Because emergency medicine is a recognized specialty, many hospital leaders assume that their emergency departments should be staffed by physicians who are residency trained in emergency medicine. Such residency training and board certification helps leaders feel assured that the physicians have achieved a certain standard.
However, there is a shortage of EM residency-trained physicians, a situation that requires a re-thinking of the ideal staff for EDs.
Fortunately, there are many fully competent emergency physicians who are not EM residency-trained. Many emergency physicians who originally trained in other specialties have been in practice for decades and are highly experienced and skilled. In fact, for rural and community hospitals, a family medicine-trained physician may be the ideal staff member or leader for the ED.
Varying ED Needs
Most of the research on ED staffing refers to data that over-represent academic centers and urban emergency departments. Such emphasis skews the thinking about ED staffing, because the skills that a physician needs to provide high-quality emergency care in an urban, academic medical center are different from those in a critical access hospital or a community hospital.
Urban emergency departments, where most emergency medicine residencies are located, see an entirely different spectrum of patients than rural, critical access hospitals or community hospitals. Although both settings provide acute primary care to an at-risk population, urban EDs see the most trauma and a disproportionate amount of substance abuse. On the other hand, critical access hospitals (the most remote hospitals) see a broad range of primary care patients who often have no access to other health care providers. Community hospitals, depending on their location and size, can resemble either urban or rural hospitals.
Another difference is that academic medical centers have access to such technology as MRIs, and they can use consultants to treat the most critically ill patients, such as those suffering from sepsis or trauma. In rural areas, emergency physicians often are working on their own, but still must provide the same level of care during the initial stages of resuscitation and stabilization.
For these reasons, hospital CEOs and other health care leaders should consider the individual needs of their emergency departments when they are hiring physicians to staff the ED.
The Benefits of the Family Physician
Family physicians are not new to the ED: They helped develop the specialty of emergency medicine and, in many areas of the nation, emergency physicians who trained in family medicine still provide the majority of emergency care.
A primary care physician's background provides a strong basis for ED care. First, they provide a broad spectrum of health care, a critical skill for EDs that see many patients seeking primary care or that lack access to specialists. In fact, EM residency-trained emergency physicians may need additional training in such fields as obstetrics if they plan to practice in the critical access hospitals.
Second, family physicians are trained in patient-centered care, so they may help improve patient satisfaction scores. The ED is often the front door of a hospital, requiring emergency physicians to excel in interpersonal skills, not just life-saving procedures.
The American Academy of Family Physicians recognizes the different requirements for academic and community EDs: "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" (AAFP Position Paper, "Critical Challenges for Family Medicine: Delivering Emergency Medical Care — Equipping Family Physicians for the 21st Century").
For some hospitals, enhanced training in trauma and other emergency medicine procedures may be needed for primary care physicians (as well as other health care providers such as nurses). The Comprehensive Advanced Life Support program, developed collaboratively by emergency medicine and family medicine leaders in rural Minnesota, is a good example of such training.
A Good Fit for Critical Care Hospitals
Although emergency departments benefit from the clinical excellence and leadership of residency-trained emergency physicians, a family physician may be the best choice for your hospital's ED. Primary care-trained physicians with additional emergency care skills can provide the spectrum of care required of community hospitals and critical access EDs, and they frequently have the bedside manner that makes patients feel comfortable and cared for.
There is no one-size-fits-all solution, but the strengths of family physicians who provide emergency care should be recognized and incorporated into decisions about workforce issues, especially in rural or community hospitals.
Danny Greig, M.D., F.A.A.F.P., is an emergency physician and a clinical faculty member in family medicine residency at MidMichigan Medical Center in Midland, Mich. W. Anthony Gerard, M.D., F.A.C.E.P., is an emergency physician at Good Samaritan Hospital in Lebanon, Pa., and an assistant clinical professor of family medicine at Penn State Milton S. Hershey Medical Center in Hershey, Pa. Kim Bullock, M.D., F.A.A.F.P., is the director of ambulatory care services in the emergency department of Providence Hospital and a clinical associate professor in family medicine at Georgetown Medical Center in Washington, D.C. Kim Yu, M.D., F.A.A.F.P., is a family physician in Dearborn Heights, Mich., and president of the South East Michigan Academy of Family Physicians.
The authors serve on the leadership team of the American Academy of Family Physicians Special Interest Group — Emergency Medicine. The authors wish to thank the AAFP for their support of family physicians who provide emergency care, with special thanks to Perry Pugno, M.D., M.P.H., F.A.A.F.P., F.A.C.P.E., vice president for education and staff liaison for the special interest group.