Medical Justice provides free 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 free consultation – or use the tool shared below.

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 free 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 free consultation – or use the tool shared below.

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 over 50 combined years of 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.