Patient Perceptions in the Emergency Department: Physicians, Physician Assistants, Nurse Practitioners

A recent survey in the American Journal of BioethicsPatient Willingness to Be Seen by Physician Assistants, Nurse Practitioners, and Residents in the Emergency Department: Does the Presumption of Assent Have an Empirical Basis?, indicates that 80 percent of patients expect to see a physician when they come to the emergency department. Parents were more insistent about their child see a physician or resident for even a minor condition such as a sprained ankle. Patients indicated a preference for seeing a resident alone for non-urgent conditions (60%) and compared to a physician assistant (42%). Interestingly, these numbers did not vary dramatically from a resident’s preference to see a resident alone (65%) over a physician assistant (38%). Patients willingness to see a nurse practitioner (NP) was less across the board, 32% of residents, 44% of non-medical patients, and 75% of physician assistants (PAs).

One of the greatest flaws of the study is a narrow patient population – English-speaking, educated, urban. Another point of interest would be to take a larger sample size and to stratify preferences based on age. The idea of NPs and PAs practicing in the emergency department is relatively new and has increased dramatically since the initiation of new duty hour regulations for residents in the 1990s. Their visibility may increase even more if the new ACGME duty hour rules pass this year (refer to a previous post, Resident Duty Hours: Loopholes in the New Regulations). The younger population of patients in the emergency department may be more willing to see PAs and NPs than the older population.

Another problem inherent in the study is that when you ask patients their preference for medical care in the hypothetical setting, it becomes difficult for them to answer the question honestly. In some ways, the act of posing the question itself – a question which relates directly to a patient’s expectations – biases people towards answering a certain way. It makes sense to prefer to see a practitioner with the most training – with physicians, followed by senior residents, at the top of the list – regardless of the medical problem. And the question which always lingers in the back of someone’s mind, especially in the hypothetical setting, is “what if the condition is a bad sprained ankle, or maybe a little worse – a break perhaps?” If, in a real situation, the patient is less concerned about this possibility, they may be more willing to see a nurse practitioner or PA.

One interesting question is whether these perceptions are changing over time – over the course of the last 5 years. My hypothesis is that they have, and that patients are becoming more comfortable being treated by practitioners without the MD behind their name. Another interesting question is whether years of experience matter – would a patient rather see a PA who has trained for 30 years, or an attending physician who has trained for 1 year? These questions further complicate matters.

Here is the bottom line, from my perspective as a health care provider: I think it is important for patients – and for residents, PAs, and NPs – to understand that the purpose of a hierarchy in medicine is to provide more support staff, not to compromise patient care. Our primary – and most important – job, as residents, PAs, and NPs, is to recognize our limitations and to ascertain whether one of our patients needs a higher level of care. Even patients who seem healthy may be sick. The common line in emergency medicine is, “Be humble or be humbled.” We need to keep this in mind with every patient we see and have a low threshold to ask for assistance.

The expectation that patients be seen by physicians is a longstanding one, but it is beginning to change. With ED volumes as high as they are, there are simply not enough emergency physicians to see every non-urgent patient . That expectation is not only unrealistic, but it is also not necessarily beneficial to patients. PAs are often very experienced at suturing simple lacerations or taking care of ankle sprains – and are often as good or better at it than physicians, depending on their experience level.

I think as times change, as PAs and NPs become more visible in the emergency department, and as long as we continue to remember our limitations as trainees (even attending physicians ask one other for help or advice from time to time, and emergency physicians call specialist consultants down to the ED if they are concerned about a patient), we will continue to provide good patient care in a health care system with a variety of trainees, all with different levels of experience and expertise.

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