Survey Unveils Tension Between Residents and Nurse Practitioners in Emergency Medicine

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In Edinburgh, TX, Dr. Andrew W. Phillips, an expert in survey techniques and an emergency physician at DHR Health Research Institute, faced resistance from his employer when he proposed conducting a survey on the impact of training programs for nurse practitioners (NPs) and physician associates (PAs) on emergency medicine residents’ education. Despite difficulty finding colleagues to collaborate with due to the controversial nature of the topic, Dr. Phillips decided to press on. 

This contentious issue gained attention with a study from Yale University School of Medicine’s emergency medicine residency program. The study examined an 18-month PA residency program, noting that the program was not designed to provide the same level of training as emergency medicine (EM) residents upon completion. The authors of the study found that NPs and PAs working alongside residents in clinical and classroom settings had predominantly positive outcomes and were highly recruited as EM-PAs. However, the study’s shortcoming was that it did not include the perspective of the residents themselves.

This study was published in Emergency Medicine News. To address this gap, Dr. Phillips and his colleagues conducted their survey by reaching out to resident members of the American Academy of Emergency Medicine Resident and Student Association. They received 393 responses, representing 34 percent of those queried. The results of the survey were troubling, with 66.9 percent of respondents reporting that NPPs had a detracting or greatly detracting impact on their overall education. The workload in the emergency department was perceived as lighter or unchanged by 85.3 percent of respondents.  

Moreover, 33.5 percent of the residents expressed that they were not confident in reporting their concerns about NPPs to local leadership without fear of retribution. Additionally, 65 percent of respondents did not trust the Accreditation Council for Graduate Medical Education to address the issues at hand. These findings indicate a lack of confidence in addressing the problems within the current system. 

One of the most significant concerns voiced by the residents was the forfeiture of procedures to NPPs. The survey revealed that many residents had to forfeit procedures to NPPs in training, including major procedures such as chest tubes and intubations. The median number of procedures forfeited increased 14 times compared to the previous year. Reasons for forfeiture varied, with 31 percent stating that it was to provide NPPs with more experience, 32 percent citing no discernible purpose, and 7.6 percent reporting intimidation leading to procedure loss. 

The resident comments revealed a culture where NPPs were preferred over residents for procedures, often without a clear justification. Residents felt disempowered to address this issue, and some mentioned instances where NPPs pushed their way into procedures, claiming ownership without room for discussion. The lack of transparency and communication raised significant concerns among the residents. 

Dr. Phillips emphasized the importance of understanding the reasons behind the forfeiture of procedures to NPPs. He questioned whether NPPs were on an accelerated timeline in their postgraduate programs, contributing to the imbalance. He called upon the organized bodies of physicians, NPs, and PAs to address these issues collaboratively. 

The initial study from Yale led by Dr. Alina Tsyrulnik clarified that it was not intended to equate the training programs or skills of MDs and PAs. Instead, it aimed to highlight the success of interprofessional educational collaboration, with a focus on the physician-led team. However, various emergency medicine organizations, including the American College of Emergency Physicians and the Emergency Medicine Residents’ Association, expressed concerns that the education of residents and medical students should not be compromised or diluted. 

Dr. Tsyrulnik and her colleagues clarified that their study did not seek to equate physician graduates of EM residencies with PA training program graduates. They reiterated that the focus was on successful interprofessional collaboration and not on diminishing the role of physicians. The controversy surrounding the impact of NPPs on emergency medicine resident education highlights the need for open dialogue and collaboration among all stakeholders.

The survey conducted by Dr. Phillips and his colleagues shed light on the concerns of residents, revealing issues related to procedure forfeiture and lack of confidence in reporting their concerns. It is crucial for the emergency medicine community to come together and address these concerns to ensure the highest quality of patient care and education for all involved. 



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