I was a senior emergency medicine resident at Darnall Army Community Hospital in Fort Hood, TX, in 1992. I wanted to do an elective rotation in anesthesia and to work closer to home because my wife and I lived 50 miles south of the military post near Austin. My wife worked at Brackenridge Hospital in Austin, so I would be close enough to catch a few extra meals with her if I could do the rotation there. There was a lot of resistance (bordering on hostility) to emergency physicians managing airways, but the anesthesia department at Brackenridge welcomed me.
On my first day, I was amazed to find that a nurse anesthetist was running every operating suite. There was only one attending on duty, and he typically walked into each room for a few minutes during a case and then sat in the doctor's lounge drinking coffee and reading the newspaper. You did not have an MBA to see how this anesthesiology group was maximizing its income by managing more cases with cheaper labor.
This, however, could not be good for the extended viability of the specialty if the physicians are showing the hospital administration that they do not need a doctor to provide anesthesia in most surgical cases. When I took my first civilian job in 1996 in South Carolina, I was not surprised to learn that the anesthesia residency at my new hospital was shutting down because there was a robust nurse anesthetist training program there. Of course, I thought this could never happen to emergency medicine.
Fast forward 23 years, and the favorable job environment that emergency medicine residency graduates have enjoyed for decades is showing some cracks. As I detailed in recent columns, we are starting too many residency programs and creating a surplus of EPs, and contract management groups are a significant cause of this because they try to staff the EDs at their facilities. (“The Unchecked Growth of EM Programs [and No Sign of Stopping],” EMN. 2019;41:6, http://bit.ly/32mT0Sl; “Is There an EM Residency Glut?” EMN. 2019;41:1, http://bit.ly/2or6kqm.) But there is another contributor—advanced practice providers (APPs).
I had no idea how many APPs there are in the United States or how many are practicing emergency medicine. My group works with physician assistants in our EDs, and we appreciate their contribution. Most specialties covet them in my town because they end up doing a lot of the call work and activities like admit notes and discharge summaries.
The Rise of PAs
EMN has already covered the lobbying efforts of NPs for independent practice (2019;41:4; http://bit.ly/2JXgzNj), so I looked only at physician assistants. Here are some interesting numbers to ruminate on:
- There are 246 PA programs in the United States, a dramatic increase since PAs first started practicing in a significant way in 2008. (Accreditation Review Commission on Education for the Physician Assistant, Inc. 2019; http://bit.ly/2VMoqzo.) For reference, there are 179 medical schools. (AAMC to come.)
- There are more than 131,152 certified PAs in the United States (National Commission on the Certification of Physician Assistants [NCCPA]. 2018 Statistical Profile of Certified Physician Assistants by Specialty. 2019; http://bit.ly/2qcR3tT) compared with 1.4 million physicians. (American Medical Association. 2019; http://bit.ly/2MJGeao.) There has been a 37 percent increase in the number of PAs over the past five years. (95,583 PAs in 2013 [NCCPA. 2013 Statistical Profile of Certified Physician Assistants; http://bit.ly/2ONa9kJ].)
- Nearly 69 percent of PAs are women. The median age of PAs is 38, and 38 percent are between 30 and 39. (NCCPA. 2018 Statistical Profile of Certified Physician Assistants by Specialty. 2019; http://bit.ly/2qcR3tT.)
- Seventy-five percent of PAs have a graduate degree. All PAs must have this level of education to be eligible for certification starting next year. (Accreditation Review Commission on Education for the Physician Assistant, Inc. 2019; http://bit.ly/2VMoqzo.)
- Nearly 17 percent of PAs are practicing emergency medicine, which is 12,860 PAs. EM is the third most popular specialty after family medicine/general practice at 19.2 percent and surgical subspecialties at 21.5 percent. (NCCPA. 2018 Statistical Profile of Certified Physician Assistants by Specialty. 2019; http://bit.ly/2qcR3tT.) There are around 45,000 practicing emergency physicians. Roughly 20 percent of the staff in emergency departments today are PAs, and the other 80 percent include emergency physicians and 14,000 emergency nurse practitioners. (American Academy of Emergency Nurse Practitioners; http://bit.ly/2qjQJtz.)
- The mean salary for PAs practicing emergency medicine is $123,006. (NCCPA. 2018 Statistical Profile of Certified Physician Assistants by Specialty. 2019; http://bit.ly/2qcR3tT.) The mean salary for board-certified emergency physicians is $350,000. (Medscape Emergency Medicine Physician Compensation Report 2018. https://wb.md/33yjrFd.)
Regardless, the point is that the proverbial train has left the station. PAs are here, and they will continue to be part of the EM workforce. This is not entirely a bad thing. Not all ED patients need an emergency physician for their complaints. Besides, we have to understand that many EDs are revenue-negative unless we want to drown in patients. This can mean choosing between more doctors working for smaller paychecks and using more APPs. APPs are cost-effective, but they have a relatively small fraction of the clinical training of a board-certified emergency physician, and this affects the quality of care for an extremely diverse and challenging patient population.
We seem to be on a path to exceed economic demand for EPs, and no organization is taking a hard look at creating a balance. Even if some group took up the cause, there is no easy solution given the historic shortage of emergency care providers, the incredible rise in the cost of health care, and our market-driven economy.
What will be the long-term effect on emergency physicians? Will we make less money? Will we increase staffing with more APPs? Will quality suffer at the altar of profitability? I cannot think of any other driver of change that will have a more significant effect on EM. The entire process will create a lot of difficult decisions in the future. In the years ahead, residents and established EPs will anxiously watch the transformation of our profession with only limited ability to alter the process.
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Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter @3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.
An editing error changed the meaning of a sentence in Dr. Cook's column, “Is There an EM Residency Glut?” (2019;41:1.) The statement should have read that only 19 of the 77 (not 27) new EM programs since 2016 have an affiliation with a university medical school. A corrected version is available at http://bit.ly/2or6kqm.