Advanced practice providers (APPs) are increasingly used in medicine today. When I talk with a provider on the phone, half the time I don’t know if I’m talking to a physician, physician assistant (PA), or nurse practitioner (NP). Go to any emergency department and there’s a good chance you’ll be treated by an APP. Primary care offices, urgent care clinics, and dermatologist offices all use APPs. Now there is a push for APPs to be able to practice independently, without any physician oversight. Will APPs take over, replacing physicians in emergency departments and elsewhere? Do APPs fit the definition of disruptive innovation?
Disruptive innovation is a term coined by Harvard Business School professor Clayton Christensen. As the theory goes, industry leaders overlook the needs of customers for simpler, cheaper alternatives. New entrants into the market address that need, first taking over low-end, low-profit businesses, but working their way up the food chain to eventually compete with and take over the market. Think Wikipedia; When was the last time you saw an Encyclopedia Britannica?
Training to become a physician is long and arduous: four years of medical school after getting an undergraduate degree, followed by residency training that is usually a minimum of three years and can be much longer depending on one’s specialty. Although a bachelor’s degree is not required to become an APP, programs are highly competitive and it’s difficult to get into a program without one. Typically, PAs and NPs have two years of education after college. There is no requirement for internship or residency training, although NPs are required to have experience as registered nurses. Does one really need four years of college, plus four years of medical school, plus three years or more of residency training to treat a common cold, sore throat, or sprained ankle?
In one sense, APPs represent a threat to physicians, but in another, they represent an opportunity. They can help address issues of physician shortages and access to care. I’m familiar with a large primary care practice in rural Pennsylvania where the two physicians are approaching retirement age but can’t find younger physicians to take over the practice. To continue to serve their patients, these physicians have hired several APPs, without whom they wouldn’t be able to see all of their patients. As a bonus, they are freed from mundane tasks like prescription refills and pre-authorizations. They now can focus on the things that require their expertise and training.
Is Cost Driving APP Use?
What’s driving this big push for the use of APPs is money. At a third of the cost of using physicians, the financial incentives are compelling. Entities that employ physicians and APPs see it as a way to reduce costs and increase profits. Third-party payers can and have reduced payments for patients treated by APPs—and not physicians.
The two groups that don’t benefit economically from this trend are physicians and patients. Physician salaries don’t increase when they have additional responsibility for supervising APPs and co-signing their charts. Patients don’t see their insurance premiums decreasing if they are seen by an APP. In fact, insurance premiums continue to rise every year. The U.S. spends more on healthcare than any other country in the world and doesn’t have the outcomes to show for it. Reducing costs is the name of the game these days. And it makes sense: Why pay a physician to suture a simple laceration or treat a patient for strep throat when a PA or NP can do it just as well? Even if an APP sees fewer patients per hour, three times the cost is a lot of ground to make up if you’re a physician.
The Use of APPs in EDs
APPs have been used for years in emergency departments, initially to treat simple, low-acuity conditions like sprained ankles, sore throats, and lacerations. Increasingly, APPs are being used to treat more complicated patients. In many emergency departments that I’ve seen, half of all medical provider hours are now covered by APPs instead of physicians. In some rural, critical-access hospitals with severe physician shortages, emergency departments are entirely staffed by APPs with telemedicine backup.
I have worked with several very good physician assistants and nurse practitioners. Sometimes they are as good as physicians. In fact, an APP can do nearly any procedure in an emergency department just as well as a physician. Even advanced skills like lumbar punctures, intubations, or central lines can be performed very competently by APPs. What I hear from my colleagues is that while they really enjoy working with some APPs, their training and experience vary, they see patients with complexity beyond their skill level, and are treating and discharging patients with little oversight. Physicians can’t see every APP’s patients because they have their own patients, they may be supervising more than one advanced practice provider, and there simply isn’t enough time to do both.
You Don’t Know What You Don’t Know
You would never hire a newly graduated medical student and let him or her work in an emergency department. Even if you wanted to, medical licensing requires at least 12 months of an approved internship: 12 months of working in a hospital under supervision, likely working 80 hours per week, or 4,000 hours before one gets a medical license. But that’s exactly what we do with new grad APPs. Someone who has two years less education than a medical student, with little orientation, gets cut loose to see patients in an emergency department.
I have seen some PAs or NPs get as little as two or three orientation shifts before being put on the schedule, although they typically are put in the fast-track area, seeing so-called low-acuity patients. But you don’t know what you don’t know. How do you know if that patient with back pain is just one of the many with typical musculoskeletal strain or something more serious, like a cord compression or epidural hematoma?
Helping APPs Gain Necessary Skills
When I was a medical student, a senior surgeon who had returned from missionary work spoke about a surgical clinic that he visited in Africa. The clinic ran a surgical schedule that rivaled many American hospitals and with equally good outcomes. When he asked how the two surgeons were able to perform so many cases, he learned that the surgeons trained young men and women with great dexterity and an eagerness to learn how to perform specific surgical procedures. Once the surgeons were confident that these operating assistants were competent to perform surgery on their own, they were given their own cases to perform. The surgeons were always available to intercede should a problem arise. One of the surgeons explained that the critical differences between the assistants and surgeons were the surgeons’ abilities to perform pre-op evaluations, decide if surgery was indicated, handle the unexpected during the procedure, and provide post-operative care—skills gained over years of training and experience.
When I was the medical director of a high-volume, high-acuity urban emergency department, APPs worked in both the fast track (low acuity) and the main area. I had great success in hiring smart, highly motivated new APPs. I made sure to:
Require an extended on-the-job training program
Give progressive responsibility as their skills and experience increased
Ensure appropriate physician supervision and backup relative to each providers’ skill level
After a year, they functioned at a very high level, probably 75 to 80 percent of a physician’s level of skill. These providers could identify the sick from the not sick, knew when something was amiss, and knew when to get help—critical decision-making skills necessary for any good clinician.
Decrease Disruption by Better Defining Standards of Practice
Are APPs a disruptive innovation? Will they follow the theory of disruptive innovation and replace physicians? The truth is, I don’t know. Unfortunately, I think the market will make these determinations. Even in healthcare, our capitalist society will continue to push for lower costs and higher profits—a goal tempered only by the threat of malpractice losses. That, I know, is not in the best interests of our patients.
To paraphrase the late, great Johnny Cash, “I hear this train a-comin’. It’s comin’ ‘round the bend.” The push for APPs is already here. I’m aware of some physician practices that no longer use APPs in the emergency department, claiming that patient acuity is too high. Perhaps they are correct, but I fear that they will get run over by this train. The cost difference between APPs and physicians is too great to ignore.
The real question is: “What is the most cost-effective care that ensures the safety of our patients?” Each medical specialty needs to have an open and frank discussion about what constitutes appropriate training and supervision and the rules of patient engagement. Who gets to do what, when, where, and how? What’s the appropriate mix of APP and physician coverage? Who better than us, as physicians, to determine these standards? We owe this to ourselves and to our patients.
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