Welcome to 'patients at risk' a discussion of the dangers that patients face when physicians are replaced with non physician practitioners. I'm your host and the co author of the book 'patients at risk, the rise of the nurse practitioner and physician assistant in health
care' Dr. Rebekah Bernard. In January 2022, The Journal of Nursing regulation published an article entitled 'analysis of nurse practitioners educational preparation, credentialing and scope of practice in US emergency departments.' The summary was really interesting - it said, "due to the variability in educational preparation, nurse practitioners should not perform independent unsupervised care in the emergency department, regardless of state law or hospital regulations."
Now, this unequivocal statement contradicts the rhetoric from nurse practitioner leadership, which insists that nurse practitioners should be allowed to practice virtually anywhere and everywhere without supervision. So today, I'm joined by family physician Christopher Garofalo, and radiologist and PPP board member Phil Schaffer, to discuss this important paper, welcome to the show.
Thank you.
Dr Garofalo, this is your first time joining us. So introduce yourself and tell our listeners how you got interested in this article.
Thank you, Dr. Bernard, for inviting me on to the show. This is a pleasure. I've been watching these shows from afar. And it's really nice to be on and talk about this important paper. I'm a family physician in southeast part of Massachusetts, we actually are along the border of Rhode Island. And I'm in a private practice, there's nine of us all together. And I want to keep us in private practice.
I have been in advocacy for probably about a dozen years now, both at the Massachusetts state level and at the national level. But I will say that the thoughts that I have tonight, and the things that I say tonight are only my own, they don't represent any other organizations. The thing that caught my eye about this paper was one of the things we talked about with mid level nurse practitioners and physician assistants is they talk about wanting to practice at the top
of their license. Yet nobody actually talks about what top of the license means. But usually it's in the context of they want to be able to do more with less supervision. And they have gotten to where they have gotten mainly through making changes in the legislature rather than actually showing what their education entails. What caught my eye about this paper is this paper actually looks at but their education and certification is and it's a good chance to be able to talk about
that. The other thing that immediately caught my eye and I know we'll touch on this later, is that this is authored by nurse practitioners and others in the nursing profession for a long time. Now there have been back and forth between physician and mid levels about, you know, what does the literature say about being able to provide safe care, and that usually are accusations of bias against
physicians. But this one is hard to say there's accusations of bias when this is written by the nursing profession themselves.
Absolutely. Now, Dr. Phil Scaffer, you are a frequent and quite popular guest of my show. And so just remind our new listeners about your background. And also tell us what interested you about this article.
I'm a radiologist recently retired, so I do have time to pay attention to this issue. I was in academic practice for about 10 or 12 years in private practice for the remainder. So total about 40. What caught my attention was the fact that it was unique in that this topic, I know is talked about amongst a lot of nurse practitioners. I see that on social media. And there are a lot of people which who agree with the authors of this and we'll talk about the authors as Lavin et al. She's the first
author. It's rare to see it in print. The reason is that, as we have seen, as soon as someone says the emperor has no clothes, there is a cascade of people with all sorts of letters behind their names. Trying to say that 'no, the sun does rise in the West.' Really, I think the one truth they get at and I think listeners need to understand this is that the NPs have a requirement for only four or 500 hours of training. And there is no actual total requirement I
think for EM NPs. Beyond that they do do some emergency training, generally a certain number of hours, but I don't know that there's actual requirement to sit for the boards and they constantly want to tell people that their care is equivalent to and or better, and physicians who do 15,000 hours. And this makes no sense whatsoever in any human endeavor. I mean, I was better after three years than I was at six months. And I think anybody regardless of what their occupation is, can understand
this yet. They push this message in legislatures, and they get it somehow accepted. The lab and paper stands apart saying no, actually, if you don't do the training, you don't know the stuff, which is entirely unsurprising. But they are being run over the coals for this. And I've spoken to Dr. Lavin and she's, she's well able to take this criticism. She understood, I mean, she was ready for it. And her paper was very well written. And it's really hard to criticize.
Yeah, it's an amazing paper. And I just want to give our listeners a little bit of background regarding what you've mentioned, and I mentioned some of the rhetoric that we hear from nurse practitioner leadership. And Dr. Garofalo, referenced both of you referenced the legislative
efforts that have been made. And so back in 2020, the American Academy of Emergency Medicine along with a few other groups, published a joint statement regarding the use of nurse practitioners and physician assistants in the emergency
room. And they said, 'physicians must lead the care team in the emergency department.' And they called on institutions to avoid compromising or diluting the training of emergency doctors, because we're seeing all of these sort of on the job training programs that they sometimes call fellowships. And so there was a lot of concern
about that. So very quickly, the Emergency Nurses Association, American Academy of Nurse Practitioners and the acute care nurse practitioners and acute pediatric care, nurse practitioners published their own joint statement. And what they wrote was so fascinating. They said, "our national organizations strongly oppose the view that emergency care is solely 'physician led'" - in quotes - "or that physician should dictate education and practice standards for advanced
practice nurses." They go on to say their usual mantra that nurse practitioners undertake rigorous preparation through their education and clinical training. They're accredited, they pass board exams. So here we go with that we can do it and we don't need doctors, and we can be in the emergency department. And that was in
2020. And so that's one of the reasons this paper is so important, because they actually reference this publication, and Levin et al say that they support the American Academy of emergency medicines position paper, and they specifically referenced this. So it's so interesting. So we'll delve more into that. But Dr. Garofalo, can you talk a little bit to us about just some background on nurse practitioners, we know that there was a consensus model
back in 2008. And that adopted some criteria for how nurse practitioners are categorized tell us more about that.
In 2008, there was this document called the consensus model that basically came about with the input of more than 40 organizations to address regulation issues such as licensing, accreditation, certification, and education, so that there would be some sort of a standard approach to the education and licensing and certification of nurse practitioners. It's interesting because it actually differentiates the scope of practice by population rather
than a practice setting. So it really says a nurse practitioner should specialize in a particular population of people, whether that's adults, pediatrics, psychiatric or emergency, and rather than you specialize because you're in an outpatient setting, or you're in an inpatient setting, and nurse practitioners are certified only in these particular areas, so they're certified in those
areas. What's particular about the emergency is that you can actually get to the emergency nurse practitioner designation in two ways. One is you can either become a specialist right out of the gate, or you can become a family nurse practitioner, then get some emergency certification.
We're gonna dig into all of those certifications. But first, Phil, you wanted to make sure that our listeners understood that even if you're a nurse practitioner with an emergency certification, you're not quite the same as an emergency physician. Can you elaborate on that point?
The paper points out that there are about 14,800 nurse practitioners working in emergency rooms. It also points out that only 10% of these - about 1500 - actually hold certification as they give it for or emergency nurse practitioners is called ENP emergency nurse practitioners, these 10% actually can qualify to take the examination by one of three routes, you can go through a route that is basically on the job training.
Or you can do 100 hours of CME, which means basically going to some meetings and reading some papers or you can go to a training program, only about 10% of these 1500 went to any sort of training program. And the training programs, like all of their programs are unsupervised. There are no criteria, there's no curriculum, it's just whatever the institution says it they want it to be. And it's what I've ever length, it doesn't need to be a year. It doesn't need to be half a year.
It's whatever they think. And one institution stands out and we're going to call them out Samford University. This is in relevance paper that she has a table that describes the educational requirements for these programs Samford University will take a person coming in as an RN, and in their program, give them both an NP and an ENP. Now, when they're doing the work to do the NP degree, it takes 500 hours clinical hours to do the NP
degree. And then you can get the EMP designation with 40 more hours, basically, you know, one week or less of work in an ER clinically, and you are now qualified to be an ENP. And for a physician, this is totally insane. To see anything this light qualify you to take an examination of this type yet,
this is what it is. So even though they give them a certificate says they pass an EMP exam, the qualifications, the learning for that examination are just totally inferior, and inadequate as Lavin points out,
one of the things in the paper two that they talked about was there's a lot of nurse practitioners who will say, 'Well, you know, I worked in the intensive care unit for five years and my nursing experience counts.' And while although there are some nurse practitioners who may at this current stage have actually done that experience, many nurse practitioners come right out of school. And when you actually look at what these programs require, some of them may require a year of being an RN.
Some of them may require a little bit of emergency experience. But I think the general message is that there is no standardization and in fact, many of these programs, you can enter that without any formal nursing background. So they aren't even really experienced in nursing background before they move on to their NP part.
And you know, one of the other things that paper pointed out is they said that just because you're an acute care nurse practitioner does not automatically make you an emergency care nurse practitioner. And I didn't really realize that distinction until I read it in this paper.
But they you know, an acute care nurse practitioner, I guess, being able to do inpatient work, maybe work in intensive care, but not according to this paper qualifying nurse practitioners to have the skills that they need to work in an emergency room, not that they even with those 40 hours of sort of, quote, certification that they're going to have it either. So getting into the study itself. One of the things I thought was interesting was that they started it by giving a
background. And they said the thing that we always hear in response to physician shortage is economic pressures to contain costs, which I think is actually the bigger issue, especially now that we know that supposedly there's an oversupply of Emergency Physicians, and evolving hospital policies that appreciate the skills and quality of care that nurse
practitioners provide. US emergency departments employ approximately 16,000 nurse practitioners, recognizing that the outcomes of patient care are impacted by providers educational preparation and training, licensure and certification and scope of practice. It is critical that all these facets are aligned for nurse practitioners who are employed in the emergency room. So they made a very good case as
to why this is important. And I think pointing out this contract management groups, I'm going to show some slides where you see envision healthcare, they did a lecture where they actually said that one of their strategic plans is to, quote employee the least expensive resource to accomplish the mission. And they say in the emergency department up to 25 to 35% of cases can be quote, effectively and successfully seen independently by non physician practitioners.
So we know that they're being used in this capacity and this is why Lavin and her colleagues wanted to study whether or not nurse practitioners are qualified,
Well, I like to take off a bit on what you just said, and make sure the listeners understand something clearly, when they talk about being cost effective, a lot of people will think, oh, it's gonna cost me less. No, it doesn't, they charge you the same. And the cost effectiveness comes to the employer. Furthermore, the corporate group that you quoted was saying 25 to 35%. And that doesn't seem to be
what's really happening. There are a lot of emergency rooms, where there may be 10% of the kerosene by physician or, and a lot of now 0% Some ERs are staffed entirely by NPs or PAs, to some extent, the other thing that that Lavin, et al looked at was, and they go through this in in, I may say excruciating detail, it is hard to read, they
were being very complete. But the pathways for their education are like a Gordian knot, they have been so concerned about making pathways for every nurse to become certified in one way or another, that there are multiple pathways, none of them again, are well taught, they're not verified, and the examinations they have to pass are not of any real consequence.
And I this probably appropriate place to talk about that we've, we've looked at their ENP examination, they get one examination at the end of their training, or after they've completed the 100 hours of reading of papers. And it's 135 questions. And it's, I think, two hours or so. And if you dissect the paper, and I did it thinking about, well, let's consider how many EKGs they have to have to read to prove that they can read eight kgs. And you
get down to it. And you figure out that cardiovascular is only a certain percentage of the examination. When you get into cardiovascular, there are five different sections of cardiovascular one of which is diagnosis. So you get to about four questions about diagnosis that they have to answer in order to pass this test, cardiovascular disease, diagnosis of it requires hundreds of questions. Okay, at least so there may be an EKG
question every year or two. And if they give that question, it occurred to me that they're not going to ask a difficult question. Because when they're validating these tests, if everybody misses the question, they throw out the, the answer. So it'll be a simple thing. And I asked some of my er colleagues today to tell me what they had done in their training. And they
responded nicely. And a told me that basically, it continues throughout their training, that they have weekly EKG conferences, you know, meeting to go through this, they go through every abnormal EKG from every day, and read over it with their mentors. And then the their examination consists of two inservices one every year, I'm not sure how long those are, but they're not. They're not gonna be short. But the final examination is 305 questions
over about five hours. And then they have to have oral boards where you can't, there is no place to hide. And I say this as someone who had oral boards for radiology, and there is no multiple choice answer. They just say, What do you think, and if you don't know what you're doing, it's immediately obvious. So the actual required training is monitored by the ACGME, and has to meet certain requirements throughout the training. And then they are tested multiple times to see if they know the
stuff. And if they don't know it, they don't pass the degree of an intensity of education and verification, of that education is is not even close to what physicians have to undergo, which I would say is only appropriate because when you walk into an ER with a cardiac issue, you deserve to see someone who knows what they're doing. And you don't want to meet up with an NP who's read one EKG in her entire life and isn't really sure what it meant. But that can certainly happen
now. And Lavin recognizes this and she says it straight out.
Yeah, I mean, it's it's very clear from this article. They are unequivocal in how they write this they say this in the summary. Using nurse practitioners in the emergency department is number one not consistent with the consensus model that nurse practitioners themselves are supposed to follow. Only 10% of nurse practitioners working in the ER even have some type of formal emergency care training before they start. And even that is
what she calls haphazard. And and I think it's interesting because I'm going to just take it back for one second in the I wrote an article in Medscape. And I called nurse practitioner training haphazard. And people got really angry at me, I got a lot of angry comments that no,
we're very standardized. And so I appreciate that this article written by a nurse and academic nurses pointing out that very same thing, and you're you mentioned that table where they had all the different, I guess there are actually hang on I have how many there are 12 universities that have this emergency nurse certification?
And what I learned from reading this paper is that you have to have a family nurse practitioner, like the emergency is built on family, because family is across the lifespan. That's why because supposedly, they're supposed to be able to take care of newborns to geriatrics, which, as a family doctor, the idea of training for that and learning how to do that in two years with 500 clinical hours is blows my mind, and it's quite insulting. What do you think, Chris? You're a family doctor, too.
I agree. 100%. I think also, if you take into account that if you look at some of the schools that are on that list, some of those schools are completely online. Also, some of these schools make the NPs find their own preceptors, which has become
increasingly difficult. And that makes their actual clinical hours of which the clinical hours already vary in terms of what they need, the quality of those clinical hours can vary significantly based upon who's being seen and where exactly you're getting that experience from. And that's not necessarily a preceptor, that's a physician that can now be a nurse practitioner.
Wow. That's a good point. So ultimately, the summary is saying this is not a good situation. The lack of standardization, even among the most educated emergency nurse practitioners is, quote, extremely problematic, according to this paper, and the ASAP statement in 2020, saying that, stating that nurse practitioners should not perform independent unsupervised care in the ED, regardless of state law is supported by this study. And in fact, they go on to say that regulatory reform is needed to
standardize these issues. Nurse practitioners should not provide unsupervised care, and that reforms should be undertaken urgently. Now, Phil, you've mentioned the term the emperor has no clothes, elaborate on what that means in this circumstance?
Well, the nursing establishment, if I will, is fond of just making broad statements like oh, yes, we're qualified. Like the statement you read from the AANP. Lavin just went and said, Wait a second, let's look at this. Let's look at it critically. And I congratulate her because she has patients welfare in mind here is she looked at it very critically and found that the educational requirements are far less than
they should be. And also, you know, we need to think about what is the minimum we should allow? I personally think that the requirements set up by medicine, as minimum requirements is I think, three years of residency training, plus prescribed a curriculum and prescribed testing to prove you've learned is the minimum. And what happens when I go in expecting somebody to care for my life and emergency system.
And I get somebody who has had maybe 40 hours of clinical work, and then er, and I get somebody who has never had a train in the training about EKG, and I'm charged just as much, that is just not fair. One other aspect of this is people are pointing out that a lot of these NPs are going to rural areas to supply rural ERs because there are places that physicians sometimes just don't want to work. And it's not. They don't want to
work there. It's just that they feel more comfortable with all their support they have in -
or what we're seeing now is that employers just don't want to hire them. They're looking for, you know, the lowest cost warm body to bring in.
Right. And so you wind up with a situation like we had in Oklahoma, in that one hospital where there was an ER open so that they could see patients in charge patients and it was staffed by an NP who had an F NP. She had no ER training, and she had no idea what she was looking at which would be evident to any third year medical student And the patient died as a result. And that's the people in small rural areas are getting second class substandard
care. And there's a lot of discussion about social equity and medicine these days. And that stands out as a glaring example of how supplying substandard care really does harm certain people in certain areas. And it's should become part of the social equity discussion.
So I would like to just finish one point that Phil, I think you were just about to get to, which is that this is almost a myth at this point that nurse practitioners and PAs go to places physicians do not want to go, the American Medical Association actually has a workforce map that you can actually go to and download, and it will show you, if you look at where NPs and PAs go and where physicians go, they pretty much
overlap each other. So these patients are not necessarily getting care or getting any care, rather than just getting care from a physician. So you know, it's sort of one of those legs that they make their argument on, but it doesn't really hold up. The other thing, and I've sort of begun to describe this a little bit to people. I know this a lot of nurse practitioners who have been out there for a long time and practicing. And I think
that's wonderful. And they like to talk about what their outcomes data are, which you can go back and forth about. However, you know, I tell people, it's sort of like if you think about building a house, you can make the house look beautiful on the inside. But if you don't have the foundation of the house that is going to be stable to hold up that beautiful home you built, that beautiful home is going to collapse. And I sort of make that analogy to the training that a lot of the nurse
practitioners have. They don't have the underlying training, they don't have the pathophysiology, they don't have differential diagnosis, they just don't have that training. So even if they can show that their care is equal to physicians, they still don't have that underlying training that really supports that. Physicians are often accused of sort of, you know, turf wars and bashing nurse practitioners. Most of us are actually very much in favor of having nurse practitioners and PAs taking
care of patients. It's not about not having them there. It's about having them do what they are trained for and have them under the direction of a physician. And I think that's really important that we have to make sure that the listeners understand and our nurse practitioner pa colleagues to understand as well.
And that's actually Lavin actually says that in the article I say we have come a very far distance from the way the professions were originally designed and created. And, you know, it sounds like she's pointing out that we have gone astray and that we really it's time to look at reining things back in to keep patients safe. Well, I want to thank both of you so much. We're out of time. I would love to keep talking about this issue. We'll have to bring you back and continue the
discussion. Thank you so much. If you'd like to learn more about this topic, I encourage you to get the book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available at Amazon and Barnes and noble.com. And if you're a physician and you'd like to learn more about advocating for physician led care and truth and transparency among healthcare practitioners, please join our group physicians for patient
protection. You can find us at our website physicians for patient protection.org Thanks so much. We'll see you on the next podcast.