The APP Residency: A New Program for Rural Emergency Departments

As the Chairman of Emergency Medicine at Western Maryland Health System in Cumberland, I love that I get to make a difference in the lives of my patients and colleagues every day. But it’s not easy.

Cumberland sits at the base of the Appalachian Mountains. It’s a gorgeous area, with plentiful hiking, skiing, fishing, and other outdoor activities. The downtown is charming and historic. Over the years, the city has served as a military outpost led by George Washington and even been dubbed “The Gateway to the West.” 

Despite these qualities, it’s difficult to attract high-quality physician talent to this rural area. Cumberland is just a little over a two-hour drive from Baltimore and Washington, DC.

Physician recruitment challenges and financially-oriented hospitals

We have a coming together of two challenging forces when trying to provide good care to patients in the emergency department in rural areas: One is that it can be difficult to recruit high-quality physicians to practice in these areas and two is that hospitals are just becoming more accountable for their finances, along with new regulations focusing on the quality of care.

Let’s parse that apart a bit. Many of our truly talented emergency department physicians drive 140 miles away from their families and even stay overnight between shifts to serve patients in the emergency room at Western Maryland because they truly enjoy the hospital and caring for the patients in this area.

Today, hospitals have no choice but to be more efficient and profitable. In the old days, the financial driver for hospitals was volume, however now there are quality metrics built in, along with new hospital reimbursement models unique to Maryland — and that has led to increased accountability for the management and outcomes of patients.

Still, our goal is the same as it ever was: To provide high-quality care to our patients. Today, we need to do that while keeping an eye on many other moving targets, such as throughput, patient satisfaction, and volume.

Solution: A residency model for APPs

Most emergency room physicians, if they’re being honest, will tell you that a good portion of the care they provide to patients could be done by physician assistants and nurse practitioners with proper guidance and support. If that’s the case, can we utilize this concept to provide excellent care in a more cost-effective manner? I believe this approach will allow us to be successful, while responding to the shortage of physicians in rural communities.

Enter an exciting new program at Western Maryland where an emergency department physician will lead the care of patients and work with an integrated team of Advance Practice Providers (AAPs) to provide direct supervision. In this model – one I’d compare to a residency program – APPs will be working with patients in a hands-on way, taking their history, ordering appropriate testing, and managing their disposition.

The physician will also be seeing these patients and providing any course correction that needs to be done, along with providing real-time education to the team.

The benefits

In this program, an emergency room physician will be available to supervise two APPs. APPs will communicate one-on-one with patients and accurately assess how they’re doing. The role of the emergency room physician will be to educate, supervise, and guide the management of patient care, and to step in and assume the care of more complex patients as needed.

Emergency room physicians went through four years of medical school, in addition to a three- or four-year residency. They are ideally suited to guiding the care of well-qualified APPs, who decided to pursue a medical career in rural areas. These APPs also want to make a real difference in the lives of their patients and serve the community.

Good judgement and following protocols are key

What’s key is the APP’s good judgement: He or she needs to know what they can handle and what they can’t handle.

Say, for example, an APP walks into a patient’s room, and the patient has low blood pressure, a high fever, and diabetes. That’s relatively easy to treat. Say, though, that you have a patient who looks fine. His vitals are good, he’s taking steroids, and he has an immune disorder – and a funky-looking rash.

That’s where having a physician supervising and guiding patient care matters, though in this model, all patients will be seen by the physician in addition to the APP.

Vital: Rigorous quality review and adherence to care protocols

Two of the program’s core features are a rigorous quality review and a set of very specific protocols for care. It’s critical to the success of this program that everyone feels comfortable with it. We need to make sure we’re following set protocols and guidelines – in addition to retrospective chart review – to ensure that the care delivered to patients is of the top quality that we expect.

An added bonus? The APP’s knowledge base will continually grow with the added education this model provides. We expect this will lead to greater work satisfaction for both APPs and physicians.

The program is launching at Western Maryland in January, and I look forward to providing an update on our success as the program develops. I’m particularly passionate about the anticipated increase in patient satisfaction, since patients should expect to see a medical professional more quickly and the extra set of eyes provided by the model will improve patient safety.