Why Did AAEM Take a Stand Against APP Independent Practice?

Sat Apr 6 13:51:57 PDT 2019

April 2019

<https://journals.lww.com/em-news/Fulltext/2019/04000/News__Why_Did_AAEM_Tak
e_a_Stand_Against_APP.21.aspx> EM News

April 2019 - Volume 41 - Issue 4 - p 4

BY THE AAEM APP TASK FORCE

Physician members of the American Academy of Emergency Medicine have voiced
concerns about the use of advanced practice providers (APPs) in the
emergency department and their push for independent practice without the
supervision or even availability of a physician. The task force spent hours
discussing the issues, comparing the education of physician assistants,
nurse practitioners, and board-certified emergency physicians, speaking to
physicians about their concerns, and examining the literature. (J Emerg Med
2004;26[3]:279; Acad Emerg Med 2002;9[12]:1452; J Emerg Med 1999;17[3]:427;
Acad Emerg Med 1998;5[3]:247; Ann Emerg Med 1992;21[5]:528.)

Most emergency physicians have worked with APPs and appreciate that they are
talented clinicians who improve emergency department flow, efficiency, and
quality of care under the guidance of the emergency physician-led team. Many
emergency physicians are aware of situations that place APPs in clinical
environments that are beyond their capabilities, level of training, and even
scope of practice. This is not the quality of care our emergency patients
deserve.

There is a vast difference in the clinical training of APPs compared with
EPs. Some APP training programs require only 500 hours of unregulated,
supervised clinical experience before graduating, while physicians must
complete approximately 4000 hours of clinical experience during medical
school and an additional 8500 hours of highly regulated and supervised
training as an emergency medicine resident before entering independent
clinical practice. (J Emerg Med 2015;48[4]:474.)

APPs do have a valuable role in many emergency departments, but their skills
should be used as part of a team led by an ABEM/AOBEM emergency physician.
APPs as members of that team should fill a role clearly defined by the
emergency physicians in that department which professionally stimulates the
APP and results in quality care. The cost of employment is lower for APPs
than for EPs. As increasing patient volume drives increased need for
coverage, the potential for increased profits grows if APPs replace EPs. The
delivery of safe, expert physician-led care to every patient must be the
primary factor when making staffing decisions, not profit.

The physicians staffing an emergency department are best capable of
determining the needs of their department. Physicians should not be told by
management that they must use APPs who have been hired for them. Rather,
they should decide how many APPs they need and hire only those candidates
who have the expertise and personality to mesh well with the culture of
their emergency department team.

Transparency to Patients

We are aware of situations where EPs are expected to supervise three, four,
or even five APPs while simultaneously seeing patients primarily. The
reality of those situations is often that the EP has only a cursory
knowledge of the patients that the APP sees and little or no time to
evaluate those patients independently. If defined patients and scenarios are
deemed safe for the patient to be seen by the APP with the supervising
physician providing only guidance and backup, then a bill should not be sent
in the physician's name. We support meaningful patient care by the
physicians who are billing for it and transparency to patients. A signature
in medicine implies that the signatory attests to the accuracy of the
document. Without direct evaluation of the patient, how can one know the
accuracy of the document?

Emergency medicine residency is a time for physicians to learn how to
practice their profession. Residents should be trained by those who practice
the profession in which they are seeking board certification. In a situation
where APPs are practicing alongside EM residents, it is imperative to
establish processes so that the training of the EM residents is not
compromised. Residents need to complete a certain number of procedures to
become competent. Attaining these skills should be a priority, and the
residents should be the first priority to perform a procedure to become
independently skilled.

It is challenging, if not impossible, for a patient to determine the role of
all the people with whom they interact in the emergency department. Patients
can easily be misled by non-physicians using the term doctor. They should
not be expected to understand the difference between an MD or DO and a DNP
or DScPAS (doctorate of science in PA studies). Patients deserve full
transparency about who is caring for them, and non-physician clinicians must
truthfully represent their level of training.

Throughout its history, AAEM has consistently asserted that ABEM/AOBEM
certification is essential. The academy has also spoken against emergency
departments staffed by non-ABEM/AOBEM physicians. Supporting the independent
practice of APPs in our emergency departments is inconsistent with these
core values. If APP independent practice is tolerated, a logical
profit-driven next step is staffing entire emergency departments with APPs
and even developing staffing companies to provide that coverage.

Our specialty owes its identity to our founders who demonstrated that the
skills required to manage an emergency department expertly were unique in
the house of medicine. They struggled to establish the specialty of
emergency medicine and define the training required to become a specialist
in emergency medicine. The independent practice of APPs has the potential to
undermine all the efforts of those men and women who created the specialty
of emergency medicine.

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

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calaaem.news.service1 at gmail.com

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