Family Medicine Embraces Emergency Care

Major Finding: Roughly 40% of family physicians in rural U.S. locations practice emergency care. In Arkansas, Montana, Nebraska, North Dakota, South Dakota, and Wyoming, 42%-51% practice emergency care.

Data Source: Data came from the American Board of Family Medicine demographic file.

Disclosures: Dr. Gerard, Dr. Pugno, and Ms. Byers had no commercial disclosures. Dr. Pugno is an employee of the American Academy of Family Physicians. Ms. Byers is an employee of the American College of Emergency Physicians.



PHILADELPHIA – Family physicians play a major role in delivering emergency-medicine care, especially in rural communities, and family physicians want more people to know that.

Family physicians took a big step toward raising their emergency-care profile 2 years ago, when they started the Special Interest Group in Emergency Medicine (SIG-EM) of the American Academy of Family Physicians (AAFP). When the group held its third annual meeting, during the AAFP’s annual sessions, a top goal was boosting recognition by the health care community that family-practice physicians are the backbone for delivering a large swath of American emergency medicine, especially in places with fewer than 20,000 people.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen."

Several SIG-EM members reported numbers documenting this last May at the Association of American Medical Colleges’ Workforce Research Conference in Washington. In U.S. communities with fewer than 20,000 people, emergency department physicians without emergency medicine residency training (primarily family physicians) supplied 40%-50% of the physician workforce, reported Dr. Kim Bullock, Dr. W. Anthony Gerard, and their associates.

During 2008-2010, family physicians specifically provided 42%-51% of emergency care in six states: Arkansas, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. They also provided 32%-41% of emergency medicine care in another seven states: Alabama, Alaska, Idaho, Iowa, Kansas, Louisiana, and Mississippi.

Data presented to the Workforce Research Conference also showed that during 2006-2010, the extent of family physician involvement in delivering emergency care held steady, with 24%-30% of all family physicians providing emergency care as part of their practice. Among family physicians in rural settings, roughly 40% provided emergency care.

"We want to improve recognition of family physicians in emergency medicine among the wider health-care community," Dr. Gerard said in an interview following the SIG-EM meeting.

Family physicians who provide emergency care have shifted from seeking a formal certification process for their subspecialty to just broadened recognition that family-practice physicians play an important role in providing Americans with emergency care, said Dr. Gerard, a family physician and AAFP member who practices as an emergency medicine physician at Good Samaritan Hospital in Lebanon, Pa.

"The reality is that family physicians are the rural emergency-medicine providers," he said. But, "we need to open doors [for emergency medicine] in the city, too."

"The data we compiled showed that all emergency medicine training programs are in urban academic centers," with easy access to technology and specialists, said Dr. Perry A. Pugno, AAFP’s vice president for education at the Academy’s office in Leawood, Kan.

But, "family medicine is the emergency medicine workforce outside urban settings," he added, and emergency medicine organizations have been slow to acknowledge that.

"We can’t produce enough" emergency medicine physicians, but the emergency-medicine organizations and societies "won’t take the step to say that we should work with family medicine because they are the ones who are out there and doing it," Dr. Pugno said.

The American College of Emergency Physicians has noticed the AAFP’s SIG-EM, and that emergency medicine organization has held out the prospect of working with family physicians. ACEP’s senior director for membership and development, Michele Byers, came to last month’s gathering of about 30 AAFP attendees.

During the SIG-EM’s meeting, Ms. Byers acknowledged the role family physicians play in emergency care: "We realize that’s a reality," she said. "We are looking at opportunities to provide CME and information to family physicians working in emergency departments," Ms. Byers said.

"I think ACEP sees that a collaborative, cooperative relationship with family medicine needs to happen," said Dr. Gerard.

Acknowledgement, but No Endorsement

There is no doubt that many hospital emergency departments in small towns and rural areas are staffed by physicians who did not train in the specialty of emergency medicine. The reality of the current workforce in our specialty is that there are not enough EM residency-trained physicians to staff all the nation’s EDs. Doctors trained in family practice and other primary care specialties will likely continue to provide such staffing for many years to come. However, it is one thing to acknowledge this reality and quite another to endorse it. Residency training in family practice does not encompass the evaluation and management of critically ill and injured patients. The Model of the Clinical Practice of Emergency Medicine is the foundation of training in the specialty, and only EM residency programs adequately cover the core curriculum that a physician must master to be properly prepared to care for emergency patients.

Dr. Pugno is mistaken when he says "all" emergency medicine training programs are in urban academic centers. Most are, but there are numerous exceptions, and more and more programs based at urban academic medical centers offer and encourage rural EM rotations.

A physician trained in family practice who subsequently chooses to practice in an emergency department may be fortunate in finding a professional "home" in the AAFP’s SIG-EM. But the physician at the beginning of a career who wishes to be an emergency physician should train in emergency medicine. A young physician who thinks an FP residency will provide suitable preparation for the practice of EM will, upon graduating and landing a job in an ED, soon discover the gaps in his training. There are many opportunities for continuing education that may, over time, serve to fill in those gaps. ACEP is eager to help with that. But ACEP cannot, and does not, recommend such a haphazard route to achieving competence in the practice of emergency medicine.

Dr. Robert Solomon teaches emergency medicine to the residents at Allegheny General Hospital in Pittsburgh and is Medical Editor in Chief of ACEP News.