. (Am J Emerg Med 2010;28[1]:90.) While these acuity data are lower than those for physicians in the ED, the role of midlevel providers, who may practice without on-site physician involvement, has clearly extended beyond minor presentations.

Limited data address the quality and patient safety of midlevel provider care of higher acuity ED patients. A recent study of 4,029 visits for acute asthma in 63 U.S. EDs found that unsupervised midlevel providers had a significantly lower quality of ED asthma care, compared with physician-supervised midlevel providers and with physicians alone. (Am J Emerg Med 2010;28[4]:485.)

The latter groups, in which physicians were directly involved, provided care of similar quality. While this is a single study of one condition, acute asthma care has well-defined treatment pathways and evidence-based national guidelines that should create more uniform care than other acute conditions. These data support a view that midlevel providers should collaborate with, rather than replace, emergency physicians, especially for higher acuity patients.

Midlevel providers have a major role in U.S. emergency care, and we support efforts to develop emergency medicine training, accreditation, and continuing medical education for PAs and NPs. Indeed, there are now several post-graduate emergency medicine training programs for PAs and NPs. Before moving forward with a midlevel provider-based “solution” to the emergency physician workforce shortage, we encourage more thoughtful discussion about training, scope of practice, and supervision. The growing acceptance of non-emergency medicine-trained midlevel providers practicing independently in EDs is difficult to reconcile with the often heated and absolute opposition to non-emergency medicine residency trained physicians. The ultimate goal of most emergency physicians and midlevel providers, regardless of their emergency medicine training and accreditation, is to provide effective and safe care for our patients. This should stay at the forefront of the emergency medicine workforce debate.

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