Knock, knock... who's there?

Who is staffing our emergency rooms these days? Around these parts, it's a hot topic. When I first moved to this town to start my residency training in emergency medicine, one of the teaching hospitals affiliated with the university had undergone a pretty dramatic upheaval. For some reason not fully understood, the hospital emergency room was being staffed by Med-Emerg, a medical staffing agency. Basically, they take over responsibility for staffing the emergency room. This was significant as it required pulling all residents out of this hospital, as Med-Emerg staff were not affiliated with the university and therefore not able to teach residents. Word around the Valium fountain in the Emergency Department was that they staffed ED's with fresh grads, most of whom didn't have any emerg training. Family doctors who got paid handsomely to drop in and staff a shift with no commitment to the hospital or the community. I'm not entirely sure why docs affiliated with this agency are instantly deemed inferior, but it definitely had an impact on the residency training in our academic centre. After the Med-Emerg one year contract with the hospital expired, the hospital was again staffed by university-affiliated staff docs. And now, residents are back in the ED there.

The Med-Emerg solution is costly, but probably better than the other alternative to EDs facing severe staffing shortages. Another ED in the region facing closure due to staff shortages managed to stay open by recruiting a CCFP-EM resident (a resident who has finished training in family medicine and is currently doing an additional year of training to specialize in emergency medicine) to cover its weekend shifts. This was widely reported in the news at the time, trumpeted as a 'partnership' between medical academia and the government to meed the regions needs.

Crazy. This wasn't a success! This was a clear failure of the system. The ED had to reach into the pool of medical trainees for staff-- while I'm impressed that the resident in question had the cojones to work without backup in a busy emergency department just two months after finishing her family medicine residency, I wouldn't have felt comfortable in that situation. Why would I be doing a third year in emergency medicine if I could just walk into an ED with nothing but my family medicine certification and an 'interest' in emergency medicine and work without concern?

This is likely to happen more and more often in a system where supply is clearly falling short of meeting demand. In Canada, there are 27 spots in FRCP Emergency Medicine each year. Twenty-seven. For ALL of CANADA. The year I matched there were about 75 applicants for these positions. Granted, these are the spots intended for academic positions in emergency medicine, but it still seems like a ridiculously small number. In the stream that I'm in, the CCFP-EM program, there are about 6 spots for each academic centre. In spite of that, there is still considerable competition for these training spots. So my point is that the lack of qualified staff to man emergency departments is certainly not from lack of interest on behalf of residents.

Now things seem to be going one step further. Out east, one politician believes that the solution lies in staffing emergency departments with nurse practitioners and paramedics. I'm not sure how, in the words of Kevin, M.D., NP + paramedic = ER doc. Paramedics are not trained in any way to diagnose disease. The paramedics scope of practice pretty much ends at assessment. Treatment is only given insofar as it fits into one of numerous protocols set forth by the BLS Manual. Advanced Care Paramedics do have an extended scope of practice, but again are not trained to diagnose disease. I do not understand the role that they are intended to play in replacing physicians at the helm of the emergency department.

I'm not putting doctors on a pedestal here. In fact, I've never really understood the difference between a primary care nurse practitioner and a primary care physician. Both may assess and examine the patient, both may order diagnostic tests, both may diagnose disease, both may prescribe and/or administer treatment. So if nurses can do all this, why have primary care physicians at all? What can they do that NP's can't?

My exposure to NP's has been restricted to academic centres. I've worked with them in the dialysis unit, in the NICU and in the PICU. Their role in those places seems to be similar to that of the Physician Assistant in the U.S. (we don't have PA's in Canada)-- but they work as members of a team, not independently from the physician. So you can understand my confusion when it comes to the role of NP's practicing independently in the community. I know this happens in remote places, but I've never had first-hand experience.

When I think about it, though, it's kind of frustrating for the primary care physician. NP's are trained in just 12 months (if they hold a university B.Sc.N) or 24 months (if they held a college nursing RN) according to this journal article. It's no wonder doctors are worried. Compare that to the university degree (4 years), medical school (4 years) and residency (2 years minimum) completed by a primary care physician and it's easy to understand why there might be resistance to declaring the two equivalent. If a NP can do a family doctor's job, why would a wanna-be family doctor bother doing medical school at all? Not when the same end may be accomplished with half the years of training and a fraction of the debt load.

Seems like a shortsighted solution to the physician staffing problem.