Mid-level Practitioners* in the Emergency Department

There is an ever-increasing presence of mid-level practitioners (MLPs) in the emergency departments (EDs) of US hospitals.  According to the standard model, as described by those who use it, these practitioners are supervised by a physician specializing in emergency medicine, typically one who has trained in, and is board certified, in the specialty.  Emergency physicians are not paid extra for supervising MLPs; it’s just part of the job. The rationale for employing midlevels is that they can safely see some patients whose problems appear to be less serious, freeing the emergency physicians to devote more time to those patients whose cases are more complex and those who are more severely ill or injured.

It is typically the judgment of the ED triage nurse that determines which patients are appropriate for an MLP to see.

It seems even more reasonable when you consider that in most EDs a patient who insists on being seen only by a physician and not by an MLP will be accommodated, albeit often with a longer wait.  And should the triage nurse’s judgment prove to be off-target – meaning the patient is actually more seriously ill or injured or more complicated than the nurse thought – the MLP has a doctor’s supervision as a “fail-safe.” 

Some do a lot of supervision and teaching; others do as little as possible. If a physician gets a productivity bonus, doing a lot of supervision and teaching torpedoes that part of his or her compensation.  If that isn’t the arrangement, the doc merely looks bad: doing a lot of supervision and teaching means the doctor sees fewer patients, and those stats are being tracked and reported, and the doc looks like a lazy, no-account ne’er-do-well. Some of that happens in real time, too, as the emergency nurses may not notice all the supervision and teaching of the midlevels, noticing only that the physician isn’t moving as many patients, and they form a negative opinion of the doc’s work ethic.

I have worked in academic medical centers with emergency medicine (EM) residents.  You know what I did there?

It was almost all case presentations to me by the residents, case discussions, and seeing the patients with them to review the most important elements of the history and exam. The case discussions focused on critical elements of the patient’s presentation and medical history; important findings on physical examination; the rational approach to diagnostic testing; the diagnostic reasoning that leads to a conclusion about what is wrong with the patient; and a plan for management, including “disposition” – sending the patient home or admitting the patient to the hospital for further evaluation and treatment.  The residents did the charting, as well as the discharge instructions or communication with the admitting service.  All I had to write was a supervisory note.

When you consider the comprehensive nature of that supervision of EM residents, it is important to understand that even a brand new resident – one who is on his or her first rotation in the ED in July, having received a medical school diploma just a few weeks earlier – has already had far more clinical experience than many MLPs who are hired to work in the ED. 

When I work with midlevels, I have my own patient load, and all the supervision – which, ideally, should be similar in nature and the time involved to what I do with residents – is on top of that.  Yes, that is insane and completely impossible.  So what happens?  The supervision and teaching of midlevels tends to range from token to nil.  Think about that. 

That is true even when the EM resident is a mere month from graduation and becoming an attending.

That might be okay if a midlevel is seeing only patients with colds and sprained ankles – in other words, patients who may not actually need professional health care at all. Or it might be okay if all the midlevels went through excellent educational and training programs that include robust EM-specific training. But neither of those scenarios matches the reality of the vast majority of US emergency departments. This is lunacy. There is just no other way to describe it.

–The writer is a board-certified emergency physician who has practiced the specialty for 35 years.  He has worked in both academic and community hospital settings and has trained many residents in his specialty.  When working with mid-level practitioners he has provided the degree of supervision he believes they require whenever possible – and deeply regrets that he and many of his colleagues often work under conditions that make adequate supervision of MLPs quite impossible.

*The term “mid-level practitioners” is one of several that have been used to describe a category of health care professionals involved in direct patient care. “Mid-level” suggests they are somewhere between doctors and nurses. This is an oversimplification, as the term encompasses both physician assistants and nurse practitioners, whose education and training are different from each other and subject to significant variability within each of those groups. However, it is easy shorthand,