Taking a Stand on the Independent Practice of APPs
Issue: January/February 2020
Author: David A. Farcy, MD FAAEM FCCM
As you are reading this issue, I want to take the time to wish you all and your loved ones, a happy and healthy new year. As you might be aware, AAEM has taken a strong stance around the role of the advanced practice provider (APP) in emergency centers across the nation. The discourse is getting louder, and in some cases becoming inaccurate, distorted, and divisive. I’d like to clarify a few things, reinforce some of what has already been said, and present the position of AAEM on many aspects of this conversation. While “Advanced Practice Provider (APP)” is referenced in many sources, AAEM recognizes that even this term invokes certain emotions for both physicians and non-physician health care professionals. This term also does not traditionally encompass all non-physicians but for the purposes of consistency, I will use the term APP.
Prior to every board meeting we have, I read the AAEM mission statement for position clarity, and as a reminder of why AAEM was created in 1993:
- every individual should have unencumbered access to quality emergency care provided by a specialist in emergency medicine
- the practice of emergency medicine is best conducted by a specialist in emergency medicine
- a specialist in emergency medicine is a physician who has achieved, through personal dedication and sacrifice, board certification by either ABEM or AOBEM
As President of AAEM, my responsibility is to uphold our mission statement and to represent our membership. In January 2019, our board reviewed the revised AAEM APP position statement (https://www.aaem.org/resources/statements/position/updated-advanced-practice-providers) written by the AAEM APP Task Force, and approved the new statement to reflect our mission statement. We received positive feedback, including from other physician groups (family medicine, anesthesia, surgery) but most importantly from the APPs within AAEM. Prior to its release we called each nurse practitioner (NP) and physician assistant (PA) and other non-physician members before implementing this to let him or her know that the Allied Health membership category was being dissolved, to be consistent with the AAEM position statement. We discussed our reasons, and individually, they each agreed with our action and supported the team concept of emergency care. They are still involved in AAEM, and are welcomed at the Scientific Assembly as well as other activities that AAEM supports.
Here’s the sentence I want you to read, even if you don’t read anything else in this message:
APPs, including nurse practitioners and physician assistants have always been and continue to be an important part of the emergency medicine, physician-led team working side-by-side for the efficient care of patients in the emergency department.
This message has somehow gotten lost in and amongst some of the enmity around this issue. We would not be able to efficiently run our emergency departments without our NP and PA colleagues working side by side with us. In the setting of an ever-increasing volume of patient visits, we need a team approach to effect the safe disposition of so many patients. With the advent and proliferation of the electronic medical record, as well as government oversight regulations on the house of medicine, we are tasked with multiple hours of administrative clerical responsibilities for each shift that we work. The end result is less time spend at the bedside caring for our patients.
The American Association of Nurse Practitioners (AANP) advertises that “patients under the care of NPs have higher patient satisfaction, fewer unnecessary hospital readmissions, fewer potentially preventable hospitalizations and fewer unnecessary emergency room visits than patients under the care of physicians” (ref: AANP) This is an astounding claim, and I had hoped to read literature supporting it. Unfortunately the reference to support this statement from the AANP website is a random sampling from 1991 of physicians and NPs responding to a hypothetical scenario by survey. (Avorn, J., Everitt, D.E. & Baker, M.W. (1991). The neglected medical history and therapeutic choices for abdominal pain. A nationwide study of 799 physicians and nurses. Archives of Internal Medicine, 151(4), 694-698.)
Where is the integrity in promoting this kind of statement with a survey? We know that literature such as this, at best is suggestive and certainly not something to support advertisements to the public. The bottom line is that there are no validated scientific studies that have shown the safety and efficacy of non-physicians practicing independently of physician supervision (ref: Physicians for Patient Protection).
Let’s talk about the trust relationship between patients and the medical community. The average layperson is not equipped, nor should he/she be expected to read between the lines of advertising that promotes APPs over physicians for emergency health care when the education and training is vastly different for each. Here is what I wish the public understood: The argument to replace physicians with NPs and PAs is at the least, divisive, and at worst, dangerous. Even if AANP supports this and an NP has the “brain of a doctor,” he/she certainly doesn’t have the education and training of one. Physicians diagnose, treat, and prescribe independently after they have logged 15,000 to 16,000 clinical hours, while NPs who work in states that allow independent practice can diagnose and prescribe independently after logging between 500 and 1,500 clinical hours (ref: Primary Care Coalition). The amount of supervised clinical training for a physician is 10-30 times that of an NP. It is indefensible to suggest the equality of these two professions for patient care, let alone the superiority of NPs.
Many will argue that APPs are filling the gaps in rural areas where there are physician shortages. The truth is that APPs don’t seek employment in these rural areas any more than physicians do. Even in states with independent APRN practice laws, APPs have not expanded into rural areas. (ref: AMA)
So how has this played out? NPs cost less than physicians. Hospitals and urgent care centers that are focused on profits are looking for cost cutting options. Independent practice for NPs certainly fits that requirement. All they have to do is convince state legislators and the public that NPs are equivalent, if not better than physicians. The truth of this position is that NPs and PAs have already been taking care of patients for decades, but with supervision by physicians, which has for the most part been invisible to the patient. If they exploit the perception that APPs are already doing the job independently, the rest falls into place.
Who loses? Patients lose when they falsely believe that the person in the white coat is a physician, or when they believe that a physician is appropriately supervising the APP. They lose when they don’t know enough about the medical system to ask questions. Who wins? Administrators do, who are for the most part – not physicians.
In November 2019 around 14-15 physicians were fired from Edward-Elmhurst Health as the suburban Chicago-based health system for replacement for less costly APP. When profits margin are keys, patients become second and patient safety is not even part of the equation of private equities.
What do physicians need to do? A few things:
Contact your state legislator(s), voicing your opinion against the independent practice of APPs.
Even if your state is one of the 23 states that have already implemented independent practice for NPs, it is worth writing or calling. If your state is contemplating it (I guarantee they all will eventually), it is even more crucial to write.
Do not agree to sign the chart of an APP unless you have been given ample time to evaluate and examine the patient if necessary.
If you are not given this option, you may be signing onto a liability claim for a case you didn’t have ample opportunity to evaluate.
Do not agree to sign the charts of patients whom were never presented to you in real time.
Depending on the attestation, this may be fraudulent practice, and with the current environment and scrutiny it becomes more likely that you will be involved in litigation if the patient outcome is poor.
Speak out in your department if NPs or PAs are utilizing the title “Doctor” even if they have a PhD or other academic title.
This title has a specific meaning in clinical setting of the emergency department, and patients deserve transparency.
There is a need to start collecting data from urgent care, freestanding staff with APPs who are practicing without direct physician supervision and document the un-necessary referral, over ordering of test and rate of complication. We need to let the data speak louder than any words. We love our APPs that work side-by-side and they are part of our family. Independent APPs without direct doctor supervision will not be good for patient care.
Join AAEM in our support for the physician-led team approach to patient care in the emergency department and educate your colleagues, friends, and family on the issue.
I want to personally thank Dr. Evie Marcolini and Dr. Julie Vieth for their contributions to my President’s Message, for the countless hours and their dedication to the APP Task Force and every member of the Task Force.
- American Association of Nurse Practitioners: https://www.aanp.org/advocacy/advocacy-resource/position-statements/quality-of-nurse-practitioner-practice
- Physicians for Patient Protection: https://www.physiciansforpatientprotection.org/ppp-responds-to-executive-order-regarding-pay-parity-and-scope-of-practice-offers-solutions/?
- Primary Care Coalition: https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf
- AMA: https://www.ama-assn.org/system/files/corp/media-browser/premium/arc/ama-issue-brief-independent-nursing-practice.pdf.