Family Physicians Delivering Emergency Medical and Urgent Care

Principle 1: Family physicians are well-trained, versatile physicians who provide highly competent emergency and acute medical care for patients of all ages in emergency department and urgent care settings due to their broad scope of training, particularly in community based and rural communities.

Support for Principle 1: Family medicine residency training produces versatile generalists competent in a variety of procedures and workplace settings, making them ideal candidates for working in emergency departments (EDs) and urgent care facilities to provide cost-effective, evidence-based care. The educational requirements for Family Physicians address both these settings, along with multiple others. Patients express higher levels of satisfaction when care is provided by a physician with whom they have an established and ongoing relationship. The explicit focus on community and continuity of care in family medicine training allows us family physicians to fill whatever roles are necessary, whether in emergency departments, urgent care facilities, or hospitals. Additionally, while a one-year decline does not establish a trend, the 2023 National Resident Matching Program (NRMP) Match results for Emergency Medicine highlight that this is the inappropriate time to begin to limit the role that family physicians play in Emergency Departments nationally.

Principle 2: Post-COVID, hospitals are facing challenges within their emergency departments that family physicians are well trained to address and manage, including logistical and care challenges such as admission holds and mental health service demands.

Support for Principle 2: Post-COVID, the state of our Emergency Departments has drastically changed. Given the loss of bedside nurses and the shortages in nursing production, it is common to see multiple patients holding for admission at facilities large and small. The multimodal talents of family physicians across the spectrum of care allow for efficient care, with providers well versed in inpatient medicine and mental health concerns (including substance use disorder) in pediatric and adult populations. From a public health perspective, the development of Rural Emergency Hospitals and the necessity of being able to care for patients held in observation and those awaiting transfer highlight the importance of family physicians in that role; there is a joint statement of the American College of Emergency Physicians (ACEP) and the American Academy of Family Physicians (AAFP) that highlight the importance of physician-led teams in these facilities and the vital role that family physicians will serve there.

Principle 3: The development of Rural Emergency Hospitals requires the presence of a physician to lead the team, which can be fulfilled by family physicians.

Support for Principle 3: Rural Emergency Hospitals (REH) are newly designated healthcare facilities created to maintain access to critical outpatient hospital services in communities that may not be able to support or sustain a Critical Access Hospital or small rural hospital. REHs are required to provide 24-hour emergency and observation services and can elect to furnish other outpatient services.

REH may be required to provide care for acute medical emergencies, in addition to emergencies related to psychiatric and obstetrical care. This broad spectrum of care necessitates physician leaders with wide skillsets capable of providing and supervising safe delivery of care across the lifespan. Additionally, because REHs are outpatient only, a key role of the leading healthcare provider is to determine which patients require higher levels of care. Family physicians are optimally prepared for practice in REH because of their comprehensive training that includes pregnancy care and neonatal emergencies. Family Medicine physicians obtain 400% more obstetric training, including operative obstetrics, as compared to Emergency Medicine physicians.

As an example of how family physicians can utilize their training to preserve limited healthcare resources, inappropriate determinations of false labor commonly result in pregnant patients in rural communities being transported many miles away to urban hospitals with obstetric capabilities, only to be discharged to home hours later when diagnosed as being in false labor and leading to unnecessary and costly escalations of care.

As the practice of emergency medicine evolves to meet the needs of communities in unique settings, family physicians remain poised to be the perfect candidates to provide, supervise, and lead delivery of care.

Principle 4: Emergency departments are best served by physicians working in physician- led teams of healthcare professionals.

Support for Principle 4: Advanced Practice Providers (APPs - including physician assistants, nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists) provide intermediary services in many locations, but there are limitations in their training. In general, APPs receive 10% or less of the clinical training hours of physicians. This leads to increasing reliance on algorithmic care, which can result in inappropriate prescribing and unnecessary use of diagnostics. Many emergency physician staffing organizations, with the support of hospitals, often attempt to replace physician hours with increasing APP hours given their reduced salaries; however, a recent study (October 2022) by the Veterans Health Administration showed that the use of Nurse Practitioners in EDs resulted in higher cost and resource utilization, increasing length of stay and readmissions. The study concludes that allowing APPs to care for even up to a quarter of Emergency Departments patients increases annual costs by $74 million to the VHA.

Principle 5: Privileges to practice in the emergency department should be based on the individual physician's training, experience, and demonstrated current competence, and not solely on the physician's specialty.

Support for Principle 5: The shortage of physicians board certified in emergency medicine is significant in rural areas, and they are often unable to afford full-time residency-trained emergency physicians. In rural areas, family physicians are often the primary providers of emergency care. If hospitals utilize emergency medicine board certification as a strict criteria for staffing, competent family medicine physicians who do not have certification in emergency medicine may be excluded from providing this crucial service to the community. This is furthered in the National Academy of Medicine (NAM)’s statement “specialty certification alone should not prevent family physicians from practicing in any emergency setting of a trauma center at any level. Emergency department credentialing should be based on training, experience, and current competence.”

Principle 6: Family physicians are well qualified to serve in urgent care settings and can help maintain continuity across the care spectrum.

Support for Principle 6: Growth of urgent care facilities is estimated to be 7% annually, with more than 10,000 facilities nationwide; much of this growth is due to the shortage of primary care physicians rendering patients unable to obtain timely appointments.

As of 2022 metrics, sixteen percent of urgent care providers were physicians, and this number is expected to decrease even further for cost considerations. Urgent Cares are increasingly staffed by mid-level providers who have severely limited scope of practice as compared to family physicians. Patients are often referred to emergency departments for simple procedures that are routinely managed by family physicians in the outpatient setting, such as stitches or incision and drainage of abscesses. Family Physicians remain cost-effective and productive providers in any setting, including Urgent Cares.

(2004) (October 2023 COD)