Why isn't EM considered Primary Care?

[sacholiver]

The definition of primary care is a subset of medicine of which fulfills the medical needs of the general population.

EM certainly seems to fit this criteria, but isn't primary care. Any insights I'm missing?

---

Members don't see this ad.

 

[kmp0410]

Semantics

 

[christmasindr]

I think it's because 1) EM gets paid really well 2) EM doesn't involve longitudinal care.

 

[The Knife & Gun Club]

Just because the general public insists on using the ER for primary care purposes doesnt mean that's what the docs there are trained to do.

Those guys are trained in a whole bunch of things involving real emergencies that a general doc doesn't have to know.

 

[LizzyM]

^ what he said
Primary care is first line care with an emphasis on preventive services and counseling to maintain health and prevent disease/disability. Also first line treatment of common conditions such as hypertension, asthma, type 2 diabetes, etc. Primary care is provided by pediatricians, family practitioners and internists in general practice.

 

[sacholiver]

Just because the general public insists on using the ER for primary care purposes doesnt mean that's what the docs there are trained to do.

Those guys are trained in a whole bunch of things involving real emergencies that a general doc doesn't have to know.

I would disagree. Of course they ARE trained in those things, but a majority of their time is spent acting as people's PC doctors.

 

[sacholiver]

^ what he said
Primary care is first line care with an emphasis on preventive services and counseling to maintain health and prevent disease/disability. Also first line treatment of common conditions such as hypertension, asthma, type 2 diabetes, etc. Primary care is provided by pediatricians, family practitioners and internists in general practice.

How does internal medicine fit the preventative care bill?

 

[deleted647690]

Would you guys say that since ER docs tend to be used by people for primary care, that true emergency med docs are trauma surgeons?

 

[LizzyM]

How does internal medicine fit the preventative care bill?

Internists treat adults. They identify and treat an array of conditions, and provide preventive services to adults. They are trained to screen and provide counseling, and medical treatment, for alcoholism, depression, cigarette smoking, obesity, hypertension, hypercholesterolemia, etc, etc. They manage patients with diabetes, arthritis, asthma, and many other medical conditions. They perform pap smears and prescribe contraceptives if the patient doesn't have a separate GYN. They refer patients for mammograms and colonoscopies and similar screening tests.

 

[sacholiver]

Would you guys say that since ER docs tend to be used by people for primary care, that true emergency med docs are trauma surgeons?

I would, from my 500+ hours working closely with ER doctors in a major trauma 1 hospital. They stabilize critical patients and trauma surgeons do the rest. The rest of their time they are diagnosing common ailments which seem very PC-like.

 

[sacholiver]

Internists treat adults. They identify and treat an array of conditions, and provide preventive services to adults. They are trained to screen and provide counseling, and medical treatment, for alcoholism, depression, cigarette smoking, obesity, hypertension, hypercholesterolemia, etc, etc. They manage patients with diabetes, arthritis, asthma, and many other medical conditions. They perform pap smears and prescribe contraceptives if the patient doesn't have a separate GYN. They refer patients for mammograms and colonoscopies and similar screening tests.

Why wouldn't such an adult patient see a FM doctor?

I always thought most inpatient IM doctors work a lot in the ICU with very sick people. But I understand outpatient IM is a very big thing.

 

[The Knife & Gun Club]

I would disagree. Of course they ARE trained in those things, but a majority of their time is spent acting as people's PC doctors.

Actually not at all. Maybe they'll prescribe a script for hypertension or something, but they're not following patients the way a PCP is.

Also, every doctor is trained in those things to some degree. Sometimes the Surgeon I work for will prescribe nausea meds or antibiotics for ear infections and stuff.

Finally, just because the meat of their time is spend doing Pcp-esque tasks doesn't mean that's why they're there. Their training is in making sure you don't die when you come in after choking on a grape.

You gotta read up on other specialties too. Internal medicine is a monstrous field with people doing nearly every kind of work within it.

 

[LizzyM]

Why wouldn't such an adult patient see a FM doctor?

I always thought most inpatient IM doctors work a lot in the ICU with very sick people. But I understand outpatient IM is a very big thing.

There are many areas where there aren't family practice docs. Internists can work with patients in the hospital, including the ICU, but many work in outpatient settings.

 

[sacholiver]

There are many areas where there aren't family practice docs. Internists can work with patients in the hospital, including the ICU, but many work in outpatient settings.

Interesting, so this implies there are more IM than FM doctors. Why not merge the residencies? What makes IM different than FM?

 

[The Knife & Gun Club]

I would, from my 500+ hours working closely with ER doctors in a major trauma 1 hospital. They stabilize critical patients and trauma surgeons do the rest. The rest of their time they are diagnosing common ailments which seem very PC-like.

I would imagine most Pcp docs don't know how to run a full code (excluding in patient internists)

 

[sacholiver]

I would imagine most Pcp docs don't know how to run a full code (excluding in patient internists)

I find that hard to believe - but that's just an opinion. I have no facts to back up my disbelief. Would love to hear an attending physician or 3/4th year med students comment on that

 

[gyngyn]

I would, from my 500+ hours working closely with ER doctors in a major trauma 1 hospital. They stabilize critical patients and trauma surgeons do the rest. The rest of their time they are diagnosing common ailments which seem very PC-like.

EM is the very antithesis of longitudinal care.
When they are managing chronic conditions they are doing so by default. This is the reason that we value primary care. We need physicians to keep patients out of the ER for chronic conditions.

 

[gyngyn]

Interesting, so this implies there are more IM than FM doctors. Why not merge the residencies? What makes IM different than FM?

FM includes the care of children, infants and the reproductive care of women (including obstetrics). IM does not.

 

[sacholiver]

EM is the very antithesis of longitudinal care.
When they are managing chronic conditions they are doing so by default. This is the very reason that we value primary care. We need physicians to keep patients out of the ER for chronic conditions.

Wouldn't an inpatient internal medicine Doctor also not really follow the longitudinal care model?

 

[gyngyn]

Wouldn't an inpatient internal medicine Doctor also not really follow the longitudinal care model?

There are many sub-specialties of internal medicine. General internal medicine is absolutely primary care of adults. Hospitalists of any stripe are not.

 

[AnatomyGrey12]

Wouldn't an inpatient internal medicine Doctor also not really follow the longitudinal care model?

No they don't. That's why hospitalists aren't considered primary care..

 

[medic86]

I find that hard to believe - but that's just an opinion. I have no facts to back up my disbelief. Would love to hear an attending physician or 3/4th year med students comment on that

Sure, they may have ACLS, but the last time they ran a code was at their ACLS megacode.

 

[deleted480308]

Because it doesn't fit the narrative for how the system is "supposed" to work. But if you look at how the system actually works, EM is absolutely primary care.

Primary care is supposed to be your first line basic management and diagnosis for health. Our system makes EM the "free" option for those that can't/dont pay an FM/ped/obgyn/psych to deal with those issues so EM does it for a decent portion of the nation. This is expensive as hell for those that actually fund the system and they want to discourage it so they don't admit it's happening. In a non-emtala universe, EM would not be primary care.

 

[sacholiver]

^ my point exactly

 

[Mansamusa]

Because it doesn't fit the narrative for how the system is "supposed" to work. But if you look at how the system actually works, EM is absolutely primary care.

Primary care is supposed to be your first line basic management and diagnosis for health. Our system makes EM the "free" option for those that can't/dont pay an FM/ped/obgyn/psych to deal with those issues so EM does it for a decent portion of the nation. This is expensive as hell for those that actually fund the system and they want to discourage it so they don't admit it's happening. In a non-emtala universe, EM would not be primary care.

I've seen ER physicians in my hospital get around this (assuming what they are doing is permitted). Like the hypertension example above, they would say, "Are you having a hypertensive emergency? No. So here is a referral to a physician who can help you with the management of high blood pressure." They make sure the patient is stable and safe to leave and then they refer them to a specialist to get whatever PCP issue they are having treated

 

[deleted480308]

I've seen ER physicians in my hospital get around this (assuming what they are doing is permitted). Like the hypertension example above, they would say, "Are you having a hypertensive emergency? No. So here is a referral to a physician who can help you with the management of high blood pressure." They make sure the patient is stable and safe to leave and then they refer them to a specialist to get whatever PCP issue they are having treated

yeah, they'll give the referral......but when the patient has no meds, they'll get a script (Even if a small one) and if that patient has no insurance/money they will simply reappear when that script runs out. It's one of the consequences with our "it's there even if you can't pay" system, people use it

 

[713470]

Would you guys say that since ER docs tend to be used by people for primary care, that true emergency med docs are trauma surgeons?

Trauma surgeons are great for just that--trauma. There are trauma emergencies, and then there are medical emergencies, like managing a patient in DKA, or a hypotensive, tachycardic neutropenic fever, or a severe COPD exacerbation requiring intubation. ER docs still handle numerous "true emergencies", even if they just require stabilization before being turfed to another specialty (patients with heart attacks, strokes, ischemic bowel, etc.). Taking care of med refills, colds, and other lower acuity or chronic medical conditions are in addition to that.

 

[hopefulERdoc251]

I would, from my 500+ hours working closely with ER doctors in a major trauma 1 hospital. They stabilize critical patients and trauma surgeons do the rest. The rest of their time they are diagnosing common ailments which seem very PC-like.

I would 100% politely disagree with this lol. Who's going to intubate the guy who suddenly is having respiratory distress? Who's going to identify an acute MI, page the cath lab and administer thrombolytics? Who's gonna workup an appy/stroke/PE/cancer/DKA ect? Your definition of "emergency" in this case only applies to trauma. Also, by your definition, the ER docs is doing more to stabilize the guy so that the Trauma Service can see them. If ER docs are out of the picture here, patient dies, and Trauma doesn't even see them.

 

[Glandzburg]

Wouldn't an inpatient internal medicine Doctor also not really follow the longitudinal care model?

I don't think you understand the scope of internal medicine. It is a very large field with lots of subspecialties and niches.

IM docs can work in outpatient clinics as PCPs. They often see the most complicated adult patients that have a laundry list of conditions and comorbidities. On the acute care side of the spectrum, they can work as hospitalists.

 

[Bones 2020]

I always wondered this myself. Thanks for the thread OP

 

[darkjedi]

Because it doesn't fit the narrative for how the system is "supposed" to work. But if you look at how the system actually works, EM is absolutely primary care.

Primary care is supposed to be your first line basic management and diagnosis for health. Our system makes EM the "free" option for those that can't/dont pay an FM/ped/obgyn/psych to deal with those issues so EM does it for a decent portion of the nation. This is expensive as hell for those that actually fund the system and they want to discourage it so they don't admit it's happening. In a non-emtala universe, EM would not be primary care.

I don't really agree with this. The emergency department doesn't really provide basic management and diagnosis for non-acute conditions. If you come into the ED to get have your hypertension diagnosed or managed, you will kindly be provided with a referral and discharged. If you come in for chest pain, but it winds up not being a heart attack and probably GERD, the ED won't bother diagnosing it and just ask you to follow up with your PCP. EMTALA or not, if you're trying to seek primary care in the ED, you won't really be able to get it since it only covers emergency conditions.

Additionally, in major hospitals, the low-acuity cases are usually in a fast track and seen mainly by NPs or PAs.

 

[QofQuimica]

The definition of primary care is a subset of medicine of which fulfills the medical needs of the general population.

EM certainly seems to fit this criteria, but isn't primary care. Any insights I'm missing?

Besides what others have said about EM not being about longitudinal care, part of the problem also has to do with what defines an "emergency." You have to realize that when you deal with the general public, you are usually not dealing with people who have the level of knowledge of your medical colleagues here. Less educated people in particular may not have the ability to recognize A) what an emergency actually is, and B) whether their symptoms in fact correspond to an emergency. But really, anyone who is a layperson can panic about a symptom and show up in the ER, simply because they don't know what's wrong with them and they're scared.

You also have to add in the psych factor, as many frequent users of the ER have comorbid psych issues (including substance abuse) along with their other complaints. A PCP can "fire" a patient from their practice, but the ER doc never has that option. It's illegal for them to turn anyone away.

And finally, there is the convenience issue. Sometimes people can't get in to their PCP, or they can't get off work, or they need something that can't be done by their PCP. Heck, sometimes PCPs send their patients to the ER on purpose because they need testing that the PCP can't provide, or to otherwise expedite their workup. Whether that's an appropriate use of the ER or not is a matter of debate, but it's hard to blame a patient who is following their PCP's instructions to go to the nearest ER for a CT scan right away.

Regarding questions of whether internists and other PCPs can run codes, the answer is yes, they can. If someone shows up to their PCP's office and drops dead on the office floor, the PCP will sure as heck start chest compressions and hook them up to the AED. That being said, an office-based PCP is hopefully not having patients code and die in their office on a regular basis, so they don't do a lot of codes. Whereas, on the inpatient hospital floors, the hospitalists often do run the codes. Obviously someone who dies in the ER would be coded by the ER doc.

Regarding the question of whether a hospitalist is a PCP, the answer to that is generally no. A hospitalist is a specialist in inpatient medical care. Once the patient leaves the hospital, their regular PCP takes over their care again. While some (usually rural) hospitalists also have outpatient practices and are therefore PCPs as well, most hospitalists do not do both primary care and hospital medicine any more than most other IM specialists do both.

 

[Tenk]

We are the alpha and the omega. The beginning and the end. We are primary care. We are intensive care. We will usher you into life, and we will watch you depart it. All while giving you percosnacks and a work note to go home with.

 

[deleted480308]

I don't really agree with this. The emergency department doesn't really provide basic management and diagnosis for non-acute conditions. If you come into the ED to get have your hypertension diagnosed or managed, you will kindly provided with a referral and discharged. If you come in for chest pain, but it winds up not being a heart attack and probably GERD, the ED won't bother diagnosing it and just ask you to follow up with your PCP. EMTALA or not, if you're trying to seek primary care in the ED, you won't really be able to get it since it only covers emergency conditions.

Additionally, in major hospitals, the low-acuity cases are usually in a fast track and seen mainly by NPs or PAs.

You must have been in different hospitals than I was....someone comes in with no insurance/money/literacy in regards to the health system and they are getting that script because they simply won't go to primary doc. It's not their enitre role, it's not their intended role, but EM docs absolutely have become a part of primary care in this country due to govt meddling

 

[Med Ed]

The definition of primary care is a subset of medicine of which fulfills the medical needs of the general population.

Here is the definition of primary care according to the American Academy of Family Physicians (AAFP):

"Primary care is that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis.

Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, day care, etc.). Primary care is performed and managed by a personal physician often collaborating with other health professionals, and utilizing consultation or referral as appropriate.Primary care provides patient advocacy in the health care system to accomplish cost-effective care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care."

EM certainly seems to fit this criteria, but isn't primary care. Any insights I'm missing?

The definition presumes the world works at is should, not as it does (i.e. nobody should be using the ED as a primary office, although people do this for various reasons). One could actually make a much stronger argument that OB/GYN (specifically the GYN) should be considered a primary care field.

 

[st2205]

The term primary care is used often in a health policy or public health sense in that it is the first person you go to who also coordinates your care (sort of), as has been defined plenty above. There's an emphasis on primary care to address needs in an efficient and cost-reductive manner, not to simply provide that care in any setting.

Sure, EM can stabilize patients and sees everything. They can give you insulin for your blood sugar, Ativan for your anxiety or refill your prescription for metoprolol when you've run out, but they don't manage these conditions over time and don't have any experience doing so. It's not what they're there for and not what they are wanting to do. But I guess it's job security.

Early on, everybody wants to be top dog and the person who can handle "anything." The further along you get, the more you realize you don't want to deal with 95% of the **** out there.

 

[Nietzschelover]

You must have been in different hospitals than I was....someone comes in with no insurance/money/literacy in regards to the health system and they are getting that script because they simply won't go to primary doc. It's not their enitre role, it's not their intended role, but EM docs absolutely have become a part of primary care in this country due to govt meddling

Due to "govt meddling"? How have you twisted what seem like annoying abuses of the ER to you into "govt meddling"? Sounds like you're trying to shoehorn something into a narrative you're invested in.

 

[The Knife & Gun Club]

Due to "govt meddling"? How have you twisted what seem like annoying abuses of the ER to you into "govt meddling"? Sounds like you're trying to shoehorn something into a narrative you're invested in.

He's refering to EMTALA, which is a government mandate that (in laymans terms means) you must treat anyone who shows up to the ER regardless of their ability to pay.

 

[Hospitalized]

Would you guys say that since ER docs tend to be used by people for primary care, that true emergency med docs are trauma surgeons?

Trauma surgeons are great for just that--trauma. There are trauma emergencies, and then there are medical emergencies, like managing a patient in DKA, or a hypotensive, tachycardic neutropenic fever, or a severe COPD exacerbation requiring intubation. ER docs still handle numerous "true emergencies", even if they just require stabilization before being turfed to another specialty (patients with heart attacks, strokes, ischemic bowel, etc.). Taking care of med refills, colds, and other lower acuity or chronic medical conditions are in addition to that.

Thank you for answering this. I was scratching my head seeing how many people didn't address this. ER docs have such a broad scope. Trauma is not the only acute thing that comes to an ER (in fact, it's much less likely, in my experience, than most of the stuff above). Acetyl's post was quite dismissive of their ability.

 

[Med Ed]

He's refering to EMTALA, which is a government mandate that (in laymans terms means) you must treat anyone who shows up to the ER regardless of their ability to pay.

Not quite. EMTALA requires that anyone who comes to the ED complaining of a "medical emergency" must receive an examination and appropriate testing to evaluate the veracity of the complaint. This includes pregnant women who may be in active labor. If a true emergency does not exist, the ED is under no obligation to do anything more. If a true emergency does exist, the ED is obligated to treat until, at a minimum, the patient is stable enough for transfer to another facility. Furthermore, EMTALA does not apply to hospitals that do not receive payments from CMS, although such facilities are relatively few and far between.

The fact that many hospitals will treat beyond their EMTALA obligation really comes down to institutional policy rather than federal hegemony.

 

[dextertrip]

people thinking ER docs are primary care docs is so financially inefficient it's frustrating that this question even has to be asked! OP now that you know it is not, share this with the many patients you meet at you 500+ hours experience. We need people to stop inflating the cost of healthcare in this country.

 

[Mad Jack]

The definition of primary care is a subset of medicine of which fulfills the medical needs of the general population.

EM certainly seems to fit this criteria, but isn't primary care. Any insights I'm missing?

Primary care has many different definitions, very few as broad as the one which you use. It is generally accepted to be something more akin to what Johns Hopkins describes it as:

"Primary care is the level of a health services system that provides entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions, and coordinates or integrates care, regardless of where the care is delivered and who provides it. It is the means by which the two main goals of a healthservices system, optimization and equity of health status, are approached."

It's the longitudinal requirement, as well as the coordination and integration of care, that emergency medicine fails to meet.

 

[Nietzschelover]

He's refering to EMTALA, which is a government mandate that (in laymans terms means) you must treat anyone who shows up to the ER regardless of their ability to pay.

Oh, OK, thanks. I wish EMTALA was a poster so I could like it.

ERs are doing "God's work," even though as a Nietzsche lover of course I don't believe in God. I want the ER to treat my kid for an overdose even though he's been there 3 times already in the last 2 weeks. I want the ER to treat the homeless schizophrenic who got the crap beat out of him again. I want the ER to save the guy who is back in yet again with stab wounds who is the child of someone's mother. I want the Vet who is in yet another diabetic crisis to get care even though he repeatedly is defiant and/or doesn't have the wherewithal to follow up "on the street."

 

[deleted407021]

It's my understanding that some physicians outside the conventional PCP triad (FM/IM/Peds) may move on and out of the PC role, depending upon the patient -- most notably OB/GYN. They provide a lot of specialty care but also act as some women's first point of contact for healthcare. Additionally, psychiatrists, physiatrists and IM/Peds sub-specialists may manage the overarching medical issues of their patients, as well as the problems specific to their specialty.

 

[sacholiver]

people thinking ER docs are primary care docs is so financially inefficient it's frustrating that this question even has to be asked! OP now that you know it is not, share this with the many patients you meet at you 500+ hours experience. We need people to stop inflating the cost of healthcare in this country.

I know that it isn't.

 

[deleted480308]

Not quite. EMTALA requires that anyone who comes to the ED complaining of a "medical emergency" must receive an examination and appropriate testing to evaluate the veracity of the complaint. This includes pregnant women who may be in active labor. If a true emergency does not exist, the ED is under no obligation to do anything more. If a true emergency does exist, the ED is obligated to treat until, at a minimum, the patient is stable enough for transfer to another facility. Furthermore, EMTALA does not apply to hospitals that do not receive payments from CMS, although such facilities are relatively few and far between.

The fact that many hospitals will treat beyond their EMTALA obligation really comes down to institutional policy rather than federal hegemony.

The letter of the law is that EDs can turn away non-emergent patients. The reality is that penalties are so huge for making the wrong call and the scope of liability so huge that very few hospitals dare risk getting it wrong. So in the real universe, EMTALA means the govt is allwing everyone to get treated regardless of ability to pay.

 

[virchow?]

Additionally, psychiatrists, physiatrists and IM/Peds sub-specialists may manage the overarching medical issues of their patients, as well as the problems specific to their specialty.

Great point. Peds endo comes to mind. E.g. A kid with T1D is not going to have 2 primary care docs, so their endocrinologist is going to make sure that they are healthy in non-endo areas too.
In some cases, PC is more accurately descried by the stage and goals of the healthcare delivered than the specialty.

 

[vantheman]

Would you guys say that since ER docs tend to be used by people for primary care, that true emergency med docs are trauma surgeons?

No. Trauma is only a percentage of the emergencies that present to the emergency department. Emergency physicians are trained to stabilize patients who come in with all kinds of emergencies (cardiac arrest, anaphylaxis, respiratory distress, CVA, etc.) and they also have a vital role in trauma patients (i.e. protecting the airway).

 

[AnatomyGrey12]

No. Trauma is only a percentage of the emergencies that present to the emergency department. Emergency physicians are trained to stabilize patients who come in with all kinds of emergencies (cardiac arrest, anaphylaxis, respiratory distress, CVA, etc.) and they also have a vital role in trauma patients (i.e. protecting the airway).

I think people just get the idea that trauma surgeons are the real EM docs because of mainstream media, particularly shows like Grey's Anatomy where every little thing that rolls in the ER is surgical and some form of trauma. On top of that the surgeons are running the ER. #itslikethewritershaveneversteppedfootinahospital

Example, I had no idea an ER doc wasn't a surgeon until I started college and had a friend whose dad was an EM doc and I talked to him

Honestly when a trauma actually does come in the door, without the ER docs the surgeons wouldn't have trauma patients to operate on

 

[Mad Jack]

I think people just get the idea that trauma surgeons are the real EM docs because of mainstream media, particularly shows like Grey's Anatomy where every little thing that rolls in the ER is surgical and some form of trauma. On top of that the surgeons are running the ER. #itslikethewritershaveneversteppedfootinahospital

Example, I had no idea an ER doc wasn't a surgeon until I started college and had a friend whose dad was an EM doc and I talked to him

Honestly when a trauma actually does come in the door, without the ER docs the surgeons wouldn't have trauma patients to operate on

And trauma surgery isn't exactly the most beloved field to begin with... It's basically complication central, unpredictable call, etc. It's like doing a fellowship after GS that will make your lifestyle worse, not better, and won't improve your pay all that much. Screw that.