Family Physicians Delivering Emergency Medical Care - Critical Challenges and Opportunities (Position Paper)

Executive Summary

Family physicians are an essential part of the emergency medicine safety net. Without their contribution, many parts of the country would be without adequate emergency medical care. While family physicians provide a significant portion of emergency care in rural, urban, and suburban areas,1 their abilities have been questioned by some within emergency medicine professional societies and organizations.2-4 Family physicians are trained to provide emergency medical care by way of residency and post-residency education, but they have been viewed as competitors and suboptimal alternatives, rather than colleagues. This perception of family physicians is unfortunate, since family and emergency medicine physicians are the only generalists who routinely see patients regardless of age, gender, or organ system.

The training environment for most of today’s emergency medicine residency programs includes ready availability of specialty consultants and advanced technology readily available to assist the physician with the assessment and care of patients. However, most rural emergency departments lack these resources, and physicians caring for patients in these settings must depend upon their own best clinical skills and judgment to a greater degree than in the typical urban center. Therefore, an argument can be made that the training breadth of the family physician is appropriate for the care of most patients presenting to emergency departments where the emergency physician is a “generalist with expertise in emergency medicine.”5

Family physicians’ participation in the delivery of emergency care is consistent with a specialty grounded in local adaptability to meet the comprehensive care needs of the community and patients, as well as the integration of primary care principles to provide cost-effective care through optimization of available resources.

Urgent care medicine is also an important part of the emergency care safety net and is primarily provided by family physicians.6 Urgent care centers may serve to increase patients’ access to medical care, as well as to decrease the care burden for both emergency departments and primary care offices.

While many family physicians have made lifelong careers in providing emergency medicine, some are facing challenges and restrictions in their scope of practice.7,8 Overall, the integrity of the emergency medical safety net will be strengthened by collaborative efforts between family medicine and emergency medicine specialties. Family physicians must continue to provide high-quality comprehensive medical services to a diverse population regardless of setting. Competition should be replaced with cooperation, and family physicians’ contribution to the emergency medical care safety net serves a vital role in the U.S. health system.

Background

Emergency Medicine Workforce Statistics

At the end of 2013, there were 34,434 emergency physicians certified by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine, out of an emergency department workforce of 45,140, representing 76% of emergency physicians in the U.S.9 The number of emergency medicine residency programs and the number of emergency medicine graduates has steadily increased each year.10,11 Indeed, the rate of growth in emergency medicine has exceeded that in most specialties overall.12 However, it is unlikely that residency-trained EM physicians will be able to fill the workforce demand for several decades, if ever.13-15

Some emergency medicine leaders feel that there is no longer a workforce shortage, but rather a maldistribution of residency-trained emergency physicians away from rural areas.16 Most emergency medicine training programs are in urban areas and emergency medicine residency-trained or board certified physicians are more likely to practice in urban settings (10.3 per 100,000 population) vs. large rural (5.3) or small rural (2.5) settings.9,13 However, newer data suggests that this maldistribution may extend beyond rural areas. For example, less than half of emergency physicians in the Veterans Health Administration have formal emergency medicine board certification.17 Non-emergency medicine residency-trained physicians, including family physicians, also play a significant role in the staffing of many urban and suburban emergency departments.1

The Evolution of Emergency Medicine as a Specialty

The birth of emergency medicine arose partly from the need for better trained physicians who could treat critically ill or multiple trauma patients.18 Prior to this, emergency medicine was defined by location (the emergency “room”), rather than being defined by a body of knowledge and the skills necessary to practice this specialty. As emergency medicine has matured as a specialty in the U.S., it has brought recognition and academic strength to a field that was previously considered to be the domain of moonlighters.

In 1979, when the American Board of Medical Specialties (ABMS) accepted the American Board of Emergency Medicine (ABEM) as a member board and thus established emergency medicine as a “primary specialty.” 19 Family physicians, including several who were charter members of the American College of Emergency Physicians (ACEP), were among those who championed the cause and were actively involved in the advancement of emergency medicine as a specialty. In a similar way, American Board of Family Practice (ABFP) members were also involved in the developmental phase of the American Board of Emergency Medicine (ABEM), with the founding ABFP executive director serving on the board of ABEM for several years.20 Thousands of physicians with family medicine backgrounds accessed the ABMS emergency medicine board exam during the 1980s, via its “grandfathering” provisions.

Rural Emergency Medicine by Family Physicians

Twenty-two percent of family physicians practice in communities with populations less than 50,000, while 20% of the U.S. population live in such communities.21 Rural communities have emergency departments with fewer patients—roughly half what is necessary to support a residency-trained emergency physician—and lower overall revenue. Therefore, they often are unable to afford a full-time residency-trained emergency physician. Due to their broad scope of practice, including procedural and obstetrical skills, family physicians may have other sources of revenue, and can potentially staff low-volume emergency departments far more cost effectively. This can be a critical factor in deciding whether a community can afford residency-trained emergency medicine physicians, as well as other health providers.

Emergency department staffing in small community hospitals by family medicine physicians allows more efficient use of resources in the hospital and in the community. Family physicians can evaluate patients in the emergency department, admit patients to the hospital, and follow them to discharge as the attending physician. This is more economical and efficient for hospitals with small medical staffs.

Access to health care in rural communities depends on the number of primary care providers.22 Emergency care is an integral part of this relationship. Family physicians in rural areas typically care for their patients from the cradle to the grave, during acute and chronic illness, as well as life-threatening events. Patients in rural communities often have strong ties with their local family physicians and a desire to see them when presenting to the emergency room. In rural communities, confidence in medical care is directly related to the length of relationship between the provider and the patient.23 This is also evident by increased patient satisfaction and outcomes that are equivalent or better for medical services when compared to urban or suburban communities.24

Urgent Care Medicine

Urgent care centers are part of the emergency medicine safety net with care that is primarily provided by family physicians. Urgent care has been a fast-growing sector of medical care since the mid-1990s, and family physicians are the foundation of this specialty. More than 20,000 physicians practice urgent care medicine, where the most common physician specialty is family medicine, followed by emergency medicine.25 There are equal numbers of family physicians providing urgent care as there are providing emergency care.26

The combination of primary care physician shortages and increased patient loads due to health care reform will likely create a need for more access to a level of medical care higher than a primary care office, but not requiring an emergency department. Urgent care centers can provide services to a diverse population of patients and help decrease care burdens for both emergency department and primary care offices.27,28

Due to the range of patient ages, gender, and chief complaints that potentially present to urgent care centers, family physicians are the ideal medical professionals to staff and administrate them. Furthermore, despite a long history of urgent care centers, there is still no consensus definition of “urgent care” and thus there exists a wide variability in the quality and scope of care provided at urgent care centers. The opportunity exists for family physicians to play a key role in not only expanding services and providing quality care, but also participating in the regulation process of urgent care clinics.

Lastly, there has been a growing interest in urgent care medicine among family physicians. Currently, there are four urgent care fellowships available to family physicians who wish to obtain more urgent care experience.29 Additional training may benefit a physician who wishes to open a primarily urgent care practice or assume organizational leadership, but is not a requirement to practice in an urgent care center.

Challenges

Credentialing, Competence, and Board Certification

Central to the issue of family physicians practicing emergency medicine are fundamental concerns over competency, job security, and board certification. Many family physicians have made careers in emergency medicine. In rural areas, family physicians are often the primary providers of emergency care. Today, there remains a shortage of board-certified, residency-trained emergency medicine physicians in certain geographic areas. At the same time, family physicians have been under recognized for their role in providing emergency care.

Some hospitals have utilized emergency medicine board certification as a strict criteria for staffing.30,31 In those situations, some competent family physicians who lack certification in emergency medicine may be excluded because they do not meet the established criteria. Specialty-neutral credentialing is not the norm in most hospital organizations.

Professional Recognition and Board Certification

The controversy surrounding certification and competency is linked to the process of certifying physicians and by which organization. The medical profession has a closely regulated structure for conferring certification to those seeking specialty recognition.32,33

The ABMS and its subsidiary boards, which include the ABFM and the ABEM, set the standards for certification processes and are widely recognized and accepted by organized medicine. The ABMS has granted specialty status to 24 allopathic specialties since 1933. The ABEM exam was first offered in 1980.34 From 1980 to 1988, there were two pathways for physicians to qualify for board examination: completion of a residency in emergency medicine or satisfying the requirements of a “practice track” pathway. The prerequisites of this latter option were 7,000 hours and 60 months of emergency department practice experience, with a specified number of continuing medical education (CME) credits in emergency medicine. In 1988, the practice track pathway was terminated. Limited access to the ABEM examination through closure of the practice track created significant controversy among non-emergency medicine residency-trained practitioners during the years that followed.35 Some felt that this closure was arbitrary and premature. However the recognition of emergency medicine as a primary board of the American Board of Medical Specialties was dependent upon the closure of the ABEM practice track.36

In 1994, a committee of the ABMS developed a proposal to revise the process of board certification. The intention was to recognize certification as a dynamic process, which “should permit movement of qualified individuals across specialties and sub-specialties.”37 It was proposed that physicians with knowledge, training, and/or experience in a given area should be given access to the examinations.38 Ultimately this proposal failed.

The American Osteopathic Association (AOA) has 18 primary certifying boards including the American Osteopathic Board of Emergency Medicine (AOBEM) that began offering certification examinations in emergency medicine in 1980.

The American Board of Physician Specialties (ABPS) was founded in 1950, and currently consists of 12 governing boards that certify 18 specialties and readily accepts qualified allopathic and osteopathic physicians. The ABPS originally came about when osteopathic physicians with allopathic residencies were excluded from both ABMS and AOA board certification.39 Unlike the ABMS, family medicine residency-trained physicians who have practiced emergency medicine for at least five years on a full-time basis and accumulated a minimum of 7,000 hours during that period are eligible to test with the Board of Certification in Emergency Medicine (BCEM) of the ABPS.

Displacement by Replacement

The care provided by experienced, non-emergency medicine, residency-trained physicians and legacy emergency physicians is important.40 As the emergency medicine specialty came to maturation, experienced family physicians were removed from job considerations based on restrictive emergency physician group hiring and specialty bias. Some hospitals have restrictive credentialing bylaws determined by specialty certification rather than previous work experience and demonstrated competence.

As employers and hospital credentialing bylaws have become more restrictive toward experienced, non-emergency residency-trained physicians, some employers have become more amenable to hiring advanced practicing clinicians who usually work under the immediate supervision of the emergency department physician, regardless of previous work experience of the advanced practice clinician. This has resulted in a rise in the use of nurse practitioners and physician assistants in the emergency medicine workforce. Practice oversight for these providers varies across emergency departments with some practicing independently.41

Legacy emergency physicians began practicing emergency medicine prior to the 21st century and are supported by ACEP.40 ACEP has positioned itself in support of the legacy emergency physician not being forced out of the workforce based solely on their board certification. Rather, ACEP asserts that they should be subject to the same quality standards of a board-certified emergency physician. On the other hand, family physicians who began practice after the start of the 21st century are not as well supported by ACEP despite their years of emergency department experience and their commitment to providing high-quality care. Both groups of experienced family physicians are sometimes denied credentialing, regardless of their emergency department work experience, with some being replaced in their practice environment by less experienced emergency medicine residency trained providers.

Education and Training

Emergency Medicine Curriculum for Family Physicians

Emergency medicine is an integral part of family medicine training.42 Several resources outline critical knowledge areas to help ensure family physicians are thoroughly familiar with emergency medicine curriculum, and can be used by family medicine residency-training programs in education planning.43-45 These guidelines provide a useful template for educating family physicians and identifying critical elements that might not be adequately addressed in other curricular areas or residency rotations.

Since there is significant overlap between family medicine and emergency medicine residency training, as well as variation among family medicine residency experiences, it is important for family physicians who provide emergency care to address potential knowledge gaps. Knowledge areas that may benefit from additional training include pediatric emergencies,46 trauma management,47 airway management,48,49 and care of patients with acute myocardial infarction.50 Furthermore, while the use of point-of-care bedside ultrasound has several applications in family medicine,51-55 core ultrasound applications may not be as numerous when compared to emergency medicine.56 Elective months during residency should be geared toward attaining these skills.

By promoting a structured emergency curriculum in residency and identifying potential knowledge gaps, the family physician will be better prepared to provide high-quality emergency care, decrease risk to litigation, and increase the health and safety of the patient. Additional training by AAFP courses and advanced life support courses should also be considered.

Family Medicine Residencies

The Accreditation Council for Graduate Medical Education (ACGME) requirements for family medicine residents reflect values that are complementary to the importance of providing emergency care.42 For example, family medicine residents must demonstrate competence to independently manage patients of all ages in various outpatient settings; evaluate patients of all ages with undiagnosed and undifferentiated presentations; recognize and provide initial management of emergency medical problems; and perform medical, diagnostic, and surgical procedures essential for the area of practice. The current ACGME program requirements for family medicine include a greater level of specificity for experiences with acutely ill adults and children in emergency settings.42

By the nature of their training, family physicians add value to the emergency care they provide in several ways. In many communities, hospital emergency departments are required to provide an enormous amount of primary care services that would ideally be provided in other settings.57 Family physicians are trained to care for patients with both acute and chronic conditions and “take a broad look at a patient with a problem, decide what’s appropriate to do and do it.”58 Since there are increases in the time between a decision to admit a patient from the emergency room to the hospital and the transfer of the patient to the hospital room,59  physicians staffing the emergency room increasingly find themselves needing to provide non-emergent care to patients who would otherwise require inpatient management. Family physicians practicing in the emergency room are well-suited to provide the ongoing care to these stabilized patients awaiting transfer to the inpatient care units. Family medicine training in obstetrical emergencies can also be advantageous, especially in resource-limited environments.

Training Considerations for Rural Recruitment

Many emergency medicine residencies are in primarily urban environments with a disproportionate number of graduates choosing not to practice in rural areas.16,60 While rural training experiences will likely increase the retention of graduates to rural areas61, several obstacles remain. Studies have shown that patient volumes are similar for urban and rural emergency physicians;62,63 however, patient acuity and procedural volume remains a concern. Furthermore, the ACGME requirement that emergency medicine faculty hold ABEM certification may be an obstacle for rural emergency training sites since many rural emergency physicians are trained by primary care programs.64

Combined Residencies

In 1976, the year that the ABEM was first incorporated, dialogue between the leaders of family medicine and emergency medicine “envisioned extensive cooperative efforts in our training programs...post-graduate efforts...legislative efforts, and residency preparation, acceptable to both family practice and to emergency medicine, which would allow us to certify that these physicians entering rural practice are indeed well prepared to practice in both of these specialty areas.”65 It was not until 1993 when the ABFP explored a combined training program leading to dual-board certification.

After 30 years, collaboration between the specialties of family and emergency medicine reached fruition and joint training programs were approved by the ABFM and the ABEM in 2006. Joint training guidelines described an integrated five-year curriculum with equal emphasis on the two disciplines.66 In 2007, the Christiana Care Health System in Wilmington, Delaware, launched the first combined family medicine-emergency medicine joint training program. By the end of 2016, there were two joint programs in the country.67 Residents that are enrolled in such programs benefit from the opportunity to train in the intense environment of advanced-level trauma centers, while at the same time reaping the educational advantages of continuing and comprehensive patient care in a family medicine center.

While combined residency (family medicine-emergency medicine) programs are a step in the right direction in terms of collaboration between the two specialties, few positions are available and are unlikely to make a significant impact on workforce and are unlikely to solve many of the issues facing rural areas. A study of graduates of combined residency programs in emergency medicine-internal medicine, internal medicine-psychiatry, and family practice-psychiatry shows these certified physicians tend to work in urban, academic centers rather than rural settings.68,69 Similar studies are not available for graduates of combined emergency medicine-family medicine residency programs.

Fellowships Enhance the Core Curriculum

Fellowships in emergency medicine were first developed in the 1990s for family physicians, as well as other primary care physicians in response to the need for additional training in emergency medicine in academic centers.70 Furthermore, several studies report that family medicine residency-trained emergency physicians may still desire additional training.47,71 One-year fellowships have been established as a logical extension of accredited family medicine residencies in West Virginia, North Carolina, Arkansas, Tennessee, Texas, and other states.72 As of 2015, there are eleven emergency medicine fellowships with a combined total of 37 fellowship positions.67

Emergency medicine fellowships have been successfully used as a pathway to credentialing in community hospitals and academic settings. They have also been used to enhance acute care skills prior to practice in frontier medicine, rural practice, and international missions. The advantages of these fellowships have been their flexibility and financial feasibility, ability to be self-funded due to the high need for workforce in rural areas, and their inclusion of graduated physicians.72 These fellowships have successfully modeled the rural reality of simultaneously staffing the office, the emergency department, and the hospital, as well as providing access to enhanced training for graduates of family medicine residencies who plan to practice in rural areas.

Emergency medicine fellowships will likely continue to remain an attractive option for family physicians who practice emergency medicine given that the fellowships allow graduates of the programs to enter practice in four years, compared to the five year requirement of joint family medicine-emergency medicine programs. While the joint training programs have an inherent academic legitimacy that both ACEP and ABEM will accept, several fellowship programs lead to accelerated board certification eligibility by ABPS if other requirements are met.73

Fellowship opportunities are beneficial, not only because they provide more emergency patient and procedural exposure and may fulfill hospital credentialing requirements, but also because fellowship graduates have a greater tendency to practice in rural environments.74

Certificate of Added Qualifications in Emergency Medicine is not an Option

According to the rules of the ABMS, primary certifying boards are prohibited from establishing subspecialties or Certificate of Added Qualifications (CAQ) in clinical domains where another major specialty already exists.75 Thus, since an ABEM is currently in existence, the ABFM cannot establish a CAQ in emergency medicine.

Unique Training for Rural and Remote Settings

A unique program has been developed for those family physicians who deliver emergency care in rural areas. The Minnesota chapter of the AAFP created an innovative Comprehensive Advanced Life Support (CALS) course in 1996.76 The CALS curriculum includes material from all the major advanced life support programs. A team-based approach involving emergency medical services (EMS) providers is integral to the program, and life-saving procedural skills and a core body of knowledge in emergency medicine are basic components of the curriculum. This course is supported by both AAFP and ACEP in efforts to improve rural emergency care.77,78 An ACEP policy statement described CALS as a valuable educational experience and may be considered as an equally acceptable alternative to other advanced life support and/or trauma life support courses.79

The CALS project promises to strengthen the preparation of family physicians, other physicians, and health care providers who currently practice in rural areas, and who desire additional training in emergency medicine. The success of this course could lead to a similar program for all rural physicians who provide emergency stabilization, and serves as a model for collaborative approaches between the specialties of family medicine and emergency medicine.

A Path Forward

Institute of Medicine (IOM) now known as the National Academy of Medicine (NAM) Report Endorses Family Physicians in Emergency Medicine

In 2006, the IOM report entitled “The Future of Emergency Care in the United States Heath System” described the condition of emergency medicine in our nation and gave it a poor prognosis unless dramatic changes occur.80 It describes, in detail, the developments in the last few decades, but also describes a system that is fragmented and inconsistent in the quality of care that it provides. In addition to focusing on issues such as overcrowding, poor coordination among emergency medical systems, shortage of on-call specialists, and lack of disaster preparedness, the report addresses the emergency care workforce (including prehospital emergency medical services as well as the multiple professions that provide care at the hospital) and rural emergency medicine.

The IOM report stands as a challenge to the current paradigms expressed by many health care experts in emergency medicine.80 The report concludes that “coordinated, regionalized, and accountable” solutions will require change in a number of the ways that emergency care is structured in the U.S. These include more collaborative efforts between specialties, and core curricula for all physicians involved in emergency care.

The essential role of family physicians in rural areas is described in detail, and the need for improved cooperation with academic emergency medicine is emphasized. Family physicians are described as part of the “essential component of the Emergency Department (ED) workforce at many hospitals, especially smaller facilities in suburban and rural settings.”8 Although certified by ABFM rather than ABEM, family physicians demonstrate a high level of competency in emergency care through a combination of residency and post-residency education, directed skills training, and on-the-job experience.80

AAFP and Other Family Medicine Organizations Strongly Support the Role of Family Physicians in Emergency Medicine

The American Academy of Family Physicians (AAFP) has long-supported its members who practice emergency medicine. In 1995, the AAFP developed and has since updated its policy about emergency care services, which currently states, “Family physicians, through their training and experience, are qualified to provide emergency care services. The American Academy of Family Physicians believes that privileges to practice in the emergency department should be based on the individual physician’s documented training and/or experience, demonstrated abilities, and current competence.”81 Additionally, the AAFP published a set of core curricular guidelines on acute and emergency care for residents in family medicine residency programs.43

Recognizing flaws in a fragmented U.S. health system, leaders of seven family medicine organizations formed the Future of Family Medicine project. The group released a report in 2004 calling for a New Model of practice that is grounded in the values of personalized, patient-centered care, coupled with the application of new technologies and systems to meet the health care needs of society in a changing environment.82 The model included enhanced educational opportunities and a “basket of services” individualized to meet the needs of the community in emergency and acute care services. The report recognized the strength of family physicians for their adaptability and diverse scope of practice. The report also acknowledged that implementing the New Model of practice may be challenged by those with vested interests in maintaining the status quo.

In 2006, the AAFP Board of Directors approved and the Congress of Delegates adopted and later updated a policy statement on emergency medicine addressing the standard of care for credentialing and workforce issues. It parallels the recommendations from the Institute of Medicine (IOM) report, and provides a foundation for defining family physician’s role in emergency care in the 21st century. The statement reads as follows:

    The provision of emergency medical care is an essential public service in the United States. Providing
    comprehensive emergency medical services to a diverse population requires a cooperative relationship
    among a variety of health professionals.

    The most important objective of the physician must be the provision of the highest quality of care.
    Quality patient care requires that all providers should practice within their degree of ability as
    determined by training, experience and current competence.

    Family physicians are trained in the breadth of medical care, and as such are qualified to provide
    emergency care in a variety of settings. Many family physicians currently provide quality emergency
    department and trauma care throughout the nation, including military, rural, and remote settings.

    Specialty certification alone should not prevent family physicians from practicing in any emergency
    setting or trauma center at any level. Emergency department credentialing should be based on
    training, experience and current competence. Combined residency programs in family medicine and
    emergency medicine, or additional training, such as fellowships in emergency medicine or additional
    course work, may be of added benefit
.83

In 2010, the first AAFP member interest group was formed in emergency medicine and urgent care. This interest group gives physician members a forum to discuss emergency medicine-related issues that they face on a daily basis.84 The group continues to hold annual meetings at the Family Medicine Experience (FMX).

Family Medicine for America’s Health (FMAHealth) was launched in 2013 by the AAFP, AAFP Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine to “position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim).” 85,86  As a part of the exploration of the scope of practice for family physicians, a document was developed that defined the family physicians’ role in health care delivery.87 These expectations include providing timely, cost-effective care; integrating care for both acute and chronic illnesses; collaborating with national stakeholders to reduce health disparities; and ensuring that the country has a well-trained primary care workforce for the future through the expansion and transformation of training.85 Among other statements, the document describes the importance of family physicians’ role in providing emergency care, their ability to provide comprehensive medical care with the capacity to handle the needs of most patients, and their ability to adapt care to the unique needs of their patients and communities.87

A Model of Collaboration - The Canadian Health System

The Canadian health system may provide a helpful model for the U.S. since emergency care in Canada is provided by a heterogenous group of clinicians. In Canada, there are three pathways for a physician to practice emergency medicine. First, similar to the U.S., residency-trained family physicians, which provide a majority of care in rural areas, provide emergency care.88,89

Second, the College of Family Physicians of Canada (CFPC) offers a two-year residency training program in family medicine with the option of an additional year of training in emergency medicine to obtain the Canadian College of Family Physicians - Emergency Medicine (CCFP-EM) certification. The CFPC supports cross training in emergency medicine for family physicians, and there is widespread acceptance of this pathway within the medical community.

The third pathway is the Royal College of Physicians and Surgeons of Canada (RCPSC) five-year emergency medicine residency program with certification as a Fellow of the Royal College of Physicians of Canada (FRCPC). The objective of this program is to prepare physicians for academic careers involving teaching, research, and administration in emergency medicine.89 The first qualifying exam was offered in 1983, and grandfather eligibility through a practice track existed through 1987. During this period, many physicians became double-board certified in family medicine and emergency medicine.

While there is ongoing debate regarding having a single, conjoint emergency medicine certification, no agreement could be reached concerning the details of such a training program.90-92 Most institutions do not differentiate between graduates from either colleges. While the RCPSC program aims to produce academically-oriented emergency physicians, physicians from both colleges work mainly in urban areas and share the same patient mix and responsibilities. Furthermore, while Canada also has more than one organization governing certification in emergency medicine, both the CFPC and RCPSC continue to collaborate on clinical practice and quality of care issues. The collaborative efforts between both groups provide a model for cooperation that could be considered by medical associations and certifying boards in the U.S.

Research Agenda

The research agenda for family physicians should be collaborative and practice-based, with a focus on how family medicine can have an impact in varied emergency environments, such as urban, rural, and remote areas. Practice-based research networks (PBRNs) are designed to address such questions through the integration of research and everyday practice. The AAFP National Research Network93 includes more than 300 family physicians in 45 states with integration of an electronic medical record (EHR) system. Collaboration with pediatric PBRNs and with emergency medicine research groups can allow for expanded research into new areas, such as the economic impact of family physicians in emergency medicine, quality of care, and efficient utilization of emergency resources, especially in rural areas.

Family physicians who practice full-time emergency medicine, whether in academic settings or community hospitals, are part of the emergency medicine infrastructure. Institutions and physicians involved in this aspect of emergency medicine should be aware of the recommendations of the IOM for emergency care research, since it “involves many disciplines and cross-cutting themes.”57 As academic cooperation increases between the specialties on the residency training level,66 educators and graduates of joint training programs will be involved in these areas of research, including resuscitation science, injury prevention, and epidemiology. Many of these areas are included in family medicine curricula. Evidence-based research for acute care is a strength of 21st century family medicine.

A small database exists on the unique aspects of emergency care that is provided by family physicians, but more research opportunities are necessary to enhance the science of family medicine in this area. Many hospitals and communities are in financial distress, and additional research in rural and critical access hospitals on the cost effectiveness and quality of care of family physicians is needed. Other topics for investigation include rural emergency care delivery, the provision of “first-hour” emergency care in family physician offices, trauma care in remote areas, and emergency and urgent care procedural skills. One successful project demonstrated that family medicine graduates providing care in Colorado emergency departments felt that they were adequately trained in emergency medicine, but would benefit from more exposure to trauma training and enhanced contact with EMS personnel.47

Conclusions

Providing comprehensive emergency medical services to a diverse population requires a cooperative relationship among a variety of health professionals.57,94 Delivering quality, comprehensive emergency care requires that emergency medical care and workforce issues be based on “best practice” models that include all necessary and contributing specialties and disciplines.57 In the 21st century, competition should be replaced with cooperation. More collaboration is needed between the AAFP and ACEP, and the ABFM and ABEM to ensure emergency department credentialing and job security is based on the quality of care delivered by the emergency physician.

Policies should be advanced that recognize and support the critical role of family physicians in emergency medicine in most communities around the U.S.

The most important objective of the family physician must be to provide the highest quality of care. Quality patient care requires that all providers should practice within their degree of ability as determined by training, experience, and current competence. The AAFP will continue to support the greater flexibility and wide scope of practice of family physicians, especially in areas where there is a workforce shortage.

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