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Tuesday, May 11, 2021

​Steer Clear of Magnesium for COPD Exacerbations


Knowingly or not, we in emergency medicine tend to lean into the Dutch hypothesis, a 1960s postulate that asthma and COPD are part of a spectrum of common disease (chronic obstructive lung disease), and should be considered a single disease with common genetic origins. It’s an approach that allows us to cognitively coordinate the management of obstructive pulmonary disease to some degree.

Both patient populations universally receive the inhaled beta agonists and anticholinergics we reflexively call for as well as a hefty dose of corticosteroids and a call to the respiratory therapist to initiate bi-level positive airway ventilation. Nebs. Steroids. BiPAP.

But growing clinical experience understands these conditions as separate entities, which for all of their similarities uniting bronchoconstriction, bronchorrhea, and hypoventilation have marked differences in the pattern of inflammation that occurs in the respiratory tract, with different inflammatory cells recruited, different mediators produced, distinct consequences of inflammation, and, importantly, differing responses to further therapy. (Breathe. 2011;7:229; These pathophysiological differences underscore an important divergence in the treatment algorithm of obstructive pulmonary diseases—the use of magnesium.

Possibility of Harm
Magnesium has become somewhat of a darling in emergency medicine over the past few years. It has long been used for obstetric emergencies, but the medication has found growing use as an adjunct for treating headaches (Am J Emerg Med. 2021;39:28;, cardiac emergencies (Acad Emerg Med. 2019;26[2]:183;, and, of course, asthma, where use in severe cases has been shown to decrease hospitalization and improve peak expiratory flow. (Cochrane Database Syst Rev. 2000[2]:CD001490.) No data, however, support using magnesium to manage COPD exacerbations, and the real possibility of harm remains.

Multiple randomized trials have undertaken the task of determining which effect, if any, magnesium may have in treating patients with acute exacerbations of COPD presenting to the emergency department. Some investigations have suggested mildly improved pulmonary function measures, but none has convincingly demonstrated a viable patient-oriented benefit to the medication’s administration. Such discordance in therapeutic response demands skepticism about the Dutch hypothesis and recognition of the underlying pathophysiologic principles that drive a lack of benefit—and potential harm—from magnesium.
The airway narrowing of asthma is predominantly due to contraction of airway smooth muscle as a result of multiple bronchoconstrictor mediators released from inflammatory cells, particularly mast cells. By contrast, the airflow limitation of COPD results from structural changes of small airways and closure of small airways as a result of disrupted alveolar attachments, resulting in air trapping and dyspnea. (Am J Respir Crit Care Med. 2006;174[3]:240; The dominant pathology in asthma is mainly located in the larger conducting airways, while COPD predominantly affects the small airways and lung parenchyma.

No Justification
Recall that the purported reason for magnesium administration in asthma is calcium channel-mediated smooth muscle relaxation, leading to relief of bronchoconstriction and opening of the large airways. Given that COPD’s smooth muscle pathophysiology principally targets smaller airways and alveoli, it’s clear that a patient in extremis is unlikely to benefit from magnesium administration. The non-reversible airflow limitations of COPD could also potentially worsen as fibrotic distal airways are further incapacitated by hamstrung smooth muscle.

Magnesium is often touted as a relatively cheap and benign intervention, but the reality is that its administration carries the real risk of harm, ranging from mild hypotension and flushing to pulmonary edema, not a good complication in a patient already in respiratory distress. Where physiologic benefit (large airway dilatation) cannot be found, only pathologic adversity remains.
The Dutch hypothesis allows emergency physicians to approach life-threatening respiratory illness with a common set of tools and pathophysiologic principles. Rapid initiation of these resuscitative measures can make the difference in severe illness and significant distress. The addition of magnesium, however, represents a divergence from the Dutch hypothesis. Magnesium administration cannot be justified by the underlying structural causes of COPD and the available literature investigating its use.

Dr. Pescatore is the chief physician for the Delaware Division of Public Health and an emergency physician at Einstein Healthcare Network in Philadelphia. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine: Follow him on Twitter @Rick_Pescatore, and read his past columns at

Tuesday, May 4, 2021

​After Years of Calling for More EPs, EM Finds Itself with Too Many


There will likely be nearly 10,000 more emergency physicians than there are jobs for them by 2030, according to a new study commissioned by the American College of Emergency Physicians. (Emergency Medicine Physician Workforce Projections for 2030. April 9, 2021;

“We are now facing for the first time in history a likely oversupply of emergency physicians within the next decade,” said ACEP President Mark Rosenberg, DO, the chair of emergency medicine at St. Joseph’s Health in Paterson and Wayne, NJ, in a webinar releasing the findings. (

Emergency medicine residency programs and the overall number of residency slots in the specialty have grown significantly. A total of 4565 residents were in 145 emergency medicine programs in 2008, a number that shot up to 7940 residents in 247 programs by 2019, a 74 percent increase. The number of EM residency slots increased by six percent between 2018 and 2019 alone.

Illustration: Sam Teng; [email protected]

“Emergency medicine is now the second most popular specialty in the country after internal medicine,” said Louis Ling, MD, formerly the senior vice president for hospital-based accreditation at the Accreditation Council for Graduate Medical Education (ACGME), during the webinar, citing the results of the 2021 residency match held in March. “More people matched to emergency medicine than to family medicine or pediatrics. Combining supply data with demand data, we would need to cut about 1000 residency graduates a year, which gives you an idea of the kind of supply we have.”

Continuing Growth

The study, conducted by Edward Salsberg, a member of the health policy faculty at the George Washington University School of Public Health and Health Services, projected future supply and demand for emergency physicians based on potential variability in the rapid growth of emergency medicine residencies; projected attrition rates in the specialty; the rise of nonphysician practitioners (NPPs), who made up 23 percent of the workforce billing independently for ED care in 2018; and projected emergency department volume.

The most likely scenario, the study predicted, is that the number of emergency medicine residents will grow two percent between now and 2030, 98 percent of whom will enter emergency medicine, and the attrition rate will be three percent among current providers, for a projected supply of 59,050 emergency physicians. Visits per physician will remain constant, with 20 percent of those patients seen by NPPs, for a projected demand of 49,637. That would result in a surplus of 9413 emergency physicians.

Mr. Salsberg’s formula can be adjusted to see what might happen if certain variables change. If, for example, the growth in emergency medicine residencies continues and the number of emergency medicine residents increase by four percent while everything else about supply and demand stays the same, it would mean that more than 10,000 emergency physicians will be looking for work in 2030.

The study was commissioned by a task force of eight specialty organizations, including ACEP, the American Board of Emergency Medicine, the American College of Osteopathic Emergency Physicians, the American Osteopathic Board of Emergency Medicine, the Emergency Medicine Residents’ Association, the Council of Residency Directors in Emergency Medicine, the Society for Academic Emergency Medicine, and the Association of Academic Chairs of Emergency Medicine. Representatives from each of those groups presented recommendations during the webinar to help address the incipient workforce crisis:

  • Encouraging or requiring emergency medicine residency training to be extended to four years without increasing the complement of residents.Increasing emergency medicine procedural requirements to be more robust.
  • Increasing resident salaries to decrease incentives for residencies to be established for the purpose of providing low-cost labor.
  • Calling for fewer residents in each new program and existing programs, or even decreasing positions in current programs.
  • Calling for a decrease in or a halt to new emergency medicine residencies.
  • Investigating the legitimacy of for-profit organizations funding training programs, including potential conflicts of interest.
  • Supporting standardized training for NPPs working in the ED.
  • Better identifying competencies of NPPs compared with emergency physicians.
  • Ensuring that the physician-led team model in the ED is endorsed and promoted.
  • Categorizing emergency departments, including metrics for physicians, NPPs, supervision, and outcomes, to set professional standards for overall better practice.

Catherine Marco, MD, a professor of emergency medicine at Wright State University and the chair of the study task force, declined to comment for this article, saying the peer-reviewed publication based on the workforce study was still in review at press time.

High-impact strategies, such as reducing the number of residents in programs or decreasing or stopping new programs, would likely have to be voluntary, as with other specialties, said Lewis Nelson, MD, a professor and the chair of emergency medicine at Rutgers New Jersey Medical School and University Hospital, who represented the Association of Academic Chairs of Emergency Medicine in the webinar. “A mandated reduction would probably only result if ACGME requirements were changed to require more resources and faculty-protected time. The ACGME cannot, at this point, withhold approval of a program if the program meets requirements.”

Other options considered but discarded as infeasible included seeking shutdown of some existing programs by the ACGME’s Residency Review Committee and working with the Centers for Medicare and Medicaid Services to deny funding to new programs in nonteaching or for-profit hospitals.

Fair Warning
Some say that the writing has been on the wall about a workforce crisis for years. Thomas Cook, MD, the director of the emergency medicine residency program at Prisma Health Richland Hospital at the University of South Carolina School of Medicine, noted in his EMN column that 77 emergency medicine residency programs had achieved ACGME accreditation between 2016 and 2019 alone. (EMN. 2019;41[10]:1; Large contract groups like US Acute Care Solutions and TeamHealth and large health care organizations such as HCA have been responsible for much of that surge, he said.

“I saw this coming, and I’m no genius,” Dr. Cook said. “Here in South Carolina, we have about five million people and five emergency medicine residencies graduating 60 doctors a year. We don’t have 60 new emergency medicine jobs a year. When I was a resident, I think Florida had two emergency medicine residency programs in Orlando and Jacksonville. Now I think they have more than 20. Two may be too few, but 20 is way too many.”

ACGME has routinely rejected programs in the past, but Dr. Cook said he thinks the organization is unlikely to flex that muscle against corporate-sponsored residencies today. “They rejected Parkland’s emergency medicine residency in Dallas the first time,” he said. “They took residents out of the program at Harborview in Seattle because the program director was not an emergency physician but a neurologist. Historically, they would act aggressively about making sure programs were supported, but now the number of site visits has gone down, and the same level of action is not happening. The ACGME’s total operating budget is about $70 million, and they’re expected to control a company like HCA, whose profit last year was $3.8 billion?”

No Quick Fixes
The American Academy of Emergency Medicine declined to participate in the workforce study because it was not allowed to participate in the selection of the investigator, the questions to be investigated, or the fee provided to the investigator. It released a position statement a few days later saying it has “long been aware that circumstances have been created which have increased the supply of emergency care clinicians beyond the demand,” attributing that to for-profit health care corporations that created “a substantial number of emergency medicine residency programs” and the training and credentialing of nonphysician practitioners to provide ED care.

AAEM criticized ACGME for decreasing the academic requirements for residency graduation by eliminating a requirement for a scholarly project and a reduction of the protected time afforded to program leadership for developing academic teaching and research for the residency. “We assert that there is a conflict of interest between profit and education when corporations run residency programs,” the statement said. “We contend that these [nonphysician practitioner] training programs have no place in the emergency department in an environment where resident physicians are unable to find employment due to supply-demand mismatch that currently exists and is predicted to continue or worsen.” (AAEM. April 12, 2021;

Robert McNamara, MD, a professor and the chair of emergency medicine at the Lewis Katz School of Medicine at Temple University in Philadelphia and a past president of AAEM, said there aren’t any quick fixes. “AAEM has been saying for a long time that we should not let corporations take over our specialty,” he said. “If we hadn’t, we wouldn’t be in this position now. The corporations have contributed to the oversupply by opening a number of new residencies and have major influence on the demand side by being in control of which practitioner will see the patient.”

The situation is “a crushing blow” for current residents and recent graduates, Dr. McNamara said, pointing to his own institution. “Four of our graduates really struggled to find jobs this year. Two of them took per diem positions, one took a fellowship when they really wanted a full-time job, and one had to take a position with a group that doesn’t mesh with his professional ethics. It has hit everybody.”

The core issue, he said, is that emergency physicians have lost the ability to control care in their own EDs. “We have not effectively used the existing rules against the corporate ownership of medicine,” he said. “We need a more widespread effort to challenge these practices. It is not just the graduating residents who are at risk. For the corporations, the bigger the workforce, the less you have to pay the doctors, so an oversupply plays right into their hands.

“[T]his crisis represents an enormous future danger to patients if emergency medicine loses its ability to attract the best and the brightest,” Dr. McNamara said. “We’re even more expendable than we were in the past, so that’s why academicians, leaders in the field, and other people who have secure jobs have to speak up now. I’m saddened, but I’m still energized.”

Ms. Shaw is 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 at

Tuesday, April 27, 2021

It’s Time to Break Up with TXA


We have been fed false promises of efficacy and manufactured optimism for success with the use of tranexamic acid in all manner of acute and subacute bleeding conditions for far too long. Beginning with the publication of CRASH-2 in 2010, emergency physicians across the world quickly fell in love with TXA, entranced by the drug’s low price and benign side effects across the spectrum of emergency department presentations. As observational data sets and anecdotal reports flourished, TXA quickly became a darling of emergency medicine, championed as the panacea to all types of hemorrhage.

It’s time, however, to recognize that this wonder drug has done nothing but fall short time and again, betraying our confidence and leaving us repeatedly stranded at the evidence-based altar. In all likelihood, TXA has little utility in the ED, much less the vaunted status it has undeservedly enjoyed.

The betrayal began with the publication of the WOMAN trial. (Lancet. 2017;389[10084]:2105; Designed primarily to identify a composite outcome of all-cause mortality and hysterectomy within 42 days of giving birth, the trial’s primary endpoint was eventually adjusted to investigate TXA’s effect on death from postpartum hemorrhage alone, justified by the authors as a needed methodological change but nonetheless a red flag by even the loosest evidence-based standards. Even with the change, however, this trial fell short in its primary outcome, finding no statistically significant difference in outcomes except in a secondarily dissected time-based endpoint. Nonetheless, the trial was widely interpreted as positive, and TXA remains in postpartum hemorrhage guidelines and algorithms to this day.

Three years ago, I wrote that the much-anticipated HALT-IT trial would settle the debate, but we were left in the meantime with consistent and compelling evidence that TXA should be routinely incorporated into the resuscitation of the critically ill GI bleeder. Our patients deserve TXA, I said. (EMN. 2018;40[11]:1;

The preliminary literature was indeed compelling. TXA showed a relative mortality improvement of 39 percent in seven randomized, controlled trials of 1385 patients with GI bleeds. (Aliment Pharmacol Ther. 2008;27[9]:752; This was confirmed by a 2014 Cochrane Review, where eight RCTs and more than 1700 patients with GI bleeding found a relative risk for mortality of 0.6, with no difference in venous thromboembolic events. (Cochrane Database Syst Rev. 2014;2014[11]:CD006640; The 2020 publication of the HALT-IT trial once again uncovered TXA’s silent duplicity. (Lancet. 2020;395[0241]:1927;

Bamboozled Again
Patients in this well-structured randomized trial received a loading dose of 1 g of tranexamic acid, which was infused over 10 minutes, followed by a maintenance dose of 3 g of tranexamic acid infused over 24 hours or placebo (sodium chloride 0.9%). Patients who received TXA had no improvement in the primary outcome (death due to bleeding within five days of randomization), but did suffer a higher rate of venous thromboembolic events. TXA was not content just to betray us; it began to hurt us as well.

There have been plenty of other hints to which we have perhaps simply turned a blind eye. Consider the CRASH-3 trial, where TXA fell short of a statistically significant improvement in head injury-related death, or the TICH-2 trial, where no benefit was found in three-month functional status among patients with spontaneous intracranial hemorrhage. Nonetheless, many emergency physicians walked away from these publications with a positive outlook on using TXA in intracranial bleeding, bamboozled once again by a drug we seem to stick by no matter the accruing literature justifying its abandonment.

Following the release of a 2017 experiment showing the superior performance of intranasal TXA to nasal packing in epistaxis, emergency physicians (myself included) flocked to the drug for nosebleeds and recalcitrant HEENT bleeding. (Acad Emerg Med. 2018;25[3]:261; Intranasal TXA became a mainstay of epistaxis management for many, a promise finally fulfilled. The publication of the NoPAC trial, however, showed TXA’s true colors once again.

This well-done trial randomized patients to saline- or TXA-soaked dental pledgets after first-line therapy (generally, intranasal phenylephrine) had failed. Despite nearly two-thirds of patients taking anticoagulants, TXA was no more effective than placebo at controlling bleeding and reducing the need for anterior nasal packing. There is plenty of room for maneuvering—a startlingly high 43 percent of patients needed packing, for example—but the conclusion is fairly clear: TXA had betrayed us again.
We have placed our confidence in tranexamic acid again and again to bring patients back from the bleeding brink, only to be recurrently jilted by perennially paltry p-values. TXA, once thought to be a simple solution to bleeding from nearly any source, has failed to deliver one too many times.

Dr. Pescatore is the chief physician for the Delaware Division of Public Health and an emergency physician at Einstein Healthcare Network in Philadelphia. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine: Follow him on Twitter @Rick_Pescatore, and read his past columns at

Wednesday, April 21, 2021

What We Don’t See in the Shadows


Some pathologies are like fiends, lurking in the shadows, often unseen, and certainly underrecognized. Nonfatal strangulation is one of those.

There’s nothing new about NFS as an act of violence and control, but it is only recently that we clinicians have understood what makes it unique.

All around the world, legislation is falling in line with NFS, with legal ramifications commensurate with its seriousness as a crime. We in medicine are now catching up with the law.

What is interesting, however, is understanding why we have been so slow to register NFS as the deadly act it is. We now know that a single episode of NFS increases a victim’s risk of being killed at the hands of that same perpetrator up to seven times over. It has been described as being on the edge of homicide, not just an act of violence but one of cold, calculating control. It says, “With my bare hands, I can take your life.” It takes not much more than the strength of a handshake to kill.

We have to parse the reasons we have been slow on the uptake. To start, we ask the wrong questions. If we inquire whether a victim has been strangled, she may not register the event for what it was, as though strangulation only occurs like it does in the movies. Instead, we should ask whether the patient has had any sort of pressure placed on the neck. Perhaps it was a knee, a weapon, or a ligature. We also need to ask questions aslant: “Did you black out, wake up on the floor, lose control of your bowels or bladder?” All of these are consequences of hypoxia.

The victim may not recall the event. Anoxia happens quickly, and the centers for memory can be affected rapidly. If this is not the first time, we may need to think about it in the same way as repeat concussion injury, with cumulative anoxic injury contributing to neuropsychiatric sequelae, including further memory loss and other cognitive changes.

Newest of the Old
We don’t appreciate the fact that less than 50 percent of victims have external signs of injury (ligature marks, abrasions, the classic petechial hemorrhage distribution, defensive scratch marks), leading us to underestimate the severity of the assault.
We don’t consider how little force it takes to cause serious injury and how quickly it can occur. The four mechanisms for potentially fatal outcomes in NFS are:

  • Jugular venous obstruction can cause sudden severe venous congestion, and it takes less pressure than is required to open a can of soda to achieve this.
  • Carotid artery compression still requires less force than a firm handshake, and loss of consciousness from hypoxia can occur within 10 seconds.
  • Airway compression requires greater and more sustained force, but can still result in hypoxia, as well as aerodigestive injury.
  • Carotid body compression or stimulation is more a postulated mechanism, and may cause bradyasystolic arrythmias.

We may overlook the important sequelae. Carotid artery dissection is uncommon but may be missed, resulting in long-term disability. The nature of NFS, with intermittent arterial compression with torsion from twisting movements, has been demonstrated to cause arterial injury. A CT angiogram needs to be requested if there is any suspicion at all.

We may not even get to the starting point. Victims of intimate partner and family violence may not feel able to answer our hurried, targeted questions. It is vital to leave a nonjudgmental, caring space wide open for the victims to speak and be believed.
NFS can be considered the newest of old conditions. By increasing our level of suspicion, asking the right questions in the right ways, we have it within our own hands to save a life.

Dr. Johnston is a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, She also contributes regularly to the blog, Life in the Fast Lane, Follow her on Twitter @Eleytherius, and read her past columns at

Tuesday, April 13, 2021

EPs Object to Calling PA Programs ‘Residencies’


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;

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.” ( 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.” (

“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; 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 program 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.”

Ms. Shaw is 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 at