Opposing views on EM PA training

This special edition newsletter explores recent commentary about EM PA training

On 5.16.23, the Emergency Medicine Workforce Newsletter included an entry titled “Where is SEMPA’s Peter Rosen?” It addressed the education and training of EM PAs. This is a response to that entry.

Let me begin by saying that I believe the challenges of EM today and tomorrow are best addressed by a united front of emergency physicians and well-trained EM NPs/ EM PAs.  I believe that the SEMPA - ACEP relationship was established on great footing. I believe it blossomed. I believe it should and will continue to do so.

Ok, now let’s address some excerpts from the newsletter.

“Who is SEMPA’s Peter Rosen?”  

I do not speak for SEMPA, so I won't attempt to do so. Rather than attempting to answer the question above, let me tell you who some of SEMPA’s pioneers are. Heroes like Arnold Zigman, Terry Carlisle, Steve Ireland, Terry Mize are great starts. Of course, there are so many more. SEMPA has a rich supply of innovators and visionaries.

“EM NPs & PAs are seeing an increasing share of higher acuity patients”

These APPs were hired by physician groups. They were granted EM privileges by physicians of a medical executive committee. An EM physician had to sign an APPs application for privileges. These privileges defined scope of practice.  EM physicians agreed to supervise these APPs.  Every shift in EDs across America EM physicians can decide, “PA Smith, do me a favor and let me see the sick patient bed 1…can you go see the less sick patient in bed 3?”  Every shift, EPs have the opportunity to check on patients that PAs see.  So, when PAs are managing an increased number of high acuity patients, they are either doing so with lots of physician approval, or they are not.  If they are not, that’s a problem and that needs to be addressed immediately.  However, when good patient outcomes were achieved by PAs and good physician supervision, then more patients were fortunate enough to receive quality EM care. 

This was the purpose of creating the PA profession: increase patient access to quality care.  So, to all you PAs who saw high acuity patients in rural areas and increased access to quality EM care (as depicted in the graph above) …thank you! To all the EPs who provided the right supervision…thank you!

In 20 years of EM practice, I have witnessed the squeezing of the emergency physician by multiple factors. Lots of these EPs are close friends of mine. However, PAs and our training are not the enemy. We are co-pilots who want to work to the fullest extent of our abilities and exhaust ourselves on shift to assist and support our supervising physicians. We want to be teammates, not renegades. We want to help, not hinder.

“... so more emergency physicians are objecting to PAs seeing high acuity ED patients after completing as little as one 4-week emergency medicine rotation in PA school “  

The thing about anecdotal evidence is that it lacks scope; we can all trade colorful stories. I am unaware of any published data that lists how many PAs with only 4 weeks of an EM rotation are managing high acuity patients. Don't get me wrong, I'm sure it does occur, but I suspect that it is not widespread. However, it doesn't matter if it occurs rarely or frequently, it’s wrong. I must ask, though, what supervising physician is allowing this to happen on shift?  Again, EM department credentials and scope of practice can be developed and modified by the hospital MEC and the ED medical director.  On shift, a supervising physician can further restrict scope of practice, e.g., “Hey, Bill, please don't pick up any level 2’s or sick level 3’s. If you think you can manage them, come discuss with me and will make a decision.”

The 2022 ACEP revised guidelines

It has never been my intent, nor is it now to battle with EPs. They trained me, mentored me, and showed me more grace and patience than I'm sure I deserved. We’ve vacationed together. We’ve attended weddings, and family funerals. We’ve watched our kids grow up together. We’ve held each other up through the tough times of emergency medicine conflicts.  However, we should be able to speak plainly. Supervising physicians do not need to be involved in the contemporaneous care of every patient presenting to the ED when seen by a qualified EM NP/ PA. That simply is overkill and inefficient. In EDs all over America, qualified EM NPs & PAs are managing patients with quality workups and quality outcomes. We mustn't needlessly distract an already overwhelming EP from the most important tasks that only an EP can manage.

I just don't believe that most EPs in busy EDs across the country want to be interrupted by qualified EM NPs & PAs to be told about a simple URI, poison ivy, or simple laceration. We would grind EM throughput to a halt! Aren’t our waiting rooms backed up enough already?

I acknowledge that ACEP may in fact be working on emergency department standards that include more supervision requirements of EM PAs and NPs than SEMPA leaders would want.  However, I do not understand any propensity to increase regulation when current legislation and regulation already exists and is not being maximized.  Again, today on shift, my supervision physician can direct me to abstain from seeing any sick level 3 patient, or any level 2 patient. She/he can direct me as to whom they want to see and not see. EPs hold that authority right now. Why is more regulation needed? It seems to me that since ACEP has concerns of EM PA scope of practice, that it would be best for ACEP EPs to dialogue with supervising physicians regarding how they supervise their PAs.

In the spirit of calling balls & strikes, YES, there are EM NPs & PAs who should not have been hired for the ED because they weren’t ready and may never be ready. The solution: don't hire unqualified providers. Best practice for interviewing & hiring is a joint effort by the medical director and an EM NP/PA department leader.

If staff EPs have a problem with the PA candidates that are being recruited and hired, EPs should address the medical director.  

However, what does one do if a hired candidate initially looked promising, but isn’t working out? If the provider has rehab potential, formally counsel the provider and develop a performance improvement plan with scheduled milestones and goals. Best practice is for an APP leader to be involved. The plan must include close physician supervision.

I do understand, however, that many EDs and staff physicians are horrendously busy and see such high concentration of acuity that they may truly not have available bandwidth for close supervision of junior EM PAs. In such cases, don't hire junior PAs. Again, EPs currently have choices on who to hire and how to supervise. Why is more regulation needed?

I understand that big EM staffing companies may “push” unqualified NPs/PAs onto staff EPs. Again, a united front by EPs to medical directors, and medical directors to staffing company executive leaders is required.

Lastly, we know that many EDs share similar characteristics. However, different EDs may have different needs for PA staffing and different resources to train and supervise PAs. I believe ED medical directors, EPs and APP leaders on the ground are smart enough to identify what PA capabilities they need, if and how they can develop PAs, and what scope of practice should be established. I don't believe an additional one-size-fits-all policy is needed. Let the locals decide what's best for their shop.

“SEMPA’s current stance on EM-specific training is unacceptably weak”

In 20 years of EM practice, I have always known SEMPA leaders to sincerely value and energetically prioritize education, as well as be completely dedicated to the delivery of high-quality emergency care. Modern day PA champions of EM education like Fred Wu come to mind. They develop valuable learning events for NPs & PAs. Make no mistake, SEMPA’s position on EM-specific training is STRONG!

I will always support any effort that promotes education and self-improvement.  Post graduate academic programs and employer developed programs have great value, and I think they are fine choices for some PAs. However, there are simply not nearly enough programs to train every practicing EM PA. I’ve heard multiple times from fellowship program directors that these programs are not a match for every PA. If fellowships were a minimum criterion to practice, we would lose thousands of EM PAs. Does anybody really think this would be a realistic outcome?  Are the majority of practicing EPs really ready to show up to busy EDs with a severe reduction in supporting APP hours because experienced OJT PAs did not hold a fellowship credential? 

I hold an EM CAQ, but it did not teach me new knowledge or skills. The credential simply gave me credit for what I already had learned: through the on-the-job training by great EP mentors.  

The overwhelming majority of practicing EM PAs, 66%, are managing patients across the acuity spectrum without an EM CAQ or post graduate degree/certificate. A large number of practicing EM PAs were trained by some form of OJT in the ED by EPs who were great teachers and mentors. Over the years this pathway has produced some awesome clinicians. This is what the right supervision can produce.

Is there room for improvement in the education and training of EM PAs? I will always say yes.  I have all the respect in the world for Peter Rosen.  I absolutely believe that collaboration with ACEP is most valued. However, I believe SEMPA is the definitive resource for practice, education and professional development of EM PAs.

I will end as I began.  I believe the challenges of EM today and tomorrow are best addressed by a united front of emergency physicians and well-trained EM NPs/ EM PAs.  I believe the SEMPA - ACEP relationship was established on great footing. I believe it blossomed. I believe it should and will continue to do so.

Please check out the new EM NP & PA Workforce podcast here  

Your contribution to emergency medicine is great. Your voice matters and it should be heard.

Thank you for what you do, 

Omar