Legal Update

October 2019

Kenneth Alan Totz, DO, JD, FACEP

Are You Training Your Replacement?

This essay is not for the faint of heart. You may very well need an adult beverage before you read on. This brief introspection into our profession outlines my objective perspective on where we are headed in emergency medicine and medicine as a whole.

Whether you’ve been practicing in academia or as an independent practitioner, you likely have noted the increasing prevalence of nurse practitioner (NP) and physician assistant (PA) providers in your emergency department. There simply have not been enough physicians trained to fulfill the needs of our communities. To that end, newly enacted state laws and sources of talent have been efficiently developed to fill in those gaps. If your EM group or hospital system has become comfortable with the idea of NP’s and PA’s seeing the same patient population alongside physicians, what is keeping your group or hospital from taking the next step to replacing you completely? In this article I will take a sobering look at some realistic staffing trends from the perspective of a board certified emergency physician still in active clinical practice.

As of this writing, there are no states that allow for the completely autonomous practice of PA’s. As such, I will not address the possibility of their independent ED practice…yet. While I will focus primarily on the NP role in the emergency department (ED), many of the same principles discussed, will be applicable to PA providers and other venues of medical practice as well.

There are thirteen states and the District of Columbia (DC) that allow for the autonomous practice and prescriptive authority (a.k.a. full practice authority) of NP’s right out of their training programs and any board certification that the state mandates. These states are: AK, AZ, HI, IA, ID, MT, ND, NH, NM, OR, RI, WA, and WY.1 Thirteen other states allow full autonomous practice and prescriptive authority following an 18-60 month transition practice period and/or 1,000-4,000 hours of physician supervision, collaboration, or mentorship. These states are: CO, CT, DE, IL, MD, ME, MN, NE, NV, SD, VA, VT, WV.2 Numerous other states, such as Texas, allow for some level of semi-independent practice under the career-long supervision or collaboration of a physician.3 For those mathematically challenged, over half of the United States will allow NP’s to practice in the same capacity as you and I. The only barriers keeping them from competing for our jobs are the hospital bylaws that dictate what level of training is required for the house staff. At a fraction of the cost of the medical school route, NP’s can set up their own independent practices in the states noted above after obtaining a bachelors degree in nursing and a two year master’s degree. That beats the heck out of four years of pricey medical school and three-four years of torture in residency!

So if you were a hospital administrator, what arguments would you make for completely replacing emergency physicians with NP’s? What arguments would you make for limiting NP’s from practicing independently in the ED? This list is by no means exhaustive, but is meant to prompt some discussion and thought into your value as an ED doc to your hospital. I realize these are very sensitive issues, but they are ones you are going to face sooner than later. Now, before you come hunting for me or verbalize a series of expletives, recall that I’m in the same boat as you; working shifts each month to pay for my kid’s college tuition and Greg Henry’s wine of the month recommendations!

Arguments For Replacing Emergency Physicians With NP’s

  1. The average salary of an NP in Arizona is $105,000.4 The average salary for an EM doc in Arizona is $278,000.5 (Arizona is being used as a representative example of a state that allows full practice authority of NP’s).
  2. An ED in Arizona could hire 2.5 full time equivalent NP’s for less than the cost of one ED physician.
  3. In 2018 there were approximately 7,800 NP’s practicing in Arizona.6 There were seven (7) medical malpractice payments and six (6) adverse action reports (AAR’s) made on behalf of those 7,800 NP’s. An AAR is an action other than medical malpractice payments, convictions and judgments, taken against a health care practitioner.7 A state licensing board removing a provider’s license would be an example of an AAR. This equates to a 0.16% rate of action taken against NP’s in Arizona. These numbers could reflect that NP’s may be generally more cautious in their patient evaluations and referral patterns than physicians or that they may be seeing fewer or less complex patients.
  4. In 2018 there were approximately 16,500 physicians (MD and DO) practicing in Arizona.8 There were 176 medical malpractice payments and there were 134 AAR’s made on behalf of those physicians.9 This equates to a 1.81% rate of action taken against physicians, greater than ten times the rate of NP’s.
  5. NP’s can charge and collect similar reimbursements as physicians for the same work performed.10
  6. A Canadian study found 71 per cent of 113 patients preferred seeing an NP over a physician and mentioned favorable views of NPs on attentiveness and comprehensive care.11
  7. A systematic review of 36 international studies analyzing the impact of NPs in the ED by Carter and Chochinov (2007) concluded that NPs are equally competent to physicians, with equivalent performance in X-ray interpretation and superior performance in documentation, physical exam accuracy, appropriateness of urgent referrals and adherence to protocols.12
  8. NP’s can be taught all of the necessary ED procedures and skills on the hospital credentialing list during the progression of a mentoring program (i.e. you train your replacement) or outside commercial coursework.

Arguments For Maintaining an all Emergency Physician (EP) or Blended EP/NP Staff

  1. EP’s have a very unique skillset developed from years of residency training in hospitals distinctively chosen to provide adequate exposure to adult, pediatric, trauma, and critical medical needs. A two-year NP masters program is simply not going to provide enough patient care exposures to satisfy the diverse demands of independent EM practice. Furthermore, many hours of post-graduate experience without the guidance of an emergency physician mentor will not provide an NP with the sufficient knowledge base and procedural proficiencies to practice independently. A well blended department of NP’s and EP’s with established protocols, timelines, and metrics for mentoring the NP house staff can provide an optimal environment for NP growth and overall departmental efficiency. It is the opinion of this author through 20 years of anecdotal experience that ED’s operate most synergistically and efficiently when NP’s are encouraged to see patients within their own comfort level and within the predefined developmental protocols of the department. For example, all NP’s with less than 1 year of post-graduate experience may not independently interpret EKG’s and must have every patient personally evaluated and signed off on by one of the staff EP’s.
  2. Most EP-only staffing models are established for a productivity of 2-2.5 patients per hour (PPH). While there are no clearly established benchmarks for NP’s, the practice environment the NP is placed in may very well be the defining factor that dictates their suggested productivity. A fast-track setting may allow for more patients per hour to be seen as opposed to a sick medical or trauma population. If EP’s are going to demand a significant salary disparity, administration will want some clarification and justification as to why an EP and NP may be seeing an equivalent number of PPH. An objective quantification of the medical severity should be part of the evaluation when comparing EP and NP productivity. In either event, residency trained EP’s are a known commodity that can be productive right out of residency without any period of mentoring.
  3. The numbers do not lie regarding the adverse action reports (AAR’s) between EP’s and NP’s (using Arizona as an example, see numbers above #3,4). NP’s are drawing far less fire from lawyers and regulators than physicians. These numbers, though, do not reflect the disparity in complexity of patients that EP’s and NP’s generally evaluate. As noted above, many NP’s may be relegated to less risky primary care or fast-track settings that have been pre-screened by physicians and are thus a lower medical-legal risk overall.
  4. EP’s more frequently volunteer their time to be part of hospital committees that ensures smooth and safe operation of the facility. Without volunteers on committees such as peer review, hospitals would be unable to economically meet their regulatory and operational mandates. This is by far and away the principal area where EP’s can outshine our NP colleagues in any system large or small. Our broad exposure to all of the medical and surgical disciplines further allows us to be effective contributors to hospital processes.
  5. There are a plethora of articles touting the customer satisfaction superiority of EP’s over NP’s and vice versa. Many of the articles appear to be conflicted as they each endorse that their own professional group provides superior customer care. The argument in many regards is irrelevant. Each of us, EP or NP, has an ethical and clinical duty to provide patients quality and efficient medical care irrespective of the patient’s color, religion, wealth, or sobriety status. For those that are unable to practice within these directives, administration or your colleagues will eventually dismiss you from the team.
  6. ACEP policy espouses that NP’s should not provide unsupervised emergency department care, as they do not replace the medical expertise and patient care provided by EP’s.13 ACEP does not stipulate in their policy statement though, why unsupervised care should be allowed, nor do they suggest that NP’s cannot acquire the equivalent medical expertise of EP’s in due time.

Final Thoughts

Our nation is currently suffering from a significant shortage of physicians. It is projected that one third of all physicians will retire within the next ten years, thus further exacerbating the issue. There are numerous critical access hospitals throughout the country that do not even have 24-hour staffing (NP’s or EP’s) in the ED. We must foster more efficient ways to staff our communities with providers that meet the basic needs of the populace. The NP model provides a truncated pathway to independent medical practice that has proven to be a viable alternative to the traditional medical school route for physicians. The distinctive training of NP’s allows for a complementary practice to the traditional all-EP emergency departments, which can expand services and care to a greater number of patients with superior efficiency and economy. At this time, public sentiment and a majority of hospital administrations have sided with the ACEP policy above regarding fully independent NP practice in the ED. As legislators though, look for more cost-effective ways to provide “healthcare to all” and patients grow more comfortable with the idea of NP’s providing their care, the pendulum may very well shift.

More than ever, EP’s need to energize the discourse that highlights our diverse clinical value over other providers seeing patients in the ED. Furthermore, we should push for mandatory hospital committee involvement of our group members that confirms our devotion to the facility’s prosperity and our commitment to upholding the highest quality of care to our ED patients.

Kenneth Alan Totz, DO, JD, FACEP

No information within this report should be construed as medical or legal advice. Independent medical and/or legal advice should be sought based on each individual’s particular circumstances.

  1. Phillips, Susan J. 31st Annual APRN Legislative Update. Last accessed 4/18/2019.
  2. Id
  3. Id
  4. Last accessed 4/18/2019.
  5. Id
  6. Phillips, Susan J. 31st Annual APRN Legislative Update. Last accessed 4/18/2019.
  7. National Practitioner Data Bank Data Analysis Tool. Last accessed 4/18/2019.
  8. Arizona Physician Work Profile. Last accessed 4/18/2019.
  9. National Practitioner Data Bank Data Analysis Tool. Last accessed 4/18/2019.
  10. Phillips, Susan J. 31st Annual APRN Legislative Update. Last accessed 4/18/2019.
  11. Thrasher, C., & Purc-Stephenson, R. (2008). Patient satisfaction with nurse practitioner care in emergency department in Canada. Journal of the American Academy of Nurse Practitioners,20(5), 231-237.
  12. Carter, A. J., & Chochinov, A. H. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. Canadian Journal of Emergency Medicine, 9(4), 286-295.
  13. Guidelines Regarding the Role of Physician Assistants and Advanced Practice Registered Nurses in the Emergency Department . Last accessed 4/19/2019.