By Andrew Phillips, MD, MEd

Patients depend on physicians’ expertise when they are sick or injured. However, over the past 10-15 years, there has been a trend towards emergency department staffing with nurse practitioners and physician assistants (NPs and PAs). Although the perspectives of administrators and NPs & PAs have been sought, no one has previously studied and published the perspectives of physician residents who were training in the context of this notable workforce change.

A study published last month of a national sample of emergency medicine residents yielded concerning results. A majority of residents reported that NPs and PAs in the emergency department detracted from their education and that they did not trust local or national authorities to resolve concerns and ensure their education. Additionally, academic centers are increasingly offering postgraduate education to NPs and PAs (structured but not accredited education after completing an NP or PA degree). Residents at such programs forfeited 14x as many procedures to NPs and PAs compared to residents at programs that did not have a postgraduate program for NPs and PAs.

It was also concerning to find that in dichotomous open-ended questions, asking the ways in which NPs and PAs in the emergency department enhance and detract education, two-thirds of residents replied in the enhancement question that there was not a single enhancement they could report.

To be sure, it is a complex issue since all stakeholders need to be sufficiently educated to perform their jobs well. For all survey items, some residents, although few, reported positive aspects of NPs and PAs in the emergency department, suggesting that in some locations a balance has been struck.

This study was a survey and sought the perspectives of individuals. Much more needs to be done with empiric evidence, now that these important stakeholders have representation in the literature. The study should raise concern amongst educators and credentialing bodies and prompt much further study, since it raises many more questions than it answers. What is perhaps most telling by the situation is that all other stakeholders’ opinions had been previously addressed. For decades we’ve seen a rise in workforce changes, and no one asked the residents who were depending on these programs for their education. We must place greater priority on our next generation of emergency physicians.