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Breaking News: The Next Big Thing? GP in ED

Scheck, Anne

doi: 10.1097/01.EEM.0000405487.08793.1c
Breaking News

Will the impending U.S. physician shortage create a perfect storm in emergency medicine or a warmer climate for collaboration with primary care? If the results of a Dutch study on general practitioners who work in urgent centers are right, crowded or underserved American emergency departments could benefit from adding an internist or family physician to the team. And if interviews with family physicians who practice emergency medicine are any indication, the combination can be as comfortable as a summer breeze.

Faster processing, significantly higher patient satisfaction scores, and cost savings of about 25 percent occurred after a general practitioner joined an accident and emergency department in Amsterdam. (Emerg Med J 2011 Mar 25 [Epub ahead of print]; doi: 10.1136/emj.2010.101949.) The Dutch investigation seems to support the inference that generally trained primary care physicians benefit emergency departments.

Unfortunately, the authors of the study in Holland didn't distinguish adequately between emergency physician and general practitioner, said Anthony Gerard, MD, a family physician who has practiced emergency medicine for more than two decades. And there is no intensely focused training program for emergency physicians there, in contrast to the American residency system, noted Dr. Gerard.

Still, the findings are intriguing, and they arrive at a time when the emergency physician shortage is becoming more acute. This past spring, a jarring report by the Center for Workforce Studies at the Association of American Medical Colleges showed gaps in the physician workforce, ones likely to worsen in the future, including in emergency medicine. Nowhere are such shortages keener than in Midwestern communities, especially rural ones. (“Recent Studies and Reports on Physician Shortages in the U.S.,” May 2011;

And U.S. physicians in emergency medicine and family medicine share an important commonality: A medical education that prepares them to see all kinds of patients across all age groups with highly varied conditions, Dr. Gerard pointed out. He said he hoped the “renewed spirit of cooperation” that arose in the past few years would continue between the two specialties. Already, there are emergency physicians moving into primary care settings, and family physicians have long been at the helm of emergency care in small towns, he observed. (An informal survey suggests Dr. Gerard is correct. Websites for hospitals from Riverhead, NY, to Roanoke, VA, boast multispecialty urgent care practices featuring family physicians and internists in addition to emergency physicians). In the past, attempts to find shared turf between the specialties on these issues has had limited success, Dr. Gerard said. The difficulty dates back to the 1989 closure of the emergency medicine practice track, although an American Academy of Family Physicians task force on the role of family physicians in emergency medicine led to the development of joint training programs among the specialty boards.



When this same task force developed the AAFP “Position Paper and Policy on Family Physicians in Emergency Medicine,” it seemed to lead to a parting of the ways, however. The American College of Emergency Physicians initially participated in the task force, but the final wording adopted by AAFP proved controversial. Missing from the final position paper was compromise language on which representatives from both specialties had agreed, Dr. Gerard recalled. “In my opinion, this is where something maybe fell apart. There seemed to be distance after that between the two,” he said.

Now, however, “I think (we) may be moving toward a new level of cooperation,” partly because some recent research clearly shows that workforce needs in emergency medicine cannot be met by “just hoping that there will eventually be enough residency trained emergency physicians,” he said.

Dr. Gerard is not alone in this sentiment. “I most definitely think there is a continued spirit of collaboration between internal medicine and emergency medicine, with common links like the dual training program and observation medicine,” said Chad Kessler, MD, the section chief of emergency medicine at the Jesse Brown VA Hospital in Chicago and the program director of the combined internal medicine/emergency medicine residency program at the University of Illinois-Chicago.

Dr. Kessler, a residency graduate of emergency and internal medicine, said dual training broadens exposure to different pathologies and provides a way for emergency physicians to experience first-hand about a patient's care after admission.

Nonetheless, there are areas short of emergency physicians, and they are likely to remain so in the coming years. In such situations, primary-care doctors may be increasingly called on to serve in emergency departments. “What do we do in rural areas? That is a good question,” he said. One step would be to develop training or formal certificate programs that will add to such providers' knowledge and practice, said Dr. Kessler.

But will family physicians be practicing alongside emergency physicians in EDs of the future? Not likely, according to Kim Bullock, MD, a family physician who practices emergency medicine in Washington, D.C. “I am not optimistic that family physicians will be practicing shoulder-to-shoulder,” she said. Nor does she think family physicians will be practicing emergency medicine in urban areas, which generally attract residency trained, board certified members of the specialty.

In rural community hospitals, however, the situation may be different. Traditionally more of a magnet for family physicians, small towns will need these primary care physicians in the ED. “I think there is some recognition of that now. And I think there is more collegial dialogue about it,” Dr. Bullock said. “The answer isn't in yet. But enough time has elapsed that the leadership has come together more” in the search for a solution.

There also may be an increasing role for family physicians in hospital clinics for those who continue to seek help for health complaints that don't constitute emergencies. “We don't really know where this will go in the next several years, how the concept of medical homes will affect it. But there are centers now where this takes place,” she said.

Added Dr. Gerard, who believes the Dutch study may be a catalyst for some discussion on the topic: “I am hopeful that the new generation of emergency physicians can be secure enough to not look over their shoulders wondering if someone is going to take their job.”

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EP or GP? Let Triage Decide

Analysis of a Dutch study into emergency medicine at a hospital in Amsterdam suggests that adding a general practitioner to the team means equal quality of care and big reductions in time.

Like many of their U.S. counterparts, patients in the Netherlands have a primary care provider. “Many patients with acute complaints go to the accident and emergency department directly, even when a GP can handle their complaint very well,” said Judith Bosmans, PhD, an assistant professor of health sciences at VU University in Amsterdam. She is the senior author of the original study on which the analysis was based. (Emerg Med J 2011 Mar 25 [Epub ahead of print]; doi: 10.1136/emj.2010.101949.)

This patient reliance on the emergency department leads to “inappropriate use of and increased waiting times” in the ED, she said. To test the hypothesis that adding a GP could help, all patients who came to the AED without a referral from a GP underwent triage by a specially trained nurse. She decided whether the patient needed to see an emergency physician immediately or a GP working in the department.

How would this model work in the American health system? Kim Bullock, MD, who practices emergency medicine in the Washington, D.C., area, noted that there are centers now in urban areas where there has been success with a somewhat similar model. In addition, some hospitals have utilized family physicians in their fast tracks.

— AS

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