why aren't EM physicians also trained in primary care?

[usmle6969]

I'm an M4 possibly going into EM, this is just something I have been thinking about on my rotation.

Yes, the purpose of the ED is to get the ball rolling by immediate recognition, evaluation, care, stabilization, and dispo of patients with acute illness and injury.

But the reality is that 30-50% of what comes into EDs is more primary care type stuff with uninsured patients. Wouldn't it be beneficial for EM docs to also have as good a grasp as FP/IM docs on primary care issues that are routinely seen? (HTN management, diabetes meds and other common chronic management issues )

Obviously the ER is not meant to be a primary care clinic, but for better or worse, it functionally is used that way for a large patient population who doesn't have insurance or patients who don't care/realize that they don't have a real emergency. And most of these patients likely won't ever follow up with a PCP to deal with the underlying issues going on, and will continue to burden the system with more ER visits that rack up thousands of dollars in health care costs. So why not add more of a one-stop shop component to EDs. My logic is that training EM docs for like a year in primary care IM/FP stuff (either in addition to or in lieu of some other rotation months) could allow them to and have a really large impact on the health care savings in terms of less ER visits from patients and less acute emergencies from uncontrolled medical problems. Thoughts?

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[Modafinil]

The ED isn't a primary care clinic.

 

[DeadCactus]

The part of primary care that frequently inappropriately comes to the ED are the sick visits which emergency physicians are well trained to handle. That is not the same as managing lipids, fine-tuning hypertension medications, adjusting insulin regimens, providing anticipatory guidance, etc. While part of the appeal for many in EM is maintaining a broad knowledge base and being a "real doctor", at some point you are wasting time you could spend mastering your craft to become an amateur in someone else's role. There probably is a role for a few select nuggets of "primary care" sort of intervention depending on the public health issues you particularly want to tackle but we don't have continuity of care so it will never be more than kicking the can down the road and hoping the next guy keeps it going. In the setting of the emergency department the bulk of primary care knowledge largely represents a waste of attention and time that should be spent taking care of acutely ill patients...

 

[Doctor Bob]

Obviously the ER is not meant to be a primary care clinic, but for better or worse, it functionally is used that way for a large patient population who doesn't have insurance or patients who don't care/realize that they don't have a real emergency. And most of these patients likely won't ever follow up with a PCP to deal with the underlying issues going on, and will continue to burden the system with more ER visits that rack up thousands of dollars in health care costs. So why not add more of a one-stop shop component to EDs. My logic is that training EM docs for like a year in primary care IM/FP stuff (either in addition to or in lieu of some other rotation months) could allow them to and have a really large impact on the health care savings in terms of less ER visits from patients and less acute emergencies from uncontrolled medical problems. Thoughts?

Adding this functionality would make the ER inefficient and not as good at managing the emergencies that come in.

Your primary care doctor's office wouldn't function very well if there were no appointment slots and people could just show up whenever they wanted. The emergency department is, by it's name, a place to evaluate and treat emergencies. It is not a convenience department. Rather than expand the function of the emergency department in a way that would make it difficult for it to fulfill its primary role, we should be drawing a harder line and kicking people out of the ED who don't need to be there.

When I see people in the ED who have little to no need to be there, my first question is "did you call your PCP" and the answer is almost always no. When I ask people who have had 4-8 weeks of symptoms if they've talked with their PCP about these symptoms, the answer is almost always no. When I ask people why they didn't follow up with their PCP after their last ED visit, there's usually some sob story about not being able to get a ride, then sleeping through an alarm, then having to go out of town, etc, etc.

PCPs aren't nearly as convenient as EDs. PCPs ask for copays up front and won't see you without them; EDs don't. So even though an ED bill is 10x the cost of a PCP bill, if you aren't planning to pay either one of them it doesn't matter how much it is.

 

[Birdstrike]

You're trained on those "primary care-like" issues that present to the ED, during your ED shifts in residency. Also, there are rotations through primary care services during your residency training. This issue is well addressed with the current educational system.

 

[Hair Police]

Well, orthopods go through the belly on the anterior approach to a spinal fusion, so why don't they spend another year doing general surgery? A pediatrician's patients will eventually have their own kids, so why don't pediatriaicns do a year of OB? Half of an internists' patients are women, so why don't they do a year of Gyn?

Training isn't additive - eventually you fill your brain-attic. You have to specialize eventually. You cannot remain pleuripotent for forever.

And the lack of real follow up is one of the reasons why I am always hesitant to start someone on a new medication (i.e., not outpt Abx or refilling a stable home med). I know many joke about repeat offenders, but these visits are not the same service that PMDs provide. If I start them on HCTZ (admittedly an low risk medication), who is going to see if the patient had a good response? Who will look out for advrse effects? Where will they get refills? If we can't answer these questions, we shouldn't be doing primary care.

 

[Hair Police]

The part of primary care that frequently inappropriately comes to the ED are the sick visits which emergency physicians are well trained to handle. That is not the same as managing lipids, fine-tuning hypertension medications, adjusting insulin regimens, providing anticipatory guidance, etc...

One thing in an otherwise great post - I absolutely give anticipatory guidance. I want the low-velocity MVC pt to know they'll be sore over the next few days so they don't bounce back. I want the parents of the well-appearing child with a fever to know to bring them back if they develop a bad rash or AMS. And I'll teach them about oral rehydration, too. Nearly all patients should have some follow up plan and be taught when to come back to the ED.

 

[deleted547339]

I'm sorry. I was too busy vomiting in my mouth thinking at the thought of doing primary to answer your question.

 

[RustedFox]

I'm sorry. I was too busy vomiting in my mouth thinking at the thought of doing primary to answer your question.

Beat me to it.

 

[TooMuchResearch]

I occasionally start lisinopril (2 week supply) or inhaled corticosteroid in an asthmatic using albuterol 10x per day.

But no, we're not a primary care clinic.

 

[Promethean]

I used to know a doc who ordered every lab and every test STAT. He figured that everything WAS important, so why shouldn't the lab / imaging suite be able to accommodate treating everything with equal importance.

Why can't ALL the tests be run STAT all the time? They start to crowd one another out, the signal to noise ratio drops, and the word "stat" becomes meaningless. The real emergencies can't be given due priority when they are lost among a sea of routine STAT orders.

EM is a specialized area of medicine. So, I would argue is FM, and certainly IM. EM is for STAT situations. That some people are like that doc, and don't know how to prioritize doesn't mean that their unwarranted sense of urgency should be better accommodated. To do so only diminishes resources available for genuine emergencies...

Besides, primary care isn't just a set of skills and algorithms. It is about building a relationship over time. EM is, should be, episodic care, not longitudinal.

 

[sluggs]

This comes from an intensivist with great respect for primary care: primary care involves relationship-building and longitudinal care for then whole patient; there is a lot more to it than just picking the right drug at a point in time!

 

[Daiphon]

This comes from an intensivist with great respect for primary care: primary care involves relationship-building and longitudinal care for then whole patient; there is a lot more to it than just picking the right drug at a point in time!

Yanno... every time I start to pen a response to this thread, I come up with yet another rebuttal; however, this comment alone encompasses all the individual problems with the OP's initial premise.

PCP's not only know what to do for long-term illness, but when not to do it... we've been trained to look for the life threats, and how to deal with decompensation; not ongoing issues that require adjustment based on other meds, insurance status, formulary coverage, etc. In fact, that's why PC has its own residencies. Furthermore, I can't tell you how many times I've gotten the "my doctor sent me here for X" or "Google says I need X" where X = some test that I don't think is indicated in the ED setting and have a devil of a time talking them out of.

A PCP, however, with an established relationship likely could...

I'm in EM because while I enjoyed something about all the specialties I rotated through, the clinic experience was not something I ever wanted. Too depressing & defeatist.

tl;dr - this is a bad idea.

-d

 

[engineeredout]

Outpatient medicine is the most horrific thing in history of horrific things. Plus, I don't really want to see these patients repeatedly.

 

[docdragon]

The ED isn't a primary care clinic.

Wait... it isn't?

OP, read Buttaravoli's Minor Emergencies if you match in EM. Or if you just want to learn. And learn as much medicine as you can. And build strong common sense. There are times that I adjust or start an anti-hypertensive, but more often look for the leverage points that encourage patients to work with their PMD for outpatient management of primary care issues.

 

[Arcan57]

I'm an M4 possibly going into EM, this is just something I have been thinking about on my rotation.

Yes, the purpose of the ED is to get the ball rolling by immediate recognition, evaluation, care, stabilization, and dispo of patients with acute illness and injury.

But the reality is that 30-50% of what comes into EDs is more primary care type stuff with uninsured patients. Wouldn't it be beneficial for EM docs to also have as good a grasp as FP/IM docs on primary care issues that are routinely seen? (HTN management, diabetes meds and other common chronic management issues )

Obviously the ER is not meant to be a primary care clinic, but for better or worse, it functionally is used that way for a large patient population who doesn't have insurance or patients who don't care/realize that they don't have a real emergency. And most of these patients likely won't ever follow up with a PCP to deal with the underlying issues going on, and will continue to burden the system with more ER visits that rack up thousands of dollars in health care costs. So why not add more of a one-stop shop component to EDs. My logic is that training EM docs for like a year in primary care IM/FP stuff (either in addition to or in lieu of some other rotation months) could allow them to and have a really large impact on the health care savings in terms of less ER visits from patients and less acute emergencies from uncontrolled medical problems. Thoughts?

Your number for primary care stuff is way off. If you wanted to make an argument that 30-50% of people in the ED come in with an acute complaint and have a concomitant poorly or unmanaged primary care issue, then sure. For every 10 "Hypertension" chief complaints on the tracking board, when you get into the room 8-9 of them are actually going to be SOB, HA, CP, or lightheadedness with a side of elevated BP. We are very well trained to spot the sick 1-2/10 in this group and to refer out the others. If we start focusing our efforts and attention on the non-emergent side of things, it may make us more susceptible to missing the emergent diagnoses.

 

[Modafinil]

Wait... it isn't?

OP, read Buttaravoli's Minor Emergencies if you match in EM. Or if you just want to learn. And learn as much medicine as you can. And build strong common sense. There are times that I adjust or start an anti-hypertensive, but more often look for the leverage points that encourage patients to work with their PMD for outpatient management of primary care issues.

This issue isn't making small adjustments to an anti-hypertensive. It is the long term relationships required for successful management of chronic conditions. The ED is not the venue for such care.

 

[link2swim06]

Wait... it isn't?

OP, read Buttaravoli's Minor Emergencies if you match in EM. Or if you just want to learn. And learn as much medicine as you can. And build strong common sense. There are times that I adjust or start an anti-hypertensive, but more often look for the leverage points that encourage patients to work with their PMD for outpatient management of primary care issues.

The real issue is you are most likely going to only address a fraction of their primary care concerns.

Are you going to check a lipid panel on these new hypertensive patients? If not, why not?...would you perform half of an intubation? What about recommend them for a screening colonscopy or a AAA screening, etc...

Treating x,y,z chronic issue today vs. waiting for a PCP likely zero difference in outcomes. But if pts start equating ER = primary care then they are not going to be getting the care they deserve because they will have no reason to see a PCP.

Customer service is one thing...and I see how giving them a script keeps patients happy if that's what they want. But the ER isn't a PCP, end of story.

 

[Tenk]

No.

 

[EDParallax]

Your number for primary care stuff is way off. If you wanted to make an argument that 30-50% of people in the ED come in with an acute complaint and have a concomitant poorly or unmanaged primary care issue, then sure. For every 10 "Hypertension" chief complaints on the tracking board, when you get into the room 8-9 of them are actually going to be SOB, HA, CP, or lightheadedness with a side of elevated BP. We are very well trained to spot the sick 1-2/10 in this group and to refer out the others. If we start focusing our efforts and attention on the non-emergent side of things, it may make us more susceptible to missing the emergent diagnoses.

True. The perceived relationship of high blood pressure to actual presenting emergency is often not accurate, but this is not necessarily our patients' fault. It is our job to be the physician and figure out why they really come in. I often see patients who don't feel well, and chalk it up to high blood pressure either because that is what they have been told or because they may not have a sophisticated understanding of how to describe what they are feeling. Or they speak another language and I swear, cyracom doesn't always give great (or barely adequate) translations. So someone is triaged as hypertension, but this last month alone I saw a stemi, a cva and a dka who all said they came in today "because my pressure is up."

To be fair, we also get sent a lot of asymptomatic hypertension from the attached primary care clinic and our share of med noncompliance. "My pressure was up so I came to the hospital!" Did you take your medicine? "Oh no! It was too high so I came to see you." Smh.

 

[Arcan57]

To be fair, we also get sent a lot of asymptomatic hypertension from the attached primary care clinic and our share of med noncompliance. "My pressure was up so I came to the hospital!" Did you take your medicine? "Oh no! It was too high so I came to see you." Smh.

That correlates well with my favorite misuse of health care resources, the volume overloaded pt who was feeling too bad to go to dialysis so they come to the ED to... get dialyzed.

 

[shookwell]

To be fair, we also get sent a lot of asymptomatic hypertension from the attached primary care clinic and our share of med noncompliance. "My pressure was up so I came to the hospital!" Did you take your medicine? "Oh no! It was too high so I came to see you." Smh.

Sometimes I troll the "to be triaged" board for asymptomatic hypertension patients from the clinics so that I can discharge them and sent them back to whatever clinic while it's still opened. Our clinic system is overwhelmed and understaffed and some clinics use hypertension as an excuse to pawn off patients on the ED. I send them back to the clinic with a copy of the ACEP clinical policy on asymptomatic hypertension. It's especially annoying when it's a primary care clinic and they don't even refill the antihypertensives before sending the patient to the ED.

Our population is very non-compliant and it is common to see asymptomatic hypertension in the 240/120mmHg range.

 

[RuralEDDoc]

Will your clinics take a patient with BP 240/120? In my area, that patient you send back to the clinic with a BP of 240/120 will then get an ambulance called and sent right back to the ED. The clinics just dont give a crap about ACEPs clinical policy. Ive seen that not just in my rural area, but that seems to be the norm every where I've worked (two urban and one rural area in California).