Meet­ing crit­i­cal needs

‘Legacy physi­cians,’ fac­ing work­force is­sues key to re­shap­ing emer­gency care

Modern Healthcare - - OPINIONS COMMENTARY - Drs. Danny Greig, W. An­thony Ger­ard, Kim Bul­lock and Kim Yu

Many health­care lead­ers have looked to hospi­tal emer­gency de­part­ments as a log­i­cal fo­cus for im­ple­ment­ing changes in their sys­tems. Emer­gency de­part­ments have al­ways served as the main en­try por­tal into hos­pi­tals, and the qual­ity of care de­liv­ered by a hospi­tal sys­tem be­gins with the emer­gency depart­ment. Strate­gies for im­prove­ment in­clude op­ti­miz­ing work flow, im­proved care path­ways, tech­no­log­i­cal ad­vances and im­proved physi­cian and nurs­ing per­for­mance. Trans­form­ing emer­gency de­part­ments to meet mod­ern de­mands is crit­i­cal to the vi­a­bil­ity of hos­pi­tals and health sys­tems, and physi­cian work­force is­sues are a key com­po­nent in this change.

Health­care lead­ers need to have a clear un­der­stand­ing of the is­sues af­fect­ing the emer­gency medicine work­force. Stan­dards for emer­gency physi­cian per­for­mance should not base physi­cian com­pe­tence solely on res­i­dency train­ing in emer­gency medicine. The U.S. has a short­age of emer­gency medicine res­i­dency-trained physi­cians, and ac­cess to high-qual­ity care de­pends on emer­gency physi­cians who trained in other spe­cial­ties. In­creas­ing use of mid-level providers has helped emer­gency de­part­ments with high vol­umes, but these providers can­not re­place emer­gency physi­cians.

Emer­gency medicine be­came an es­tab­lished spe­cialty more than 40 years ago and was founded by fam­ily physi­cians and pri­ma­rycare-trained physi­cians. Emer­gency medicine res­i­dency pro­grams have brought ex­cel­lence to the spe­cialty, trans­form­ing emer­gency care into a dis­ci­pline. Although it was ini­tially be­lieved that emer­gency medicine res­i­den­cies would pro­duce enough emer­gency physi­cians to meet the na­tion’s needs, data show that this is un­likely. Pro­vid­ing a high-qual­ity work­force still de­pends on “legacy physi­cians,” who trained in other spe­cial­ties and sub­se­quently fo­cused on a ca­reer in emer­gency medicine.

Although the strengths of emer­gency medicine res­i­dency-trained physi­cians are an as­set to the spe­cialty, emer­gency depart­ment en­vi­ron­ments vary de­pend­ing on pa­tient vol­ume, lo­ca­tion and avail­abil­ity of con­sul­tants. Ur­ban and aca­demic emer­gency de­part­ments are dif­fer­ent from those in com­mu­nity and ru­ral set­tings. In some de­part­ments, the large ma­jor­ity of care pro­vided is “acute pri­mary care,” punc­tu­ated by trauma or crit­i­cal pa­tients who need to be sta­bi­lized for trans­fer be­cause of a lack of lo­cal ac­cess to con­sul­tants and tech­nol­ogy.

The com­plex­i­ties of the physi­cian work­force is­sue are not amend­able to a “one-size-fits-all” model.

Be­cause of this vari­abil­ity, the ideal so­lu­tion to emer­gency depart­ment work­force is­sues is not clear, and emer­gency physi­cians who have train­ing in pri­mary care may be ide­ally suited for many of these set­tings. The spec­trum of emer­gency de­part­ments varies and the com­plex­i­ties of the physi­cian work­force is­sue are not amenable to a “one-size-fits-all” model, but fam­ily physi­cians have a unique role in ru­ral and com­mu­nity hos­pi­tals.

Fam­ily medicine train­ing pro­grams have served as a re­source for cre­den­tial­ing physi­cians to staff emer­gency de­part­ments in ur­ban, com­mu­nity, ru­ral and re­mote ar­eas. These physi­cians are es­sen­tial to en­sur­ing na­tion­wide ac­cess to emer­gency care. An Amer­i­can Academy of Fam­ily Physi­cians pol­icy state­ment says: “The train­ing en­vi­ron­ment for most of to­day’s emer­gency medicine res­i­den­cies is one where spe­cialty con­sul­tants and ad­vanced tech­nol­ogy are read­ily avail­able to the emer­gency physi­cian to as­sist in the as­sess­ment and care of their pa­tients. Most ru­ral and re­mote emer­gency de­part­ments lack those kinds of re­sources, and (fam­ily physi­cians) de­pend upon their own best clin­i­cal skills and judg­ment to a greater de­gree. In these ar­eas, the ideal physi­cian is a gen­er­al­ist with ex­per­tise in emer­gency medicine.”

The pa­tient-cen­tered med­i­cal home model has driven a par­a­digm shift in health­care per­for­mance im­prove­ment, and fam­ily physi­cians are trained in “pa­tient-cen­tered care,” an as­set to the kind of in­ter­per­sonal skills that im­prove pa­tient sat­is­fac­tion scores. Hospi­tal lead­ers of­ten bring in con­sul­tants to coach physi­cians, and the con­cept of pa­tient-cen­tered care is likely to have pos­i­tive im­pacts on physi­cian per­for­mance. All emer­gency physi­cians would ben­e­fit from adopt­ing these prin­ci­ples, which in­clude qual­ity and safety, ev­i­dence-based medicine, use of clin­i­cal decision-sup­port tools, an un­der­stand­ing of cul­tural dif­fer­ences and shared de­ci­sion­mak­ing be­tween physi­cians, pa­tients and fam­i­lies.

A co­op­er­a­tive ap­proach to work­force staffing in emer­gency de­part­ments was rec­om­mended in the In­sti­tute of Medicine’s re­port on emer­gency care. Emer­gency medicine res­i­dency-trained physi­cians should col­lab­o­rate with pri­mary-care-trained emer­gency physi­cians to pro­vide lead­er­ship and clin­i­cal ex­cel­lence. The Com­pre­hen­sive Ad­vanced Life Sup­port Course, fo­cus­ing on ru­ral emer­gency medicine, is an ex­cel­lent ex­am­ple of this since it was jointly de­vel­oped by fam­ily and emer­gency medicine lead­ers.

A firm grasp of work­force is­sues that ex­ist in emer­gency medicine should help guide health­care ex­ec­u­tives in the com­plex de­ci­sions needed to im­prove per­for­mance and pa­tient sat­is­fac­tion. The aca­demic lead­er­ship of res­i­dency-trained emer­gency physi­cians is wellestab­lished but the im­por­tance of “legacy” emer­gency physi­cians and fam­ily physi­cians who pro­vide emer­gency care must be rec­og­nized. De­ci­sions about work­force must in­cor­po­rate these con­cepts, par­tic­u­larly in ru­ral and com­mu­nity hos­pi­tals. Meet­ing the needs of a new health­care sys­tem will re­quire a more col­lab­o­ra­tive model that rec­og­nizes that the “ideal” emer­gency physi­cian varies with dif­fer­ent emer­gency depart­ment set­tings.

Dr. Danny Greig is chair of AAFP Spe­cial In­ter­est Group-emer­gency Medicine. Drs. W. An­thony Ger­ard, Kim Bul­lock and Kim Yu are co-au­thors of the SIG-EM.

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