A new study on the feasibility of a physician assistant postgraduate training program embedded within an existing emergency medicine residency has sparked heated discussion in emergency medicine, with many voicing concerns that an EM-PA residency could create confusion over the scope of practice. (West J Emerg Med. 2020;22:45; https://bit.ly/3rccs01.)
The department of emergency medicine at the Yale University School of Medicine created its EM-PA residency in 2015 as an 18-month program consisting of one- to four-week rotations, with two physician assistant residents alongside 15 physician residents. “During all rotations, EM-PA residents functioned as primary team members,” wrote the authors led by Alina Tsyrulnik, MD, an assistant professor of emergency medicine at Yale.
“All rotations were identical to the physician residency with the exception of an additional four-week rotation at an affiliated freestanding ED for the PAs,” they said.
PA residents had experience in all procedures and ultrasounds, they reported, but stressed that the program, as designed, “is not meant to provide PA trainees with the same level of training as EM residents upon residency completion.”
Yale's is not the only emergency medicine training program open to postgraduate physician assistants. The Society of Emergency Medicine Physician Assistants listed more than 40 such programs on its website as of March, and at least a few—including those at Penn State, Johns Hopkins, Duke, and UCSF—call their programs “residencies” or “fellowships.” (http://bit.ly/PAprograms.) The publication of the Yale paper, however, was the catalyst for renewed attention to these programs.
Shortly after the Yale paper was accepted for publication this past September, multiple emergency medicine organizations, including the American College of Emergency Physicians and the American Academy of Emergency Medicine, released a statement affirming that “the education of emergency medicine resident physicians and medical students must not be compromised or diluted,” and declaring that “the terms ‘resident,’ ‘residency,’ ‘fellow,’ and ‘fellowship’ in a medical setting must be limited to postgraduate clinical training of medical school physician graduates within GME training programs.” (https://bit.ly/3cWa0pl.)
“We are proud of the educational aspect of our program,” said Dr. Tsyrulnik. “We knew going in to publishing the paper that this is a bit of a controversial topic, but we didn't expect the level of feedback we got.”
The controversy led Dr. Tsyrulnik and her colleagues to write a letter in response to their own paper, in which they affirmed that APPs in emergency medicine should work under the supervision of an EM-trained physician and that patients should be cared for by EP-led teams in the emergency department. (West J Emerg Med. 2020;22:49; https://bit.ly/313zuvz.) Their study, they wrote, “does not support or suggest the equivalence of physician graduates of a three- or four-year residency in emergency medicine with PA training program graduates. As such, it does not seek to equate the two programs or the skills of their respective graduates, but instead to describe a successful interprofessional educational collaboration.
“Further, we want to make it clear that due to our high ED patient volume, including multiple training sites, our physician trainees have not had a decrease in patient or procedure exposure.”
That clarification is important, said ACEP President Mark Rosenberg, DO, MBA, who is also the chair emeritus of the emergency department at St. Joseph's Health in Paterson and Wayne, NJ. “Yale addressed the fact that they're not diluting or hurting the EM resident experience,” he said. “That's a positive, and that should be the standard for any type of postgraduate training we are giving PAs or nurse practitioners.”
Not every emergency medicine program has the capacity to adopt a training program like Yale's without potentially diluting the medical residents' experience, Dr. Tsyrulnik said. “We were able to do this because of the large volume and high acuity in our ED, and those things have to be taken very seriously to ensure that the number of procedures is not taken away from physician residents.”
Dr. Rosenberg said it is wrong to apply the term “residency” in a medical context to nonphysician training programs. “It's more than semantics,” he said. “Completion of a rigorous, mandatory, and accredited medical residency is one of the most important criteria that differentiate physicians from the other care team members. These residency training standards assure employers and patients that anywhere in the country emergency physicians have had the same training and met the same milestones.”
“We are concerned about using the same language for very different processes,” said Fiona Gallahue, MD, the president of the Council of Residency Directors in Emergency Medicine and the director of the emergency medicine residency program at the University of Washington. “The use of the word ‘residency’ creates a false equivalence when PA residencies don't have an accreditation body or established milestones and requirements for testing and outcomes.”
Dr. Tsyrulnik said she hopes that the issue of terminology can be addressed so that the programs at Yale and other places can be successful. “One of the ACGME guidelines is that our medical residents need to learn how to work in interprofessional teams, and in a lot of institutions, emergency medicine residents might never have the opportunity to work with someone on the APP level until they become attendings.”
Yale's fourth-year residents on the critical care side have always supervised junior residents, for example, she said, but until the new training program was launched, they had never interacted with or supervised APPs until they eventually became attendings themselves. “Having that interaction early on in your training is beneficial to the physician resident,” she said. “And as the acuity of our patients in emergency medicine is increasing, learning on the fly—which has been the model for APPs upon graduation—may not be of benefit to the patients being cared for by them or the physicians who are working alongside them.”
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Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com.