October 10, 2019

ACEP Workforce and the Cosmos

I spent the Labor Day weekend with a group of medical school classmates in Amagansett, Rhode Island. One of my classmates shared with me was that he had just finished reading Astrophysics for People in a Hurry by Neal DeGrasse Tyson. DeGrasse Tyson starts the book with “In the beginning, nearly fourteen billion years ago, all space and all the known matter and all energy of the known universe was contained in a volume less than one-trillionth the size of the period that ends this sentence.” He then describes how this developed into particle soup in two minutes and then into the cosmos in billions of years. I shared with my classmate that I had recently read Seven Brief Lessons on Physics by Carlo Rovelli. One of the takeaways for me in that book was the concept that gravity is not a force, as I had been taught, but instead is a shift in the time-space continuum caused by entities with mass.

For the last two days I have been reading DeGrasse Tyson’s book while traveling on the Rocky Mountaineer train from Vancouver, BC to Banff, Alberta. He describes the development of the cosmos, dark energy, dark matter and the concept that the cosmos is expanding. Many of these are entities or forces that astrophysicists have discovered or proposed in an effort to explain how the cosmos and celestial bodies have been observed to behave. Reading this while traveling through some of the most majestic and beautiful landscape in North America is about as much as my mind can accommodate at one time. It is almost like a busy Monday in the single staffed ED where I work.

What does this have to do with the Workforce section of ACEP? Carlo Rovelli’s redefinition of gravity reminds me of the saying that 50% of what we learn in medical school is ultimately found to be false. The problem is as students we don’t know which 50% is which. DeGrasse Tyson’s one-trillionth of the period reminds me of the small number of hard-working visionaries that founded emergency medicine  (EM) and the leadership that has guided us to where we are in 2019. DeGrasse Tyson’s descriptions of the entities and forces proposed to guide and explain the behavior of the cosmos and celestial bodies reminds me of the variables that impact our practice of EM and the shifts in the workforce that we have and are continuing to experience.

EMTALA, HIPAA, The Patient Protection and Affordable Care Act (Obama care), EHRs, CMS, MIPS and quality measures are a few of the regulatory bodies and regulations that have impacted our practice. The EM workforce is evolving. The use of “physician extenders” (PA’s, NP’s), with or without direct or indirect physician supervision, is growing. There is the model used in Mississippi where physician assistants (PA) or nurse practitioners (NP) staff emergency departments with physician telemedicine back up. There is the model used in Iowa where PA’s and/or NP’s are trained by the referral tertiary care centers and practice independently. Lastly, there is the issue of non-ABEM or non-AOBEM physicians practicing EM. We tried to get a handle on the extent of this in Tennessee. We looked at the American Medical Association specialty registration for physicians practicing EM in Tennessee and about ten years ago we estimated 25-30% were non-EM trained. That is changing with three EM training programs now in Tennessee and more hospital boards requiring ABEM certification to practice, although we do have at least one family practice EM fellowship in Tennessee.

The question I advance to you is what role should the Workforce Section play moving forward? Two presidents ago developed “type of practice” grouping and definitions. The goal was to determine the type of practice the ACEP membership was engaged in; academic, military, rural, community, urban, trauma center, etc. Do we want to focus on the extenders? We have reached out to the Emergency Nurses Association (ENA). There continues to be discussion about reaching out to family practice in that a majority of the non-ABEM or non-AOBEM physician practitioners are from the family practice community.

Years ago, I worked with a Chief of Surgery who when approached with questions such as this would respond with “show me the data”. I think the data to help guide these decisions would be how many patients (or what percent of patients) are treated by extenders with or without physician supervision. How many patients (or what percent of patients) are treated by non-ABEM or non-AOBEM physicians? Let us discuss this at the ACEP Scientific Assembly Workforce Section meeting Tuesday, October 29 12:30-2:30 PM at the Colorado Convention Center room 706.

Thom R. Mitchell, MD, FACEP