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Pawn and King Play: a Stalemate on Rural Emergency Medicine Staffing

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Pawn and King Play: a Stalemate on Rural Emergency Medicine Staffing J Am Board Fam Med: first published as 10.3122/jabfm.2019.03.190077 on 8 May 2019. Downloaded from COMMENTARY Pawn and King Play: A Stalemate on Rural Emergency Medicine Staffing W. Anthony Gerard, MD (J Am Board Fam Med 2019;32:292–294.) “It is certain, whether we be first rates, or lowly percentage of FP’s working in UC went up. FM’s recipients of the Queen, at the end of the game, strength in providing UC is well known, so turf ‘the King and the Pawn both go into the bag.’” Old wars between FM and EM are rare in UC. Proverb from The Westminster Articles: A Mon- But the history of “turf wars” in EM dates back thly Journal of Chess, 1873. to the beginning of our specialty, and has led to a In the article titled, Family Physicians Make “game of chess” in rural health policy, in which EM Significant Contributions to the Rural Emergency has controlled the board. FM has not “sacrificed it Care and Urban Urgent Care Workforce,1 Peter- is pawn,” but this history of competition has led to 2 son and colleagues show that “Family physicians a stalemate. (FPs) are likely to continue to be the backbone of We have arrived at a stalemate as the health emergency care in rural America.” The authors policy debate on rural EM has been “specialty cen- provide data and compelling arguments for this tric,” not “patient centric.” Collaboration—not claim. But will this help “move the pawn to the end competition—is needed to solve rural ED work- copyright. of the board?” Rural emergency department (ED) force issues and improve patient care. Health policy workforce issues should not be subject to this game recommendations have emphasized the importance of chess between emergency medicine (EM) and of a partnership between specialties to solve rural family medicine (FM). EM issue, but due to the politics of medicine, these 3 The authors demonstrate a sharp increase in recommendations have largely been ignored. the proportion of American Board of Family In 2006, the Institute of Medicine (now the Medicine (ABFM) –certified FPs working pri- National Academy of Medicine) issued a report on EM.4 This called for “more collaborative efforts marily in rural EDs. They show that up to 8.5% http://www.jabfm.org/ of FPs work full time as emergency physicians between specialties… [because] family physicians (EPs) in the most rural EDs. There are about are an essential component of the ED workforce… 90,000 diplomates of the ABFM, which translates with a high level of competency in emergency care to an estimated 7600 FPs working full time in through a combination of residency and postresi- these “frontier” emergency departments. Many dency education, directed skills training, and on- more work part time covering local EDs. These the-job experience.” Other authors have repeated 5–7 on 28 September 2021 by guest. Protected data clearly show that “FPs are likely to be likely this theme but FM and EM continue to move to continue to be the backbone of emergency chess pieces instead of collaborating. care in rural America.” The reasons for EM’s “specialty-centric” focus Peterson’s study also emphasizes the important were understandable a few decades ago, when the role that FM has in providing quality urgent care certification debate was threatening to the EM 8 (UC). FM already provides the lion’s share of the scope of practice. But EM is almost 60 years old, workforce in urgent care, and in this study, the and it is time to move past our adolescent angst about our scope of practice. Residency-trained emergency physicians lead the specialty, and the Funding: none. academic emphasis of EM has greatly improved the Conflict of interest: none declared. quality of care in EDs. Emergency medicine is now Corresponding author: W. Anthony Gerard, MD, Emergency Department, Lebanon VA Medical Center, 1700 S Lincoln Ave, one of the most sought-after specialties. We are no Lebanon, PA, 17042 ͑E-mail: [email protected]). longer considered just “ER docs,” as evidenced by 292 JABFM May–June 2019 Vol. 32 No. 3 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2019.03.190077 on 8 May 2019. Downloaded from our vital role in the health care system and recog- trained in the breadth of medical care, and as such nition by other specialties. are qualified to provide emergency care in a variety But in rural and community hospitals across the of settings. In rural and remote settings, family country, FPs are part of this workforce (even physicians are particularly qualified to provide though they may be lowly pawns.). In critical access emergency care.”17 Since we are developmentally hospitals, FPs are likely to be the only physician and intrinsically linked, EM and FM should be specialty. “The King may be the most important collaborating to solve rural EM issues, not continue piece on the chess board, but there would be no the stalemate. Competition between EM and FM a game of chess without the pawns.” should be replaced with cooperation. The chess Emergency medicine and FM are developmen- game should be considered a draw. tally linked, making it ironic that we have not In 2008, the Institute for Health care Improve- cooperated on rural EM workforce issues. The pi- ment introduced a program intended to improve oneers of EM included FPs who helped develop the health care in the US, titled, The Triple Aim.18 specialty. They championed its cause with the The program was intended to improve population American Board of Medical Specialties because health while also improving the patient experience, they saw the need for better-trained physicians to and simultaneously reducing costs. This health care staff the “ ERs of America.” In these early days, the transformation has become widely used—or at leaders of both specialties “envisioned extensive 9 least widely referenced—as hospitals and health cooperative efforts….” systems have strived to improve patient outcomes. The authors quote from an overly optimistic The concept of the Triple Aim has now been ad- study of the EM workforce,10 which predicts that opted as part of the national strategy for US health “within 5 to 10 years there will be enough board- care, and should be considered for rural EDs. certified EPs to provide care to all patients.” This Rural EM needs to have this kind of approach, study, published in a journal sponsored by the Amer- since neither EM or FM can improve rural health copyright. ican Academy of Emergency Medicine (AAEM), but- care working alone. The Triple Aim requires an “in- tresses the academic EM perspective that the entire tegrator,” which is an entity that “links health care EM workforce should be residency-trained EPs (this organizations and induce coordinative behaviors.” is one of the reasons AAEM was founded11). But The Triple Aim also requires “disruptive innova- several other workforce studies show that this is a tions” to barriers such as “physician centric care.” dream that is unlikely to ever become a reality, espe- Under this new model, primary care and EM would cially in rural areas.12,13 This argument also furthers collaborate to provide rural emergency care and the debate between physician specialties instead of http://www.jabfm.org/ focusing on what is best for patients in all parts of achieve gains on all 3 aims: care, cost, and health. But, America. as the authors clearly state, the “barriers (to this type In the most rural EDs, the likelihood of being of innovation) are not technical, they are political.” seen by an American Board of Emergency Medi- There are reasons for hope. Academic EM lead- cine (ABEM) board-certified EP decreases 5-fold ers from several universities recently published an 19 compared with larger hospitals, and patients are excellent article on the EM workforce.” Accord- seven times more likely to be treated by a FP.14 In ing to the lead author, “more than one third of ED on 28 September 2021 by guest. Protected Iowa, almost a quarter of EDs were staffed exclu- clinicians are someone other than an emergency sively by FPs, and only 12% of EDs were staffed by physician…. [The] EM workforce is broad based residency-trained EPs.15,16 Peterson et al1 correctly with a variety of ambulatory care skill sets in addi- conclude that “ low-volume rural EDs will likely tion to EM experience.” remain highly dependent on broad-scope FPs to An innovative idea for improving rural health in meet their staffing needs.” EDs was recently proposed by Greenwood-Ericsson FPs who provide emergency care do not want to et al20 They propose a “new health-care delivery replace EPs, and depend on the leadership of model for rural population health based on a partner- ABEM physicians, but are a logical choice to sup- ship between EM and primary care.” Rural EDs plement the EM workforce. The American Acad- would become “a collaborative domain of both emer- emy of Family Physicians (AAFP) Position State- gency and primary care.” Implicit in this is a recog- ment makes this clear: “Family physicians are nition of the important role FPs play in rural ED’s, doi: 10.3122/jabfm.2019.03.190077 Commentary 293 J Am Board Fam Med: first published as 10.3122/jabfm.2019.03.190077 on 8 May 2019. Downloaded from where a “mixed staffing model is common… provid- liveries and emergency medicine as a way of de- ers trained in both EM and primary care.” veloping a rural teaching site.
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