Physicians Taking Back Medicine: Is there an emergency physician in the house?

Editor’s Note: Welcome to the first episode of Physicians Taking Back Medicine, a new podcast from Medical Economics. Hosted by Dr. Rebekah Bernard, each episode dives into the real-world challenges facing today’s doctors. The show will explore how doctors can reclaim their autonomy and shape the future of health care with candid interviews and actionable insights. Join Dr. Bernard and her guests each month as she guides you toward an empowered and sustainable medical career. The views expressed in the episode do not necessarily reflect the views of Medical Economics or MJH Life Sciences. Scroll to the bottom for show notes, including topics and timestamps,music credits and more.

Consider this scenario: You are having a medical emergency. An ambulance takes you to the nearest emergency department, where you are met by a nurse practitioner (NP) or physician assistant (PA), who may or may not have extra training in emergency care. You ask for a physician, but there are none in the department, or even in the hospital. In fact, there isn’t even a physician available by telephone to guide the NP or PA in your care.

While this scenario may sound like the dystopian future, a new study reveals that in 2022, 7.4% of all emergency departments across the country had no physician on-site, with rates higher than 30% in some states. Of emergency departments staffed only by a NP or PA, 50% reported no access to a physician in the hospital and 19% had no access to a physician outside the hospital. Three percent of emergency departments without a physician on-site had no ability for the NP or PA to communicate with a physician at all.

Deborah Fletcher, MD, an emergency physician in Louisiana, helped to author the workforce study. “This is a survey that is sent out every other year to all of the emergency departments in the country,” she said, noting that this is the first time that the survey asked about physician staffing. “I wanted to see which departments had a physician 24/7, not to be punitive, but to find out the landscape.”

Fletcher said that she was shocked to find that so many facilities lacked physician staffing. “While 7.4% of emergency departments without physicians may not sound dreadful, that’s a total of 344 across the country, or 1 in thirteen.” Fletcher also notes that the count may be underestimated, as about a hundred departments did not answer the physician staffing question.

Episode topics and timestamps

Introduction to the Podcast (00:00:07)
Dr. Rebecca Bernard introduces the podcast and its focus on inspiring stories from physicians.

Meet the Guests (00:00:37)
Dr. Debbie Fletcher and Dr. Mercy Hylton share their backgrounds in emergency medicine.

Replacement of Physicians (00:00:53)
Discussion on the alarming trend of replacing physicians with non-physician practitioners in emergency departments.

Impact of Management Changes (00:01:15)
Dr. Fletcher recounts her experience of being replaced by a nurse practitioner due to management decisions.

Concerns During the Pandemic (00:02:28)
Dr. Hylton discusses the replacement of pediatricians with nurse practitioners during fluctuating emergency department volumes.

Patient Care and Supervision Issues (00:03:01)
Concerns about inadequate supervision and care for patients by non-physician practitioners.

Observations of Mismanagement (00:03:51)
Dr. Hylton shares experiences of patient mismanagement and safety concerns in emergency care.

Mismanagement in Emergency Departments (00:05:28)
Dr. Fletcher agrees on the mismanagement issues observed, including overconfidence among non-physician practitioners.

Study on Nurse Practitioners (00:06:36)
Dr. Hylton discusses a concerning study on the educational preparation of nurse practitioners in emergency departments.

Alarm on Educational Standards (00:08:34)
Discussion on the alarming findings regarding nurse practitioners' training and its implications for patient safety.

Workforce Study Initiative (00:08:43)
Dr. Fletcher initiates a workforce study to assess physician staffing in emergency departments.

Survey Findings on Physician Staffing (00:09:30)
Dr. Fletcher reveals alarming statistics about emergency departments lacking 24/7 physician staffing.

Access to Physician Communication (00:11:51)
Findings on the lack of two-way communication between non-physician staff and physicians in emergency departments.

Legislative Changes in Indiana (00:14:06)
Dr. Hylton shares her advocacy efforts leading to Indiana's law requiring physician presence in emergency departments.

Impact of the Alexis Ochoa Case (00:15:14)
Discussion of the tragic case that motivated Dr. Hylton's advocacy for patient safety in emergency care.

Legislation Journey (00:16:13)
Dr. Hylton details the process of getting legislation passed to ensure physician presence in emergency departments.

Legislative Advocacy (00:17:22)
Dr. Hylton discusses gathering data to support the need for physician staffing legislation.

Truth in Advertising for Emergency Departments (00:18:48)
Discussion on the importance of transparency in advertising emergency departments' staffing levels to patients.

Closing Remarks (00:20:09)
Dr. Rebecca Bernard thanks the guests for their advocacy work and concludes the episode.

The replacement of physicians by nonphysician practitioners (NPPs) is personal to Deborah Fletcher, who worked in a department that was staffed entirely by board certified emergency physicians for many years. In 2018, Fletcher’s employment contract was sold to new contract management group. “Initially, they said that things would not change, but in the spring of 2019, they decided that they would start the use of nurse practitioners and PAs,” she said.

The first move: to replace part-time physicians with NPPs.“I was working part time because I was also enjoying being a full-time mom. But I still wanted to use my skills and work as an emergency physician,” said Fletcher. “They told us that they needed to make space for the nonphysicians as they were supposedly less expensive to use.” Fletcher said that one of the top agency executives told her, “It’s just business.”

Emergency physician Mercy Hylton, MD, also has personal experience with physicians being replaced. “I practiced adult and pediatric emergency medicine in the Central Indiana area for close to 20 years,” she said, noting that changes in staffing accelerated during COVID-19. “During the pandemic our volumes really fluctuated a lot, very low at times, very high at times,” she said. “During all of this, the general pediatricians that provided double physician coverage for about half of the day were let go and replaced with nurse practitioners and physician assistants.

The remaining emergency physicians were expected to oversee the new NP and PA hires, in addition to medical students and residents. But Hylton said that the new staffing plan was inadequate for safe supervision. “When I questioned how I would be able to adequately supervise during times of high volume, since we previously had two supervising physicians and now there would be just one, I was told [by hospital leaders], ‘You won’t be able to see the patients yourself—you’ll just have to sign off on the chart.’”

Hylton felt uncomfortable. “I had been seeing a lot of mismanagement from NPs in primary care, urgent care, and from other emergency departments that referred to our specialty hospital,” she said. For example, she recalled a newborn baby that was diagnosed with poison ivy by a nurse practitioner. “My third-year medical student was immediately able to recognize the rash as herpes simplex virus, which could have been fatal in an infant if not recognized and properly treated.”

In addition to her personal experience, Hylton had reviewed an article from nurse researchers expressing concern about the training of NPs working in emergency departments. “They found that few nurse practitioners working in emergency departments were certified in emergency care—the vast majority were certified as family nurse practitioners,” Hylton said. Among NPs with emergency certification, research authors expressed concern about wide variability in training programs. “There were some programs that required as little as 180 clinical hours in emergency care, where others were closer to 600,” said Hylton, adding that some programs didn't require nurses to have any emergency room experience before enrolling in NP programs.“Ultimately, the research authors concluded that NPs should not perform independent, unsupervised care in the ED regardless of state law or hospital regulations in order to protect patient safety,” said Hylton.

With this knowledge, Hylton refused to oversee NPPs without proper supervision and left her position. “I felt that it was not safe for patients, and it was not safe for physicians from a liability standpoint,” she said, noting that she also had ethical concerns about patients being billed by the hospital for physician-level care while only being seen by an NP or PA.

While advocates for nurse practitioners and physician assistants argue for expanded scope of practice due to a ‘physician shortage,’ qualified and experienced physicians like Dr. Deborah Fletcher and Dr. Mercy Hylton’s five pediatrician colleagues were willing and able to work—but were replaced by nonphysician practitioners due to corporate ‘business’ decisions.

Unfortunately, replacing physicians has resulted in tragic consequences. In fact, Mercy Hylton points to the tragic death of Alexus Ochoa-Dawkins as a major motivator in her fight to ensure that emergency departments retain physicians on-site. In 2017, 19-year-old Alexus died when a family nurse practitioner working all alone in an Oklahoma emergency department failed to diagnose her pulmonary embolus.

“I read about the case in the book Patients at Risk, and it really touched me because Alexus was from my hometown,” said Hylton. “I had no idea that there were emergency departments anywhere without any physician present, much less in a state where I grew up and still have family.” As she researched the case, Hylton discovered that the large hospital system that owned the emergency department where Alexus was treated systematically replaced physicians with unqualified nurse practitioners to save money.Further, the emergency room wasn’t located in a rural area without access to physicians, but just a 35-minute ambulance ride from a major metropolitan city.

“It horrified me, so I started digging into Indiana's laws to see if that could that happen here,” said Hylton. “And what I found is that yes, it could. There was no requirement for a physician to be present in an emergency department.”Galvanized by this knowledge, Hylton joined other physicians to prevent similar deaths in her state.

At first, legislators weren’t convinced that there was a problem. “In the months before session started, State Senator Brown reached out asking why we needed this bill,” said Hylton. “She wanted to know the prevalence of emergency departments without a physician.”At the time, there was no published data on the issue, so Hylton reached out to colleagues on social media. “I posted on a national group of tens of thousands of emergency physicians asking if they were aware of any departments without 24/7 physician staffing,” said Hylton. “I received several hundred responses, including some very prestigious names. It was shocking.”

Thanks to efforts from advocates like emergency physician Mercy Hylton, in 2023, Indiana became the first state to require that all hospitals must have at least one physician on-site at all times that the emergency department is open. “We were trying to legislate a minimum safety standard, which is a physician who has training and experience in emergency care,” said Hylton. A year later, Virgina enacted a similar law requiring physician staffing of all emergency departments.

According to Hylton, one of the reasons that Indiana and Virginia were successful in passing this legislation was because most emergency departments in the stateswere already physician staffed. “Part of our argument to legislators was, we're not asking the hospitals to spend more money than they currently are on staffing. We're just asking that the standard that they have now does not get any worse.”

Hylton acknowledges that this type of legislation may be a tougher sell in states that have more than 30% of emergency departments staffed by non-physicians. “In this case, I would turn the legislative argument into truth and transparency: What does a layperson perceive of the level of care that they will receive when they go to an emergency department?” she said. “If there is no physician present, maybe you don’t call yourself an emergency department, but rather, a ‘triage and transfer center.’”

Hylton argues that the issue centers on a patient’s ability to choose the type of care that they want to receive. “To have true choice, patients need to know transparently what they can expect when they walk into a healthcare facility. The assumption that people make when they walk into an emergency department is that they will see a physician, and that’s not always the case.”

Hylton points to the lack of transparency about the care provided to Alexus Ochoa, whose family believed that a physician was treating her. “As Alexus got sicker and sicker, had her family known that a family nurse practitioner was treating her, they may have demanded that she be transferred to a physician,” said Hylton.