PA-rt of the Solution: Physician Assistants on the Emergency Department Front Line

It was the availability of Medicare and Medicaid in 1965 that ushered in a new era of healthcare in America. Until that time, hospitals were largely community funded and emergency care was limited. For the most part, doctors still visited patients in their home. In the 1970s and 1980s, emergency medicine became more exact. Professional organizations were formed; best practices established, and examinations and certifications within the field were required. Now, decades later, emergency care is at a crossroads as America struggles with the escalating costs of healthcare and the need for more trained medical professionals. Once more, emergency care departments are having to rethink how they deliver services while saving lives.

A visit to the emergency department (ED) is a common experience for most Americans. Whether you are the patient or someone you know is, it is the ED that treats the unexpected such as a car accident, broken bone, heart attack, or an ill child. For many of us, there is a sense of relief there is somewhere to go at any hour of the day or night. In fact, the latest statistics from 2016, as reported in Becker’s Hospital Review, indicate that in the U.S. there were 42 ED visits per 100 persons. And for the last 25 years, the number of visits by Americans to the ED has been going up year after year. Go to any ED at any hospital and you will find the same scenario: they are full of people.

Emergency Departments: The Litmus Test for American Healthcare

There are many reasons why emergency room visits continue to rise, even though it is one of the most expensive options in healthcare.

First, if a primary care doctor or other health practitioner is not available, people turn to EDs. Certainly, when it is midnight or off hours, the ED may be the only option. But there is another underlying problem—there are not enough primary care doctors, physician assistants, and nurse practitioners to take care of the population, regardless if they reside in the cities or rural towns. The ED may be the only place to go.

Second, there is a lack of awareness of options. People want the comprehensive care and attention the EDs provide. In the words of Dr. Paul Seward, an emergency room doctor for almost 50 years and author of Patient Care: Death and Life in the Emergency Room (Catapult, July 2018), “Using emergency departments to create access to healthcare is like putting a snowplow on a Porsche.”

Finally, by law, emergency departments cannot turn people away for treatment and are required to admit regardless of a person’s ability to pay. It is an incredible promise, but one that is taxing the system to capacity.

Despite these troubles, EDs provide immediate and lifesaving care. They are in their own unique ways responding to this critical problem.

Part of the Solution

One of the solutions is the increasing use of physician assistants (PA) on the front line of EDs. Although the intention of EDs is to treat severe and life threatening injuries, in reality, many patients use EDs for non-life threatening conditions, such as the flu, broken bones, cuts and viral infections. Without a doubt, PAs help shoulder the pressure of patient volume in the ED.

Working in an emergency department has compared to ‘drinking from a fire hydrant’ all day.

Since the first graduating class of Bay Path’s MS in Physician Assistant Studies in 2014, several physician assistant alumni have chosen to concentrate in emergency medicine. For Ernest Darkoh G’16, Nathanial Moore G’14, and Carly Muniz G’16, they couldn’t imagine being anywhere else but in the ED. When asked what specifically drew them to work in an environment that is a ceaseless hub of activity, their answers were all the same: you see patients at all ages and stages of their lives; you treat cases and situations that cut across the medical spectrum; and, most important, you are part of a supportive team of medical providers with an emphasis on the word team.

“Since I was a young boy, I knew I wanted a career in medicine. When I was growing up, my best friend’s father was an ED doctor at Mercy Medical Center,” states Ernest Darkoh. “I had the opportunity to shadow him, and I saw that the ED was an exciting place to practice medicine. From the moment I entered the PA program, I knew this was my area of focus. As a first-year PA student, I took part in a class trip to the UMass Memorial Medical Center and I was so impressed with the areas of specialties it offered, and it was a teaching hospital. When a position in the ED opened up, I applied. I feel very lucky to work here.” The UMass Memorial Medical Center is the clinical partner for the UMass Medical School, and the largest health care system in Central Massachusetts.

For Nathaniel “Than” Moore, it was a clinical rotation in an ED that convinced him this was his calling. “Initially, when I entered the PA program at Bay Path, I thought I would go into pediatrics or orthopedic medicine. But when I did my ED rotation at MaineGeneral Medical Center, I found it was the perfect blend of surgery, diagnostics, and other areas of medicine. I would be a master of all crafts.” Than applied and was accepted to a position at the University of Vermont Medical Center, a Level 1 trauma center and partner with the University of Vermont College of Medicine. The Center sees over 65,000 patients in a calendar year and serves a population area of over one million people.

Carly Muniz’s journey to the ED also began in her clinical rotations as a graduate student. “While I enjoyed aspects of all rotations, I realized on my first day of emergency medicine rotation that it was the best specialty for me. Emergency medicine is fast paced, requires technical skills, a vast knowledge of medicine in pediatrics to adolescents along with the elderly population, the ability to establish patient rapport within seconds and the aptitude to integrate limited information rapidly. Preceptors commented that my strengths included adapting rapidly to change, instilling confidence and trust with patients, having great communication and teamwork skills, including dealing with challenging personalities. This is why I chose Emergency Medicine!” Carly now works at the Holyoke Medical Center ED which was recently renovated in 2017. The state-of-the-art ED also has a Fast Track section which focuses on quick turn arounds—less than two hours—for patients with non-life threatening conditions.

The EDs of each of these Bay Path PAs may be strikingly different, but Ernest, Than and Carly each point to a positive feature that defines their roles— autonomy. Although they all work on teams and report to a doctor on call, they are expected to be independent and confident in their decision making. “The ED quickly developed my skills as a PA,” said Than. “With each new patient experience, I gained skills that attributed to my diverse skillset. There were cases that I became more comfortable treating. However, given the chaotic, humbling environment, I always knew when to turn to my fellow physician and PA colleagues with questions.”

Want to work in the ED? Here are some of the qualities you need.

Confidence is only one of the qualities a PA needs to succeed in the ED. “It’s so important to be a strong communicator,” according to Ernest. “Often, we are the first person the patient meets when they are brought through the door. We have to develop an instant relationship with the patient and communicate with them appropriately.”

Carly agrees with Ernest and adds: “You also need great teamwork skills. EDs are all about the team. Yet, individually, PAs need to be compassionate and optimistic. Finally, it’s important to separate work and home life. There needs to be a balance.” Than best summed up a typical day in the ED and the soft skills PAs need to succeed: “It is like ’drinking from a fire hydrant’ all day. Even though it is very rewarding, it can be very stressful. People are always coming up to you and asking questions. You have to keep a level and intelligent head on your shoulders and know your team has your back.”

Looking to the Future

At each of these hospitals, PAs already make up a significant percentage of the team, their numbers varying from shift to shift. They have learned, as well as many others, that the benefits of using PAs are enormous: lower costs, shared workload, enhanced patient attention, and increased throughput of patients resulting in better outcomes and overall environments for EDs. And the importance of PAs will only grow.

There is no doubt physician assistants help shoulder the pressure of increased patient volume in EDs.

The Association of American Medical Colleges forecasts that in 15 years the United States will face a deficit of up to 159,300 physicians. The American College of Emergency Physicians (ACEP) reaffirmed that saying, “there is currently a significant shortage of physicians appropriately trained and certified in emergency medicine.” Hospitals have already felt the squeeze and are turning to PAs, as well as nurse practitioners, to fill the gap in ED services. That makes the PA profession one of the most sought after career paths with the Bureau of Labor Statistics projecting that employment of physician assistants is expected to grow 37 percent by 2026, much faster than the average for many occupations.

Ernest, Than and Carly all agree it is inevitable that the numbers of PAs will increase in EDs. They are seeing that trend already. Yet, it is more than just statistics. As the profession has grown in reputation, people are growing accustomed to having a PA administer treatment. Sometimes, patients even ask for a PA. In the coming years, that may be a request heard over and over again.

Meet Carly Muniz G’16

Carly attended Our Lady of the Elms College, graduating with a major in biology and a minor in chemistry. In 2018, Carly was employee of the year for the ED at Holyoke Medical Center.

Meet Ernest Darkoh G’16

Raised in Springfield, MA, Ernest graduated from the University of Massachusetts Amherst with a degree in biology. A competitive individual, his favorite sport to play is basketball. Much like in the workplace, basketball always pushes Ernest to work harder and challenges him to be better.

Meet Nathaniel “Than” Moore G’14

Than Moore broke ground as a member of the inaugural class in the MS in Physician Assistant Studies. As an undergraduate, he attended Colby College, majoring in biology and mathematics. A New England native, he is an avid outdoorsman and also teaches a wilderness medicine course.