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.


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

  1. Edna Birch says:

    I am a senior citizen, age 67 and was taken to the ER by ambulance not knowing I had pneumonia, but knowing I was very ill. Because of the greed of for profit hospitals, and advertising they wills see patients in 30 min or less, the EMT’s were told to divert me past a monitored ER bed, in their new multi million dollar ER and divereted to a closed ER room in the rear of the hospital that is unstaffed. I am a retired RN Certified Risk Manager and the care in hospitals these days makes me sick. To think, that a PA or even RN can assess an elderly patient, brought in in obvious distress and then not being placed in a hospital bed, because it will tie up that bed, so that the staff can not make their quotas to see all patients in 30 min or less, in order to herd patients through the ER little cattle should make everyone concerned.

    My white blood count was 25800 and I had a right middle lobe pneumonia. I was having chest pain over the site of the pneumonia, and I told a RN my medical history, that included six shoulder surgeries, including tendon repairs on each, allergergies to two antibiotics, etc. I was never undressed, I was in street clothes including sneakers, yet the ER physician who never examined me, documented a physical he never did. I had to google his name to see what he looked like and found in on Utube ( a jogger), He said my family history was neg, I was adopted I do not know my family history. I was left a lone in this closed room, there was no call light system, no telephone. I knew I was very ill and not being care for. I asked for a telephone and was refused, I tried to get the bed rail down on the 20 year old guerney and couldn’t. I asked that my husband be called and was refused. He is 69 and waiting at home for a call from the ER physican that never came. I could not get to the bathroom, I could not get a drink, they knew I was on meds that should not be stopped, but the ER physician did not order them, and ordered nothing for the pain I was in, a very signficant one. I was in this room for six hours with only three visits from a RN, and she did not check my vitals. This ER phsician ordered Levoquoin 750 mg IV for me but did not give a rate, so three hours after they found out I had pneumonia the RN gave it by IV push, isntead of over a 90 min period. They knew I was sensitve to antibiotics but left me unattended and unmonitored. I was in this room until 4 a.m. when I was taken to telemetry. The ER physician discharged from his care two hours after arrival, however I did not get admitted to another physician’s care on telemetry until 10 a.m.the next day, that left me 14 hours, being a patient in a hospital but not under the care of any physician.

    Within 24 hours I developed an adverse drug reaction to Levoquoin that included a pleural effusion that kept getting worse over one week, because no one recognized it was an adverse drug reaction. I developed an anemia and received a unit of blood, I was type and cross matched wrong, and received the wrong blood. In addition there were other medication errors and omissions.

    The idea that patients will be seen in 30 min or less, as a marketing took and to rush patinets through is dangerous, as in my case they knew I was a senior, and ill, and that I would take up a monitored ER bed. Instead of transfering me, as I requested, I was left alone without any monitoring. The ER physician discharged me in guarded care to telemetry because I needed monitoring but failed to have me monitored in their own ER.

    I had to be readmitted to another hospital within one week of discharge with complications of the Levoquoin and damge to one of my lungs, and the neuropathy nerve damage to my legs is permant. I reported the hosp. to the Health and Senior Services, the doctor, who worked for a private company, resigned after I complained. I have reported him to the Medical Examiner’s board for his practice. I have notified my politicians and asked them to change existing laws for elder abuse, to include not only nursing homes but acute care hospitals.

    PA’s or nurses may be able to treat a sprain, or a laceration, but when it comes to a senior, who comes in very ill, we should have a right to a monitored hospital bed in the ER, and we deserve to be examined by an experienced MD, when we have critical blood values, and a pneumonia that can be fatal in someone my age. I was in seclusion in that room, and the restraints were side rails I could not get down. I was denied access to my husband, and refused transfer to another hospital.

    Now some may feel you have all the answers, but you don’t. I have 45 years experience as a nurse and a Risk Manager, and this hospital placed my life in danger. I was given a drug that I had an adverse reaction to, I was given the wrong blood type. I have permanent damage to my legs, and have been told, that instead of any longer walking around I should use a walker. So do not tell me the advantage of PA’s seeing patients, unless there is some security system for people like myself, seniors who are very ill but don’t know what is wrong. I felt like a sick animal, picked up by a spca vehicle and locked up until a medical treatment would be offered. this is what happens, when for profit hospitals try to see patients in thirty min or less, and staff are monitored on this performance scale. Their raise is based on their performance. Is it there fault, not always no, but in my case a RN should have insisted I be placed in a monitored hosp. bed until the telemetry bed was open, and why was it only open at 4 a.m when I arrived by 9 pm? Now this hospital and personnel will have to answer questions, and I will pursue this and speak out so other seniors do not get treated the way I was.

    • Edna Birch says:

      When I said I was given the wrong blood type, I will add this. I developed an anemia which is an adverse reaction to Levoquioin, and required a transfusion. I was type and cross matched wrong, and given the wrong unit of blood.

      • Edna Birch says:

        I will also add this final comment, I would have gladly been seem by a resident in the emergency room, I know a resident would have been thorough, and would have ensured I would have been undressed, placed in a hosp. gown, given a proper physical and tests, placed me on monitoring to include cardiac, oxygen, blood pressure, respiratory etc. Antibiotics would have been started immediately, when my lab values came back BTW the WBC were not the only abnormal values. I would have had oxygen started, the head of the bed would have been raised ( the head of the guerney would not raise) and I would have been monitored closely to ensure I did not have an adverse drug reaction. A resident would have known that the FDA has warned that Levoquoin is contraindicated in a patient over sixty, with tendon disease, which I have and used another antibiotic. I have been told at another hosp. I should never received that drug. In addition, I would have received pain medication and it would have made breathing easier, and my meds, which my family doctor ordered, would have been continued so I didn’t have missed doses for 14 hours. A resident would not have left me 14 hours without a physican in charge of my care, or allowed me to be alone in a secluded section of the hospital with no crash cart, no call light or telephone. I would trust a resident’s care any day instead of a doctor hired through some agency, who is paid by the hospital, and one who falsifiies medical records. I would not have had the bad outcomes. I have been in for teaching hospials, one the Medical Center hosp. of Vermont, and always received excellent care. Resident’s would not have allowed the care I received, and I would not have been abused as an elderly patient. So if a Resident sees any patient in an emergency room setting you are more safe then you are if a physician’s assistant sees you, who may not be qualififed, and under pressure to keep beds open so the waiting times remain under 30 min. Angry, yes I am and I am going to keep speaking out. The solutions to more patients being seen in emergency rooms are not to hire more physician assistants, but to cut down on the number of non emergency cases, by ensuring there are more walk in clinics who can see sprains, colds, ear infections etc.

    • Mo says:

      Thank you for the comment above. One important component of good patient care is to respect the patient as you want to be respected. It would do a world of good for the clinician to turn the table around and think of oneself as the patient. In this switched setting where you are now the patient, what would you expect of your clinician. Remember that the patient is a person with feeling, with family, with good and expectation. In the above comment, I am confused. Were you seen by emergency physician or a PA?

  2. Elizabeth says:

    With all due respect, Emmy, the fact that “he generally treated you like you were an idiot” is not associated with any level of training, and in my experience, sometimes providers with less training (PAs, NPs, interns, residents, and nurses) are better than attending physicians at helping patients understand their conditions and listening to their concerns (certainly, there are exceptions).

    You do of course have the right to see a physician, but this does not mean that anyone will listen to your needs better, or provide you with better care. I have a friend who is a PA, and she found a lung cancer in a patient who was told by his doctor that “nothing was wrong with his heart, so go home and don’t worry about it.”

    You probably understand your medical condition much better than the average patient, so please dont’ get offended if you feel like a medical provider is “treating you like an idiot.” Many of us dumb down our language a bit because some patients would not understand what a “cardiologist” was, even if they had seen one for 20 years (you would be surprised). However, if you feel that anyone is not listening to you, or ignoring your needs, please bring this up. As a patient, you absolutely have the right to have a say in your treatment, have your questions answered, and your needs experessed. (I’m a PA student, by the way).

  3. emmy says:

    Very respectfully, I realize that you need to finish your training. But the last resident in the emergency room who took care of me told me that I needed to change EP’s because my EP no longer was affiliated with the hospital and could not consult with them. He then looked at my QTc of 550 and inverted T waves and told me that I didn’t have Long QT Syndrome and beta blockers weren’t the right treatment for it anyway. When I refused Zofran and Kytril for my nausea because they are on the Arizona CERTS list, he ordered Ondansetron and told me it was Phenergan. And didn’t listen to me when I told him the pain I was in was because my potassium level was 2.3 and would be alleviated when the level went up. Instead he ordered morphine when my heart rate was hoovering in the low 50’s. He generally treated me like I was an idiot and didn’t know anything about this body that I’ve lived with my whole life. There are reasons why some of us insist on having physicians.

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