Talk to any emergency medicine resident, and you'll hear how the incredible burden of student loans looms over them. They calculate the percentage of their future salaries that will be dedicated to repaying these loans, but say the upside is that they expect to have a lucrative job waiting for them.
Residents have delayed their gratification for so long that these loans are just another expected and painful hurdle, but now they face a new and scarier concern, that the golden ring of a secure, lucrative job is no longer certain. What role will they have in the emergency department? Will all advanced practice providers (APPs) with doctorates be called doctors and work independently without physician supervision, limiting the “need” for those expensive and pesky physicians?
It is predicted that the number of APPs will increase by more than a third in the next decade. (Bureau of Labor Statistics. April 13, 2018; http://bit.ly/2RUqnGt.) The evolving relationship between emergency physicians and APPs cannot be ignored.
Emergency physicians need to take a stand on this trend if they want to have any impact on the outcome. If money is the reason for the developing role of APPs in EDs, then insurance companies, government agencies, and corporate management groups will devalue board-certified emergency physicians in the workforce in favor of a less expensive option. The bottom line is that this decision will be easy if the dollar is the major determining factor, especially if physicians are out-lobbied.
Various posts and programs by corporate management groups show where this is going. One by Envision on May 18, 2017, stated, “A new program is empowering emergency department advanced practice providers (APPs) to practice at the top of their license....” (http://bit.ly/2Gh7hsO.) This post stated that the goal of the company's APP Skills, Training, Experience, and Professional Credential (STEP) program is to “prepare APPs to become expert emergency medicine caregivers.”
Another example comes from Apollo MD's website: “Apollo MD is proud to offer rewarding practice opportunities for our Advanced Practice Clinicians who serve as vital members of our team. We support our APCs practicing at the top of their licenses....” (http://bit.ly/2Btuvb4.)
Are they supporting independent practice for all of their APPs? What is the top of an APP license? My license enables me to practice as a physician. My credentials and rigorous training enable me to practice as a board-certified emergency physician. The same cannot be said for any APP license.
A report from the relatively new organization, the American Academy of Emergency Nurse Practitioners (AAENP), stated that 62 percent of emergency departments were using APPs as of 2016, up from only 23 percent in 2010. (April 2018; http://bit.ly/2E0O4JA.) AAENP helped create a national board certification exam for nurse practitioners in emergency care, and they reported a rapidly increasing number of graduate-level programs in emergency care; four new programs opened last year alone. This document also stated that AAENP now represents almost 800 ENPs and “is endorsed and supported by the American College of Emergency Physicians and the American College of Osteopathic Emergency Physicians in its mission to promote high quality, evidence-based practice for nurse practitioners providing emergency care for patients of all ages and acuities in collaboration with an interdisciplinary team.”
How slippery of a slope is this to you? Nurse practitioners of the future will have a doctorate of nursing practice and be “board-certified!” Are they the board-certified emergency doctors of the future?
What about the workforce shortage we hear so much about? Do we really need all of these APPs in our EDs? Does anyone else notice the number of emergency physician residencies popping up each year? There is increasingly rapid growth in the number of these new programs, especially those run by corporate management groups. CMGs running residency programs is certainly questionable and is not the subject of this essay, but is the sky really falling? Will there not be enough ABEM/ABOEM emergency physicians available?
Mark Reiter, MD, a past president of the American Academy of Emergency Medicine (AAEM), has studied this and said if there is really a significant shortage, the question is where APPs would be most helpful. The job market is always tight in areas where people want to live, and many opportunities are available in less desirable areas. Do we have a shortage or just a distribution problem?
AAEM remains committed to our core and founding beliefs and values, and has taken a clear stand on this issue. We believe every patient should have unencumbered access to quality emergency care provided by a specialist in emergency medicine, which means certification by ABEM or AOBEM. AAEM does see a role for APPs in EDs but with a clearly defined and supervised role as part of a physician-led team. Because of these values, the AAEM board of directors decided to eliminate the allied health category of AAEM membership. The academy is a physician organization for ABEM/ABOEM physicians.
I ask you to review these guidelines carefully. (http://bit.ly/2Sj69Lz.) Our profession faces many significant challenges in the near future, and the expanding role of APPs is high on this list. Please advocate for what you believe, and please consider commenting on this vital matter with a letter to the editor.
The Story Behind the Story
Read more about why AAEM decided to dissolve its allied health membership category for nurse practitioners and physician assistants on p. 4.
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Dr. Mayer is the president and medical director of the West Jefferson Emergency Physicians Group, a single-hospital democratic group, in Marrero, LA. He is also the editor of AAEM's newsletter, Common Sense.