amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News

Nurse practitioners and physician assistants account for at least 10% of outpatient visits and increasingly are being used to handle patient care in emergency departments, according to previous research. 

But a new survey said 80% of patients expect to see a physician when they come to the ED. Fewer than half would be willing to see an NP or PA for an ankle injury — they would rather wait two more hours to be cared for by a physician.

via amednews: Most ED patients willing to wait longer to avoid nondoctor care :: Aug. 30, 2010 … American Medical News.

For the record, if I went to the ED with a straightforward, well defined problem I’d just as soon see a PA/NP if it’s quicker.  (And, per the article, I’d like to know who’s seeing me and my problem).

Also for the record, my ED doesn’t utilize midlevels at all, so my knowledge of working with them is from my residency and my prior job, over 8 years ago.

Nearly every discussion I have with colleagues from other departments has a time when they are surprised we don’t have midlevels, and tell me the benefits, which boils down to either a) ‘they make us money’ or b) they do all our procedures, so they’re better at them than we are.

I find ‘a’ objectionable, but that’s just me.  ‘B’ is somewhat more defensible as it at least implies an increased level of patient care, but at the cost of a physician voluntarily relinquishing skills, then using that lack of practice as evidence of the superiority of others.  This has a rather obvious answer, which I’m too polite to point out to them.

I’m not saying there are no roles for midlevels in some ED’s, but I have yet to hear a compelling argument for them from a patient care aspect.

So, school me BUT do it without denigrating anyone else.


  1. nurse 1961 says:

    Midlevels, NP and CNS specifically would be an asset at our triage. They could weed out those that don’t need to be there at all and could see, treat, and discharge those that have minor problems.

    I think that midlevels that have worked in our department, then return to school for their NP/CNS, and are given the chance would make our LOS shorter, and would be that second pair of hands and could keep the Track moving especially from 4AM though 9AM when we seem to have the longest waits.

    Is it because I will be there in less than a year? Maybe, but I see a bigger picture where the MD sometimes has tunnel vision.

  2. I keep reading that EDs are clogged by people with flu, sprains, strains, STDs, and other minor or nonemergent injuries and illnesses. Seems to me that midlevels could treat and discharge these as well as quickly assessing and triaging more serious cases, thereby reducing waiting times for emergent cases.

  3. We use midlevels, PAs to be specific. We started using them because of economic reasons. They are cheaper to staff and they can see really profitable patients. (Don’t blame me — I didn’t make the payment rules — but fast track patients are our profit center. They subsidize the tricky/risky/undercompensated seriously ill patients.)

    All things being equal I would staff all physicians if I were creating a new group from the ground up. As it is, we have good people working for us and they do a good job within a clearly and narrowly defined scope of practice.

    I would not disparage the “make money” element, though. There are not enough ER docs out there to staff all the ER positions. Recruiting is not easy for many economically marginal groups. If a group can improve the compensation for their docs by using MLPs and thereby present a more competitive face to prospective physician employees, that makes sense. Now the wealthy boutique groups that use PAs to boost already lucrative MD salaries, well, that’s less defensible. But in my limited experience, the boutique groups are the least likely to use MLPs. Maybe it’s because they have no trouble recruiting, maybe it’s because their clients demand MD treatment, or both.

  4. doc Russia says:

    How about they turn that question around and ask patients whether they would rather wait twice as long, pay twice as much, or see a PA.
    I think that this is yet another manifestation of the disconnect between what things actually cost in terms of resources consumed, and what patients are paying.
    I work in a large, urban ED, the majority of whose patients do not pay anything, nor have they any intention of doing so. They already accept very long wait times, but since many are unemployed, they are not missing work. So, the marginal cost to them of waiting 8 hours or waiting 10 hours is negligible (I am assuming that they are low acuity to be candidates for midlevel care, and thus, have longer wait times). For them, it is simply a matter of whether a doctor sees them or not.
    I am willing to bet dollars to donuts that if you were to give them a $20 bill and offer them to either be seen in 10 minutes by a PA or give the $20 back and be seen by a doctor in 10 minutes, they would keep the twenty.

    I totally agree that justifying the use of midlevel coverage by them being more adroit at procedures says a lot more about the ineptitude of the physician than the usefulness of the PA.

  5. penguinman000 says:

    You cannot divorce the fiscal aspect from the physician extender equation. The majority of the argument for physician extenders is fiscal. For significantly less $$ and time you can employ a PA to care for the large number of patients who come into most ERs for non-emergent/easily treated/diagnosed issues. It costs less to train a PA. PAs make less (on average) than a physician. A PA can complete all necessary schooling in 5-6 years and enter into his/her field fully trained. A physician takes a decade + to be fully trained for their specialty. The fiscal compenet is a serious issue in all medical faciliities, as I’m sure you are well aware of. It sounds as if you are in a fairly lucky situation where you have enough physicians to go around.

    An ankle sprain dosen’t require a physician. A simple laceration dosen’t require a physician. A properly used physician extender is a force mulitiplier. This allows the physician’s skill set to be utlized on patients that actually need a physician instead of a whole day of seeing back and ankle sprains (remember working in a Marine unit, how much did your skills atrophy seeing the same 10 complaints for 2-3 years?).

    If a physician is allowing his/her skills to atrophy out of laziness (“they do all our procedures, so they’re better at them than we are.”), this is the fault of the physician. Not the fault of the physician extenders or administration. It’s important that providers in all shapes and forms keep their skills current and continue to expand their knowledge base. If a provider does not desire to put in the effort needed to do that then perhaps a career change is warranted…

    A PA is not to be confused with a physician anymore than a nurse is. There are times when it is approriate that only a physician treat a patient (too numerous to list) but there are other times when it would also be approriate to have a physician extender treat a patient in lieu of a physician. The reality is physicians are a finite asset in this country and that isn’t going to change in the near future (unless Obamacare really is some magical fix…). A properly trained and maintained PA is capable of providing equivalent standard of care (as a physician) for simple straight forward disease/injury and can identify when a patient needs the services of a physician. They can be the eyes, ears and hands for a physician (still going with the extension metaphor). Physican extenders have a place and when properly utilized they are a benefit to both the medical facility and the patient.

  6. I’ve spent quite a bit of the active portion of my life in a situation where care was exclusively provided by “mid level providers” aka independent duty corpsman. This was in a population that was young, healthy, and who had been carefully screened for co-morbidities. In that situation it worked well.

    I’m now twice the age I was then, and the situation is much different. My last “screening exam” was something like ten years ago. Even a seeming straight forward “slip-fall” injury might be complicated by co-morbities of which I am completely unaware. The deeper education of the MD provides a greater oportunity for other problems to be discovered and treated.

    For the true elderly, this is particularly true. Detailed examination and evaluation by an MD is greatly prefered. For procedures, I have no problem being referred to the most skilled in the ED, regardless of the ending letters on the name badge.

    Ideally, the mid-level will pass off any case of high concern, or ask for backup. It would have to be a very slow paced ED for this to happen in practice.

  7. Jim in Plano says:

    Anecdotally, I prefer my PA to my doctor. Not that he’s worse than the PA but he seems to be more rushed and the PA takes longer with an exam.

    And my doctor (I’m probably going to start another argument here) seems to be…less familiar with computers than either of his PA. He struggles to find a test, or can’t even find it at all while the Pas seem to be more computer literate.

    As I said, anecdotally.

  8. Gotta agree with you, Jim In Plano!
    Also, on a slightly different note, if you need an IV or intubation while in the ED, beg, plead or bribe for a Paramedic to start it. They’ll get it first time, every time.

  9. Jim in Plano says:

    Maybe GD can comment on how it was in the USMC, in the USAF if you had to get stitches then you wanted the ER medtech to sew you up. About the only USAF physician I would consider would have been a honest-to-gawd surgeon.

  10. how about this – i don’t care about titles or schooling or training but i definitely prefer somebody who’s smart and thorough.

    gotta love the unrealistic expectations the general public has of any group of professionals.