Tensions have risen in the ongoing clash between emergency medicine physicians and the advanced practice professionals (APPs) who specialize in their discipline over the latter group's use of terms like "residency" and "fellowship" in postgraduate training programs.
Last month, nearly all professional organizations representing emergency physicians issued a joint statement calling for those terms to be reserved solely for physician graduates of medical schools.
"The terms "resident," "residency," "fellow," and "fellowship" in a medical setting must be limited to postgraduate clinical training of medical school physician graduates within GME training programs," the statement said. "Hospitals or employers should not create or advertise post-graduate training of nurse practitioners or physician assistants in the emergency department without explicit involvement and approval of the emergency medicine departmental and residency leadership."
Over the next few weeks, societies representing physician assistants (PAs) and nurse practitioners (NPs) shot back. The Society of Emergency Medicine Physician Assistants (SEMPA) issued a statement that it was "disappointed that, once again, postgraduate EMPAs find themselves the target of a divisive and paternalistic position statement from emergency medicine physician representative organizational leaders and colleagues," and garnered a statement of support from the American Academy of Physician Assistants.
A joint statement from the American Association of Nurse Practitioners (AANP) and several other NP organizations said the groups "strongly oppose the view that emergency care is solely 'physician-led' or that physicians should dictate education and practice standards for advanced practice registered nurses (APRNs)."
Loaded Terminology
The controversy centers around a rise in PA and NP postgraduate training programs, which usually incorporate terminology like "residency" and "fellowship." This has raised questions in resident physicians' minds about whether an overall increase in trainees will have an impact on caseloads and, ultimately, threaten programs' accreditation.
"If the hospital insists on having NP or PA trainees, that is going to dilute the caseloads available to residents," Lisa Moreno, MD, president of the American Academy of Emergency Physicians, told MedPage Today. "If caseloads are diluted, number one a program can lose its accreditation. Two, if residents get less supervised training, they may be less prepared to take good care of patients when they graduate."
The dispute picked up steam this February when the University of North Carolina at Chapel Hill announced a residency program in emergency medicine for advanced practice professionals (APPs).
Sources told MedPage Today that the emergency medicine physician residency program director had not been made aware of the program before it was launched. They also said APP residents would earn $60,000 annually, higher than a physician residency salary of $57,000.
In a statement posted Feb. 23, the director, Nikki Binz, MD, said the school's announcement was "very premature"; Binz also wrote that "UNC does not have an APP EM education pathway, and no pathway will be introduced this year." She also stated that the salary information was "not true and would never be true." Binz did not return a recent request for comment.
EM physician professional societies met not long afterward to respond to concerns around the incident, but COVID-19 had swept the U.S., so the groups decided to postpone their statement.
Then about a month ago, Indiana University began setting up an APP postgraduate program without the emergency medicine residency program's knowledge, sources in the physician community said. That's what triggered the joint statement, MedPage Today was told.
Hannah Hughes, MD, MBA, president of the Emergency Medicine Residents' Association (EMRA), which signed onto the joint statement, posted it on Twitter with the comment: "Every EM physician, resident & student should be paying attention to the battle on scope of practice."
The tweet was widely engaged, garnering hundreds of responses -- many supportive, but some questioning a lack of respect for multidisciplinary colleagues.
Focus on NPs
About 40 postgraduate training programs in emergency medicine exist for PAs in the U.S. The number for NP emergency medicine programs is less clear, but they're said to be gaining popularity.
"There's been a huge surge in NPs having these programs, and we are concerned about misleading the public," Moreno said. "Essentially, this is a natural outgrowth of our concern about NPs telling patients they are a doctor," as some NPs have doctorates.
NPs are relative latecomers to the "physician extender" category that PAs started in the 1960s, but they've blazed a path to independent practice that PAs have not. In all 50 states, PAs must have a supervising physician, but in 22 states plus the District of Columbia, NPs can practice independently.
Physicians who have sounded alarms about encroachment into their practice have typically cited transparency and patient safety as their chief concerns.
Patients should know if they're being treated by a physician or a different type of professional, Moreno said.
Hughes said medical school graduates typically have 5,500 clinical hours under their belts before residency, whereas PA school graduates have 2,000 hours; DNPs graduate with 1,000 hours, and FNPs have 650 hours. (NPs often respond that most come into their programs with thousands of hours of clinical experience as RNs or other professionals, unlike MD and DO students.)
New concerns have cropped up around physician trainees potentially being squeezed to maintain appropriate caseloads to complete their residencies, and for programs to maintain accreditation.
"Is there enough volume? Are we going to have to compete for procedures?" Hughes told MedPage Today. "How does this impact my training if we're going to bring on other learners?"
Fiona Gallahue, MD, president of the Council of Residency Directors in Emergency Medicine (CORD), which also signed the statement, told MedPage Today that hospitals and schools can create NP and PA postgraduate programs at will. There's no oversight by a central regulatory body like the American College of Graduate Medical Education (ACGME) and no funding requirements from the Centers for Medicare and Medicaid Services (CMS) as there is with physician residency.
"There's not a lot of coordination between those who are developing programs, and the leadership of [physician] residency training programs, to ensure that there's not a conflict in educational priorities," Gallahue said. "We hope that hospitals ramp up investigations of how these programs might be affecting trainees."
Moreno said she doesn't know of any emergency medicine residency programs that are on the verge of losing their accreditation because of reductions in caseloads, but that the societies "want to head it off before someone does lose accreditation."
APPs Respond
While physician professional societies have emphasized in their statements that they value every member of the clinical care team, they all support physician-led teams.
NP societies took issue with that in their joint response: "Our national organizations strongly oppose the view that emergency care is solely 'physician-led' or that physicians should dictate education and practice standards for advanced practice registered nurses."
Sophia Thomas, DNP, president of the American Association of Nurse Practitioners, said NPs are "highly educated and trained. There's no evidence to support that physicians should dictate the education of another clinician.... Our educational standards have been set and vetted."
"Any profession can have fellowships or residencies," Thomas said. "Reserving those terms strictly for postgraduate clinical training of physician graduates is inappropriate."
Mike Hastings, MSN, RN, president of the Emergency Nurses Association, agreed, noting that pharmacy, dentistry, and podiatry all have postgraduate programs they call residencies.
"We want to make sure the providers treating the patients have the necessary skillset to deliver the best care possible, and we will continue to advocate for that," Hastings said.
While there isn't a single, centralized exam like the USMLE or board certification for NPs, they must take a national certifying examination, the two most common being those offered by AANP and the American Nurses Credentialing Center. To earn an NP degree, a candidate must have an undergraduate degree and have earned their RN license. Many practice for years before entering an NP program, which lasts two years on average.
Hastings said adding residencies and fellowships for NPs would help improve providers' skillsets and raise the bar for training of NPs in the U.S.
It remains to be seen how the issues will play out over the coming months or years. Leadership from all organizations said they wanted to come together to resolve any issues.
"If we work together to help solve this, we win and patients win," Hastings said. "We can make sure we all deliver high-quality care for patients."
However, Gallahue drew one line in the sand. While PAs and NPs play a "very valuable role in patient care, we don't believe in independent practice."
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