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EPs Object to PA Program ‘Residencies’

Shaw, Gina

doi: 10.1097/01.EEM.0000751844.04996.6c
    Figure
    Figure:
    PA, emergency medicine residency

    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[1]: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.

    Controversy Ensues

    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[1]: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.”

    Misleading Names

    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.

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    • sbestpa10:58:17 AMI'm a PA. I've practiced EM for about 24 years. I've managed cases from minor to critical, medical and major trauma, performed invasive procedures and bedside ultrasonography, mostly in pretty busy community EDs. Prior to becoming a PA, I was a paramedic, then a flight paramedic. I've had all the BLS, ACLS, PALS, APLS, ATLS, FCCS, etc. My master's is in EM, I hold an EM certificate of added qualification from my certifying body, and have worked collegially with many emergency physicians over these decades. I've been published in PA Journals and have even been an "expert witness" in emergency medicine-related malpratice case. I'm sorry some of our soon-to-be medical colleagues feel threatened by post-graduate programs for PAs, but there should not be a problem here. No one is attempting to take anyone's job, but rather to optimize our skills to better meet the needs of the patients, which should be the primary goal that we all share. There is no room for this type of animosity in our profession. 
    • mheller12:34:26 PMThe problem is not training or dilution or whatever. The problem is economic. Physicians were in high demand and short supply and therefore expensive. The market responded with expanded supply and cheaper alternatives. Expanded supply and cheaper alternatives quickly led to physicians being in much lower demand and over-supply. The solution is not, cannot be, trying to put the APP toothpaste back in the tube. The solution is to reduce the supply of EM physicians. The RRC gave (residencies), and the RRC must take away.
    • azcomgrad8:38:19 PMR. Booth's comment that "it allows me to function as a solo EM provider in a critical access ED" is the primary concern to many physicians: A PA working solo without supervision. I have personally seen PAs perform procedures and make medical management decisions that were far beyond their scope of education or training. With regard to the numerous physician concerns, the use of the word "residency" very much dilutes the professional education, standards of that education, and the standards of testing performed to ensure a competent physician is practicing. From what I've gathered in this article, what is termed as a PA "residency" should be termed a "clerkship" to delineate the difference between who is being educated and the standards to which they are held while in training and afterward.
    • hrizvimd2:35:31 PMListing all the titles--DNP, ANP-BC, GNP-C, PMHNP-BC--is insecurity. The conflict is aptly not between competing workforces. The problem is corporate sabotage of medical integrity that has conventionally been fielded by attending physicians. What is particularly galling is when academic departments and research regulators like the NIH and National Cancer Institute become shameless shills for the industry.
    • temarnie3:07:57 AMWhy all this bickering? If the PAs want to be in charge, why don’t they just go to medical school and get an MD? They obviously feel equally talented and educated when they are compared with their rivals. So why not just get the full educational requirements to be on top? This has always perplexed me.
    • J. Sugarman, DNP, ANP-BC, GNP-C, PMHNP-BC10:49:35 PMR. Booth has it precisely right: “...there is only one standard of care in medicine," "medicine may be the most political, juvenile, and petty of professions," and "the territorial protectionism at all costs is sad and hurts patient care and access to care.” The professional insecurity of too many practiced, practicing physicians is astonishing, and has the deleterious effect of compromising the quality of care provided potentially to all patients. As R. Booth said, “...why would you not want to train all members of the team to be the best and safest providers they can be?” Whatever happened to “first, do no harm?”
    • jdbashore6:33:11 PMWe have had an EM fellowship for ACPs (PAs & NPs) here in SW Virginia for nine years. We seat four fellows a year. Large tertiary care center and level 1 trauma center. We've also had an EM residency for the last 11 years. With a volume of 97,000 (pre-COVID), there has been zero dilution of the residents' education or procedures and zero turf skirmishes. In fact, many of the PGY3 residents teach and mentor the EM ACP fellows. Our total ACP group (about 30 full- and part-time) work very well alongside the with the 36 EM residents. Maybe it's a function of our volumes in a large health system (three of our five EDs using residents and PAs/NPs), but I like to think it's mostly a result of our EM leadership, departmental culture, and ethos: We're all here to learn, and there are plenty of patients to go around.
    • R. Booth, EMPA-C, CAQ-EM11:14:40 AM<p>Many of the EM PA residency programs are not intertwined with EM MD residency programs. It is a false narrative that the primary concern here is the “dilution of MD resident training.” The primary concern is the additional specialty training being given to the PA, bringing their capabilities closer to that of the MD. The fear is the devaluation of the MD. The fear is baseless. The MD will remain the leader of the medical team. However, what that leadership position looks like is changing. The PA should receive as much training as possible especially if he is going to work in high-acuity environments. As stated in the article&#58; “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.” You must first acknowledge that there is only one standard of care in medicine. There is not a PA standard and an MD standard. I have done work on many malpractice cases, and I can assure you that whether you are a PA, an NP, or an MD, we are all held to the one standard of care. So why would you not want to train all members of the team to be the best and safest providers they can be? It benefits the patients, it benefits the supervising MD, the hospital system, and the community at large. In my 25 years as a medical provider, I can say medicine may be the most political, juvenile, and petty of professions. The territorial protectionism at all costs is sad and hurts patient care and access to care. As a residency trained EM PA, I am grateful for my additional training and expertise. It allows me to function as a solo EM provider in a critical access ED. If it were not for the PAs staffing this ED, the community would have no one. MDs do not want to come out here. So, if MDs are not going to cover rural America in the middle of nowhere, then let’s train the brave PAs who are willing to care for these communities to the highest level possible. Let us work together and strengthen each other.</p>
    • hrizvimd1:57:02 PMSo the Yale School of Medicine residency program has sold out those who fester in the tragic end of this specialty. While Dr. Tsyrulnik is showered with a faculty job, we have frontline practicing EPs to stop the insurrection. However, the first stage of sabotage of honest scholarship is the prized residency leadership itself.