Patients at Risk

If you need emergency medical care, will you be treated by a physician?

April 25, 2021 Rebekah Bernard MD Season 1 Episode 25
Patients at Risk
If you need emergency medical care, will you be treated by a physician?
Show Notes Transcript

 In our book, we discuss the case of Alexus Ochoa, a healthy 19 yr old woman who died when a nurse practitioner failed to properly diagnose her. What is particularly worrisome about this case is that when Alexus was taken to the emergency room by ambulance, the only medical practitioner working there was a nurse practitioner.  Unfortunately, this situation is occurring in hospitals across the country. Physicians are being replaced by non-physician practitioners, and patients often have no idea.

Today we are joined by two emergency physicians who have become aware of this trend and are publicly speaking out about their concerns, Dr. Thomas Cook and Dr. Jason Adler.

Get the book!  https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/

Articles by Drs. Adler and Cook
https://journals.lww.com/em-news/Fulltext/2021/02000/After_the_Match__Boosting_Profits_Drives_NP.6.aspx

https://journals.lww.com/em-news/Fulltext/2021/03000/After_the_Match__NPs_Pushing_Expansion_of.2.aspx?context=FeaturedArticles&collectionId=3

PhysiciansForPatientProtection.org

Rebekah Bernard MD:

Welcome to'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host, Dr. Rebekah Bernard, and I'm joined by my co host and the co author of our book patients at risk, the rise of the nurse practitioner and physician assistant in healthcare. Dr. Niran Al-Agba.

Niran Al-Agba MD:

Good evening.

Rebekah Bernard MD:

In our book, we discuss the case of Alexus Ochoa, a healthy 19 year old woman who died when a nurse practitioner failed to properly diagnose her. What is particularly worrisome about this case is that when Alexus was brought to the emergency room by ambulance, the only medical practitioner working there was a nurse practitioner. Unfortunately, this situation is occurring in hospitals across the country. Physicians are being replaced with non physician practitioners, and patients often have no idea. Tonight, we are being joined by two emergency physicians who have become aware of this trend, and are publicly speaking out about their concerns. Dr. Thomas Cook and Dr. Jason Adler, welcome to the show.

Thomas Cook MD:

Welcome. Thanks for having us.

Jason Adler MD:

Thank you.

Rebekah Bernard MD:

The two of you have co authored several really excellent pieces about this issue in emergency medicine, among others. Tell us how did you guys start collaborating together?

Thomas Cook MD:

I think Jason did that. I've been writing for Emergency Medicine News for about eight years. And over the last couple of years, I turned my attention to the issue of more and more advanced practice providers sort of taking the place of Emergency Physicians for a number of different reasons and sort of pressures in the workforce and Jason unfortunately, had been subjected to reading some of my some of my work and found a common cause. And he reached out to me by by email, sort of a cold email, and we started emailing and talking and like two strange lovers, we sort of sort of figured out 'Oh, my goodness, we have a lot in common'. And I think, you know, we have similar families. And similar Marriages and children. And also we have sort of similar viewpoints, but we come at it from different angles. So it was it was a marriage born. And I've never met Jason. So it even makes him more interesting. And we've only we've only collaborated by by email and in the occasional zoom.

Jason Adler MD:

So if that's true story, it was it was a cold email. I've spent the past several years working in emergency medicine. But I'm also very much involved in practice management industry trends, actually have a reimbursement background with the coding side that will really put you to sleep right away. But in that world, I've noticed these trends and Tom's articles really resonated with me. He was talking about the increase - specific to emergency medicine - the increase in graduates that were coming out through residency, and looking at the bigger picture bringing in the reimbursement and the practice management side, the general trend that I've been noticing is that reimbursements are dropping. On the commercial side, you've got surprise medical billing, you've got some bad payer behavior. On the public side, you have Medicare cuts that seem to be happening more and more. The states, especially with COVID, we're dropping are kind of dropping the Medicaid budgets, usually one of the top three line items of every state. And at the same time that's happening, you have a workforce of clinicians, an increased number of emergency physicians, and also nurse practitioners and all these things are coming together. It's dropping reimbursements dropping pay and increasing number of clinicians, and we were talking about the contraction of the industry within emergency medicine. So different perspectives for Tom and myself, but it sort of paints different pieces of a larger chessboard.

Niran Al-Agba MD:

You know, it's interesting, talking about the contraction of the field. And the only reason you know, my father, started in practice in 1971. And there was no emergency medicine. And so if you get a group of older doctors together, they used to talk about how they each were assigned a night to work the, quote, emergencies that came in, it wasn't even the, quote, emergency room. It was simply this idea that if I cover your patients, then I then on the nights, I'm not here, you'll cover mine. And it's this sort of quid pro quo. And he had talked about this patient with a heart attack that came in and he had done radiology, Family Medicine and Pediatrics, actually, in his total training. And he sort of was chuckling later, when he had to call someone for help. He said, Look, I can't be alone in the emergency room anymore. As a pediatrician, it makes no sense. I need somebody who has experienced for when the heart attacks come in. And so what I find fascinating is he witnessed the expansion and the need for well trained emergency physicians. So I was wondering beyond funding, which I completely agree as part of the problem. Do you think it's that people think it's easy? Do you think that other physicians, I mean, I think most physicians respect emergency medicine, but what is it that's leading to this shrinking of your profession after we've witnessed an expansion 50 or 40 years ago?

Thomas Cook MD:

I probably should clarify earlier, in my in my real life, I'm a residency director. I've been running the same residency for 20 years and had over 200 residents for 20 years. When people ask me the question, 'do your graduates get jobs?' It's it's like, yes, it's a no brainer. It's very easy. It has been a feast for us for the 30 years of the specialty in which there's been very, very high demand and not enough supply. And even the Institute of Medicine back 15 years ago put out this very blatant statement in their report, which says 'we'll never get there,' was basically what they said. And this is detailed by Bennett's paper which came out in Annals of Emergency Medicine this past December. But just recently, we had the same group of people looking at this and saying, 'Oh, we're going to hit this in the next 10 years, supply will exceed demand.' And then just recently, another paper comes out and says,'whoops, we're there. Supply is going to meet demand.' And so we're in a place we've never been in our lives, my 13 residents per class, and 12 of them have gotten jobs, but it has been more of a struggle, has been more of them talking to more and more employers about this, it's about them sort of going well, maybe I'll have to go to a corporate EM to go to get my job, which most of them are a little bit leery of that. And I still have one one senior resident who is still sort of not - hasn't found anything that really suits him. And this just didn't exist a few years ago. And largely is just because the huge number of EM health care providers that sort of exist now, that combined with a pandemic, which has decreased patient census across the board, and people gotten comfortable with telemedicine and talking to physicians and health care providers by zoom and so forth. The other thing that's pretty interesting, which we can maybe dive into a little bit later, if you're interested is we've just gone through a match this this annual ritual of the spring of which I've done it 20 times, it's interesting that 25% of the applicants to emergency medicine did not match. Now think about that for a second. On the one hand, you have residents graduating having a hard time getting into the profession. But still on the other side, there's an enormous interest to go into this specialty, to the point where a quarter of them one in four, get blanked on Match Day, you can see right there that this is just another added pressure to an already pressure cooker situation where people can't get jobs. And still more people are coming in, you know, through the door trying to get get this type of work.

Rebekah Bernard MD:

It is so interesting, in fact, I pulled some of the articles that you guys have written. So just to recap what you said, emergency medicine is a relatively new specialty. It was just founded 43 years ago. And as Niran pointed out, it really went through its expansion to the point where as you mentioned, the Institute of Medicine had predicted 15 years ago, they said that the supply of emergency physicians might never reach demand. But then just 10 years later, they said well, maybe we can get enough doctors in about five or 10 years. And then fast forward now to just last year, we're now supposedly the supply exceeds the demand. So you guys went through an outline some of the reasons why you thought that and you mentioned the increase in medical schools, the increase in residencies. We also talk a lot about the growth of advanced practice. Will you call them advanced practice professionals? I call them non physician practitioners in emergency departments. And can you talk a little bit about what you're seeing in that trend?

Jason Adler MD:

Yeah, I mean, hospitals like using them, there's no question about that. And they certainly have a role in the world in which we live. But at the same time, there are obviously some issues there on both sides of the fence. Right, we've talked about in our articles, we talked about some educational variances from a lack of consistency across training and some of the newer generations, you talk about public safety and reporting to the board of nursing. There's been conversations about training in the lack of standardized - one standardized system. And it seems as though some hospitals may be taking advantage of that. Because because it's a lower rate to increase the number of people on the floor per square foot of hospital space. And we don't really know what that means, in the end for the patient or for cost the healthcare system or anything else raises more questions than it does answers.

Thomas Cook MD:

I think also, if you look at our last two column, in February, we published a column based on a US News and World Report. And they were sort of bragging about it, ironically, which was the title of it was like these 10 schools will give you a Doctorate of nurse practitioner and they accept all applicants. So immediately, I am a little bit intimidated by that because my immediate thought is like well, do they accept all applicants to become nuclear engineers and to police academies and to be become airline pilots and all sorts of other things? And this is a little spooky, and when we started to investigate a look at some of these schools, what exactly they were doing. It even got more concerning where you know, some of these schools the tuition to get a doctorate of Nurse Practitioner was $1,000. And so the bar to entry was,'look apply. You'll get in and it don't cost much' and then the subsequently, well, the most concerning one was one affiliated with Purdue University where they had 500 students in a class, my goodness, how do you vet 500 people, and all of them are have the ability to practice independently? I find this amazing having interviewed over 3000 medical students, how do you vet them?

Rebekah Bernard MD:

You don't. Because that's just not possible. And then even further, how do you educate that many people? And how do you make sure that they're getting proper training, as I look at this, I start thinking about really the vicious cycle. And you guys have written quite a bit about the corporatization of medicine and the fact that a lot of these private equity firms really enjoy employing non physician practitioners, because they can pay them less. And they can maybe hire a few emergency physicians to supervise increasing numbers of them, or in some states, they can practice independently. And then what that does is increase the demand because these corporations are hiring. So now we need to graduate more students. And so then the quality of the programs decreases, and it really becomes a vicious cycle.

Thomas Cook MD:

Well, that was that was a lot of what we were talking about in our article this month, where we were actually looking at the number of states that would allow nurse practitioners to practice independently it there was a humongous movement in this late last year, when California our largest state, after years of sort of vicious battling, allowed nurse practitioners to practice independently after some period of time of what they referred to supervision. But what we pointed out was, there are 31 states right now that allow a nurse practitioner to practice independently. And that about half of those states, all you need is to graduate from school. This is a two year curriculum, it might be entirely online, there's there's no accreditation process like ACGME, there's there's no way to sort of validate what clinical experience they've had. And they don't take USMLE exams 123 They don't take MCAT they don't have to compete with all those other smarty pants undergraduate students to get into medical school. And oh, by the way, if they don't like what they're doing today, tomorrow, they can decide to be in nephrology or cardiology, or pediatrics or anything else, a physician doesn't have that luxury. In fact, when we graduate in every state that I'm aware of, you have to finish at at least a three year residency to practice independently. Nurse practitioners don't this, this is incredible. How did we get to this place?

Niran Al-Agba MD:

Well, that's the question. And I was going to ask, since you're part of education, you know, number one, how did we get to this place? And now what do we do? I mean, especially in emergency medicine, you know, there aren't really emergency trained nurse practitioners that there are some acute care nurse practitioners, I understand that. But as far as to work in an emergency room, unsupervised and alone, and I would extend that to even urgent cares. I mean, how did this happen? When what do we do about it? Because it's exploding?

Thomas Cook MD:

Well, we get a lot of people who write to us and you know, say the same thing, you know, sort of it's'what what are we going to do' the collective way. And a lot of people are looking at ACGME to control it. ACGME being the Accreditation Council for Graduate Medical Education, which oversees all postgraduate education and states. And my conversations with leadership there are, 'look, we're just an accrediting body, we we just set the standards, we can't police who who creates a residency who doesn't create a residency and those kinds of things.' And so there was an explosion. I mean, it's not just corporatization terms of getting NPPs, its corporatization in terms of hire, and train and retain is their motto. And so they want to get as many emergency physicians as possible in their pipeline, irrespective of the fact that they're also at the same time going to be putting a APPs in those positions. Where do all the graduates go, I mean, the average debt burden for for medical students these days is about a quarter million dollars. That's a house for crying out loud. Do these guys care about that? Doubt it.

Rebekah Bernard MD:

And as you pointed out, a lot of medical students did not match I when I looked at the numbers for this year, this last match, it seemed to me like about 4000 medical students, and of those at least 2000 of them were united states seniors. So there's supposedly a physician shortage that we need all these APs. So what about these two to 4000? Physicians, potential physicians that now don't have a residency spot,

Jason Adler MD:

you just hit the nail on the head, you talk about time, effort and work for years, assuming debt, putting in putting in the time and then what do you do when you when you don't match? It's crushing to the soul to know that there's so many people out there that just don't have that opportunity, and now would have to find a gap year or something else to just you're assuming all this debt anyway. I mean, I just can't imagine what that must feel like. And there's so many slices to this, this giant picture here and we're focusing a little ones here. And there. I just, I just keep thinking about the patient and emergency medicine, how it's changed over the years. We have the silver tsunami with 10 plus thousand people joining Medicare the program per day. These patients are medically complex, more so than they ever have been in the past. You have urgent care and retail clinics that are just siphoning off the low acuity patients, and really just leaving the sickest of the sick, they're coming in to the emergency departments. And, you know, you see a geriatric patient with a weakened disease, that's not something you can just halo-in out of an online program and just manage, it's just that takes, there's a lot of time and a lot of effort and experience to get to that point. And it makes me a little bit, my my senses go up, when you have the potential for a very different type of experienced clinician to be taking care of these patients, think about your family members, and what you would want for them and what you know, from the inside looking out, I work alongside nurse practitioners in my current job, I worked alongside PAs and my old job and all, in my personal experience, I found them, everyone I've worked with has been outstanding was in that five to 10 plus years of experience block, really high quality care, and really thoughtful with the medical decision making. There is in the newer generation, I think there is because of these training programs, the way that they've accelerated so fast, there's more variation in what is being pushed out. And with that, absent some kind of formalized process of credentialing. Like on the like the boards right, you have a national board and individual state rules, you really don't know what you're working with, when you make that hiring. You know, Tom just talked about 13 residents a year for 20 years. And then one program this year pushed out 500 People with one program, that's that's vastly different. So the question is, what does that mean? What does it what does it mean to the - I know what it means the hospitals, right? I know what it means to people who have the opportunity to make a good living assuming that role? What does it mean for the patients? What does it mean to the cost of the health care system, right. And it's interesting, because my friends that are nurse practitioners, and very experienced, I asked them what they think of all of this. And when you really dive into it, and they really look back, they're not, they're not very happy to see where the industry is going. There's a little bit of resentment, and just the small cohort that I spoke with just my friends, because they put their time in, and they went through, put a lot of time in years to get to where they are today. And then you work with someone like that. And then you work with someone who just graduated and right next to you, and everyone has the same exact defined role in the department. And you talk about how sick these patients are. It's lots of moving parts.

Rebekah Bernard MD:

Yeah, and we definitely hear from a lot of those nurse practitioners and physician assistants who trained in a different generation about how things have changed now. And I guess this is probably where now we're coming up with this new concept of, quote, residency programs. For non physician practitioners, I have to put it in quotes because you guys know residency for physicians is a very different beast from what we're seeing for these non physician practitioners tell us what you know about these new residency programs in emergency medicine.

Thomas Cook MD:

Oh, this, this is a total hot potato topic. So this past match cycle, and I'm not familiar with the with the dark web, and all these sorts of things that go on, obviously, the generation of residents day, these young adults are much more facile at social media. And I'm I'm leery of the trouble you can get into in this. But there were a couple of very prominent university programs, who behind the program directors back had started when essentially were emergency medicine. And I use the quotation 'residencies' for advanced practice providers. I think in these cases, I remember where physician assistants, and the word went out like a wildfire in which everybody said'boycott these programs do not go there.'And so you really just sort of see this grassroots effort on the part of the residents, it's just to say,'what are you doing? You are screwing us big time, because here I have killed myself as an undergraduate. I've paid a lot of money to go through a very tough medical school, and you're giving them residency training, which by the way, lasts a year and mine is three years. What are you doing? This is craziness.' And you know, I think about my my residency, we are one of the programs that allows them to moonlight we have a very, what we consider a safe moonlighting opportunity for and I know they've been working for two years in residency and four years of medical school, and they're still nervous to go out there for the first time, you know, and hear you have this other situation where they're going 'oh Yeah, just you know, go see a patient figure something out.; It's incredible. The bar is sinking so fast. And we're just trying to figure out how to find somebody who can just eek over the bar and fill that time slot. And they just don't know what they don't know.

Jason Adler MD:

Yeah, you're talking about nomenclature. And that's the core of it is what what is used and how do you represent yourself and, you know, in 2021, there's a lot of that going on and how people define themselves but to Tom's point, and Rebekah and Niran, the word residency means something. The word fellowship means something. The word Doctor means something. And when you apply that in something that when people hear It isn't - like I think when it's said out loud outwards, it's oftentimes projected in a way that the person who's listening, here's a doctor, nurse practitioner, I know that Florida just passed a law like 1152. In the Senate, there was about the 'ologists' bill, right is where nurse anesthetist cannot call themselves nurses and anesthesiologists, because those words matter. We keep talking about words that matter. So saying that your residency trained, has a traditional definition and implication to what you're saying residency training is? So it's, it could be a truth. If you go through one of these programs to say,'No, I'm a residency trained emergency medicine specialist, nurse practitioner,' that may be a true statement. I'm not sure if that the general public would understand that to mean the same thing as I'm a board certified emergency physician.

Rebekah Bernard MD:

I would say not. Patients will not understand that, I'm pretty sure and we can speak about the case of Alexus Ochoa, who was who met a person in a white coat, and was under the impression that it was an emergency physician, of course, it was a family nurse practitioner, but the patient didn't know better. And if they had known differently, maybe they would have sought other care, I don't know. But that transparency is important. A physician residency, at least in my day was 80 to 100 hour work weeks for minimum of three years. And I believe that these residency quote programs for non physician practitioners are like 40 hour work weeks for a year or five days a week, weekends off that kind of thing. So there are no way the same kind of level of responsibility, or intensity is what physicians go through.

Jason Adler MD:

You know what, I don't want that. I don't want that for me. I could tell you, you know, I've never seen my residency was too easy. I had a hard residency, and I'm so thankful for that every single day, I really mean that. I had some grueling months. I'm sure everyone on this call hasn't grueling, grueling months. And that's what that's where you earn your chops. And not to say people have to suffer - not saying that at all. But you're, it's not the age, it's the mileage, and you earn a lot of mileage in those three years of training. And then you're ready to go out, and then you're terrified. And then you go through five years, like, I think I got this, and then you get a little confident and next five years, you're terrified again, it's because of your experience and what you know, I just can't imagine, again, going through quick online programming that haloing down to emergency departments. Saying, here are the keys of the kingdom, go for it.

Niran Al-Agba MD:

Well, I love that. That's what you're talking about, because I'm old enough that I trained actually, Rebekah is the same. And you know, we trained under the old system when there were no limit hours. And so, you know, we put in a boatload of hours. And I remember covering, you know, 70 children at the Children's Hospital, you know, every night on call, and there were always codes and there weren't even enough ICU people to go around. I mean, again, these were it was like trial by fire. And I think that is so so important. And now we sort of have this idea that if you want to be a rural Doc, you go work somewhere rural in residency, and I would disagree with that, because I was just talking to a med student about this. And I said, you know, I did a month on the helicopter in Colorado, I landed on people's lawns, I did all sorts of procedures on adults even and it was so valuable to think outside the box and to win and to lose and like you said to get slapped in the face over and over, because that's what medicine is about. And I'm afraid that some of these folks come out, like you said, and they're not adequately afraid. I mean, residency should make you afraid. It should make you strong, but it should, it should make you realize that there are going to be a lot of face plants. And I think that's what's missing, to be honest. And one year residency can't compare to the three years we did.

Rebekah Bernard MD:

But it seems like a lot of these academic centers are interested in these residency programs and this appropriation of nomenclature, as you mentioned, but we are seeing some academic emergency physicians pushing back, you guys are really leading the way. And your professional organizations actually recently signed a joint statement saying that, quote, '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 and that physicians must lead patient care teams and training.' So I personally want to thank you guys for standing up because many of our other professional organizations are kind of hanging back a little bit on that. And then I'll just point out that course after the American Association of Emergency Physicians put out that statement. Then there was of course, a rebuttal by the Emergency Nurses Association and the American Association of nurse practitioners. They published a joint statement and they refuted that position stating, quote, 'our national organizations strongly oppose the view that emergency care is solely, quote, physician-led or that physicians should dictate education and practice standards for advanced practice registered nurses,' which I think is so interesting because we're always hearing about we need to be a team we need to work together and they're making it very clear. We don't need physicians. physicians don't need to lead the care team and in fact, you guys should have nothing to do with our training. What are your thoughts when you hear that?

Thomas Cook MD:

Yeah, those those two statements we put in one of our articles and I think could just see the nurse practitioners effectively sticking their tongues at us and saying we're going to do what we want. And when you think about it, they've got a reason to say that because they're not afraid. They're regulated on the state level, not by anybody but other nurses. They're not regulated by physicians who are, you would have to say, are acknowledged as the experts in medical health care. They're managed or regulated rather by other nurses who, of course, are going to champion whatever it is that they want to accomplish. And yeah, it's a conflict of interest. It's a horrible conflict of interest.

Rebekah Bernard MD:

And we should point out that they're not held to the same standard of care as physicians when it comes to a medical malpractice case. And I think that's something important for patients to realize.

Jason Adler MD:

It's so complicated, it's so complicated. There's so many layers, it's easy to outline some of these problems and different areas of uncertainty. But I always go back to what what are the solutions, what we propose here, I think, from my perspective, having some form of governing body that's national, right, similar to the American Board of Emergency Medicine, similar to the American Academy of Pediatrics, that requires some form, required curriculum, at least to start that, and then you take a standardized exam, I, I'm not a big fan of exams, right, they've got their problems, but something that levels the playing field, so that there's less variation from clinician to clinician, that's, that's, I think, one of the first steps, then the state's gonna have their role in governing what how much independent practice you have, but at least there's a standardized process, floor and ceiling of education that we all start with on day one, too, I'm not really sure what to make of the governing body that you report to being the Board of Nursing, how they regulate the practice independent practice of medicine, from the Board of Nursing. I'm not sure how that works. I know there are issues in California, with some form of potential what is the issues, but there was that experience didn't work out too well, that strikes me is really unusual. And then some form of continuing maintenance of certification, right, you want to have some standardized process, and maybe even specialty specialty board certification, specialty exams, I think that would be interesting as well. So that that would be my proposal as a top three, three things of what we could do to advance because it really is a team sport. I think that macro economics are not going to change. We can be an old man yelling at the clouds forever. But there's there's some challenges here. There's some real challenges. And money is a driver of many things for the healthcare systems, for the groups for everybody involved, and how do we work better as a team? I do think in the future, we're going to have you know, we've got a CMO you got to see I know, you're probably a Chief Nurse Practitioner officer, I see that coming down the pike. I wouldn't be surprised there. And right now, where are they? They're either flipping between the medical side or the nursing side, they don't really have a home. I think we could all be one big team all work together in a physician led environment and go there. I'm not this us versus them thing is kind of go away. But I think that's a result of the lack of any formalized process to have that conversation.

Rebekah Bernard MD:

Well, thank you so much. I want to thank our guest, Dr. Thomas Cook and Dr. Jason Adler, for helping to enlighten us as to some of the issues that are happening in emergency medicine today. If you'd like to learn more about these issues, we encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and Barnes and Noble. And of course, we would love for you to subscribe to our podcast and to our YouTube channel. It's called patients at risk. And if you're a physician and you'd like to learn more about helping out with this topic and helping endorse physician led care, please join us physicians for patient protection.org Thanks so much and we'll see you on the next podcast.