First study of impact of NPs, PAs on emergency medicine physician trainees cause for concern

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Most medical students and resident physicians in academic medical centers today work side-by-side with nonphysician practitioners (NPPs)—nurse practitioners (NPs) and physician assistants (PAs). While teaching facilities report resident work-hour restrictions as a leading cause for hiring NPPs, little research has been performed to evaluate the impact of these NPPs on resident physician education. According to Andrew W. Phillips, MD, MEd, the lead author of a new study evaluating the effect of NPPs on emergency medicine resident physicians, there is cause for concern.

“Most residents in our study reported that NPs and PAs in the emergency department detracted from their education,” said Phillips, noting that one factor was the forfeiture of procedures, especially at academic centers with postgraduate training programs for NPPs.Phillips said that the study also found a lack of confidence by residents that local leadership or the Accreditation Council for Graduate Medical Education (ACGME) would address concerns from medical trainees about the impact of NPPs.

Study outcomes

Effects of Non-physician Practitioners on Emergency Medicine Physician Resident Education was published in May 2023 in the Western Journal of Emergency Medicine. The survey, which was distributed to emergency medicine residents across the country, found that 66.9% reported a detracting or greatly detracting impact on their education caused by NPP presence in training facilities. The survey also identified a significant loss of procedure opportunities, which was greatest at facilities that included postgraduate training programs for NPPs, where emergency physician residents reported a 14x increased loss of procedure opportunities.

Lead author Andrew Phillips said that while procedure forfeiture may have contributed to the reported negative impact on resident education, analysis shows that this was not the ultimate cause. “When we compared residents at facilities with NPP postgraduate programs with far more procedure loss against those without, there was no difference in the overall negative education impact.” Because of the study design, Phillips cannot make conclusions about the exact cause of the negative impact on resident education but notes that qualitative data suggests factors like a loss of patient variety, attending physicians who are supervising NPPs, and time required for residents to teach NP/PA students.

One finding that surprised Phillips was that 60 percent of survey respondents reported no benefit of the NPP role in their education. “This finding was quite striking,” said Phillips. “With medicine taking a multidisciplinary approach, we would hope to see some benefit for all stakeholders, including residents.” While some residents reported logistical assistance from NPPs, such as how to access resources, Phillips said that the qualitative data was disappointing. “The residents spoke quite firmly that in general, NPP presence was not a benefit to their education.”

While previous studies have shown an improvement in workload among surgical residents working with NPPs, 40% of emergency physician residents reported no impact. “While 45% reported that workload was a little lighter, the qualitative data showed that NPP presence did not make a big difference on meaningful workload, such as charting time,” said Phillips.

Procedure forfeiture

Across all procedures, 57 percent of residents reported forfeiting at least one procedure to an NPP during an emergency department (ED) rotation and 59.5 percent during a non-ED rotation. In addition, residents reported that NPPs taught or supervised them in procedures 15 percent of the time in the ED and 38% of the time on other clinical rotations.

Narrative responses to explain the loss of procedure opportunities in the emergency department revealed several themes: Direct competition, especially for NP and PA postgraduate students to practice procedures (31%), unit culture, such as attending preference to have NPPs perform procedures rather than residents (16.7%), failure of NPPs to offer procedures to residents (10%), and intimidation by NPPs (7.6%).

Lead author Andrew Phillips expressed concern about decreasing procedure opportunities for physicians. “It’s not just learning how to do a procedure; it’s doing enough of them so that you know what to do when things go wrong.” For example, as an emergency physician himself, Phillips said that he tells residents, “If you haven’t hit the carotid artery doing a central line, you haven’t done enough of them,” noting that this is a known complication that occurs once every two to three thousand procedures. “You have to know what to do when this inevitably happens.”

Residents afraid to report concerns

While most emergency medicine residents reported a detracting impact of NPPs on their education, survey respondents reported being ‘not confident at all’ in the ability to raise concerns about NPPs to local leadership (33.5%) or the Accreditation Council for Graduate Medical Education (ACGME) (65.2%) without retribution. “Residents feel that their education is being compromised but lack confidence that local leadership or the ACGME would address any of their concerns,” said lead author Andrew Phillips. “That’s a problem. I think we can all agree that if there’s a concern of any major stakeholder, that needs to be heard and addressed.”

Concerns about retribution may be one reason that the issue of NPPs on resident education has not been addressed in the scientific literature. According to Phillips, researchers have been strongly dissuaded from even studying the issue. “It’s a very politically charged topic,” he said. “It’s the medicine equivalent of religion and politics that you can’t bring up at a dinner party.” In fact, this controversy is part of what motivated Phillips to investigate the subject. “My colleague had an idea and wanted to pursue research on the impact of NPPs on emergency physician trainees, but was threatened with termination,” said Phillips.“It bothered me terribly, because I firmly believe that we should be able to have an open conversation about research—we should be able to research any topic and ask any question.”

Phillips, who has a research background and authored a book on survey methods for medical and health profession education, made it his mission to evaluate the subject as fairly as possible. “We went through great lengths to make it something that was as unbiased as possible. We sent it around to multiple individuals, including non-physicians and other survey experts to make sure that the language was as neutral as possible,” saud Phillips. “We just asked—what is the impact of having NPPs in your emergency department during your training?” Answer choices included ‘greatly helped, helped some, neutral, detracted, greatly detracted.’ “We wanted the chips to fall wherever they were. The item was available for them to say, ‘this is fantastic, we learn a ton from them, they’re super helpful,’” said Phillips. “But that’s not where things generally laid out.”

Phillips hopes that this study prompts further conversations on the topic. “I hope that academic and emergency medical societies tackle this subject and are willing to do follow-up studies to ask the broader questions,” including the impact on NPPs. “I think we need to have a broader understanding about how NPs and PAs feel about this, too,” he said. “I suspect that they are going to say that they’re not getting enough procedures, either. There’s got to be a way to ensure that everyone within their role in the emergency department gets the education that they need to care for patients safely.” He suggests that further research explore programs where residents reported positive comments. “There is a lot of variety, and identifying those programs that have made this work is going to be number one, to start aligning practice models in a helpful way.”

Rebekah Bernard, M.D., is a family physician in Fort Myers, Florida, and the coauthor of “Physician Wellness: The Rock Star Doctor’s Guide.”