Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors

Background: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). Methods: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. Results: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. Conclusions: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training

Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations

As emergency department (ED) visits continue to increase nationwide, the utilization of advanced practice providers (APPs) has been steadily increasing. Academic centers face unique challenges in the inclusion of APP staff into the educational and teaching environment. Effort should be made to both take advantage of and support the educational mission of academic centers while bolstering clinical care provided by APP staff. This paper highlights some of the considerations and challenges in incorporating APPs into academic EDs as discussed at the Society for Academic Emergency Medicine Annual Meeting in Indianapolis, Indiana, in May 2018. The panel included representation from Massachusetts General Hospital, Yale New Haven Hospital, Warren Alpert Medical School of Brown University, and University of Massachusetts Medical School-Baystate. Distillation of our common experience shows that best practices in supervision favor uniformity between resident and APP staff except with low-acuity patients. Likewise, professional development takes advantage of the educational environment to provide feedback and identify areas for improvement as well as development of formal clinical and educational curricula for APPs working in academic institutions. Already established medical doctor residencies can be leveraged to provide postgraduate education for APPs in either formal or informal training programs

Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees

The gender pay gap among physicians is a well documented and persistent problem and has a profound impact on earnings over a career lifetime. This paper describes examples of concrete initiatives three institutions took to identify and address gender pay gaps. Salary audits at two academic emergency departments highlight the importance of not only ensuring equity in salary among physicians of the same rank but also monitoring whether women are achieving equal representation at higher academic ranks and leadership, elements that typically contribute to compensation. These audits reveal how senior rank and formal leadership roles are significantly associated with salary disparities. A third school of medicine-wide initiative entailed conducting comprehensive salary audits followed by review and adjustment of faculty compensation to achieve pay equity. Graduating residents and fellows seeking first jobs out of training and faculty looking to be compensated equitably would benefit from understanding the elements that drive their compensation and advocating for frameworks that are understandable and transparent

A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine

The employment and utilization of advanced practice providers (APPs) in the emergency department has been steadily increasing. Physicians, physician assistants (PAs), and nurse practitioners (NPs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training. It is important that as supervisory physicians, patients, hospital administrators, and lawmakers, we understand the differences to best create a collaborative, supportive, and educational framework within which PAs/NPs can work effectively as part of a care team. This paper reviews the trends, considerations, and challenges of an evolving clinician workforce in the specialty of emergency medicine (EM). Subsequently, the following parameters of APP training are examined and discussed: the divergence in physician, PA, and NP education and training; requirements of PA and NP degree programs; variation in clinical contact hours; degree-specific licensing and postgraduate EM certification; opportunities for specialty training; and the evolution and availability of residency programs for APPs. The descriptive review is followed by a discussion of contemporary and timely issues that impact EM and considerations brought forth by the expansion of APPs in EM such as the current drive to independent practice and the push for reimbursement parity. We review current position statements from pertinent professional organizations regarding PA and NP capabilities, responsibilities, and physician oversight as well as billing implications, care outcomes and medicolegal implications

Mobile vitreous opacities on ocular ultrasonography are not always pathologic: a cross-sectional survey in an asymptomatic population

BACKGROUND: Ultrasonography is often used in the evaluation of patients with ocular concerns; however, several pathologic conditions and even some age-related changes can have similar sonographic appearances. One approach that clinicians use is to assume that unilateral findings visible at normal gain are acute, whereas bilateral findings requiring high gain are chronic, especially in the elderly population. To date, no studies have systematically evaluated this assumption. OBJECTIVES: The objectives are to determine the prevalence of monocular and binocular mobile vitreous opacities (MVOs) in the vitreous chamber in an asymptomatic population at normal and high gain levels and to determine its prevalence with higher age stratifications. METHODS: We conducted a cross-sectional survey using 2-dimensional ultrasonography with a high-frequency transducer of 105 asymptomatic subjects aged 20-89 years and evaluated each subject\u27s eyes for the presence of MVOs at both normal and high gain levels in progressive age stratifications. RESULTS: Ultrasonographic scans were obtained on 105 subjects. At normal gain levels, MVO was present in only 1 subject (0.95%; 95% confidence interval, 0.0%-5.0%). At high gain levels, MVO was present in 28.6% (30/105) of subjects. Of the subjects with MVO at high gain, 60% (18/30) had unilateral MVO. Mobile vitreous opacity was found more frequently with advancing age, being present in 23 subjects older than 59 years, compared with 7 subjects 59 years and younger (51.1% vs 11.7%, P \u3c .001). CONCLUSIONS: Mobile vitreous opacity in the vitreous chamber visualized at high gain levels is relatively common and may not be pathologic, even if unilateral and occurring at a relatively young age