ACEP EM Workforce Section Meeting

- So my name is Debbie Fletcher. I'm the chair of our workforce section. And, we are wanting to talk about the Hattiesburg study that came out last year. So, let's see. I would also like to see if we can do some introductions quickly. We've got Doctor Schmidtz is on the line. She's our new board liaison.

- Hi everybody. I'm an emergency physician in San Antonio and ACEP's immediate past president.

- Okay and then, Jonathan Fisher.

- Hey everyone, I'm John Fisher. But most of you know me as Fish. I am the senior director for EM Workforce Force and EM practice at ACEP.

- Okay, then we've got Leslie Polls.

- Hey everybody, I'm Fish's administrative coordinator.

- And then, our guest for today is Doctor Teresa Camp-Rogers. She is an emergency physician and ACEP member as well. And she is from Mississippi and helped work with the group that put together the, what we're calling the Hattiesburg study. So, Teresa if you can tell us a little bit about yourself.

- Sure. My name's Teresa Camp-Rogers. I'm an emergency physician. In full disclosure I always say this, I'm actually also a hospital administrator, sorry. But I'm on the good side, hopefully. This is all dark, right? It's all the dark side. But, I work at a community-based hospital and I answer to my CEO and he is very physician friendly. I am sad when he retires in three years. He's been there for about 30. And he's very pro physician. He and I talked frequently about this topic. So anyway, but I'm a hospital administrator. Not at where this study, where this study was done. So, anyway, I guess I'll go ahead and tell you kind of how I got, like you said, how I got involved. Or how I know about it. So firstly, I am not a representative of Hattiesburg Clinic. I don't work there. I don't live in Hattiesburg. I live next to it. And I work at a competing hospital. But the way I got involved in this study, and as I'm speaking today, I'm speaking as an editor and as a physician who cares about Scope in Mississippi. And so, about a year, almost two years ago now, I got invited to be the editor of our state medical association journal. The, and so one of the things that I did when I first started was I created a column called Mississippi Frontline. And the purpose of Mississippi Frontline was to highlight that small gap between science and implementation. That space where we're like, well what are we going to do? And how are we going to do it? Right? And so, the point was to take or to look for hospitals and physicians, and clinics around the state that were taking the best evidence and putting it into practice. And giving them an outlet for them to describe their experience with that. And so we had created Mississippi Frontline a couple months before and had published it and it was met with, you know, great readership and positive feedback. And so, Doctor Batson submitted this article. I had--

- Easy to kind of throw away.

- Say what? Oh sorry. Anyway, so he submitted the article and, and that's how I got involved. So I was involved as, as an editor and from a critiquing standpoint. And, and that that's how I got involved. As an aside to that, I'm very interested in the topic. And so, anyway, so we can go in and go through some parts of it or I'm happy to answer any questions.

- So that's how you got involved in it. Because I know you weren't the original researcher and the data came to you and you decided to help publish it. But can you talk about how their study got started and how they collected their data?

- Yes, yes. And so what was very interesting to me about it is it really fit the mold of what we wanted to accomplish in Mississippi Frontline, right? Here is one place in Mississippi that's looking to do the best thing where, the best thing in practice, right? So had a little bit about Hattiesburg Clinic. It is the largest physician owned multi-specialty clinic in Mississippi. They have over 300 physicians and over 150 nurse practitioners and PAs. They have a, they serve a market of over 750,000 people. And this is important from a strategy standpoint because that represents over 25 percent of Mississippi's population, right? So when we discussed this at the legislature, it's important to put that into context nationally when we think about the impact of this particular article. But in Mississippi specifically, the data really was very important because they studied Medicare patients in Mississippi. And they, it was Medicare in a 25 percent of the state. And so they have I think 33,000 Medicare patients. So like any hospital, and like any clinic, Hattiesburg clinic is going to collect data. They're constantly, and this is me just interpreting what I read, They're going to collect data to evaluate their business decisions. And so if you read the article, you can see that between 2005 and 2020, they had increased their number of NPs and PAs from about 26 to I think about 118. And, they decided to look at quality, cost, utilization, and patient experience to determine kind of the downstream effect of that, that decision. The way their practice model works is they describe in the article is that some of their NPs and PAs have independent, did have independent panels. So we are a state that does not have full practice authority, but the nurse practitioners in the state you know, could have their own panels and then reach out to the physician through the collaborative agreement if needed. So that's how they got started. Any questions so far? I'm always hesitant to talk too long.

- Could I ask Patricia Aronin to please mute. It's a little bit distracting, if possible. Or if one of our hosts could maybe mute people who are not presenting.

- And so that brings me to the next part. So they knew that there'd been this shift from 2005 to 2020 where they had an increase of NPs and PAs and then those NPs and PAs had independent panels. And so the question came, well you know, could we compare these groups? Could we compare these groups of people that are giving care to our patients? On these categories of metrics of utilization, cost, quality and patient experience. And, and this is the next important part, because the data is at, was at their fingertips through an ACO. Just the Accountable Care Organization. Using data from Epic, Press Ganey and their ACO, they were able to create this model that showed that care for physicians was in some ways and in many ways improved when it was provided strictly by the physician. And that care was not, did not meet the standard or had lower quality care, had higher utilization and increased cost. So, the data was pretty compelling for quality. 9 of the 10 metrics were better. Some were, were more significantly improved among physicians when compared to NPs and PAs. Those included like flu vaccines and pneumonia vaccines. There were higher rate of completion of those vaccines when the patients were seen by the physician. Most striking to me was the cost of care. The cost of care for physicians, sorry, the cost of care for patients that only had a nurse practitioner or a physician's assistant was 119 dollars per member, per month, when adjusted for risk, or when adjusted for HCC scores. And when they calculated that out for just for Hattiesburg clinic and just for Medicare patients, it was 10.3 million dollars a year of potential savings. And so that, that to me was I mean, we all know that, you know we're not, we all know that we're not in this for the money, but we have to talk about money, right? Because at one, we don't wanna waste it, right? We have to keep lights on. Like we have to, and you know, some hospitals in our state and other people in the south I know, I don't know what hospital closures are in the rest of the US, but I know in the south it's pretty significant. And so we are talking about, you know, we do have to talk about cost of care. And so for me, that was one of the most compelling parts. The specialty referral was higher for in NPs and physicians. And then the patient experience. The overall, you can see in the paper most of the, there were some cases where it was about equal, but then overall care was higher, just barely higher for physicians. The, the third most compelling thing that happened in this particular article was what Hattiesburg Clinic decided to do because of the results. They actually created this really beautiful model, I thought. That still welcomed NPs and PAs into the healthcare system, right? They we're not talking about kicking anybody out. We're talking about weaving NPs and PAs into our healthcare system in a safe and a cost effective way. And what they did was actually for all the NPs, no NP or PA is allowed to have an independent panel. And for any patient that does have an NP or PA, they have to alternate visits with a physician. And so the hope was would be that that would decrease some of the utilization, decrease some of the cost and then, but then still give, still incorporate NPs and PAs into the healthcare system.

- Now one thing I thought was interesting, not one thing. So many things I thought were interesting, but from what I understood, the original authors really thought they were going to set out to prove that the NPs and PAs were equal to positions.

- I think that was the goal. Yeah if you read it, it's really, that's one of the things I liked about the way it was written. Is, you know, I felt like it was very transparent. You can picture, I can picture this as a boardroom discussion, right? Like, you know, I can picture this saying okay, well we made this decision, let's just make sure that we did the right thing. Because you know, we have the data. Now that we have the ACO and now that we have epic, you know the data's at our fingertips, we really should just make sure. Because who wants to look back and say we didn't. I mean in some ways you could say we looked back and we did maybe the wrong thing, right? Sorry, I look at things that way. That's why maybe--

- That's the administrator in you though.

- Well yeah, but I mean like but that's the thing. It's like nobody wants to say that. And then, and you know, I think that there was transparency and I think the way that they, they laid out the argument was very savvy. So.

- Can I ask a quick question? That was fantastic work and I'm so glad to get this type of data out there published because it really helps our advocacy efforts when we meet with legislators in DC. And that's their first question, is show me the data. So this is incredibly valuable. With emergency medicine, we don't typically have a panel of patients like they do in primary care. Can you speak to that a little bit of like what type of supervision when they have a panel, was there at that time someone still like reviewing their charts after the fact? Or like what supervision if any like, because I know you said you don't have independent practice in Mississippi. So there must have been some sort of oversight, but I'm just curious what they did.

- That's a great question. I would need to ask them on how, what percentage of charts were reviewed by the physician. In Mississippi I think it's only like 10 or 20 percent that has to be reviewed. But some hospitals and clinics and medical staff will do more, right? So some ERs might do all the charts. I don't I mean, and then some might do, obviously the minimum. I would have to ask. My understanding is that when it was independent it was, it was they would see patients all day by themselves and reach out if they had a problem. I think. But I don't know. I mean that to me is like the, but that's the model I think. I think that it would be the model that's you know, in practice in a lot of clinics. But I don't know, I'd have to ask them. That's a great question. Oh and another thing, sorry just so you all know, hopefully my goal is to get this on PubMed soon. So when I first took over the journal, we were not, we had, we were not on PubMed. And I took over in August of 2020, sorry, I have to like count back the months. August of 2020. And we did a number of things to meet the standards of PubMed and we've put those in place. Like being on schedule, having robust peer review process, and having like real science, you know, out there. And so we resubmitted and fingers crossed we'll hopefully be able to backdate some of our publications so we can hopefully get this on there and then as soon as we get that PubMed ID we'll, be able to promote it even more. I know it's hard to find it, I'm sorry.

- And I know when we had this zoom with you and then we had Rebecca Lauderdale, who was one of their lead physicians in that Hattiesburg group. She went over all of this with us too. And so I think some of those questions she could possibly answer as far as what their staffing was. But, she was going to meet with us today and had a conflict at the last minute, last week.

- But that's actually, and and another thing, ER utilization was higher among patients that were taken care of by NPs and PAs alone. So, that's one of the things that's most fascinating to me is that at any hospital we work at or any hospital that's part of an ACO, and this you know, I would say to everybody on this call is like if you, if your hospital is part of an ACO, then this data is at your fingertips. It's right there. And you can pull up, from my understanding, I have not done it at my hospital. I'm still trying to gauge if that's appropriate with my specific opinions on things. So, but if you are, if you have access to the ACO data or you can compare physicians and NPs and see how the data differs between per, between those.

- I might be mistaken. But I don't think emergency departments right now, like we have a ACO system that includes emergency departments. We've been trying to advocate for a different payment model that would include emergency medicine in sort of an accountable care organization. But, someone correct me if I'm mistaken but, I think that's part of the issue of trying to prove outcomes. And then the other issue we have is that, you know, we don't necessarily have follow up. So a lot of their outcomes are not attributable necessarily to the care they receive in the emergency department. And where primary care has that kind of continuity. And you can say, well this is you know, what their vaccine compliance rate was or their outcomes. It's a little harder with emergency medicine, but I think the cost effectiveness and the ED utility is really relevant to us. And I think that's lived most of our experiences and when people are referred to us and oftentimes they get there and you're like, why are you here? Like, I'm going to send you back to your primary care.

- With a non-emergency complaint.

- Yeah, like to the point where like, I've started calling people back. I'm mean like, what did you want us to do? Like I don't understand. And we've been talking about trying to get data on that, but it's, it's hard to report an aggregate because it's more just anecdotes. But I still think this is a great step forward. And, I think there was another paper, and I don't know the journal that was published in, but it was PubMed reviewed with by a healthcare economist. A very similar you know, comparing physicians to nurse practitioners and PAs and looking at costs and outcomes to the point where we can, and again the more data we have, even if it's not emergency medicine specific, I think the more helpful it is in challenging some of the state laws that are, are broader than just emergency departments.

- Yes. And I love both of those studies. Hattiesburg clinic and I think, are you talking about the NBER? The economics--

- I believe so, yes. Yeah.

- Oh, the 93 page?

- Yeah, the 93 pages. Gosh you all, I've tried. I can get, every time I read it I get a little further in it. But what I like about it though is that you can, with both of those studies it's, it's a certain amount per patient, right? And it's Medicare and so you can, you know, with the NBER study in Mississippi, right I started thinking, okay wait, it's a hundred and I wanna say 59 dollars per visit more expensive for NPs versus physicians. And then you just start like saying okay, well where are their NPs that practice alone? Because that's similar to the model for the VA, right? Where their NPs that practice alone in the ER and then how many ED visits will they have? And then how many Mississippi Medicaid dollars is that over a year? And it really becomes pretty astronomical if you just think about how many visits we have a year. Anyway.

- Is that how you use that data to defeat your scope of practice with your legislators this year?

- This year?

- [Debbie] Last year.

- Yeah. So yeah, we're still waiting hear back about this year. Some bills anyway. But last year, yeah this was definitely an important piece of the presentation last year. This was actually the closing. This is what I wanted the positions to walk away with. Is that dollar, right? Because, that dollar amount. And I hate, I apologize that this first time I've met a lot of you all, I apologize that I'm talking about that. But it really, like it matters. It matters because that's what's going to make the legislatures listen. So, quality of safety is my heart, but what makes them listen is the dollar sign unfortunately.

- And the quality and measures what, there were 10 different ones and the nurse practitioners independently failed on 9 out of the 10 on the quality from what I remember.

- Yes. Yes. Oh that was it, go ahead sorry.

- No, I was going to say if you had any details that you liked about that, the quality part.

- What was interesting about quality is that, that they were things that were kind of task related and process related. That, that the first thing, and they point this out, that it's task related. And so seemingly you could, it wouldn't be super complicated to, it was an unanticipated finding, right? To have a task related issue show up as less frequently met for NPs and PAs versus physicians. The other thing that I thought was interesting, it's been a little while since the article came out and every time that I read it, I look at it a little bit differently. And so when I see the deficiencies, I automatically think, well where did they learn that in school? Right? And I think that's an important question. And I would, I would just propose everybody you know, ask that everybody in the group you know think about that. When somebody misses something or when there is a difference, when did they learn about the flu vaccine in school and what did they learn? And I think the answer's going to be they didn't. Right? And so then that changes the question, how did we end up in a spot where somebody that didn't learn it in school is given the responsibility of doing it? So, difficult questions for difficult times.

- We're trying to do the same thing. So I work in the military system. And the military does allow independent practice right now, both in the VA and in our government hospitals. And we do it training exercise at the culmination of medical school. So we're not even comparing residents, we're comparing medical students to nurse practitioners. And we have them do a field exercise where you have a number of casualties and sort of a mass cal situation. And they have to be able to control the airway and do you know, basic kind of recitation. And, we get told by the nursing command that they want their nursing students to be treated every bit the same as the doctors and to evaluate them on the same score. And every year, like they fail miserably and we end up like passing them with like a asterisk like, you didn't actually learn this, so we can't really evaluate these on their score. But that has also been publication in the press right now, hopefully going to get peer reviewed and picked up because it does show that nurse practitioners were not as competent as medical students. So even someone who hasn't finished medical school yet had a better quality of care than nurse practitioners. I might get fired over it because the military's not going to like when we publish that but, we're trying just again not to point fingers or really show that it's bad. We can all be members of the healthcare team, but it has to be in a physician-led care so that they're getting the appropriate supervision. And my hope is to point just like you said, to link back, where did you learn this? Because clearly we didn't hit these marks and oh it wasn't in the curriculum? Okay let's just identify where those gaps are so that we can apply that forward and really purely point out the differences in our training of why that is a patient safety issue, right? In addition to cost and everything else.

- Yes, exactly. So that's awesome--

- And that does point to like to the study from Roberta Lavin last year being the NP. Where she and other NPs determined through their research that the nurse practitioners shouldn't practice alone independently in an emergency department due to the variation of their education. It was like you were saying, if they don't have it in their curriculum and they never learned it, how do you have them be responsible for this knowledge?

- Right. Yes.

- And another question I was going to ask too was one of the factors that they looked at was the patient experience. I know that so many people say heart of a nurse and that, but we can push back that with physician quality too. We do have good patient experiences and we know that for, for the emergency department.

- Yes, absolutely. Yep.

- And Doctor Batson is the one that you said originally wrote up the article?

- They all three did. Doctor Batson, Doctor Crosby, and Doctor Fitzpatrick. It was just him that submitted it. Sorry, he was the contacting author.

- How are they doing? I was wondering if they had any negative feedback, repercussions from the NP community?

- I don't, I don't know. I'm not sure. I think they're going to be okay though. It's you know, because the way they phrased it, and the way they phrased it and is true to the, I think the way that they believe. You know the goal was to take this healthcare role, right? And use it in a, use it and incorporate it into their business model in a way that is safe and effective. Right and who can, right? Like how, like I don't know how to debate that. Like, it's the bottom line that we should all strive for. Is let's do what's right. So, I think it'll be okay. If there is anything, I haven't heard about it. But I think he'll be fine.

- I think we have actually been able to change the narrative with physicians that it's not a turf war, it's not greed of physicians, that we are actually concerned about patients. And that's getting out to patients, other physicians, legislators, the people that are making these decisions. Another question and interestingly you being an admin too, have you had anybody be able to use this? Not just scope of practice in your own states, but maybe with your hospital bylaws? Have you had any?

- That's a great question. Our clinic is sep, well let me think. The clinics, yeah not as much at ours. I mean we're kind of, we're just like a little island. Although we're in a golden chapter if everything's okay right now at our hospital. And it's very proposition. And the, and I haven't heard of anywhere else that has specifically. But that's a really good question. I'd love to hear stories of that, that'd be great.

- Okay. Henry Patel, you have a question?

- Yeah, thank you so much. First of all, thanks so much for coming to talk to us. It's fantastic. The paper's fantastic. And I'm very much on the side of physician-led teams and, and I do believe this is a giant quality difference. I'm from Chicago and I've been with the VA in emergency medicine for about 15, almost 16 years. What I have to say is about the Chen and Chen paper, the giant 93 page NBER paper. I don't know if that necessarily reflects reality. I think that the Hattiesburg paper is amazing. I think that the Levin paper is groundbreaking. I think that the VA study main, I mean it's lovely data. I just don't know how real it is. I don't think there's a lot of actual main, main emergency departments within the VA system where APPs are being alone. I think that within the VA system, the place that they're getting their data from mixes urgent care and emergency medicine, almost into the same pot. And there are plenty of urgent cares where NPPs are working alone in the VA. But as far as main EDs, I don't think there's a whole lot of them. And I think when you mix that data, you're not comparing apples to apples as far as utilization or outcome. Or even cost. And I just, I don't think that data necessarily reflects reality. I think that it probably would if we delve deeper. I just think it's kind of a, it's a first study. It's a very high level study. And it's kind of a, I mean it's, they even label it in the first couple paragraphs. It's a pseudo experiment that's really based on abstracting data at a very high level. So I can't wait to see more data come out. I'd love to make some data happen out of the VA. I just don't know if the Chen and Chen paper really reflects reality. I don't know if anybody else had thoughts on that.

- Jamie, you're also VA too. What what are your opinions?

- [Jamie] I think my opinion would be more based on just personal bias. It would not be grounded in any kind of real research. But you know, I think that, that's a really good point that you make. But about like we're not sure if it's really happening in real life. But I did see, you know Doctor Chen is, he's a part of the, that the research group at the VA. So it seems to me like he would be very knowledgeable on how to really sort out that data. And, I did read probably like the 20, the first 20 pages of the study. It's just, like everybody else, I'm struggling getting through it. And the way that they selected out, it seemed legit to me. But, you know I will say that just at a personal level, when I speak to my specialist at the ER and what I'm seeing at the ER, you know the, the NPs and the PAs, they really are not required to come check out to us. Like when I first started working there five years ago, you know, I saw the deficit and that's why I became, I felt so strongly about supervision at that point. Before that I had worked in a system where supervision was a given. So when I saw them, I offered every single NP and PA, I gave them the offer to come sit with me and present 100 percent of their patients to me because I saw the deficits and they didn't. And you know what? I can't make them. And so I saw, I would do their chart reviews and I would see that they were consulting inappropriately. They were treating a UTI five different ways. And it just depended on the day and the recommendations were arbitrary. And it made no sense to me. So I tend to want to believe what Chen wrote. I feel like it confirms my bias. I guess is the best way to say it. But, but I don't know, I'm not a researcher. So I can't really confirm anything.

- That may be great. We can have him on a workforce zoom and reach out to him. He can give us his opinions on it too.

- [Jamie] Yeah, it was my understanding that Gillian and everybody, didn't you all do an interview with him a few months ago? Gillian?

- I did not do an interview with him. I'm not sure if it was, like a different section of ACEP maybe did. That's possible, but I personally did not.

- [Jamie] Okay, I guess it was Chris. Chris Johnson. Wasn't it Chris Johnson? I do have a question while I have the microphone. The question is for Teresa. You know you were talking about, we have pounced on this information and we meet regularly with our legislators here in Louisiana. And we present your information. We started in presenting the VA information and of course we present all the LAVEN data. I come with a huge stack of papers and I, they make fun of me, but they take them. But my question to you is, how have you all used the data with your legislators? Has the medical society continued to present it to the legislators? Do you feel like there is, you know, a shift in thinking there? Because I know that it was pretty close to passing last year. You all did an excellent job suppressing the bill and it didn't. But I'm wondering have you've used it since then?

- Yeah it definitely, it's definitely come up in those one-on-one conversations, at least on my end when I meet with my legislators as well. And I'm confident that MSMA has through all their mechanisms of advocacy promoted it. So, yeah I think it's been really critical. I think it's been one of the really critical pieces of information because it's Mississippi data, it's about the catchment area for Hattiesburg clinic includes a lot of senators and legislators. So we're like these, this is your, this is what you know, this is the money that you're spending. So you can spend it safely or with quality or not. It's your choice.

- [Jamie] One of my constant frustrations with advocacy and I experienced this at the federal level too, and I think it's just politics is, every time we present, we give them the what they want. They change the goal posts, right? So, you know, you go and you testify and they say, well what you all need to come meet us in the off season. Then we meet them in the off season and they're like, well you all need data. So now we present them data and they're like, well now you all need to come testify again. And, it's a constant struggle. So--

- That is like the advocacy process, right? It is often a multi-year thing. It is getting to know them in the off cycle and making those connections and just coming back with more data. And it's just like again, and again, and again. I don't think I've had any success with something on the first try. I think even the Lorna Breen Act, you know took us a year and a half of meeting with legislators. That's just sort of a cycle of politics. That's frustrating but, it's that persistence, right? It is the showing up because the nurse practitioners definitely do. And that's why it's so important that we be involved and show them our data and like kind of keep at it to really show our advocacy too. But I, it's exhausting Jamie I get it. And thank you for--

- Absolutely, yeah.

- One of the things that I like those like, and it just echoes. This is, so I'm new to all of this. I jumped in, in Covid first scope specifically to this whole arena. And what I like about it is kinda highlighting what Debbie said is, you know saying look, it's really, really expensive and the care isn't the same. And, and then like, at the same time we've caught their attention with this one big thing. It'll hold for a while. And then kind of like nurturing it with other stuff like the education and you know, online schools and like all this other stuff. And like, I think the tide is changing. And I think you know, timing the delivery of that information is, I like it, it's fun.

- And I think now is a really great opportunity with the nursing school scandal out of Florida. We know that that's big, the fraud is out there. We've known fraud in the NP schools because we've seen it. We know how they're shallow, their clinical rotations can be. Some are way better than others, but some of the students really put more effort into it than others. So it's dependent on the learner. So this is a really good time because the nation has the attention with this that we can kind of segue into well you know, this is kind of going on for nurse practitioners as well.

- [Teresa] Right.

- So has anybody on this group used that, that new stuff from last week with anyone, any legislators?

- I'm waiting to meet with them and see if they've heard about it, and oh you know. So we're, I'm still kinda letting it, letting the wave go. Because we're in session right now. So I'm just going to, I'm going to wait to see if I need to use that this year or next.

- Yeah I did send it out to a number of ours and sent them the article and some commentary on it. I have heard back from one of my state reps and maybe it's just appalling. And with the nurse compacts, that is, they could be anywhere. So, additionally we know because our nurse practitioner group in Louisiana, they really want independent practice. And the reason they gave to help them was that they could join the NP compact. They cannot be members of the nurse practitioner compact until they've had independent practice. So, we need to make sure that everyone knows that's making these legal decisions, this could happen with the compacts.

- With the Operation Nightingale, it was diplomas and transcripts, Right? It wasn't just the diploma because the nursing board's supposed to get copies of the transcripts too, so they had those ready? All right I see it, thank you. Thank you.

- Well this has been a great session. I know if anyone has any extra questions for Doctor Camp-Rogers we can take them. I can get them to her offline if you didn't wanna mention it now.

- Debbie, there's a couple hands up. There's Tom Fisher.

- Oh sorry. I can't, there okay I'm sorry. I couldn't see them, thanks.

- Doctor Fisher you go first. You got the official logo behind you.

- No, thank you. One of the things that I would challenge the legislatures around rather than sort of going after the nurses, which sort is in his poor performance saying as the state legislator, how did your nursing board allow fake licenses to processed, right? What the oversight as the legislature are you providing of the process? That's really the sort of I think probably the most effective strategy here because you know, if anybody else had a fake license, they would be crucified. And the board that gave them the fake license would be crucified. So, I would, I think that's the question I would ask. Has your state looked in to see who has fake licenses? Right? You know, how are we protecting our patients here?

- Yeah. I think Becker's came out with something recently that was like telling hospitals to don't wait, please don't wait to find out from your state or the FBI that you know that there's a nurse that might have that. You know check on your own because it's going to take too long to go through 7,600 of them.

- Oh like the Georgia, and I know it's so much from Georgia, I forgot who basically ask the nurses to voluntarily surrender their licenses. Why are we asking to voluntarily surrender your license? If you had a fake driver's license, you would be in handcuffs.

- [Teresa] Oh, gosh.

- Does ACEP have any public response to this? Are we going to have a, like a public comment?

- Yeah again it's a challenging thing not to go after but you know, standing up for patient safety is praised. It's still being discussed and we're waiting for more facts to come in because it's still, right? You know, there's always the initial media hit but, we haven't really seen all the stuff.

- I think that's one thing I learned a lot as president last year is a lot of this news. It's sensationalized and you find out after the fact that there's a lot of facts that we're missing and then you have to like walk it back a little bit. So, I think you gotta get both sides of the story and hear all the information before an official statement is made. But, yeah we also participated in monthly meetings with the scope of practice partnership with the AMA. And I have not been on those meetings now that Chris has taken over, but I'm sure that will come up there as well.

- Okay. Doctor Mayer.

- I think Tom's in front of me, Tom?

- Oh, Tom. Oh sorry.

- I don't understand much on ceremony. Been doing this too long. I'm in my 40th year of this and I got to tell you what, I'm the curmudgeon decade so, you young folks have done a wonderful thing with this, with this specialty. Hats off to you. And I love the way the conclusion was written, in the study you've written that you got there. I've just got a little, that they, we failed to meet our goals in the primary care study. That is such a cool conclusion to a study. I'm saying I was wrong. That's just, I got a lot of respect for anybody who's got the, can you say balls in here? Who's got the guts to say it now. That's just cool.

- I agree.

- And as I watch us, so you'll get bored to death. Those of you in North Carolina know my brothers, your attorney general. I've got a lot of lawyers in my family. We lose as physicians. When you got old guys like me coming in and saying we're not making enough money, scope of practice protection all that, that's just, mmm. I think much more useful would be fully revealed. Looks like a duck, walks like a duck. It's a duck. So I'm in Iowa where the nurse practitioners have independent practice. So they can walk into a room and say, Hi I'm Doctor so-and-so that have the DNP sticker on. Then why when there's a problem, if the patient under the concept of looks like a duck, walks like a duck, it's a duck, their in a healthcare setting, someone walks in, they say that they're a doctor, why doesn't that patient have the right when they sue to be held to the standard of care of a physician? That's what they walked in and represented as. I think those type of things will help us much more than saying, oh keep them away, because that's a self-inflicted wound. You've heard this saying every system precisely designed to achieve exactly the results it gets. We are here because we've been busy saying, oh there's not enough doctors. Woe is me, sky is falling. And here comes somebody else who's busy listening who says, oh pick me, pick me. I'm in part of a large healthcare system. And I've just been recently looking through our statistics. I come in from before the days of CAT scans, so I do CAT scans on about 8 to 9 percent of my patients. And a cash-based system, which we are, now ACOs generally are not, but unless they're capitated, Kaiser may be different. Unless they are, I don't want a physician with 40 years of experience. I want a brand new grad who one of our people orders CAT scans and 56 percent of their patients. I want that person in my ER because that's where I'm going to make the money. I just think we, we have to watch our arguments and understand how they can be turned in the opposite direction.

- Yeah I can speak to that. I agree in general, we never wanna advocate that we need more money. That sort of shuts down the whole conversation with legislators. When we've tried to say they should be held the same standard of care, nurses are not accountable to the medical board. They're only accountable to the nursing board, which makes it very frustrating. And we've tried to advocate that they are actually practicing medicine and therefore they should be held accountable to the medical board. And I think there was a resolution that actually came up last year, and I'll have to go back and see why, why that failed. But essentially the politics and the powers that be, are as long as they are, even if they're writing a prescription or diagnosing, evaluating, they have held that, that is not quote unquote practicing medicine. And so they're really only the oversight is to the nursing board who tends to look the other way and not hold them as accountable. The other reason is that plaintiff attorneys right go after the deeper pockets. They want the physicians, they want the hospitals, the nurses, that there's not as much incentive to go after them. So from a legal perspective, particularly if you have a state that requires that you sign the charts on someone, they're going after the bigger fish. And it's incredibly frustrating. But I know I don't have the latest updates, but I know that as an advocacy effort that ACEP is working on this as well.

- Yeah, CMS might be a good route. Put it in Medicare regulations because CMS is paying as if they are a physician. So if they're, if you're paying as a physician then, that would be your standard. But anyway I just, it's been interesting to watch. And on my ex, and my sister was one of the first nurse practitioners to give full responsibility, but she ran a neurosurgical unit with Doctor Schneider for many years before she went to be a nurse practitioner.

- And Doctor Mike Mayer.

- Yeah hi, I'm Dan Mayer. I'm a retired emergency medicine physician from Albany, New York. And, something else that ACEP is doing is in the medical legal committee, I'm leading a subcommittee to try and upgrade the previous position paper on advanced practice providers. It's got a different name, I don't remember that. And I think this has been incredibly helpful for us. I mean we recognize some of the issues that have been brought up, especially specifically the medical legal ones. And so we're trying to at least work on that. And certainly physicians shouldn't be responsible medically, legally responsible for any patient that they don't have medical responsibility. And where does medical responsibility start if you're in the same room but don't talk to that person? You know, our position is that we don't have any medical legal responsibility even though we maybe in the same room if they don't choose to add, to present the patient to us as Jamie said, or even if you know, if we have to sign the charts of a patient we haven't seen or haven't spoken to the physician, to the advanced practice provider about what's going to be our responsibility. So certainly we're working on that. I see Mark Olivier is on this. I think you're on that, on that group too, Mark. And so anyway, any input that you guys have, I will start signing up to come to your regular--

- Can I just, can I make one comment on it? It connects to the school comment that I had earlier and how whenever any of us, whether it's physician or nurse practitioner or PA does anything it's, but when did they learn it in school? And the reason I'm going to try and make this connection, I apologize. It's, when we think about people with, hmm, let me back up. I'll come back to it, sorry. It's too, it's sorry. There's, it's from a medical legal standpoint, it kind of echoes back to the question that we talked about earlier is, you know, one of the things that's not being asked, we're assuming that they were taught the information in the first place. And if you go back and you read Alexis Ochoa's, if you read the, the nurse practitioner that took care of Alexis Ochoa, if you read her testimony, they sued the hospital for hiring somebody that was not properly trained and they won. And they won 6.1 million dollars. The hospital closed six weeks later. They announced their closure in October. But the relationship's there. So if you read her testimony, she starts crying at the end of it and it's very moving. And she says, I didn't know. So, so there's to me, there's the system failure, right? If she didn't know, why was she there? And, and I don't think the hospital was at fault. I think the school was at fault. And I think the laws are at fault. And eventually I think that will, I don't know, I hope that, that issue will be resolved on our healthcare system. To me that's the main problem. But anyway, just food for thought. She didn't know. And because if you asked any of us, we would say I should have known, right? I should have seen that it was this particular diagnosis because I learned about it on all these days in residency or, you know, we can at least 99 percent of the time I should have known, I think. But food for thought.

- That is a great comment. Especially you know, my thought would be the Flexner report for NP schools. That is something that I've been passionate about and I had a resolution on that one last year too. But they need to be held to a better standard. They need to be teaching the things that the people need to know if they're going to be out doing this job. So yeah they're at fault.

- And incidentally, she went to a school that is a hundred percent online and has open book exams. So, just throwing throwing it out, sorry.

- I think we do have some plans then. Maybe we can invite Doctor Chen to our next one and we can go over some of that data from that study. I did want to thank Doctor Camp-Rogers for being here. Thank you so much. We've been putting this off since the fall. I really appreciate it and appreciate you and Doctor Lauderdale also. She had agreed to do it, but couldn't. And thanks for everyone for joining it. I did want to introduce Doctor Leon Alderman. He's on there. And he is going to be helping with our workforce newsletter. I know I've been working on my workforce Wednesdays and I'm not the best at this, but I don't know if anyone's had a chance to read Leon's newsletter, but he is fantastic and super organized. So Leon, if you wanna say something.

- Sure. Thanks Debbie. I really, really appreciate you having all of us here and, and the work that you're doing. It is really, really great stuff. And I do wanna give a shout out to Gillian. She was on, there's a podcast that I put a comment in at the beginning of the chat. If anybody wants to be inspired, I'd definitely listen, listen to that. So I'm Leon Edelman, I'm obviously an emergency physician, former medical director, and I'm kind of on this mission to bring transparency to the emergency medicine job market. Part of that is the Emergency Medicine Workforce newsletter, which I've been writing through Substack and cross-posting on the emergency, on the ACEP Workforce Facebook page. We're also creating the Emergency Medicine Workforce podcast, which Debbie has been interviewed for. That'll come out over the next few, probably a month and a half or so. And I'm also the founder of IV Clinicians, which has the, it's the only place that has connected every ER with which practice hires the physicians, PA's, nurse practitioners at that ER.

- So you will have some great data on that.

- Yes. Lots of data about to, so we're just doing some formatting, but there's some exciting data that'll be coming out. Probably next week, maybe two weeks.

- Okay. All right, if no one has any other questions. Oh, let's see what there's, I'm going to check some things in the chat, let's see. Yes we do need stricter supervision requirements. Definitely interested in how medical legal works this angle too. But we can, I can make some comments and kind of put a email together back to everyone. And then for those of your colleagues that missed it, we will have this recording up some time and we'll let you know when. So thanks everyone for being here, I appreciate it. Have a great Friday.