When I came here in 2000, we had two physician assistants working in the emergency department (one of whom recently retired). A couple of years later, I hired the first nurse practitioner. (She’s still with us, and recently got her Doctor of Nursing Practice degree.) We now have a dozen advanced practice providers in emergency medicine, and they see roughly 20% of our patients either alone or together with a physician. Our APPs not only provide excellent patient care, but they participate in the education of students and residents. Our approach has been one of a team of professionals, with complementary if somewhat overlapping roles. This growing role of APPs is paralleled in the practice as a whole. One-third of the CSG membership now consists of advanced practice providers. In many of our specialties, they are a critical part of our workforce, a great example of our values of collaboration and innovation. Nationally, nurse practitioners, physician assistants, pharmacists, and other providers are increasingly seen as a way to address shortages of physicians, and to attempt to maximize value by providing high quality care at a lower cost.
Interestingly, despite our commitment to innovation, academic centers in general, and children’s hospitals in particular, seem to have been slow to adopt this innovation. About five years ago a colleague did an informal survey of nine academic pediatric EDs. We were one of only five that used APPs at all, the only one that used them in both the main ED as well as a “fast track,” and had 50% more APP coverage than the next highest.
The growth of the APP role has not been without controversy, both in our practice and in the larger community. There has been a good deal of media discussion lately about scope of practice, quality, cost, and other issues related to the appropriate workforce composition. Two recent articles shed some light on some of the tensions involved. A paper in NEJM reported on a survey of nearly 1000 primary care providers, approximately equally split between physicians and nurse practitioners. They appeared to do similar work: when asked about the services they provided, NPs and physicians generally reported a similar distribution except that physicians were much more likely to provide care of patients with chronic conditions that were not yet well controlled. Yet there were large differences of perspective between the groups. For example, while large majorities of both agreed that NPs should be able to practice to the full extent of their training and education, only 17% of physicians believed NPs should lead medical homes, vs. 82% of NPs. Physicians were far more likely to endorse the concept that physicians provide a “higher quality of examination and consultation”; 66% of physicians agreed with this statement, while 75% of NPs disagreed. And on the issue of pay, only 4% of physicians believed that NPs should be paid the same as physicians for providing the same services, compared with two-thirds of nurse practitioners.
What about patients and families? A study in the June issue of Health Affairs examined preferences of 2000 adults, the vast majority of whom had had prior experience with both physicians and advanced practice providers. When asked about which type of provider they would prefer if both were available, 50% had a preference for a physician, 25% for an APP, and 25% no preference. Perhaps as a sign of evolving attitudes, younger respondents were more likely both to have had a prior experience with an APP and to prefer one. And when specific clinical scenarios were probed, in which there was a trade-off in terms of timeliness – in one case, a choice between seeing an APP the same day or a physician the next day for worsening cough, and in the other seeing an APP the next day vs. a physician in 3 days for chronic persistent headaches – 60-67% preferred to see the APP sooner. This all suggests that APPs are highly acceptable to patients, especially if it means more timely care.
Taking the holistic view of quality as care that is effective, efficient, timely, safe, patient-centered, and equitable, it appears that APPs have an important role to play in assuring that quality, especially in an evolving healthcare environment. There are legal and attitudinal barriers to maximizing their potential, but I’m proud that CSG has been a leader among academic pediatric enterprises in innovating and embracing APPs as part of our team.