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Letter to the Editor: FPs Should Not Fill In for EPs

doi: 10.1097/01.EEM.0000515697.05968.67
Letter to the Editor

Editor:

I disagree with October's editorial, “An Unfulfilled Mandate: FPs Vital to EM,” by Drs. Anthony Gerard, Perry Pugno, and William Rodney. (EMN 2016;38[10]:3; http://bit.ly/2eM6iSn.) The authors quoted the American Academy of Family Physicians: “Family physicians ... are qualified to provide emergency care in a variety of settings” and have “a high level of competency in emergency care.” As an emergency residency director, I do not feel family medicine training and emergency medicine training are comparable.

Our emergency medicine residency includes 31 months of emergency medicine and critical care rotations, compared with only two months for our family medicine residency. Family medicine residency training is great preparation for being a family physician but inadequate for practicing as an emergency physician. Becoming an emergency medicine specialist is a lifelong process, of which residency training under the supervision of emergency medicine faculty is the cornerstone. By the time ABEM closed the practice track in 1988 (before many of my residents were even born), there were enough excellent training programs that a practice track no longer made sense. Today, more than 210 emergency residencies graduate more than 2,100 residents annually.

The authors believe it's unlikely that there will be enough emergency medicine residency-trained physicians to meet workforce needs. They wrote: “Family physicians are the logical choice to supplement the EM workforce,” “the solution to the workforce shortage is to keep family physicians in the ER,” and “the geographically determined shortage of board-certified emergency physicians will remain an unsolvable problem until EM cooperates with FM.” I've heard for years that we have a critical need for non-certified emergency physicians, and this imbalance won't be resolved during our careers.

This simply isn't true anymore. Ninety-eight percent of emergency physicians graduating in the past five years were EM-trained. From 2000 to 2010, emergency physicians increased by 44.6 percent, more than other specialty. (J Emerg Med 2016;50[4]:690.) Likewise, EM has added more new residency positions than any other specialty over the past five years. There are currently more than 45,000 emergency physicians practicing in the country, with more than 38,500 (85%) ABEM/ABOEM-certified or eligible. More than 2000 EM residents enter the workforce each year, and about 770 ABEM/AOBEM-certified physicians retire, resulting in a net gain of around 1230 ABEM/AOBEM-certified physicians. The data are clear: The gap between all emergency physicians and those board certified or eligible has become small, and it's closing quickly.

The authors correctly noted that rural areas have difficulty recruiting board-certified emergency physicians. I expect these difficulties will abate somewhat as the number of emergency physicians desiring urban or suburban jobs eventually exceeds the number of available opportunities. However, rural emergency physician shortages are a poor rationale for recommending those without EM training or certification. Note that shortages of FM physicians are also common in rural areas, but in response, we do not see emergency physicians being recruited to practice as family physicians. On the contrary, FM physicians in underserved areas sometimes practice in the ED, exacerbating the FM shortage.

The authors noted, “Delivering high-quality emergency care requires that emergency medical care and workforce issues be based on best practices that include family physicians.” However, there is no evidence that having family physicians practicing as emergency physicians is a “best practice.” On the contrary, AAEM's “White Paper on the Value of Board Certification and Residency Training in Emergency Medicine” concluded, “There is clear evidence in the literature that supports that board certification and residency training in EM improves the quality of care provided to patients in the nation's EDs.” (http://bit.ly/2fX6HEv.)

Lastly, the authors asserted, “This critical challenge remains, and family medicine organizations may need to move forward on these issues independent of emergency medicine.” Really? Family physicians feel they have a better sense of who should be practicing EM than emergency physicians do? I could imagine the uproar if our EM organizations decided to move forward, independent of the affected specialties, to increase the number of emergency physicians practicing as family physicians, neurosurgeons, or cardiologists.

Mark Reiter, MD, MBA

Nashville

Dr. Reiter is a former president of the American Academy of Emergency Medicine.

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