Meeting critical needs
‘Legacy physicians,’ facing workforce issues key to reshaping emergency care
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.