Last month, I wrote about provider satisfaction.  In that article, which you can read here, I discussed factors that affect provider satisfaction.  Professional development was one extrinsic factor that I wrote about in that article.  Soon after publication, I received an email from Doximity surveying professional development satisfaction, specifically among ER PAs.  To my surprise, 60% of respondents indicated dissatisfaction.  This hit a little too close to home for me.


I enjoyed my time in the ER, and it was not easy to leave the ER group I worked for and go back to Urgent Care, as I did last summer.  So, what leads to such a high rate of dissatisfaction for APPs in the ER?  What trends in Emergency Medicine could be contributing to this survey result?  In this article, I will discuss my answers to these questions and give my advice to current and aspiring ER APPs as they experience these issues firsthand.


The Draw of the ER


If you have spent any time in the ER during rotations or as a nurse, you know the ER is not for everyone.  From the moment I finished my last ER rotation, I knew I wanted to be an ER provider.  My personality thrives in chaos, so I naturally loved the fast pace the ER provided.  I loved the challenge of managing acutely ill patients and how this made me a stronger and more confident provider.  Most providers I know that thrive in ER have similarities: The desire to improve their skills, the ability to tolerate a flexible shift-work schedule, and an appreciation for the increased compensation that comes with it.

high acuity


Inside Look at the ER


ER layouts will differ based on location and patient volume.  Larger ERs will have several different areas where patients are seen.  Areas will be a variation of these: A fast-track area with lower acuity patients staffed with a Nurse Practitioner or a Physician Assistant, a section for high-acuity and trauma cases, and a step-down area responsible for patients requiring intermediate care and smaller workups.

Every ER runs a slightly different operation.  I have worked at two places with differing staffing models.  The private ER group I worked with staffs their APPs on a rotational schedule, allowing them to work shifts across fast-track, step-down, and higher acuity areas.  The smaller corporate hospital I worked for did not have a designated fast-track area.  Still, the APPs were expected to see the lower acuity patients, primarily level 4s and 5s, with occasional level 3s slipping onto my board.  The two experiences were drastically different, and I doubt it will surprise you that I only worked at the corporate hospital for six months before giving that up.



My experience and opinion of being an ER provider may be skewed because I worked for a small, private ER group.  Although I ultimately left because there was no room for continued growth, I appreciated other parts of the job and still enjoy working shifts there occasionally.

In my opinion, the utilization of APPs directly relates to job satisfaction.  In emergency medicine, the two trends I have seen increasing are at two different ends of the spectrum.  At one end, rural hospitals are moving to staff their ERs solely with APPs and do not require a physician to be present 24/7.  On the other end, many larger hospital systems are moving to utilizing APPs in high-traffic, low-acuity areas like fast-track.  What role would you prefer?  Could pushing APPs to fast-track areas contribute to lower satisfaction and a lack of professional development among ER providers?


The Fast Track Experience


To answer these questions, let’s talk about what working fast-track as an APP is like.  It is no secret that busy ERs need a fast-track area because 30-50% of the patients who end up in the ER could have their needs met in an Urgent Care.  However, the Emergency Medical Treatment and Labor Act (EMTALA) mandates that all individuals seeking emergency care must be attended to, leading to a need to quickly move patients in and out who do not require extensive workups.

It makes financial sense for hospitals and ER groups to use APPs in these areas as “meat movers” over physicians.  Although this is not the most glorious part of the ER to work in, it does have some advantages.


Advantages of Fast Track

I’ve never met an ER provider who is happy seeing coughs and colds day in and day out, but working in the fast-track area has benefits.  The autonomy of running the area without needing constant consultation with physicians is appealing.  Also, sometimes, it is a nice change of pace from seeing sick people and worrying about your patient’s outcomes to seeing minor injuries and illnesses.  However, we can never get too comfortable because we know triage isn’t foolproof.  The fast-track shifts flow easily with little hiccups.  Although you will see a higher patient volume, patient turnovers are quick, and your charts are easier to burn through with low-acuity patients.


Disadvantages of Fast Track

While the occasional change of pace can be refreshing, the allure of the ER lies in its unpredictability.  Without any thrill, it is difficult to put up with the crappy hours, unpleasant conversations with specialists, and to deal with hospital politics.  Ultimately, if your staffing requirements in the ER were predominantly fast-track, the advantage of working in emergency medicine over an Urgent Care setting with potentially better hours would be diminished, at least for most providers, with increased pay perhaps being the only remaining draw to the ER.


Treating Higher Acuity Patients


Ideally, you get to work for a place that allows you to rotate through all the different areas.  However, if you find yourself in a rural hospital alone, you’ll be required to see high-acuity patients without backup.  Unfortunately, most of these places are desperate for staffing and aren’t too picky about the providers they hire.  You will form this opinion yourself if you ever receive a transfer from these rural providers.  Their resources are limited; you are typically alone in the ER and are expected to see and stabilize every patient that comes through the door.  Managing these types of patients can be challenging, especially when you are new.  On top of treating these patients, dealing with specialists, consults, transfers, and hospital admitting teams is challenging to learn.  Perhaps these jobs are more suited for APPs who complete emergency medicine fellowship programs or those with years of ER experience.

If you are fortunate enough to find an ER that allows you to rotate through areas and have physician support, this is an ideal learning environment for new ER providers.  You will have the opportunity to grow and gain experience with sick patients.  Learning to collaborate with a physician on complex patients while maintaining a degree of autonomy creates professional growth.  You have the advantage of seeing high-acuity patients and increasing your confidence as a provider without risking your license.


Financial Choice for Hospitals


Financial considerations fuel the staffing decisions hospitals make.  In rural hospitals, it is challenging to find physicians because nobody wants to live in those areas, and the physicians will typically make less money.  Hiring an APP in these areas is cheaper and easier, but you must be careful before taking on these types of jobs.  Although you will see fewer patients, you won’t have specialty backup and might find yourself in potentially overwhelming situations.  Without experience or advanced training, this could negatively impact your satisfaction as a provider.

In larger hospitals, utilizing APPs to manage lower acuity patients and reserving physicians for trauma and high-acuity cases is financially advantageous.  Given the expense of employing physicians, leveraging APPs to oversee a large, fast-track area presents a cost-saving opportunity.  This approach not only streamlines patient flow and reduces wait times but also potentially boosts patient volume, as each APP can efficiently manage 30-40 low-acuity patients per shift.  Both trends are financial choices that can affect provider satisfaction.



The dissatisfaction expressed by 60% of surveyed ER PAs regarding professional development prompts reflection on the consequences of these trends.  Limiting APPs to low acuity cases may attract less experienced providers, potentially comprising the skill level and experience within the ER team.  Furthermore, decreased opportunities for professional growth and limited exposure to challenging cases may lead to increased turnover rates among seasoned providers.  APPs who have been around for years and are accustomed to managing high-acuity cases could face skill erosion if confined to fast-track staffing.  This would be a loss for the individual provider and the healthcare team since seasoned APPs bring experience and expertise to the table to train the next generation of APPs.

Using inexperienced providers in rural areas can create potentially unsafe patient encounters.  Feeling overwhelmed doesn’t precipitate a healthy learning environment.  I would not recommend a rural job unless you have training and experience.  You don’t want to find yourself in a potentially dangerous situation without backup while learning to be a good provider.




Although I doubt these trends are the only factors contributing to the dissatisfaction among ER APPs, I certainly think they are playing a part.  My tips for employers would be to foster a culture of continuous learning and provide opportunities for leadership roles.  For ER APPs or aspiring ER APPs, I encourage you to find a group that will utilize your skills across the ER.  If you can find a place that will provide you with opportunities to learn and improve your skills, this will be invaluable for the rest of your career.  If you want to work solo in a smaller ER, consider seeking advanced training to avoid finding yourself on the wrong end of a patient encounter.

While I understand the business rationale behind the hospital decisions for the staffing models we discussed, I encourage you, as the provider that this affects, to understand the value that your skills bring to a team.  Don’t settle in a job where you don’t feel appreciated or utilized.  Please share your thoughts with us in the comments.  How do you think APPs should be used in the ER?  Subscribe to Business is the Best Medicine if you want to hear discussions about content like this.