Are family physicians the answer to ED doctor shortage, or 'blasphemy'?
Professional organizations plan meeting to discuss alternatives
The debate has been simmering for a while, but it came to a boil recently when the American Academy of Family Physicians (AAFP) threw down the gauntlet with its recent position paper,
"Critical challenges for family medicine: delivering emergency medical care equipping family physicians for the 21st Century."1
"The evidence is clear that EM residency training programs will not meet workforce needs for decades, and family physicians will be needed in the work force,"1 the AAFP asserted. It went on to note that "[f]amily physicians are trained to provide emergency medical care through residency and post residency education . . ."1 That might be true, but as one observer put it, many emergency medicine professionals consider suggestions that family physicians join the ED staff to be "blasphemy."
The American College of Emergency Physicians (ACEP) doesn't go that far, but president Sandra M. Schneider, MD, FACEP, says "The gold standard for training is ED residency." ED residents spend three to four years training to be emergency physicians, Schneider says. "The family practice resident may spend one, two, or at most three months of training in the ED," Schneider observes. "We feel the difference between three months and three to four years is significant."
Having said that, however, Schneider says that there are some family physicians who have obtained through experience the skills necessary to provide emergency care in most situations. She believes credentialing should be based upon an individual's skills. "I also believe that individuals who work in EDs should have those essential skills before they start working," Schneider adds. That requirement is determined by the hospital. "Hospitals generally have a credentialing process where they talk to individuals who have seen this physician work and can state what their competency is with certain procedures and certain types of patients," Schneider says.
Another problem with moving family physicians into emergency medicine is that it might be a case of robbing Peter to pay Paul, she says. "Clearly we need more emergency physicians, but we also need more primary physicians," says Schneider. "Every time we pull one, particularly in a rural area, to work in the ED, they are not available to meet the needed primary care." Observers note that this need will become even stronger under the new health care law.
Kasimir Oganowski, MD, director of physician services for Premier Health Care Services in Dayton, OH, says, "All of us agree that there is this need a workforce problem stemming from the lack of residency-trained physicians and we need to find other avenues to bring other physicians into the workforce who can do the work." Oganowski says that he originally was trained in primary care, but now he has more than 21 years' experience in the ED.
"I agree the gold standard is a residency-trained, board certified doctor, but the reality is there are not enough of them," Oganowski says. "I was in a meeting yesterday in West Virginia, and all the EDs represented said they were one to two doctors short."
In an effort to meet that shortage, Premier has created a year-long training program for family physicians who are interested in practicing emergency medicine. Oganowski acknowledges the argument that there is also a shortage of family physicians, but he insists this program is not contributing to the problem. "We are not trying to take every primary care doctor out of their offices to bring them into the ED," he says. "What we are trying to do is accommodate a number of them who for various reasons want to do emergency medicine. We want to make sure as much as we can that they have the skills and knowledge to do that work." (For more on the Premier program, see the story below.)
For Schneider's part, she believes the solution to the ED physician shortage should be addressed by those organizations that represent ED professionals. "There is an ACEP study in process right now, and we will be making recommendations in January after bringing together all emergency medicine organizations to have a summit on this very issue," she says. "We believe we ought to be the ones to fill the need." (Look to upcoming issues of ED Management for coverage of those recommendations.)
Reference
- Gerard WA, Staffer A, Bullock K, et al. Family physicians in emergency medicine: new opportunities and critical challenges. Ann Fam Med 2010; 8:564-565.
Sources
For more information on family physicians in the ED, contact:
- Kasimir Oganowski, MD, Director of Physician Services, Premier Health Care Services, Dayton, OH. Phone: (800) 726-3627 Ext. 3468. E-mail: [email protected].
- Sandra M. Schneider, President, American College of Emergency Physicians, Irving, TX. Phone: (800) 798-1822.
Program trains family physicians Dayton, OH-based Premier Health Care Services, which places emergency medicine physicians and mid-level providers and staffs and manages hospital EDs, has instituted a year-long training program for family physicians interested in working with the ED. "We were unable to fill a lot of the staffing requirements with experienced, boarded, emergency medicine residency-trained physicians," says Jerry Tasset, MD, PhD, FACEP, who runs the program. Kasimir Oganowski, MD, director of physician services for Premier, adds, "We looked at the crisis, and as a group asked ourselves a question: How can we take care of this?" The program, which is now in its third year, has two main components, says Oganowski. "There is a didactic portion one day a week, typically four to six hours," he says. "During those sessions and during the year we use Tintinalli's Emergency Medicine: A Comprehensive Study Guide." In addition, he notes, all students participate in the American College of Emergency Physicians Ohio Chapter's emergency medicine board review course. "We have a procedures lab at Wright State [University, Dayton, OH] where they practice placing chest tubes, central lines, and other procedures," he says. Tasset says, "We have the lecture piece in the morning and a practicum in the afternoon with fresh cadavers. They spend 36 hours a week working with our emergency physicians in one of our EDs." The students take a provider course in Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ATLS). Oganowski says, "We test the physicians regularly, and evaluate them three times a year." Tasset says, "They have a teaching attending at the clinical sites that also monitor their progress and give feedback to us." Oganowski believes such a program provides a viable alternative to board-trained emergency physicians when there are an insufficient number of them available. "Our goal is when they finish our program they can go to work in an ED and with confidence take care of anything that comes through the door," says Oganowski. Feedback from ED managers who have hired graduates convinces him that goal has been achieved, he adds. Source For more information on training family physicians for the ED, contact:
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