Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
The AMA brought national media attention to a recent study, The Productivity of Professions: Evidence from the Emergency Department. This was a Working Paper by David Chan Jr. and Yiqun Chen for the National Bureau of Economic Research. The study used data to study patient outcomes and utilization costs between nurse practitioners and emergency physicians rendering care to patients in Veterans Health Administration hospital emergency departments between 2017 to 2020.
The authors concluded:
“Nurse practitioners (NPs) delivering emergency care without physician supervision or collaboration in the Veterans Health Administration (VHA) increase lengths of stay by 11% and raise 30‐day preventable hospitalizations by 20% compared with emergency physicians.”
The study noted NPs tended to order more tests and consult medical specialists more frequently in the ER compared to emergency physicians. The paper posited that this led to delays in admitting patients and contributed to worse outcomes.
The AMA news report stated, “Overall, the study shows that NPs increase the cost of ED care by 7%, or about $66 per patient. Increasing the number of NPs on duty to decrease wait times raised total health care spending by 15%, or $238 per case.”
To be fair, the authors noted:
“We show that the performance gap between NPs and physicians narrows as NPs gain more experience, suggesting that differences in training could explain some of the gap. The VA does not require NPs to be emergency certified (ENP). The majority are FNPs, meaning they are trained to practice family medicine. According to American Association of Nurse Practitioners, a survey of NPs working in emergency care identified 78% were certified as FNPs. Only 0.9% of NPs were emergency certified.”
In contrast, most ER Physicians ARE specialty trained in ER Medicine and Board certified.
The Cato Institute tried to make the case that adding NPs to the mix increases access to care. Still, even Cato conceded:
The VHA emergency medicine study that the AMA is touting makes no case against NPs and FNPs independently providing primary care. However, its findings do suggest that hospitals should prefer board‐certified ENPs to FNPs when staffing their emergency departments with non‐physicians.
Which brings me to this blog post “Emergency Medicine’s Popularity Plummets.”
“So, imagine the shock and awe that hit emergency medicine during Match Week 2023 when it was revealed that the number of unmatched positions had increased by more than 100X. That’s right, 555 residency spots were entered into the SOAP in March 2023. That’s out of just 3,011 total spots, meaning 18.4% of spots went unmatched. Compare that to internal medicine (545/11,911 = 4.6%) or family medicine (589/5,100 = 11.5%).
Emergency medicine has officially become the easiest specialty to match into. It is now the least competitive and arguably the least desirable to medical students.”
The author, Dr. James Dahle, an ER Physician, hypothesized the following reasons:
(a) Too many new residency positions.
(b) Jobs forecast suggesting supply will outpace demand.
(c) Pandemic. It was soul-crushing being in the ER during the COVID-19 pandemic.
(d) Job has gotten worse. EMTALA, HIPAA, Board certification hassles, assorted mandatory CME (stroke, trauma, opiates), merit badge medicine (ATLS, ACLS, PALS, etc.). 20-40% of patients are self-pay (aka no-pay). Laws against surprise billing have put downward pressure on ER Physician incomes.
If hospitals are staffed with NPs (who are not certified in emergency medicine), then the supply of those health care providers will be high and their costs lower than staffing with fully qualified board-certified emergency physicians.
Back to the NBER Working Paper:
“Compared to physicians, NPs incur greater resource costs to treat patients but achieve worse patient outcomes……Even under the most conservative assumptions, the resource costs implied by the lower productivity we find outweigh any salary savings from hiring NPs, despite NP wages that are half as much as physician wages. This reflects the outsize importance of productivity in modern health care, in which the utilization of considerable resources rests on the judgment of workers.”
My take:
Either increase the requirements for NPs to work in the ER, leveling the playing field -even if imperfectly (e.g., emergency training and certification), or shift the hiring to MORE ER physicians who have demonstrated throughout the years they know what they are doing. There honestly is no substitute for experience.
What do you think?
Medical Justice provides consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a consultation – or use the tool shared below.
“Can Medical Justice solve my problem?” Click here to review recent consultations…
all. Here’s a sample of typical recent consultation discussions…
- Former employee stole patient list. Now a competitor…
- Patient suing doctor in small claims court…
- Just received board complaint…
- Allegations of sexual harassment by employee…
- Patient filed police complaint doctor inappropriately touched her…
- DEA showed up to my office…
- Patient “extorting” me. “Pay me or I’ll slam you online.”
- My carrier wants me to settle. My case is fully defensible…
- My patient is demanding an unwarranted refund…
- How do I safely terminate doctor-patient relationship?
- How to avoid reporting to Data Bank…
- I want my day in court. But don’t want to risk my nest egg…
- Hospital wants to fire me…
- Sham peer review inappropriately limiting privileges…
- Can I safely use stem cells in my practice?
- Patient’s results are not what was expected…
- Just received request for medical records from an attorney…
- Just received notice of intent to sue…
- Just received summons for meritless case…
- Safely responding to negative online reviews…
We challenge you to supply us with a medico-legal obstacle we haven’t seen before. Know you are in good hands. Schedule your consultation below – or click here to visit our booking page.
Jeffrey Segal, MD, JD
Chief Executive Officer and Founder
Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.
Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.
Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.
In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.
Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2023 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With decades of combined experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.
Related:
Not mentioned in this discussion (unless I missed it) is the terrible hours necessary for emergency care physicians that destroy normal sleep patterns. Serving a protracted resident training trauma, and exquisitely difficult exams to pass board certification does not bode well for staffing ER’s
And the hospitals that build these departments are always looking to cut staffing costs. A way to do this is to deliberately under staff those clinics.
I see this locally. There is (another) huge hospital being built in the Las Vegas metro area not far from us. There is plenty of capital available for “bricks and mortar.”
But this supply will STOP as soon as staffing efforts start.
The very first thing that will happen will be for the corporations to reduce staffing.
There are so many comments that could be made regarding this and related topics.
1)The nurse practitioners save hospitals money by costing less in salary. They also generate more revenue by ordering more tests. They are also easier to control than those irascible physicians who try to uphold standards. So, hospitals prefer nurse practitioners to physicians.
2)The same issues have been documented in different studies with nurse anesthetists.
3)Having worked in rural hospitals for almost all my career, ER board certified physicians are rarer then hens teeth. Can the family practitioners, general practitioners, surgeons and other specialists be as effective as ER residency trained physicians? No. But that is not talked about. There is still a scarcity of ER residency trained physicians.
4)Increasing the standards for nurse practitioners to work in the ER, is never going to happen. You would have to contend with both the nursing boards of licensure in each state and the certification organization for each specialty of nurse practitioner. They would contend that they are already well enough trained. Interestingly enough, the nurse anesthetists contribute more by percentage of their practitioners and more in dollar amount per person, by a far larger margin than do anesthesiologists. This has been true for decades. We see the results when their lobbyists show up.
5)The boom or bust cycle of training residents continues in a number of specialties, but typically not neurosurgery, or orthopedics, urology, ENT, etc. Why? Because they tightly control the number of residents entering each year to keep an artificial shortage and keep demand high, and salaries high. Anesthesia goes through boom and bust periods. For years during the peak in supply there was a dearth in demand, and newly graduated residents and fellows could not get jobs or got very inferior jobs.
6)The inability to balance bill for hospital based physicians (RAP), radiologists, anesthesiologists, pathologists, (and we can include ER) has lead to a loss of revenue from those patient populations with commercial insurance. Reimbursement rates for medicare to anesthesiologists never got back to 1987 levels in the time I was in practice. Reimbursement rates never keep up with inflation or other costs. As a result of that and many regulatory pressures like EHR adoption in private practices, most physicians have just given up independence to be employed physicians. But as employed physicians can one advocate for one’s employer or the patient?
7)In situations that I am aware of from years ago, hospitals put high pressure to admit as many patients as possible on the ER physicians. In one case, with a patient that had burned through every family practitioner in town, the ER doctor was seeing this patient for a simple pneumonia. But he could not find any physician to admit the patient. Then he called me as chief of staff. My first question to the ER physician was why are you admitting a simple pneumonia patient at all. His answer was done with great bluster. “I have made up my mind to admit the patient”. I’ll spare you the rest of that individual story. But the hospital chain involved was fined huge amounts of money for the same practice.
8)The latest statistics also indicated (if I remember my numbers correctly) that there were 2000 more people graduating medical school then there were residency slots? How does that happen?
What do those poor grads do when they cannot get into residency training? That should never happen. These manpower issues have been going on for 40 years. There is no interest in solving these problems or they would have been solved long ago.
9)When a relative of mine was in the hospital last year with C diff a month after a wound infection and colon resection, they were admitted to the surgical service. But the diagnosis of Cdiff was not made immediately and the relative was starved for 4 days with just IV fluids, after losing 10% of their body weight after their surgery the month before. The surgical residents refused to allow a gastro enterology consult, until I demanded it. Then the diagnosis and treatment began. But that was a 4 day delay in diagnosis and treatment. So we have still more problems about communication, intellectual honesty and breaking down silos. The residents told me that they like to take care of everything within their service. Great if they are making the diagnosis, assuring proper treatment and seeing patient improvement. None of that was the case and they cannot admit it.
10)I feel for the ER docs, as they have one chance to make the right diagnosis. They can either admit a patient or discharge a patient. If they discharge a patient who should have been admitted, there is a real malpractice case waiting in the wings. But to have to contend with nurse pracs running the ERs, well why have the least qualified rather than the most qualified person seeing you? When I was in the ER 2 months ago with the aftermath of a kidney stone, doubled over in pain, I was only seen by the nurse prac in a major university teaching hospital. The physician on duty never saw me. I am sure we will be billed for a physician visit however.