Many physician assistants (PA) and nurse practitioners (NP) are drawn to the excitement and challenge of working in the emergency department (ED). "I fell in love with the fact that anything can happen in emergency medicine," says Igor Melnik, PA-C, a physician assistant practicing in Sacramento, Calif.
Melnik was first exposed to the ED as a technician, a job he held for 12 years before becoming a PA. "You have a large variety of patients you care for including pediatrics, geriatrics, oncology, orthopedics, and anyone else who comes through the door," he says. "I loved the idea of mastering multiple specialties, so it was the perfect place for me."
But despite his extensive ED experience, Melnik was a little nervous about making the leap to clinician after graduating from his PA program. Over the years, he'd personally watched many advanced providers struggle upon entering emergency medicine. The rigors of managing sick patients while trying to figure out charting, admissions, consultations, and discharges could quickly overwhelm new professionals.
Fortunately, Melnik found a way to bridge the gap. Vituity's advanced provider internship helps PAs and NPs make smooth, supported transitions to emergency medicine. In today's post, we'll take an in-depth look at the internship and its benefits for aspiring emergency medicine clinicians.
Emergency medicine's unique challenges
Many experts believe that employing PAs and NPs is the best way to meet the runaway demand for emergency care. Almost every ED in the country is now competing to hire emergency medicine advanced providers. But what happens once those recruits report for their first shifts?
Too often, new hires are expected to pull their weight with minimal training and onboarding. "The demand for advanced providers is so high that recruiters tend to overpromise when it comes to training and support," says Anthony Shultz, PA-C, who also practices in Sacramento. "But nine times out of ten, it never happens as described."
This is unfortunate given the high-stakes nature of emergency medicine. A typical advanced provider needs to manage six to ten patients at once while simultaneously charting cases in the EHR, requesting consults, wrangling admissions, and managing discharges.
"In a field where you have so much responsibility and literally hold patient's lives in your hands, it's too much to ask of someone with limited training," Shultz says.
It comes as no surprise to Shultz that a significant percentage of PAs and NPs last less than a year in emergency medicine. This is true not only for new professionals but also for seasoned clinicians transferring from other specialties.
Advanced providers determined to enter emergency medicine can pursue an additional year or so of training in the form of a post-master's certificate (for NPs) or fellowship (for PAs). But these programs don't always make financial sense for new graduates, many of whom are burdened with considerable student loan debt.
Ravneet Kang, PA-C, worked as a scribe in the Mercy General Hospital ED in Sacramento before attending PA school. But even with some real-life ED experience under his belt, he found himself between a rock and a hard place after graduation. "It's tough for new-grad PAs interested in emergency medicine," he says. "Common choices are applying for a competitive EM fellowship versus applying for an EM job, which usually requires experience."
Up to speed in just 3 months
Fortunately, both Melnik and Kang had the opportunity to participate in the pilot of Vituity's advanced provider internship in emergency medicine. As interns, they spent several months working in the EDs of both Mercy General Hospital and Methodist Hospital of Sacramento under the close supervision of experienced advanced providers and physicians.
The internship helps new grads transition to professional practice through a structured program of didactic learning, clinical education, and mentoring. Experience suggests the program speeds time to clinical competence while reducing stress and improving job satisfaction. This aligns with research suggesting clinicians who receive formal onboarding are 69% more likely to stay in their jobs for at least three years.
Vituity's internship also has financial benefits for new providers. Throughout the 12-week program, interns earn partial pay while participating in educational activities. After completion, they immediately start earning a full salary.
Here's a look at how the internship breaks down:
Upon accepting a position, new hires immediately participate in learning activities and an online orientation. They also have an opportunity to shadow providers at their practice site during the credentialing process.
Interns spend 8 to 10 hours per week following a structured program of reading and online education. Activities include journal readings, CME activities, and completing the Hippo EM Board Review program. Interns also attend a three-day EM boot camp.
Former interns say that the didactic portion of the course deepened skills learned in their NP and PA programs. "We studied cardiology in school, for example, but this was a nice refresher," Melnik says. "This time I could really focus on how it applied to emergency medicine."
Interns work three to four clinical shifts per week under the supervision of a preceptor (usually a senior advanced provider or emergency physician). Throughout their first month, they work in the main ED learning to manage the most acute patients.
"For the first couple of weeks, we saw only a couple patients per hour," Melnik says. "Our preceptor walked us through managing the patient from start to finish. We were trained to triage, order labs, consult, admit — everything in detail."
Kang also appreciated the opportunity to work with high-acuity patients as a new hire. "The goal the first month was to distinguish 'sick' versus 'not sick,'" he says. "Preceptors were willing to proctor and go through management and treatment plans along with the common procedures performed in the ED."
Shultz, who served as a preceptor for the pilot program, says there was concern at first that patients might feel overwhelmed with two clinicians in the room. However, the opposite turned out to be true. "They actually appreciated the fact that someone was supporting the new provider," he says. "They liked to see us working as a team."
After one month in the main ED, interns spend a second month caring for lower-acuity patients and a third month staffing the Rapid Medical Evaluation (RME) area. (At Vituity, RME is a team-based triage process that initiates early treatment and speeds patients to the right level of care.)
As they gain confidence and learn the flow of the department, interns gradually increase their patient loads. However, they still receive ongoing support and supervision. "Throughout the program, we were encouraged to work at our own pace and ask questions of our preceptors," Melnik says.
One-on-one support and mentoring
Interns meet with preceptors on a regular basis to review charts, practice reading diagnostic studies, and ask questions about clinical practice. Preceptors also discuss the intern's goals and concerns and offer constructive feedback.
"We focus on our jobs instead of worrying."
As a preceptor, Shultz has personally observed the benefits of the internship. "There's a striking difference between the former interns and the rest of the new hires six months out," he says. "They're far more confident and self-sufficient. They go home less stressed."
Kang agrees that the internship transformed his first year of practice. "Thanks to the internship, we are able to work efficiently and keep up with the ED pace — all in an effort to provide a high level of patient care," he says.
Kang also appreciated the teamwork and clinical education gained through great mentors who were willing to pass on their knowledge and experiences. "See one, do one, teach one. That's the motto," he says.
Vituity is currently working to roll out its advanced provider internships in emergency medicine and hospital medicine to new practice sites. The partnership is also exploring the option of establishing regional training centers so that all new hires can participate, regardless of where they will eventually practice.
Since the pilot, Vituity has also developed an abbreviated internship for experienced advanced providers interested in changing specialties. This "mini-internship" centers around onboarding and learning the unique clinical aspects of the specialty.
Having experienced the benefits firsthand, Kang is enthusiastic about expanding the internship. "I believe this should be the standard for new graduates everywhere," he says.
To learn more about advanced provider careers at Vituity, click here.