American Academy of Emergency Medicine

Why Don’t EM Physicians Reproduce

Thank you for writing in Common Sense. I wonder why you say, “Are we ready to eliminate mid-level practitioners from the ED?” I am also wondering if you have read Dr. Walker’s “From the Editor’s Desk” article in the same issue of Common Sense. His article, about the percentages of patients with minor problems coming to EDs, would support more mid-level practitioners in EDs and not less. Certainly I am unaware of a move to eliminate mid-levels from EDs. Why do you want to do this? Your article does not make a case for such.

Are there plenty of ED patients who could be seen by mid-level practitioners? Are mid-level practitioners working with EPs cheaper than more EPs? Are there plenty of locations that have difficulty attracting EPs? I say we need to train more mid-level practitioners. I prefer that an ED with low acuity patients have several mid-levels and one or two EPs. I prefer that the mid-levels be directed by an EP. However, in the current state of ED staffing there are not even enough EPs to supervise the mid-levels in many EDs. We don’t need to eliminate the mid-levels but do need more EPs working with mid-levels.

In Colorado we still have EDs run by family practitioners turned ED docs. We have plenty of mid-levels in the EDs. Some places have family docs supervising mid-levels in the ED. Some places have an EP on call to the ED while the mid-level sees the patients. The EP comes in when called by the mid-level or when it gets so busy that the mid-level is falling behind. None of the above situations would support complete EM trained coverage. The system and the patients don’t need it. The cost would be extreme. And I don’t believe that patient care is suffering. Do you have evidence to the contrary? I just can’t see why we would do this.

— Anthony DeMond, MD MAAEM FAAEM

Thank you for your letter. As you mentioned, Dr. Walker’s column in the same issue may have pointed us in the right direction, or at least asked another interesting question. As you, I am unaware of any move to eliminate mid-levels from the ED and in fact I would not support such a move. I stated, “Emergency care provided by non-physicians is not expert care.” This is my opinion and I will always believe it, otherwise, I am not sure why I have been studying and working so hard for the last 15 years of my life. This statement does not mean that non-physicians have no role in an ED or cannot provide expert care in an ED. I asked the questions I did in an attempt to generate discussion on solutions to the problem of not enough EM trained physicians.

I agree that mid-levels will likely play a role in providing patients expert care. However, I strongly feel that the most complicated and dangerous patient is the undifferentiated patient, i.e. the emergency medicine patient. Dr. Walker correctly points out that not only do many of our patients not have an emergent medical condition, but that many of them do not even present as undifferentiated patients. I propose that these patients do not need expert emergency care. An effective model to deal with this reality could be similar to what you suggest: a team of highly qualified nurses and mid-levels working with a single similarly qualified EP. This group could likely provide expert emergency care to double, triple, or quadruple the number of patients cared for by one EP now. However, I see many obstacles in the way of making this a reality, not least of which is the current onerous, ineffective, and inefficient documentation standards and processes.

— The Assistant Editor


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