Speaker 1 00:00:07 Welcome to Physicians Taking Back Medicine. A new podcast sponsored by Medical Economics. I'm your host, doctor Rebecca Bernard, and I'm excited to share with you inspiring stories from day to day physicians just like you, who are working to make a difference in healthcare. In our first podcast episode, you will meet two physicians who noticed a serious problem in their field of emergency medicine and decided to take action. I am Debbie Fletcher. I am an.

Speaker 2 00:00:37 Emergency medicine community physician in Shreveport, Louisiana. I'm Doctor Mercy Hilton. I practiced adult and pediatric emergency medicine in the central Indiana area for close to 20 years.

Speaker 1 00:00:53 Although they worked in different parts of the country, both Doctors Fletcher and Hilton noticed a similar problem. Physicians in their emergency departments were being replaced with non physician practitioners, nurse practitioners and physician assistants. In fact, in 2019, Doctor Fletcher herself was fired and replaced with a nurse practitioner.

Speaker 2 00:01:15 I worked for one of our emergency departments at a hospital system, and I had been there for many years. Was part time at the time in 2018 because I was enjoying being a full time mom as well, and still wanted to use my skills and work as an emergency physician.

Speaker 2 00:01:36 In the fall of 2018, a contract management group took over our Ed contract. Initially, they said things would not change, but in the spring of 2019, they decided to start the use of Mid-Levels, nurse practitioners and Pas. At the time, we didn't have those. We were all physicians staffed. Board certified emergency medicine. And so they would need to carve out space to use them. And they decided, well, the part time physicians would go so that they could make spaces for the non physicians as they were supposedly less expensive to use. I was told by one of the head people in that company that it's just business.

Speaker 1 00:02:28 Likewise, Doctor Hilton noticed that physicians in her emergency department were being replaced with non physician practitioners during the pandemic. Our volumes had really.

Speaker 3 00:02:40 Fluctuated a lot, very low at times, very high at times. And during all of this, the general pediatricians that provided about half of the day's coverage, they were let go with the plan to replace them and those hours with nurse practitioners and physician assistants.

Speaker 3 00:03:01 And when I questioned this during times of high volume, as the remaining emergency physician there, how would I be able to adequately supervise and see their patients and make sure things were going as they should? What I was told was that yes, when things are busy, you won't be able to see all of the NPS and PA patients. You'll just have to sign off on the chart. And I felt that that was an inadequate model of care for me. I felt that it was not safe for patients. It was not safe for physicians from a liability standpoint. And I had ethical issues with that in terms of the way things are built in the emergency department and people getting bills for what may not be the best type of care.

Speaker 1 00:03:51 And you actually saw some patient harm. Can you talk about any stories of when you saw really scary things in your field.

Speaker 3 00:03:59 It's hard to put an exact finger on when I started seeing changes, but I can say that at the beginning of my career, which was in the mid 2000, I had never even heard the term AP.

Speaker 3 00:04:11 Like I had never even heard that term. Probably around the early 2010. Things started changing. We started seeing more non physician practitioners on different patient services at our hospital. They would come down to the Ed to admit patients or consult on patients, and that was probably the first time that I became familiar with them in the hospital setting. But really where I was seeing a lot of mismanagement was from NPS in primary care clinics and urgent cares and other emergency departments that were sending their patients to us in our Ed with inadequate care. So I would say two subsets of patients. The first were patients where bad diagnoses were missed. The other class of mismanagement that I saw was patients with minor conditions that did not need to come to the emergency department that were referred to the emergency department.

Speaker 1 00:05:16 So over diagnoses and under diagnoses, which are very bad. Debbie, did you notice any of this type of mismanagement in your E.R.?

Speaker 2 00:05:28 I did, after I returned to working at that facility for a little while because they still needed extra coverage.

Speaker 2 00:05:37 So I went back and did a few shifts there, and it was definitely scary because sometimes they were overconfident and wouldn't ask for any help from a physician. And sometimes you would find something in passing as they're checking out to you. You know, wait a minute. You didn't consider this. So part of it is you don't know it. If you haven't learned it, how can you know to look for it? So the depth of education there is different.

Speaker 1 00:06:11 The depth of education is indeed different between that of an emergency physician and a nurse practitioner. In fact, there was a study that was published by nurse researchers evaluating the training of nurse practitioners staffing emergency departments, and what they found was really quite concerning. Here's Doctor Hilton to share information about that study.

Speaker 3 00:06:36 The study is called Analysis of Nurse Practitioners Educational Preparation, credentialing, and Scope of Practice in U.S. Emergency Departments. And this is from the Journal of Nursing Regulation, January 2022. They looked at all of the nurse practitioner is working in emergency departments, and they said that approximately 16,000 NPS work in emergency departments, and of those, very few were certified as an emergency nurse practitioner.

Speaker 3 00:07:11 So a very small number, the remainder of them. So the the vast majority were certified as family nurse practitioners. They did find that there was wide variability in what is actually required in their educational materials, their didactic, what constitutes their credit hours, how many credit hours, but also a wide variability in their clinical hours, too. So there were some programs that required as little as 180 clinical hours in emergency care, where others were closer to like 600. Some of the programs didn't require any type of emergency nursing experience before admission and others. A couple of them did, and the author goes on to say that because of extensive variability across academic preparations as well as on the licensure and certification requirements governing PNP practice and EDS, and until this variability is resolved, they conclude that NPS should not perform independent unsupervised care in the Ed, regardless of state law or hospital regulations and order to protect patient safety. So I thought that was a remarkable statement. The authors of this were all nurses.

Speaker 1 00:08:34 So we have academic nurse researchers sounding the alarm on the educational preparation of nurse practitioners working in emergency departments.

Speaker 1 00:08:43 And we have emergency physicians saying, hey, we are being replaced by nurse practitioners, or here we are being forced to supervise a slew of nurse practitioners because our colleagues have been let go. So that's when Doctor Fletcher decided to do a little more research to figure out exactly how serious this problem was. She joined a workforce study with the American College of Emergency Physicians to find out exactly how many emergency departments were staffing with nurse practitioners, rather than physicians. What Doctor Fletcher discovered was alarming, which is that 7.4% of all emergency departments across the country are not staffed 24 over seven with a physician. And in some states, that number is as high as 30%. Here's Doctor Fletcher to explain the study.

Speaker 2 00:09:30 Doctor Carlos Camargo is the main researcher on the rural task force for ACIp. And he has a survey that goes out to every emergency department every year that questions the different things that their emergency department might have. So I contacted him, and I'm asking, is there any way that you could add a question to your survey?

Speaker 1 00:09:58 So you asked the lead researcher of this workforce survey to include a question that really had never been asked before, which is do you have a physician on site 24 over seven in your emergency department?

Speaker 2 00:10:14 Correct.

Speaker 2 00:10:14 And we didn't want it to sound punitive. We just wanted to find out this information so that we could see how to help from the emergency medicine community. They sent this survey out to 5622 emergency departments. This included freestanding EDS as well, and they had 82% 4621 response rates, which is excellent, and 344 of them, which is 7.4%, said no, they did not have a physician 24 over seven. So if you look at the percentage 7.4 doesn't sound extremely high, but 344 emergency departments do not. If you look at where they were, most of them are rural. 58% of the nos were in North Dakota, South Dakota, Montana. And 92% of them were ultra rural, with a volume annually of less than 10,000 patients.

Speaker 1 00:11:22 And even though the average was 7.4% across the nation, there were states that had 0% of of not having a physician. And there were quite a few states that had over 30% of their emergency departments not having a physician on site. Now, the question was asked whether those hospitals that had no physicians had access to a physician by telephone.

Speaker 1 00:11:48 And what were the findings on that?

Speaker 2 00:11:51 Of the places that said they did not have physicians. 77% did have access to a telehealth network and 23% did not. And the scary part is, 3% of those had no two way communication at all with the physician. So that the number is 138. Could you look at percentage? Again, it's not terrible, but given the sheer number and volume of the responses, there are 138 emergency departments in our country that do not have any two way communication with the physician.

Speaker 1 00:12:33 When you say two way communication, you mean access where the nurse practitioner or physician assistant staffing that emergency department alone does not have the ability to call and speak to a physician directly about the patients under their care.

Speaker 2 00:12:49 Right.

Speaker 1 00:12:50 That is really frightening. I mean, how are these patients being managed, do you think?

Speaker 2 00:12:56 I think they are being managed by the nurse practitioner. PA that's alone in the emergency department and they do not have the training to do that.

Speaker 1 00:13:09 How is this being allowed?

Speaker 2 00:13:12 Well, there are a number of states that have legislated independent practice for nurse practitioners and some for Pas because of the shortage.

Speaker 2 00:13:22 And the nurse practitioners speak to their legislators, and this is given to them in law and not in education, so that they can do this. But still they don't have the training and the education to do that. So it is scary.

Speaker 1 00:13:42 With this information about physicians being replaced in emergency departments. Physicians decided to take action. And Doctor Mercy Hilton was instrumental in helping her state of Indiana become the first state to require that all emergency departments must have a physician on site 24 over seven. Let's hear her story.

Speaker 3 00:14:06 2019 was a centennial year for me. That was the first year that I did any type of advocacy. I was not a member of any type of organized medical association at the state or national level. But like I said, I had been seeing increasing numbers of mismanaged patients referred to my Ed by non physician practitioners. And that year in Indiana there was a nurse practitioner independent practice bill. So I just as an individual, went to the statehouse and started talking to legislators about my concerns. But the other thing that happened in 2019 that was a catalyst for me was the court verdict in the Alexis Ochoa case came out.

Speaker 1 00:14:52 Doctor Hilton is referring to the tragic death of 19 year old Alexis Ochoa, who died when she was treated by a family nurse practitioner working all alone in an Oklahoma emergency department without any physician on site. The nurse practitioner missed pulmonary embolism and the story was featured in the book Patients at Risk.

Speaker 3 00:15:14 That case really, really touched me because Alexis was from my hometown of Del City, Oklahoma, so I didn't know her or anything. But I grew up in Oklahoma, and when I heard this, I was horrified. I had no idea that there were emergency departments anywhere where there were no physicians present, much less in the state where I grew up, where I still have family. It horrified me. And so I started digging into Indiana's laws to see could that happen here? And what I found is that yes, it could happen here. There was no requirement for a physician to be present in an emergency department, so I decided to join my state medical society and start getting active. I wrote a resolution for my state medical society asking for legislation to require emergency departments in Indiana to have a physician present.

Speaker 3 00:16:13 And then in 2023, the Indiana law was able to pass through the legislature.

Speaker 1 00:16:18 Well, that was a lot of work done by people who care an awful lot about patients. And fortunately, you're able to make a persuasive argument to legislators that this was about patient safety. I'm imagining that it was not really easy, though, to get this legislation through, and especially being the first state in the country to pass something like this.

Speaker 3 00:16:40 Well, the primary author of the bill, Senator Les Brown, at one point, like in the months before the session started had reached out to me asking, why do we need this bill? What is the prevalence of emergency departments without a physician? Because honestly, like nobody had ever heard of that. Is that really happening? And there was at that time, no study. Now we have the study that Debbie had a hand in. But at that time we had no study. So I literally reached out to a large group of emergency physicians on a social media group and posted something asking for people to please private message me.

Speaker 3 00:17:22 If you are aware of emergency departments that do not have a physician present 24 over seven and I got several hundred responses with names, and I tabulated all of those, and I presented those to Senator Brown in terms of this is what's happening. And there were some very prestigious names on that list. people would be shocked. So I'm glad that we have more of this data more formally presented, and the study that Debbie was able to help with.

Speaker 1 00:17:57 Well, you mentioned the story of Alexis Ochoa Dawkins. And she was treated in a hospital owned by Mercy Health Systems, which is a large multi-billion dollar corporation. And a lot of people will say, well, we need the NPS or the staff because these are rural critical access hospitals. But that hospital where Alexis died was not a rural hospital. It was just a few miles outside of Oklahoma City, a 35 minute ambulance ride. So Indiana was the first state to pass a law regarding emergency staffing. And then after you were able to get that into law in Indiana, Virginia became the second state to have encoded in law that if you advertise yourself as an emergency department, you must have a physician on site 24 over seven.

Speaker 3 00:18:48 We were trying to legislate a minimum safety standard, which is a physician who has training and experience and emergency care. I really would argue that you should turn the legislative argument into. This is about truth and transparency, truth and advertising. And what does a layperson perceive as the level of care that they will get when they go to a, quote, emergency department? So for the states in which there are many hospitals that don't have a physician present, what you might be able to do is pass legislation saying that these hospitals that don't have a physician present are not allowed to call themselves emergency departments, because then that allows the layperson patient to know, well, that's not an emergency department. That's a triage and transfer center. There's no doctor there. I should drive on to find the the next emergency department where there will be a physician. So it is really about giving patients some choice. And to have choice, true choice. They need to know transparently what is the truth and what can they expect when they walk into a health care facility.

Speaker 1 00:20:09 Thank you so much to my guests, Doctor Debbie Fletcher and Doctor Mercy Hilton, for the work that you're doing to make sure that patients have access to a physician in the emergency department. I hope you've enjoyed this first episode of the new podcast, Physicians Taking Back Medicine. Sponsored by Medical Economics. I'm your host, doctor Rebecca Bernard, and I'll see you on the next episode.