The employment of physician assistants (PAs) and nurse practitioners (NPs) has increased dramatically in emergency departments (EDs). Their participation in emergency care fills a critical need by providing enhanced access to emergency medicine (EM) resulting from emergency physician shortages and increased demand for emergency care. Menchine published the results of a survey reviewing the increased utilization of Midlevel providers over the 10-year period from 1997 to 2006.1 Over that period, use of midlevel providers in hospital EDs increased from 28% to more than 77%. Further, more than 12% of all ED patients were cared for by physician assistants or nurse practitioners, with the absolute number growing from 5.2 million to 15.2 million ED patients managed by midlevel providers. In light of this trend, it is crucial for the ED Leader to have a clear working knowledge of the education, background, and issues surrounding the utilization of these nonphysician practitioners (NPPs). Though “advanced practice clinicians,” “allied health professionals,” and a myriad of other names are used, NPPs will be used in this chapter to refer to PAs and NPs working in the ED.
PAs in Emergency Medicine
The fact that most emergency physicians have more familiarity and experience with PAs than NPs has a historical etiology. Since the mid-1960s under the leadership of Dr Eugene Stead,2 at Duke University, PAs have practiced alongside emergency physicians. The evolution of emergency medicine as a physician specialty paralleled the evolution and development of the physician assistant profession. Emergency physicians were among the earliest adopters of this evolving profession. The American College of Emergency Physicians worked in tandem with the American Academy of Physician Assistants and played an important part in the formulation and development of the PA profession from its earliest beginnings.
Today there are well over 75,000 clinically practicing PAs with approximately 10% specializing in emergency medicine. In fact, emergency medicine represents the second largest specialty practice of physician assistants, superseded only by the combined surgical specialties and subspecialties. These phenomena might well be traced to those historical precedents of early involvement of emergency physicians in the training and development of physician assistants. Not surprisingly, this tandem evolution created a profession that fits well into the mindset and performance of emergency medicine practice.
PAs practice medicine with the supervision of licensed physicians. This has been an unwavering tenet of the profession since its development over 40 years ago. The PA profession has long aligned itself with medicine and the physicians who practice and supervise it.
Although by law PAs are dependent practitioners, typically they exercise considerable autonomy and clinical decision-making in many ED practice settings. In most cases, the relationship between the physician and PA is one of mutual trust, respect, and reliance. The emergency physician trusts the PA to provide the same or similar quality care to ...