Graham Center Research

Family Physicians Play Major Role in Urban ERs

September 29, 2015 01:48 pm Michael Laff

It's probably not all that surprising that in rural areas where the nearest physician might be a long drive away, ER patients are likely to receive treatment from a family physician. Now, though, researchers have learned that even in urban ERs, patients are likely to be cared for by a family physician.

[Doctor looking at a chest xray]

The findings, published this month in American Family Physician as a one-pager from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, were totally unexpected.

"We know that family physicians in outlying rural settings are contributing to ERs, but nobody ever looked at their contribution in urban and suburban settings," said paper co-author Gerald Banks, M.D., M.S., a researcher at the Graham Center.

The paper's authors used the AMA Physician Masterfile to determine how many family physicians are working in rural and urban ERs. They then studied Medicare claims data from 2012 to identify how many family physicians were contributing to ERs in various locations.

They found that family physicians submitted nearly 12 percent of the 15 million urban emergency department claims that year. In fact, filings by family physicians in urban ER settings represented 67 percent of all claims related to emergency care submitted by family physicians for the year.

Story highlights
  • Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently reported that 4,000 physicians who identified themselves as ER physicians actually completed their last residency in family medicine.
  • Filings by family physicians in urban ER settings represented 67 percent of all claims submitted by family physicians in 2012.
  • One of the researchers contends that family physicians must remain in ERs, contrary to the actions of some urban hospitals that are replacing them with board-certified ER physicians.

Another stereotype about family physicians also crumbled when the researchers looked more closely at the CPT codes that were filed on Medicare forms. The perception was that family physicians in the ER handle simple cases, but records show they are treating strokes, heart attacks and fractures.

"The board-certified ER docs say family physicians are just treating colds and coughs, but if you look at the complexity of cases, there is no sign that's true," Banks said.

Family physicians are vital to ERs, yet many urban hospitals are replacing them with board-certified ER physicians as a marketing tool to attract patients.

The Institute of Medicine (IOM) has weighed in on this issue,( noting that a nationwide shortage of board-certified ER physicians is unlikely to be improve for decades, if ever, because of lagging rates of emergency medicine training.

Another looming concern is the continued rise in ER visits combined with the closure of some ERs at smaller hospitals and health systems during the past 10 to 15 years, a situation that Banks called "a perfect storm."

"If family physicians were removed from all ER facilities because they don't have certification, that could represent one-third of the physician workforce in large cities," he said.

Banks believes the solution to the workforce shortage is to keep family physicians in the ER while an emergency medicine certification program is created with an exam that allows them to demonstrate the knowledge and skills they've gained through situations they already encounter in ER settings.

Canada has a certification program for family physicians in ER medicine, but it is not recognized in the United States. There also are no emergency medicine fellowships for family physicians that have been approved by the Accreditation Council for Graduate Medical Education.

Still, said Banks, the subspecialty organizations would argue that there is no need to train family physicians in the sector because ER physicians are already being trained.

But, he added, "Board-certified ER physicians who are just out of residency have no experience. How can you just kick out the family physicians? The IOM has said that you should staff the ER based on competency, not board certification. They should stop pushing out doctors who have competency."