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Life in Emergistan

Life in Emergistan

Why Staff with EPs When APPs Are Cheaper? Because Safety

Leap, Edwin MD

Emergency Medicine News: May 2020 - Volume 42 - Issue 5 - p 19
doi: 10.1097/01.EEM.0000666324.33499.8a

    I have recently embarked, yet again, on the adventure that is locums tenens emergency medicine, and I've already learned a few lessons.

    First of all, the complexity of locums is greater than ever. There seem to be more forms, not fewer. There also seems to be greater confusion in etiquette—if you talk to this company about a job, you can't talk to the other because this company works under that company but is also competing with its parent company. Companies X, Y, and Z are all covering the same contract, so Z can't talk to you if you worked for X two years ago. It has always been this way, but it feels worse now, suggesting that the competition for contracts (and possibly good physicians) is stronger than before. These companies need to get together and create a flowchart so that physicians know when they should or should not bother to talk to someone.

    I have also learned a new lesson in caution. Just because a company tells you that a job will be open on a particular date does not mean you can count on it. The best rule is to have a couple of jobs in the works and also have two months of income in savings before believing anything you're told because work can suddenly and inexplicably evaporate. Furthermore, credentialing takes about two months on the low end, not to mention licensing. If a hospital really, really needs help, it can happen in a week or two.

    As I look at job opportunities online and talk to company representatives, I'm often surprised by the degree of coverage, or lack of it, in busy emergency departments. When departments get to a yearly volume of about 20,000, they will often add an advanced practice provider to work alongside a physician for part of the day. (This is not always the case; it's just an average from my informal survey of the advertisements I see and jobs I have done.)

    The ratio of physicians to APPs, however, seems to be about the same up until around 30,000. I too often see another APP added in departments that have volumes in the 35,000-40,000 range, while there continues to be only two 12-hour physician shifts per day.

    Not the Same

    I have worked in busy community departments, and I can say with absolute confidence that coverage with two physicians is the safest way to go at about 25,000 visits per year, with more added as volume grows. Throw an APP on top if desired, but there are lots of very sick, very complicated patients in that range. One of two things happens with one physician per 12-hour shift and one APP: Either the APP sees things that he is not fully trained to handle, or he sees only the simplest cases and the physician ends up seeing every chest pain, every older person with abdominal pain, every trauma, every sick child, and every toxicology case.

    In the first scenario, the physician has to be diligent and make sure that appropriate workups and examinations are being done. It is incumbent on the physician that the APP is protected, educated, and mentored, and that patients in the care of the APP have neither too much nor too little testing. These are the duties of the physician who signs the charts of the APP. This, of course, distracts the physician from patients on his own tracking board and adds to his stress.

    The latter scenario is equally miserable because after a while it's tough to keep all 10 chest pain patients separate in one's mind. The ECGs and repeats pile up even as nurses continue to notify the physician of sepsis alerts, vascular access that needs to be obtained, complaints from patients and families, and every other responsibility that falls squarely on the shoulders of the physician.

    It's easy to understand why departments are staffed in such a manner. It has to do with money—it's cheaper to hire an APP, in salary and in cost of malpractice insurance. As such, a CFO has a pretty easy decision to make. Why have two physicians per shift when everyone thinks an APP is the same? Even more so when patients seen in the ED often have no payer source, resulting in a lot of lost charges.

    Except it isn't the same. This is a very unpopular thing to say, but it has to be said. There are outstanding APPs in practice, but the education of an APP is not the same as that of a physician and certainly not the same as that of a physician residency-trained and board-certified in her specialty.

    A busy emergency department where APPs are seeing very sick patients is typically an understaffed department. I say this with apologies to the APPs I know who are extraordinary, well educated, and caring. But the current trend is toward degree mills, in which online APP degrees are seen as equal to a medical degree. This fills me with trepidation, not because of professional protectionism but because of genuine concern for safety (and my own sanity).

    For new residency graduates and gray-bearded curmudgeons like me, the facts remain the same: Pay attention, whether on the locums trail or in a new full-time job, because things are not always as they seem.

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    Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter@edwinleap, and read his past columns at

    Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • mlewittmd1:10:09 PMDon’t drink the Kool-Aid. Midlevels aren't advanced, no matter how loudly they shout it. Some are very good, perhaps better than the worst doctor. Most are middling, some dangerous. Unfortunately, in a busy setting, even without COVID-19 superimposed, they can quickly get in the weeds because their experience is often so narrow. Midlevels with military experience are often quite good at trauma, but kids, elderly, toxicology, pregnancy, complexity? Not so much. Remember, when you put your name on a chart, you’re assuming responsibility for that patient, even if never seen by you.